Chapter 57: Nursing Management: Acute Intracranial Problems Flashcards
Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best?
“This type of monitoring system is complex and it is managed by skilled staff.”
“The monitoring system helps show whether blood flow to the brain is adequate.”
“The ventriculostomy monitoring system helps check for alterations in cerebral perfusion
pressure.”
“This monitoring system has multiple benefits including facilitation of cerebrospinal fluid
drainage.”
ANS: B
Short and simple explanations should be given initially to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members’ anxiety.
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
Blood pressure 154/68, pulse 56, respirations 12
Blood pressure 134/72, pulse 90, respirations 32
Blood pressure 148/78, pulse 112, respirations 28
Blood pressure 110/70, pulse 120, respirations 30
ANS:A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad. These findings 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.
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as:
flexion withdrawal.
localization of pain.
decorticate posturing.
decerebrate posturing.
ANS: B
Internal rotation, adduction, and flexion of the arms in an unconscious patient 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.
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication’s effectiveness?
Blood pressure
Oxygen saturation
Intracranial pressure
Hemoglobin and hematocrit
ANS: C
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.
A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient’s Glasgow Coma Scale score as:
9.
11.
13.
15.
ANS: B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patient’s spouse and teenage children stay at the patient’s side and ask many questions about the treatment being given. What action is best for the nurse to take?
Ask the family to stay in the waiting room until the initial assessment is completed.
Allow the family to stay with the patient and briefly explain all procedures to them.
Refer the family members to the hospital counseling service to deal with their anxiety.
Call the family’s pastor or spiritual advisor to take them to the chapel while care is given.
ANS: B
The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling 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.
. A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
Encourage coughing and deep breathing.
Position the patient with knees and hips flexed.
Keep the head of the bed elevated to 30 degrees.
Cluster nursing interventions to provide rest periods.
ANS: C
The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme 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.
A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?
Have the patient gently blow the nose.
Check the drainage for glucose content.
Teach the patient that rhinorrhea is expected after a head injury.
Obtain a specimen of the fluid to send for culture and sensitivity.
ANS:B
Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal 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.
Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?
Coordinate the transfer of the patient to the operating room.
Provide discharge instructions about monitoring neurologic status.
Transport the patient to radiology for magnetic resonance imaging (MRI).
Arrange to admit the patient to the neurologic unit for 24 hours of observation.
ANS: B
A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not usually indicated in a patient with a concussion.
An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg, and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.
ANS: 74
Calculate the CPP: (CPP = mean arterial pressure [MAP] – ICP). MAP = DBP + 1/3 (systolic blood pressure [SBP] – diastolic blood pressure [DBP]). The MAP is 94. The CPP is 74.
