Question 1

The charge nurse observes a new graduate nurse who is caring for a patient who has had a craniotomy for a brain tumour.Which action by the new graduate requires the charge nurse to intervene and provide additional teaching?

Accepted Answer

Deep breathing and coughing can cause an increase in intracranial pressure and should be avoided in patients who have had a craniotomy. The charge nurse should intervene and provide additional teaching to the new nurse. The other actions performed by the new nurse are appropriate for caring for a patient who has had a craniotomy.

Question 2

A patient is brought to the emergency department by ambulance after she was found unconscious on the bathroom floor by her husband.In admitting the patient,what is it most important for the nurse to assess first?

Accepted Answer

The patient was found unconscious, which puts her at risk for airway obstruction. Assessing airway patency is the highest priority to ensure the patient’s ability to breathe and receive oxygen. Without a patent airway, the patient will not be able to maintain adequate oxygenation, and other assessments will be irrelevant. Once the airway is secured, the nurse can move on to assess other aspects of the patient’s condition, such as obtaining a health history, checking neurological status, or assessing the status of bodily functions.

Question 3

When a patient's ICP is being monitored with an intraventricular catheter,what is a priority nursing intervention?

Accepted Answer

Maintaining strict aseptic technique is crucial to prevent infection, which is a significant risk with intraventricular catheters.

Question 4

Patient manifestations of a headache,CSF leakage,and cranial nerve deficit are signs of which one of the following indications for cranial surgery?

Accepted Answer

Patient manifestations of a headache, CSF leakage, and cranial nerve deficit are signs of a skull fracture, which may require cranial surgery. Brain tumours, hydrocephalus, and intracranial infections may also require surgical interventions, but their signs and symptoms differ from those in a skull fracture.

Question 5

A patient with a head injury opens his eyes when his name is called,curses when he is stimulated,and does not respond to a verbal command to move but attempts to remove a painful stimulus.How should the nurse record the patient's Glasgow Coma Scale score?

Accepted Answer

The patient's best eye response is spontaneous opening, which scores 4 points. The patient's best verbal response is inappropriate words, which scores 2 points. The patient's best motor response is withdrawal to painful stimuli, which scores 5 points. Therefore, the total Glasgow Coma Scale score is 11 (4+2+5).

Question 6

The physician prescribes intravenous (IV)mannitol (Osmitrol)for an unconscious patient.What would the nurse expect the therapeutic effect of this drug to result in?

Accepted Answer

Mannitol is an osmotic diuretic that reduces intracranial pressure by decreasing cerebral edema. It does not affect seizure activity, cerebral metabolism, or cerebral inflammation.

Question 7

When assessing a patient with a head injury,which assessment information is of most concern to the nurse?

Accepted Answer

Difficulty arousing may indicate a decline in neurological status and increased intracranial pressure, which are signs of a worsening head injury. The other assessments may also be important, but difficulty arousing is the most concerning in this situation.

Question 8

A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D₅W)at 50 mL/hour for 4 days.The nurse will anticipate the need for which of the following?

Accepted Answer

The patient has been on intravenous fluids for 4 days and will likely need enteral feeding for nutritional replacement as soon as possible to facilitate healing and recovery. Continuing the current IV fluid will not provide sufficient nutrition, decreasing the infusion rate could cause dehydration, and administering albumin is not indicated for this situation.

Question 9

A patient has a systemic blood pressure of 120/60 mm Hg and an intracranial pressure (ICP)of 24 mm Hg.What does the nurse determine that the cerebral perfusion pressure (CPP)of this patient indicates?

Accepted Answer

The cerebral perfusion pressure (CPP) is calculated by subtracting intracranial pressure (ICP) from systemic blood pressure. In this case, CPP is 96 mm Hg (120-24=96). A CPP of less than 70 mm Hg indicates impaired blood flow to the brain, which can lead to brain damage or ischemia. Therefore, a CPP of 96 mm Hg suggests that the patient may be at risk for impaired cerebral perfusion.

Question 10

An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral)related to cerebral tissue swelling.What is an appropriate nursing intervention for this problem?

Accepted Answer

Elevating the head of the bed 30 degrees can help to decrease cerebral tissue swelling by improving cerebral blood flow and oxygenation. This can help to improve tissue perfusion to the brain. Providing a position of comfort with the knees and hips flexed and clustering nursing interventions to provide uninterrupted periods of rest may be appropriate interventions for other nursing diagnoses or patient problems. Teaching the patient to cough and breathe deeply to prevent the necessity for suctioning is not directly related to improving tissue perfusion to the brain.

Question 11

A patient with a serum sodium level of 115 mmol/L has a decreasing level of consciousness (LOC)and complains of a headache.Which of the following orders should be the priority?

Accepted Answer

The patient's low serum sodium level (hyponatremia) is likely the cause of their decreasing LOC and headache. Hypertonic saline is the most important intervention as it will immediately raise the serum sodium, improving brain function and relieving symptoms. Administering Tylenol or drawing ABGs is not the priority at this time. While CT of the head may be indicated later, it is not as urgent as addressing the hyponatremia.

Question 12

ICP monitoring is instituted for a patient with a head injury.The patient's arterial blood pressure is 92/50 mm Hg,and her ICP is 18 mm Hg.Which nursing action is most appropriate?

Accepted Answer

An ICP of 18 mm Hg is considered elevated and outside of normal range. A MAP (mean arterial pressure) of at least 70 mm Hg is required to ensure adequate cerebral perfusion pressure (CPP), and a CPP of less than 60 mm Hg for a prolonged period of time may result in ischemia and neuronal death. Therefore, the nurse should notify the physician about the patient's ICP and blood pressure readings so that appropriate interventions can be implemented to maintain adequate CPP and prevent further neurological damage. Documenting and continuing to monitor the parameters and checking the patient's pupillary response are important nursing actions but do not address the elevated ICP and low blood pressure. Elevating the head of the patient's bed may be appropriate if ordered by the physician, but it would not be the most appropriate action in this scenario without further assessment and intervention.

Question 13

When assessing a patient with a head injury,what will the nurse recognize as an early indication of increased ICP?

Accepted Answer

Change in the LOC is an early indication of increased ICP. The patient may become confused, restless, or drowsy. It is important to monitor the patient closely for these changes and report them to the healthcare provider immediately. Vomiting, headache, and sluggish pupillary response to light are all later signs of increased ICP.

Question 14

A patient is admitted to the hospital with a head injury resulting from an automobile accident.On admission,the patient's vital signs are temperature 37°C,blood pressure 128/68 mm Hg,pulse 110 beats/min,and respiration 26 breaths/min.One hour after admission,which of the following vital signs does the nurse note indicates the presence of Cushing's triad?

Accepted Answer

Cushing's triad is characterized by three primary signs: widened pulse pressure (increased systolic and decreased diastolic pressures), bradycardia (slow heart rate), and irregular respirations. Choice A (Blood pressure 140/60 mm Hg, pulse 60 beats/min, respiration 14 breaths/min) best fits this description, indicating increased intracranial pressure.

Question 15

The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system integrative function for a patient who has post-traumatic brain swelling based on which of the following findings?

Accepted Answer

Apneustic breathing, also known as cluster breathing, is characterized by irregular, deep, gasping breaths with brief pauses between each breath. It indicates an ineffective breathing pattern and can occur in patients with central nervous system dysfunction, such as post-traumatic brain swelling. Crackles on inspiration may be indicative of pulmonary edema or respiratory infection, but do not necessarily suggest an ineffective breathing pattern related to loss of central nervous system integrative function. A Glasgow Coma Scale score less than 8 indicates a decrease in consciousness level but does not specifically point to the breathing pattern, and CPP less than 60 mm Hg is related to cerebral perfusion pressure, not breathing pattern.

Question 16

When the nurse applies a painful stimulus to an unconscious patient,the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists.How should the nurse interpret this finding?

Accepted Answer

The described response is characteristic of decerebrate posturing, which indicates a disruption of motor fibers in the midbrain and brainstem, rather than an interruption of voluntary motor tracts. This type of posturing is a more severe sign of brain injury compared to decorticate posturing.

Question 17

A woman is admitted unconscious to the emergency department after striking her head on a boulder while hiking.Her husband and three teenaged children will not leave her side and constantly ask about the treatment being given.What is the best approach to the patient's family?

Accepted Answer

Allowing the family to stay with the patient and explaining procedures thoroughly can help alleviate their anxiety and provide comfort to the patient. Family presence has also been shown to improve patient outcomes in critical situations. However, it may be necessary to limit the number of family members present and their participation in certain procedures to ensure patient safety and privacy. Pastoral or spiritual support and counselling can be provided in addition to allowing family presence. Asking the family to wait in the waiting room may increase their anxiety and negatively impact patient outcomes.

Question 18

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury.Which of the following should the nurse do to evaluate the effectiveness of the therapy?

Accepted Answer

The answer of Mechanical ventilation with a rate and volume...

Question 19

Which of the following assessment data of the oculomotor nerve make the nurse suspicious of a possible supratentorial herniation and compression of the brainstem?

Accepted Answer

Compression of the oculomotor nerve (cranial nerve III) can cause a pupil to become non-reactive to light, which is a sign of possible brainstem compression due to supratentorial herniation.

Question 20

The wife of a patient who is in a coma is optimistic about her husband's recovery because he opens his eyes and appears to be awake.What is the most appropriate response to the wife's comment?

Accepted Answer

The correct response acknowledges the presence of sleep-wake cycles as a potential sign of arousal system function while also clarifying that these cycles do not necessarily indicate higher brain function or conscious awareness. This provides a balanced perspective that neither dismisses the wife's observations nor gives unfounded hope for recovery.

Quiz 59: Nursing Management: Acute Intracranial Problems

The charge nurse observes a new graduate nurse who is caring for a patient who has had a craniotomy for a brain tumour.Which action by the new graduate requires the charge nurse to intervene and provide additional teaching?

A patient is brought to the emergency department by ambulance after she was found unconscious on the bathroom floor by her husband.In admitting the patient,what is it most important for the nurse to assess first?

When a patient's ICP is being monitored with an intraventricular catheter,what is a priority nursing intervention?

Patient manifestations of a headache,CSF leakage,and cranial nerve deficit are signs of which one of the following indications for cranial surgery?

A patient with a head injury opens his eyes when his name is called,curses when he is stimulated,and does not respond to a verbal command to move but attempts to remove a painful stimulus.How should the nurse record the patient's Glasgow Coma Scale score?

The physician prescribes intravenous (IV) mannitol (Osmitrol) for an unconscious patient.What would the nurse expect the therapeutic effect of this drug to result in?

When assessing a patient with a head injury,which assessment information is of most concern to the nurse?

A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D₅W) at 50 mL/hour for 4 days.The nurse will anticipate the need for which of the following?

A patient has a systemic blood pressure of 120/60 mm Hg and an intracranial pressure (ICP) of 24 mm Hg.What does the nurse determine that the cerebral perfusion pressure (CPP) of this patient indicates?

An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling.What is an appropriate nursing intervention for this problem?

A patient with a serum sodium level of 115 mmol/L has a decreasing level of consciousness (LOC) and complains of a headache.Which of the following orders should be the priority?

ICP monitoring is instituted for a patient with a head injury.The patient's arterial blood pressure is 92/50 mm Hg,and her ICP is 18 mm Hg.Which nursing action is most appropriate?

When assessing a patient with a head injury,what will the nurse recognize as an early indication of increased ICP?

The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system integrative function for a patient who has post-traumatic brain swelling based on which of the following findings?

When the nurse applies a painful stimulus to an unconscious patient,the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists.How should the nurse interpret this finding?

A woman is admitted unconscious to the emergency department after striking her head on a boulder while hiking.Her husband and three teenaged children will not leave her side and constantly ask about the treatment being given.What is the best approach to the patient's family?

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury.Which of the following should the nurse do to evaluate the effectiveness of the therapy?

Which of the following assessment data of the oculomotor nerve make the nurse suspicious of a possible supratentorial herniation and compression of the brainstem?

The wife of a patient who is in a coma is optimistic about her husband's recovery because he opens his eyes and appears to be awake.What is the most appropriate response to the wife's comment?

Quiz 59: Nursing Management: Acute Intracranial Problems

The charge nurse observes a new graduate nurse who is caring for a patient who has had a craniotomy for a brain tumour.Which action by the new graduate requires the charge nurse to intervene and provide additional teaching?

A patient is brought to the emergency department by ambulance after she was found unconscious on the bathroom floor by her husband.In admitting the patient,what is it most important for the nurse to assess first?

When a patient's ICP is being monitored with an intraventricular catheter,what is a priority nursing intervention?

Patient manifestations of a headache,CSF leakage,and cranial nerve deficit are signs of which one of the following indications for cranial surgery?

A patient with a head injury opens his eyes when his name is called,curses when he is stimulated,and does not respond to a verbal command to move but attempts to remove a painful stimulus.How should the nurse record the patient's Glasgow Coma Scale score?

The physician prescribes intravenous (IV) mannitol (Osmitrol) for an unconscious patient.What would the nurse expect the therapeutic effect of this drug to result in?

When assessing a patient with a head injury,which assessment information is of most concern to the nurse?

A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D5W) at 50 mL/hour for 4 days.The nurse will anticipate the need for which of the following?

A patient has a systemic blood pressure of 120/60 mm Hg and an intracranial pressure (ICP) of 24 mm Hg.What does the nurse determine that the cerebral perfusion pressure (CPP) of this patient indicates?

An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling.What is an appropriate nursing intervention for this problem?

A patient with a serum sodium level of 115 mmol/L has a decreasing level of consciousness (LOC) and complains of a headache.Which of the following orders should be the priority?

ICP monitoring is instituted for a patient with a head injury.The patient's arterial blood pressure is 92/50 mm Hg,and her ICP is 18 mm Hg.Which nursing action is most appropriate?

When assessing a patient with a head injury,what will the nurse recognize as an early indication of increased ICP?

The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system integrative function for a patient who has post-traumatic brain swelling based on which of the following findings?

When the nurse applies a painful stimulus to an unconscious patient,the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists.How should the nurse interpret this finding?

A woman is admitted unconscious to the emergency department after striking her head on a boulder while hiking.Her husband and three teenaged children will not leave her side and constantly ask about the treatment being given.What is the best approach to the patient's family?

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury.Which of the following should the nurse do to evaluate the effectiveness of the therapy?

Which of the following assessment data of the oculomotor nerve make the nurse suspicious of a possible supratentorial herniation and compression of the brainstem?

The wife of a patient who is in a coma is optimistic about her husband's recovery because he opens his eyes and appears to be awake.What is the most appropriate response to the wife's comment?

A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D₅W) at 50 mL/hour for 4 days.The nurse will anticipate the need for which of the following?