ch 13 Flashcards
The nurse is caring for a patient with increased intracranial pressure (ICP). Which action would be considered to be a collaborative intervention?
a. Decreasing perfusion
b. Administering an osmotic diuretic
c. Assessing orientation
d. Assessing for edema
ANS: B
Collaborative interventions are aimed at preventing secondary injury by improving cerebral perfusion. This would include decreasing edema by administering an osmotic diuretic which in turn would lead to decreased ICP and improved oxygenation. Assessing orientation and for the presence of edema would not be considered as a collaborative intervention.
Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation?
a. Change in level of consciousness
b. Inability to focus visually
c. Loss of primitive reflexes
d. Unequal pupil size
ANS: A
A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refer to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.
When caring for a patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes along with what other findings?
a. Hypertension and bradycardia
b. Hypertension and tachycardia
c. Hypotension and bradycardia
d. Hypotension and tachycardia
ANS: A
Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushing triad). It is bradycardia, not tachycardia, which is the component of this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad.
Which components of the Glasgow Coma Scale (GCS) should the nurse use to assess a patient after a head injury?
a. Blood pressure
b. Cranial nerve function
c. Head circumference
d. Verbal responsiveness
ANS: D
Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale. Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale.
The nurse is teaching a patient about head injuries. Which information should the nurse include as a primary prevention strategy to reduce the occurrence of head injuries?
a. Blood pressure control
b. Smoking cessation
c. Maintaining a healthy weight
d. Violence prevention
ANS: D
Injury prevention measures such as wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries. Smoking cessation is one primary prevention strategy which can decrease the risk of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.
The nurse preparing to care for a patient after a suspected stroke would question which order?
a. Antihypertensive
b. Antipyretic
c. Osmotic diuretic
d. Sedative
ANS: A
Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia. Osmotic diuretics such as mannitol can decrease interstitial volume and decrease intracranial pressure. Short-acting sedatives can decrease intracranial pressure by reducing metabolic demand. Long-acting sedatives would be avoided to provide times for periodic neurologic assessments.
After shunt procedure, the nurse would monitor the patient’s neurologic status by using which test?
a. Electroencephalogram
b. Glasgow Coma Scale
c. National Institutes of Health Stroke Scale
d. Monro-Kellie doctrine
ANS: B
The GCS gives a standardized numeric score of the neurologic patient assessment. An electroencephalogram is used in diagnosing and localizing the area of seizure origin. This scale is an example of one type of specific tool for nurses to use when assessing a patient following stroke. The Monroe-Kellie doctrine is not an assessment or monitoring strategy; it describes the interrelationship of volume and compliance of the three cranial components, brain tissue, cerebral spinal fluid, and blood.
