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. “The monitoring system helps show whether blood flow to the brain is adequate.”

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. Blood pressure 156/60, pulse 55, respirations 12

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. Decorticate posturing

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. Intracranial pressure

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. 11

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. Allow the family to stay with the client and briefly explain all procedures to them.

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. Keep the head of the bed elevated to 30 degrees.

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. Check the nasal drainage for glucose.

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. Provide discharge instructions about monitoring neurological status.

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. Prepare the client for immediate craniotomy.

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. Insert nasogastric tube.

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. Short-term memory

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. Judgement changes

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. “I am going to drive home and go to bed.”

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. Perform range-of-motion (ROM) exercises every 4 hours.

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. Encourage family members to remain at the bedside.

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. Immunize adolescents and postsecondary students against Neisseria meningitidis.

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. The student nurse goes into the client’s room without a mask.

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. The client’s blood pressure is 86/42 mm Hg.

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. Report the BP and ICP to the health care provider.

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. Assure that the client’s neck is not in a flexed position.

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. A 61-year-old who has increased ICP and is receiving hyperventilation therapy

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. Administer 5% hypertonic saline intravenously.

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. A client whose right pupil is 10 mm and unresponsive to light

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. Temperature of 38.6°C (101.5°F)

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. Oral temperature 38.7°C (101.7°F)

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. The staff nurse suctions the client every 2 hours.

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. Obtain oxygen saturation.

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. CPP 38 mm Hg

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. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg

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 client is more difficult to arouse.

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. Urine output of 800 mL in the last hour

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. Up to 2 months

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. Swab the nasopharyngeal mucosa for cultures.