Question 1

Which nursing intervention will help prevent spikes in intracranial pressure in the post-neurosurgical patient?

Accepted Answer

Postoperative vomiting must be avoided to prevent sharp spikes in intracranial pressure (ICP)in the postoperative neurosurgical patient.Antiemetics are administered as soon as nausea is apparent.Fluid restriction may be ordered as a routine measure to lessen the severity of cerebral edema or as treatment for the fluid and electrolyte imbalances associated with the syndrome of inappropriate antidiuretic hormone secretion.Most craniotomy patients can be turned from side to side within these restrictions,using pillows for support,except in some cases of extensive tumor removal,cranioplasty,and when the bone flap is not replaced.Routine pulmonary care is used to maintain airway clearance and prevent pulmonary complications.To prevent dangerous elevations in ICP,this care measure must be performed using proper technique and at time intervals that are adequately spaced from other patient care activities.

Question 2

Which independent nursing measures can assist in reducing increased intracranial pressure (ICP)?

Accepted Answer

A treatment modality that increases the incidence of noxious stimulation to the patient carries with it the potential for increasing intracranial pressure.

Question 3

What is one of the earliest signs of increased intracranial pressure (ICP)?

Accepted Answer

One of the earliest and most important signs of increased intracranial pressure is a decrease in the level of consciousness.

Question 4

Which patient position is optimal to prevent elevated intracranial (ICP)pressures?

Accepted Answer

The recent trend is to individualize the head position to maximize cerebral perfusion pressure and minimize intracranial pressure measurements.

Question 5

A patient becomes flaccid with fixed and dilated pupils.The patient's intracranial pressure (ICP)falls from 65 to 12 mm Hg.What should the nurse suspect is happening?

Accepted Answer

Herniation of intracerebral contents results in the shifting of tissue from one compartment of the brain to another and places pressure on cerebral vessels and vital function centers of the brain.If unchecked,herniation rapidly causes death as a result of the cessation of cerebral blood flow and respirations.Signs and symptoms of brain herniation include fixed and dilated pupils,flaccidity,and respiratory arrest.The intracranial pressure drops as the pressure is relieved by shifting the intracranial components downward.

Question 6

The patient has uncontrolled intracranial pressure and now is receiving high-dose barbiturate therapy.The nursing management plan for this patient should include monitoring the patient for what complication?

Accepted Answer

Hypotension,the most common complication in barbiturate therapy,results from peripheral vasodilation and can be compounded in an already dehydrated patient who has received large doses of an osmotic diuretic in an attempt to control intracranial pressure.Myocardial depression results from cardiac muscle suppression and can be avoided by frequent monitoring of fluid status,cardiac output,and serum drug levels.

Question 7

Which intervention should be considered LAST in treating uncontrolled intracranial hypertension?

Accepted Answer

Barbiturate therapy is a treatment protocol developed for the management of uncontrolled intracranial hypertension that has not responded to the conventional treatments previously described.The two most commonly used drugs in high-dose barbiturate therapy are pentobarbital and thiopental.The goal with either of these drugs is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained.

Question 8

A patient has been experiencing drowsiness,confusion,and slight focal deficits for several days.The initial noncontract computed tomography (CT)findings are negative.The patient is being prepared for a lumbar puncture.What appearance does the nurse anticipate that the cerebrospinal fluid (CSF)would look?

Accepted Answer

If the initial computed tomography findings are negative,a lumbar puncture is performed to obtain cerebrospinal fluid (CSF)for analysis.CSF after subarachnoid hemorrhage (SAH)appears bloody and has a red blood cell count greater than 1000 cells/mm³.If the lumbar puncture is performed more than 5 days after the SAH,the CSF fluid is xanthochromic (dark amber)because the blood products have broken down.Cloudy CSF usually indicates some type of infectious process such as bacterial meningitis,not SAH.

Question 9

The nurse is caring for a patient who is had trans-sphenoidal surgery for removal of a pituitary tumor.The nurse observes a large amount of clear drainage from the nose.The provider requests the drainage be tested for the presence of glucose.Why did the physician order this test?

Accepted Answer

To differentiate cerebrospinal fluid (CSF)drainage from postoperative serous drainage,a specimen is tested for glucose content.A CSF leak is confirmed by glucose values of 30 mg/dL or greater.

Question 10

Which medication is a fast-acting,short-duration agent used for breakthrough seizures?

Accepted Answer

Lorazepam is a fast-acting,short-duration agent that may be indicated for breakthrough seizures until therapeutic drug levels can be reached.Phenytoin is the recommended medication for seizure prophylaxis.Phenobarbital is a barbiturate whose action produces central nervous system depression and reduces the spread of an epileptic focus.

Question 11

A patient is admitted with an acute head injury after a motor vehicle accident.The patient is intubated and ventilated,and a ventriculostomy is placed.In addition to monitoring of intracranial pressure,what treatment can be provided with the ventriculostomy?

Accepted Answer

Advantages of a ventriculostomy include access for cerebrospinal fluid drainage and sampling,access for determination of volume-pressure curves,direct measurement of pressure,and access for medication instillation.

Question 12

After neurosurgery,the patient is at risk of developing what problem?

Accepted Answer

After neurosurgery,the patient is at risk for infection,corneal abrasions,and injury from falls or seizures.After neurosurgery,patients are at risk for a variety of infections,including meningitis,cerebral abscesses,bone flap infections,and subdural empyema.

Question 13

Which diuretic is the most effective in the reduction of increased intracranial pressure (ICP)?

Accepted Answer

The most widely used diuretic is mannitol,a large-molecule agent that is retained almost entirely in the extracellular compartment and has little of the rebound effect observed with other osmotic diuretics.Administration of mannitol increases cerebral blood flow and thus induces cerebral vasoconstriction as part of the brain's autoregulatory response to keep blood flow constant.

Question 14

What are the most common medications used in high-dose barbiturate therapy?

Accepted Answer

The goal with either drug is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained.Phenytoin and fosphenytoin are anticonvulsants.Mannitol is an osmotic diuretic,lidocaine is a local anesthetic,and nimodipine is a calcium channel blocker.

Question 15

Which medication is prescribed to decrease cerebral vasospasm?

Accepted Answer

Nimodipine is used to decrease cerebral vasospasm.

Question 16

A patient's ICP is 34 mm Hg,and his cerebral perfusion pressure is 65 mm Hg.Given that the practitioner has left appropriate orders,which action should the nurse take next?

Accepted Answer

Mannitol is an osmotic diuretic and will pull swelling out of edematous brain tissue,thereby decreasing intracranial pressure (ICP).Having the patient lie flat in bed will impair venous drainage from the head and worsen ICP.Suctioning will cause increased intrathoracic pressure,which will also worsen the already elevated ICP.

Question 17

The extrusion of cerebral tissue through the cranium is what type of herniation?

Accepted Answer

Transcalvarial herniation is the extrusion of cerebral tissue through the cranium.In the presence of severe cerebral edema,transcalvarial herniation occurs through an opening from a skull fracture or craniotomy site.These effects are indicative of central herniation from an expanding mass lesion of the midline,frontal,parietal,or occipital lobes.In uncal herniation,a unilateral,expanding mass lesion,usually of the temporal lobe,increases intracranial pressure,causing lateral displacement of the tip of the temporal lobe (uncus).Cingulate herniation occurs when an expanding lesion of one hemisphere shifts laterally and forces the cingulate gyrus under the falx cerebri.

Question 18

What is the target range for PaCO₂ in the patient with intracranial hypertension?

Accepted Answer

The current trend is to maintain PaCO₂ levels on the lower side of normal (35 ± 2 mm Hg)by carefully monitoring arterial blood gas measurements and by adjusting ventilator settings.

Question 19

Downward displacement of the hemispheres,basal ganglia,and diencephalon through the tentorial notch is indicative of what type of herniation?

Accepted Answer

These effects are indicative of central herniation from an expanding mass lesion of the midline,frontal,parietal,or occipital lobes.In uncal herniation,a unilateral,expanding mass lesion,usually of the temporal lobe,increases intracranial pressure,causing lateral displacement of the tip of the temporal lobe (uncus).Cingulate herniation occurs when an expanding lesion of one hemisphere shifts laterally and forces the cingulate gyrus under the falx cerebri.The two infratentorial herniation syndromes are upward transtentorial herniation and downward cerebellar herniation.

Question 20

A female right-handed patient has been admitted with an intracerebral hemorrhage.A computed tomography (CT)scan of the patient's head reveals a large left parietal area bleed.While assisting with personal care,the nurse notes that the patient is unable to comb her hair with her left hand.The nurse suspects the patient may be experiencing which complication?

Accepted Answer

Lesions in the parietal lobe,as well as in other cortical structures,can result in apraxia,an inability to perform a learned movement voluntarily.

Quiz 23: Neurologic Disorders and Therapeutic Management