chapter 59

Question 1

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?
a. “This type of monitoring system is complex and highly skilled staff are needed.”
b. “The monitoring system helps show whether blood flow to the brain is adequate.”
c. “The ventriculostomy monitoring system helps check for alterations in cerebral
perfusion pressure.”
d. “This monitoring system has multiple benefits including facilitation of
cerebro-spinal fluid drainage.”

Answer 1

B
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 2

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 to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30

Answer 2

A
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 3

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?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing

Answer 3

C

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 4

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?
a. Hematocrit
b. Blood pressure
c. Oxygen saturation
d. Intracranial pressure

Answer 4

D
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 5

A client 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 nurse
document?
a. 9
b. 11
c. 13
d. 15

Answer 5

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

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 best for
the nurse to take?
a. Ask the family to stay in the waiting room until the initial assessment is completed.
b. Allow the family to stay with the client and briefly explain all procedures to them.
c. Call the family’s pastor or spiritual advisor to support them while initial care is
given.
d. Refer the family members to the hospital counselling service to deal with their
anxiety.

Answer 6

B

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

A client 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?
a. Keep the head of the bed elevated to 30 degrees.
b. Position the client with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.

Answer 7

A
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 8

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?
a. Have the client blow the nose.
b. Check the nasal drainage for glucose.
c. Assure the client that rhinorrhea is normal after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity.

Answer 8

B
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 9

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?
a. Coordinate the transfer of the client to the operating room.
b. Provide discharge instructions about monitoring neurological status.
c. Transport the client to radiology for magnetic resonance imaging (MRI) of the
brain.
d. Arrange to admit the client to the neurological unit for observation for 24 hours.

Answer 9

B

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 10

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?
a. Administer IV furosemide.
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the client for immediate craniotomy.

Answer 10

D
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 11

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?
a. Insert nasogastric tube.
b. Turn client every 2 hours.
c. Keep the head of bed elevated.
d. Apply cold packs for facial bruising.

Answer 11

A
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 12

Which of the following assessment information should the nurse collect to determine
whether a client is developing post-concussion syndrome?
a. Muscle resistance
b. Short-term memory
c. Glasgow coma scale
d. Pupil reaction to light

Answer 12

B
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 13

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?
a. Judgement changes
b. Expressive aphasia
c. Right-sided weakness
d. Difficulty swallowing

Answer 13

A
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.

Question 14

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?
a. “I will return if I feel dizzy or nauseated.”
b. “I am going to drive home and go to bed.”
c. “I do not even remember being in an accident.”
d. “I can take acetaminophen for my headache.”

Answer 14

B
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 15

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 nursing
intervention?
a. Position the bed flat and log roll the client.
b. Cluster nursing activities to allow longer rest periods.
c. Turn and reposition the client side to side every 2 hours.
d. Perform range-of-motion (ROM) exercises every 4 hours.

Answer 15

D
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 16

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?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the client from injury.
c. Keep the room well lighted to improve client orientation.
d. Minimize contact with the client to decrease sensory input.

Answer 16

A
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 17

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?
a. Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
b. Emphasize the importance of handwashing to prevent spread of infection.
c. Immunize adolescents and postsecondary students against Neisseria meningitidis.
d. Encourage adolescents and young adults to avoid crowded areas in the winter.

Answer 17

C
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 18

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?
a. The bedrails at the head and foot of the bed are both elevated.
b. The client receives a regular diet from the dietary department.
c. The student nurse goes into the client’s room without a mask.
d. The lights in the client’s room are turned off and the blinds are shut.

Answer 18

C
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 19

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?
a. The client has a positive Kernig’s sign.
b. The client complains of having a stiff neck.
c. The client’s temperature is 38.3°C (100.9°F).
d. The client’s blood pressure is 86/42 mm Hg.

Answer 19

D
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 20

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?
a. Elevate the head of the client’s bed to 60 degrees.
b. Document the BP and ICP in the client’s record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the client’s vital signs and ICP.

Answer 20

C
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 21

The nurse is suctioning a client with a traumatic head injury and notes that the intracranial
pressure has increased from 14 to 16 mm Hg. Which of the following actions should the
nurse take first?
a. Document the increase in intracranial pressure.
b. Assure that the client’s neck is not in a flexed position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol infusion.

Answer 21

B

Since suctioning will cause a transient increase in intracranial pressure, the nurse should
initially check for other factors that might be contributing to the increase and observe the
client for a few minutes. Documentation is needed, but this is not the first action. There is
no need to notify the health care provider about this expected reaction to suctioning.
Propofol is used to control client anxiety or agitation; there is no indication that anxiety
has contributed to the increase in intracranial pressure.

Question 22

After receiving change of shift report, which of the following clients should the nurse
assess first?
a. A 44-year-old receiving IV antibiotics for meningococcal meningitis
b. A 23-year-old who had a skull fracture and craniotomy the previous day
c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head
injury a week ago
d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy

Answer 22

D
The client that should be seen first is the one that requires the closest monitoring—the
client with ICP and receiving hyperventilation therapy. The postcraniotomy client, client
with an ICP monitor, and the client on IV antibiotics should be assessed as well but the
priority would be the most critically ill clients.

Question 23

The nurse is caring for a client with possible cerebral edema who has a serum sodium level
of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache. Which of
the following prescribed interventions should the nurse implement first?
a. Draw blood for arterial blood gases (ABGs).
b. Administer 5% hypertonic saline intravenously.
c. Administer acetaminophen 650 mg orally.
d. Send client for computed tomography (CT) of the head.

Answer 23

B
The client’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. Acetaminophen will
have minimal effect on the headache because it is caused by cerebral edema and increased
intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful
information, but the low sodium level may lead to seizures unless it is addressed quickly.

Question 24

After the emergency department nurse has received a status report on the following clients
who have been admitted with head injuries, which client should the nurse assess first?
a. A client whose cranial radiograph shows a linear skull fracture
b. A client who has an initial Glasgow Coma Scale score of 13
c. A client who lost consciousness for a few seconds after a fall
d. A client whose right pupil is 10 mm and unresponsive to light

Answer 24

D
The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage, brain
herniation, and increased intracranial pressure. The other clients are not at immediate risk
for complications such as herniation.

Question 25

Which of the following assessment findings in a client who was admitted the previous day
with a basilar skull fracture is most important to report to the health care provider?
a. Bruising under both eyes
b. Complaint of severe headache
c. Large ecchymosis behind one ear
d. Temperature of 38.6°C (101.5°F)

Answer 25

D
Clients who have basilar skull fractures are at risk for meningitis, so the elevated
temperature should be reported to the health care provider. The other findings are typical
of a client with a basilar skull fracture.

Question 26

The nurse is monitoring a client’s intracranial pressure (ICP) with an intraventricular
catheter. Which of the following information obtained by the nurse is most important to
communicate to the health care provider?
a. Oral temperature 38.7°C (101.7°F)
b. Apical pulse 102 beats/minute
c. Intracranial pressure 15 mm Hg
d. Mean arterial pressure 90 mm Hg

Answer 26

A
Infection is a serious consideration with ICP monitoring, especially with intraventricular
catheters. The temperature indicates the need for antibiotics or removal of the monitor.
The ICP, arterial pressure, and apical pulse are all borderline high but require only
ongoing monitoring at this time.

Question 27

The charge nurse observes an inexperienced staff nurse who is caring for a client who has
had a craniotomy for a brain tumour. Which of the following actions by the inexperienced
nurse requires the charge nurse to intervene?
a. The staff nurse suctions the client every 2 hours.
b. The staff nurse assesses neurologic status every hour.
c. The staff nurse elevates the head of the bed to 30 degrees.
d. The staff nurse administers a mild analgesic before turning the client.

Answer 27

A
Suctioning increases intracranial pressure and is done only when the client’s respiratory
condition indicates it is needed. The other actions by the staff nurse are appropriate.

Question 28

A client is brought to the emergency department (ED) by ambulance after being found
unconscious on the bathroom floor by the partner. Which of the following actions should
the nurse take first?
a. Obtain oxygen saturation.
b. Check pupil reaction to light.
c. Palpate the head for hematoma.
d. Assess Glasgow Coma Scale (GCS).

Answer 28

A
Airway patency and breathing are the most vital functions and should be assessed first.
The neurological assessments should be accomplished next and the health and medication
history last.

Question 29

Which of the following assessment findings should the nurse report immediately to the
health care provider when caring for a client with increased intracranial pressure?
a. CPP 38 mm Hg
b. MAP 92 mm Hg
c. PaO2 110 mm Hg
d. BP 140/82

Answer 29

A
A cerebral perfusion pressure (CPP) of 38 mm Hg would be reported to the health care
provider. MAP, BP, and PaO2 are all within normal limits.

Question 30

Which of the following information about a client who is hospitalized after a traumatic
brain injury requires the most rapid action by the nurse?
a. Intracranial pressure of 15 mm Hg
b. Cerebro-spinal fluid (CSF) drainage of 15 mL/hour
c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg
d. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/minute

Answer 30

C
The PbtO2 should be 20–40 mm Hg. Lower levels indicate brain ischemia. An intracranial
pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of
20–30 mL/hour. The reason for the sinus tachycardia should be investigated, but the
elevated heart rate is not as concerning as the decrease in PbtO2.

Question 31

The nurse is caring for a client who has had a head injury. Which of the following
assessment information requires the most rapid action by the nurse?

a. The client is more difficult to arouse.
b. The client’s pulse is slightly irregular.
c. The client’s blood pressure increases from 120/54 to 136/62 mm Hg.
d. The client indicates a headache at pain level 5 of a 10-point scale.

Answer 31

A
The change in level of consciousness (LOC) is an indicator of increased intracranial
pressure (ICP) and suggests that action by the nurse is needed to prevent complications.
The change in BP should be monitored but is not an indicator of a need for immediate
nursing action. Headache is not unusual in a client after a head injury. A slightly irregular
apical pulse is not unusual.

Question 32

The nurse is caring for a client with a head injury. Which of the following findings should
be reported rapidly to the health care provider?
a. Urine output of 800 mL in the last hour
b. Intracranial pressure of 16 mm Hg when client is turned
c. Ventriculostomy drains 10 mL of cerebro-spinal fluid per hour
d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.

Answer 32

A
The high urine output indicates that diabetes insipidus may be developing and
interventions to prevent dehydration need to be rapidly implemented. The other data do
not indicate a need for any change in therapy.

Question 33

The nurse is providing discharge teaching with a client who has a concussion. Which of
the following time frames should the nurse tell the client to continue to monitor for
post-concussion syndrome?
a. Up to 2 weeks
b. Up to 4 weeks
c. Up to 2 months
d. Up to 6 months

Answer 33

C
Post-concussion syndrome is seen anywhere from 2 weeks to 2 months after the
concussion. Symptoms include persistent headache, lethargy, personality and behavioural
changes, shortened attention span, decreased short-term memory, and changes in
intellectual ability. This syndrome can significantly affect the patient’s abilities to perform
the activities of daily living.

Question 34

The nurse is caring for a client admitted with bacterial meningitis who has a temperature
of 38.9°C (102°F) and has prescriptions for all of the following collaborative interventions.
Which action should the nurse take first?

a. Administer ceftizoxime 1 g IV.
b. Use a cooling blanket to lower temperature.
c. Swab the nasopharyngeal mucosa for cultures.
d. Give acetaminophen 650 mg PO.

Answer 34

C
Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be
done before antibiotics are started. As soon as the cultures are done, the antibiotic should
be started. Hypothermia therapy and acetaminophen administration are appropriate but can
be started after the other actions are implemented.