Question 1

The nurse is caring for a client with a head injury who has clear nasal drainage. Which of the following actions should the nurse take?

Accepted Answer

Clear nasal drainage in a client with a head injury suggests a dural tear and cerebro-spinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful.
Blowing the nose is avoided to prevent CSF leakage.

Question 2

The nurse is admitting a client with a basal skull fracture and notes clear drainage from the client's nose. Which of these admission orders should the nurse's question?

Accepted Answer

Rhinorrhea may indicate a dural tear with cerebro-spinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the client, elevating the head, and applying cold pack are appropriate orders.

Question 3

The nurse is caring for a client who has increased intracranial pressure and is disoriented and anxious. Which of the following nursing actions should be included in the plan of care?

Accepted Answer

Clients with increased ICP and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The client requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most clients. The client will have photophobia, so the light should be dim.

Question 4

Which of the following assessment information should the nurse collect to determine whether a client is developing post-concussion syndrome?

Accepted Answer

Decreased short-term memory is one indication of post-concussion syndrome. The other data may be assessed but are not indications of post-concussion syndrome.

Question 5

The nurse is caring for a client with a head injury and has admission vital signs of blood pressure 128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute. Which of these vital signs, if taken 1 hour after admission, will be of most concern tothenurse?

Accepted Answer

Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

Question 6

The nurse is admitting a client to the emergency department (ED) who is unconscious following a head injury. The client's spouse and children stay at the client's side and constantly ask about the treatment being given. What of the following actions is bestfor the nurse to take?

Accepted Answer

The need for information about the diagnosis and care is very high in family members of acutely ill clients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counselling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.

Question 7

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which of the following nursing actions is most important?

Accepted Answer

The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and postsecondary students. Handwashing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.

Question 8

Aclient with a head injury opens his or her eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. Which of the following Glasgow Coma Scale scores should the nursedocument?

Accepted Answer

The client has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

Question 9

A client who is suspected of having an epidural hematoma is admitted to the emergency department. Which of the following actions should the nurse plan to take?

Accepted Answer

The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

Question 10

Which of the following parameters is best for the nurse to monitor to determine whether the prescribed IV mannitol has been effective for an unconscious client?

Accepted Answer

Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.

Question 11

Family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a client. Which of the following responses by the nurse is best?

Accepted Answer

Short and simple explanations should be given to clients and family members. The other explanations are either too complicated to be easily understood or may increase the family member's anxiety.

Question 12

Which of the following statements by a client who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse?

Accepted Answer

Following a head injury, the client should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The client can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.

Question 13

The nurse is caring for a client who has a head injury and is diagnosed with a concussion. Which of the following actions should the nurse plan to take?

Accepted Answer

A client with a minor head trauma is usually discharged with instructions about neurological monitoring and the need to return if neurological status deteriorates. MRI, hospital admission, or surgery is not indicated in a client with a concussion.

Question 14

The nurse is caring for a client who has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which of the following actions should the nurse take first?

Accepted Answer

The client's cerebral perfusion pressure is 56 mm Hg, below the normal of 70-100 mm Hg and approaching the level of ischemia and neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral perfusion. Immediate changes in the client's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.

Question 15

The nurse is assessing a client who is unconscious and applies a painful stimulus to the nail beds. The client responds with internal rotation, adduction, and flexion of the arms. Which of the following terms should the nurse use when documenting the findings?

Accepted Answer

Internal rotation, adduction, and flexion of the arms in an unconscious client is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

Question 16

The nurse is assessing a client with bacterial meningitis and obtains the following data. Which of the following findings should be reported immediately to the health care provider?

Accepted Answer

Shock is a serious complication of meningitis, and the client's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

Question 17

Aclient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which of the following nursing interventions should be included in the plan of care?

Accepted Answer

The client with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

Question 18

The nurse is caring for a client following a craniectomy and left anterior fossae incision who has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. Which of the following is an appropriate nursingintervention?

Accepted Answer

ROM exercises will help to prevent the complications of immobility. Clients with anterior craniotomies are positioned with the head elevated. The client with a craniectomy should not be turned to the operative side. When the client is weak, clustering nursing activities may lead to more fatigue and weakness.

Question 19

The nurse is caring for a client who has just been admitted with meningococcal meningitis. Which of the following observations requires the nurse to act?

Accepted Answer

Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions for at least the first 48 hours. Because the client may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia.
Nutrition is an important aspect of care in a client with meningitis.

Question 20

The nurse is admitting a client who has a tumour of the right frontal lobe. Which of the following findings should the nurse expect to observe?

Accepted Answer

The frontal lobes control intellectual activities such as judgement. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumour. Swallowing is controlled by the brain stem.

Quiz 59: Nursing Management Acute Intracranial Problems