Acute Intracranial

Question 1

Bacterial Meningitis
manifestations
a) head
b) skin
c) other
d) what are positive for?

Answer 1

a) Headache,Fever, inc ICP,LOC
b) petechiae,red macular rash
c) nuchal rigidity(neck stiffness)
photophobia
SIADH(too much ADH=hyponatremia)
d) Kerning sign(kenn)
Brudzinski sihn(neck)

Question 2

Meningitis DX
a) Analyze CSF bacterial or viral?
b) Lumber puncture pre-ope
c) lumber post-ope

Answer 2

a) bacterial=cludy, viral=clear
b) Consent
lateral recumbent, “cannonball” position
Make sure patient has not received heparin lovenox, w/in 24hrs.
c) Send specimen to lab
Supine 4-6 hours
Monitor puncture site
Increase fluid intake

Question 3

Meningitis
Collaborative Care
a) what isolation? then what?
b) Minimize exposure to what?
c) Monitor for?

Answer 3

a) DROPLET ISOLATION
Private room
Report to Public Health department
b) exposure to bright light
c) increased ICP
HOB 30*

Question 4

A nurse is assessing for the presence of Brudzinski’s sign in a patient who has suspected meningitis. Which of the following are appropriate actions by the nurse when performing this technique?SATA
A. Place patient in supine position
B. Flex patient’s hip and knee
C. Place hands behind the patient’s neck
D. Bend patient’s head toward chest
E. Straighten the patient’s flexed leg at the knee

Answer 4

A,C,D

Question 5

What does a positive Kernig sign, Brudzinski sign, photophobia, and nuchal rigidity mean?
Infection
Increased intracranial pressure
Meningeal irritation
Cranial nerve dysfunction

Answer 5

Meningeal irritation

Question 6

a) Thrombolytics, Inclusion
b) Thrombolytics, Exclusion

Answer 6

Ishemic cause PE, DVT
b) ischemic stroke
neuro defict present
non-contrast CT
(negative for hemorrhage)
Initiated within 3-4.5hr
c) >3-4.5 hr passed since onset
CT POSITIVE for hemorrhage
INR/PT/aPTT prolonged
major surgery within 14 days
previous stroke/head injury/GI bleed w/in 3M
recent active internal bleeding w/in 22days

Question 7

Hemorrhagic Stroke
a) characteristics?
b) causes?

Answer 7

a) more serious
all sudden,get worse very quick
b) HTN
ruptures cerebral anerusym
cocaine use
trauma,a fib

Question 8

Aneurysm and AVM
assessment
a) s/s?
b) BP must less than?

Answer 8

a) worst headache of my life
dec LOC
nuchal rigidity
photophobia
positive kerning or brudzinskin sign
b) 160

Question 9

Answer 9

Question 10

Brain tumer
S/S

Answer 10

Headache common worse at night
Seizure with metastases
N/V
Memory altered, mood/personality changes
Hydrocephalus
Increased ICP, cerebral edema

Question 11

Brain tumer
a) surgery post-ope
b) VP shunt

Answer 11

a) monitor for ICP
b) make sure to monitor for infection
-inc ICP, dec LOC. restlessness, headache, blurred vision.vomiting

Question 12

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. Which nursing intervention protects the client without increasing the intracranial pressure?
Place client in jacket restraint
Wrap client hands in soft “mitten” restraints
Tuck client arms and hands under the drawsheet
Apply a wrist restraint to each arm

Answer 12

Wrap client hands in soft “mitten” restraints

Question 13

The earliest signs of increased ICP the nurse should assess for include?
Cushing triad
Unexpected vomiting
Decreasing level of consciousness
Dilated pupil with sluggish response to light

Answer 13

Decreasing level of consciousness

Question 14

Exam
Change in respiratory status
a) cycle of hyperventilation and apnea(periods of shallow breathing alternate with periods of deeper, rapid breathing)
b) Sustained, regular, rapid deep breathing(even during states of sleep, low PaCO2)
c) prolonged inspiration
d) clusters of breath followed by irregular pauses(apneic episodes)
e) completely irregular with irregular pauses and increasing periods of apnea

Answer 14

a) Cheyne-stokes
b) Central neurogenic hyperventilation
c) Apneustic
d) cluster
e) ataxic

Question 15

Exam
Glasgow Coma Scale
a) Possible score from?
b) critically ill patient is less than?

Answer 15

a) 3-15
b) 9

Question 16

A patient with an intracranial problem does not open his eyes, has no verbal response except moaning and muttering stimulated, and flexes/withdraws his arm in response to painful stimuli. The nurse records the patient’s GCS score as
6
7
9
11

Answer 16

7

Question 17

Monro-Kellie hypothesis
a) what is 3 elements?
b) loss of autoregulation occurs with?

Answer 17

a) 80% is the brain tissue
10% is the cerebrospinal fluid
10% is the intravascular blood
b) injury to the brain which cause hypotension and hypoxia
→ cerebral ischemia and impaired cerebral autoregulation

Question 18

Chemical autoregulation
a) Vasoconstriction occurs when?
b) Cause ICP inc or dec?
c) we don’t want dec too much PaCO2 why?

Answer 18

a) body becomes alkalotic(PaCO2 <35)
b) dec
c) leads too much vasoconstriction and brain tissue death

Question 19

hemical autoregulation
a) Vasodilation occurs when?
b) Cause ICP inc or dec?

Answer 19

a) becomes acidotic or hypoxic
b) Inc

Question 20

An unconscious patient with increased ICP in on ventilation support. The nurse notifies the health care provider when arterial blood gas measurements reveal a
a. pH 7.43
b. SaO2 of 92%
c. PaO2 of 50
d. PaCO2 of 30

Answer 20

c

Question 21

Cerebral Perfusion Pressure
a) How CCP calculated
b) Normal CPP is?
c) High ICP means?
d) CCP 50?
e) CPP less than 30?

Answer 21

a) MAP-ICP=CPP
b) 60-100 mmHg
the higher number is better blood flow
c) compressed arterioles in the brain= Low oxygen, low glucose= Ischemia
d) Ischemia
e) Incompatible with life!!!!

Question 22

BP 150/80 ICP 25
What is the CCP?

Answer 22

Question 23

Early S/S of Increased ICP

Answer 23

Changes in Level of Consciousness
Vomiting-usually not preceded by nausea
Vital signs:no change until late
dec motor function
decorticate and decerebrate posture

Question 24

s/s inc ICP posture
a) DeCORticate
b) DEcErEbratE

Answer 24

a) flextion
b) extend/more serious

Question 25

Late Sign
Cushing Triad

Answer 25

Cushing triad involves
Inc SBP
Widened pulse pressure
Bradycardia with full bounding pulse
Irregular respiratory pattern

Question 26

The nurse recognizes the presence of Cushing triad in the patient with
Increased pulse, irregular respiration, increased BP
Decreased pulse, irregular respiration, increased pulse pressure
Increased pulse, decreased respiration, increased pulse pressure
Decreased pulse, increased respiration, decreased SBP

Answer 26

Decreased pulse, irregular respiration, increased pulse pressure

Question 27

to Decrease ICP
a) position?
b) how to prebent Hypoxia
Maintain PaO2 and PaCO2 how much?
c) drug?

Answer 27

a) HOB 30*
Maintain head/neck in neutral alignment
b) Maintain PaO2 > 100 & sat > 95%
Maintain PaCO2 35-45
c) Mannitol

Question 28

An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion r/t cerebral tissue swelling. What nursing intervention will be included in the plan of care?
Keep HOB elevated to 30 degrees
Position patient with knees and hips flexed
Suction patient frequently to improve oxygenation
Cluster nursing interventions to provide uninterrupted rest periods

Answer 28

Keep HOB elevated to 30 degrees

Question 29

SIADH
a) s/s
b) osmolality
c) serum osmolality

Answer 29

a) very small, very concentrated urine
JVD,crackles, tachycardia, HTN
b) greater than 1.030
c) less than 285
hyponatremia

Question 30

Diabetes insipidus
a) s/s
b) osmolality
c) serum osmolality

Answer 30

a) super pee out,super thirsty
b) less than 1.005
c) grater than 295