Flashcards in Chaps 59 & 63:Neurological Trauma: Head and Spinal Cord Injuries Deck (62)
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?
a. High blood flow to the brain
b. Normal ICP
c. Impaired blood flow to the brain
d. Adequate autoregulation of cerebral blood flow
The patient’s CPP is 56 mm Hg, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death.
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?
a. Document and continue to monitor the parameters.
b. Elevate the head of the patient’s bed.
c. Notify the physician about the assessments.
d. Check the patient’s pupillary response to light.
The patient’s CPP is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial blood pressure, so the most appropriate action is to contact the physician.
Patient manifestations of a headache, CSF leakage, and cranial nerve deficit are signs of which one of the following indications for cranial surgery?
a. Brain tumour
b. Skull fracture
d. Intracranial infection
Patient manifestations of a headache, CSF leakage, and cranial nerve deficit indicate a skull fracture, which requires cranial surgery.
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?
a. Administer acetaminophen (Tylenol) 650 mg orally.
b. Administer 5% hypertonic saline intravenously.
c. Draw blood for arterial blood gases (ABGs).
d. Send the patient to the radiology department for computed tomography of the head.
The patient’s low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse’s first action should be to correct the low sodium level.
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. “Your husband’s behaviour is only a reflex and does not really show improvement in his condition.”
b. “Sleep–wake cycles are encouraging signs of recovery, and you should be optimistic about your husband’s condition.”
c. “You are right to be optimistic. When patients begin to recover from a coma, the first behaviours seen are those of wakefulness.”
d. “Your husband may show sleep–wake patterns if the part of the brain responsible for arousal is not injured, but these patterns do not reflect activity of the higher brain centres.”
Arousal is controlled by the reticular activating system in the brainstem and will allow the patient to maintain wakefulness even though the damage to the cerebral cortex is severe.
When assessing a patient with a head injury, what will the nurse recognize as an early indication of increased ICP?
c. Change in the LOC
d. Sluggish pupillary response to light
LOC is the most sensitive indicator of the patient’s neurological status and possible changes in ICP.
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?
a. Blood pressure 140/60 mm Hg, pulse 60 beats/min, respiration 14 breaths/min
b. Blood pressure 130/72 mm Hg, pulse 90 beats/min, respiration 24 breaths/min
c. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respiration 28 breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respiration 30 breaths/min
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce the ICP.
Which of the following assessment data of the oculomotor nerve make the nurse suspicious of a possible supratentorial herniation and compression of the brainstem?
a. Absent corneal reflexes
b. Development of nystagmus
c. Right pupil does not react to light
d. Left pupil is 10 mm in size
A dilated pupil on the ipsilateral side in a patient with an acute brain injury indicates herniation.
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. Decorticate posturing indicating an interruption of voluntary motor tracts
b. Decerebrate posturing indicating an interruption of voluntary motor tracts
c. Decorticate posturing indicating a disruption of motor fibres in the midbrain and brainstem
d. Decerebrate posturing indicating a disruption of motor fibres in the midbrain and brainstem
With decerebrate posturing, the arms are stiffly extended, adducted, and hyperpronated
When a patient’s ICP is being monitored with an intraventricular catheter, what is a priority nursing intervention?
a. Maintaining strict aseptic technique to prevent infection
b. Maintaining the patient’s head in a fixed position
c. Continuous monitoring of the ICP waveform
d. Removing CSF to keep pressure at normal levels
Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters; therefore, a priority intervention would be strict aseptic technique at all times.
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. The new nurse has the patient breathe deeply and cough.
b. The new nurse assesses neurological status every hour.
c. The new nurse elevates the head of the bed to 30 degrees.
d. The new nurse administers an analgesic before turning the patient.
Coughing can increase ICP and is generally discouraged in patients at risk for increased ICP
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?
a. Health history
b. Airway patency
c. Neurological status
d. Status of bodily functions
Airway patency and breathing are the most vital functions and should be assessed first.
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?
a. Monitor oxygen saturation.
b. Check ABGs.
c. Monitor ICP.
d. Assess the patient’s breath sounds.
The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective.
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?
a. Decreased seizure activity
b. Decreased cerebral edema
c. Decreased cerebral metabolism
d. Decreased cerebral inflammation
Mannitol is an osmotic diuretic and will reduce cerebral edema and ICP.
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. Continue the D5W to provide the needed glucose for brain function.
b. Decrease the rate of IV infusion to avoid increasing cerebral edema.
c. Insert an enteral feeding tube to provide nutritional replacement.
d. Administer IV 5% albumin to increase serum protein levels.
The patient is in a hypermetabolic and hypercatabolic state, and enteral feedings will provide nutrients for brain function and for healing and immune function. D5W does not provide adequate nutrition to meet patient needs and can lead to lower serum osmolarity and cerebral edema.
When assessing a patient with a head injury, which assessment information is of most concern to the nurse?
a. The blood pressure increases from 120/54 to 136/62 mm Hg.
b. The patient is more difficult to arouse.
c. The patient complains of a headache at pain level 5 of a 10-point scale.
d. The patient’s apical pulse is slightly irregular.
The change in the LOC is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications
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 patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
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?
a. Apneustic breathing
b. Crackles on inspiration
c. Glasgow Coma Scale score less than 8
d. CPP less than 60 mm Hg
Apneustic breathing is caused by loss of central nervous system integration in the pons and is not effective in maximizing gas exchange
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?
a. Call the family’s pastor or spiritual advisor to support them while initial care is given.
b. Refer the family members to the hospital counselling service to deal with their anxiety.
c. Allow the family to stay with the patient, and explain all procedures thoroughly to them.
d. Ask the family to wait in the waiting room until the initial assessment can be completed and care can be started.
The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures.
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. Elevate the head of the bed 30 degrees.
b. Provide a position of comfort with the knees and hips flexed.
c. Cluster nursing interventions to provide uninterrupted periods of rest.
d. Teach the patient to cough and breathe deeply to prevent the necessity for suctioning.
The patient with increased ICP should be maintained in the head-up position to help reduce ICP.
The nurse notes that a patient with a head injury has a clear nasal drainage. What is the most appropriate nursing action for this finding?
a. Obtain a specimen of the fluid for culture and sensitivity.
b. Check the nasal drainage for glucose with a Dextrostix or Tes-Tape.
c. Take the patient’s temperature to determine whether a fever is present.
d. Instruct the patient to blow his nose and then check the nares for inflammation.
If the drainage is CSF leakage from a dural tear, glucose will be present
A patient was brought to the emergency department when he became faint and disoriented after being hit in the head with a baseball bat during a company picnic. On admission, he has a headache and cannot remember being hit, but he has no other signs of neurological deficit. What would the nurse expect treatment for the patient to include?
a. Diagnostic testing with magnetic resonance imaging
b. Hospitalization for observation for 24 hours
c. Discharge with observation and monitoring instructions
d. Administration of a narcotic for the headache, followed by observation for several hours
A patient with a minor head trauma is usually discharged with instructions about neurological monitoring and the need to return if neurological status deteriorates.
A victim of an automobile accident was found unconscious at the scene of the accident but regained consciousness during transport to the hospital. Shortly after admission, her Glasgow Coma Scale score is 8, and an acute epidural hematoma is suspected. The nurse plans care for the patient based on the expectation that which of the following treatments will be included?
a. Immediate craniotomy
b. Administration of IV furosemide (Lasix)
c. Administration of IV corticosteroids
d. Endotracheal intubation with mechanical ventilation
As the Glasgow Coma Scale indicates a severe head injury, the principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation; therefore, an immediate craniotomy is expected
The nurse notes clear drainage from the nose of a patient with a frontal skull fracture and recognizes that which of the following interventions is absolutely contraindicated for this patient?
a. Lying flat
b. Eating solid food
c. Inserting a nasogastric tube
d. Cold packs for facial bruising
Rhinorrhea may indicate a dural tear with CSF leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis.
In planning long-term care for the patient following brain trauma, what is the primary reason the nurse includes teaching and support for the family?
a. Patients will always have some residual deficits of the brain damage.
b. Most patients experience seizure disorders in the weeks or even years following head injury.
c. Families become dysfunctional and unable to cope with the role reversals required during convalescence.
d. Patients with head injuries with unconsciousness often have changes in personality with loss of concentration and memory processing.
Changes in personality, concentration, and memory are common after severe head injury and require anticipatory guidance for the patient and family
During the assessment of a patient who has a tumour of the left frontal lobe, what would the nurse expect to find?
a. Speech disturbances
b. Ataxic gait and vertigo
c. Personality and judgement changes
d. Papilledema and vision disturbances
The frontal lobes control intellectual activities such as judgement.
A patient with increasing headaches who is having diagnostic testing for a brain tumour asks the nurse what type of treatment will be used if a tumour is discovered. Which response is most appropriate?
a. “If the tumour is benign, treatment may not be necessary.”
b. “Therapy to remove or reduce the tumour size will be recommended.”
c. “Surgery will initially be used to reduce or remove the tumour.”
d. “Chemotherapy is used to shrink the tumour, followed by craniotomy.”
Treatment is designed to reduce tumour size or remove the tumour
Which one of the following types of cranial surgery is done to remove a bone flap?
a. Burr hole
A craniectomy is an excision into the cranium to cut away a bone flap.
Which one of the following can be caused by bacteria, fungi, a parasite, or a virus?
b. Brain abscess
d. Brain hemorrhage
Encephalitis can be caused by bacteria, fungi, a parasite, or a virus