Lewis: Chapter 56: Acute Intracranial Problems

Question 1

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 for this situation?

a. “This type of monitoring system is complex, and it is managed by skilled staff.”
b. “The monitoring system helps show whether blood flow to the brain is adequate.”
c. “The ventriculostomy monitoring system helps check for changes in cerebral
perfusion pressure.”
d. “This monitoring system has many benefits, including the ability to drain
cerebrospinal fluid.”

Answer 1

ANS: B
Short, simple, and accurate explanations should be given initially to patients and family members. Explaining that the system is complex, and it is managed by skilled staff or that it has multiple benefits does not address the family question about purpose for this patient. Terminology such as ventriculostomy and cerebral perfusion pressure is too complex for the initial explanation and may increase family members’ anxiety.

Question 2

Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mmHg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min
b. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min
c. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respirations 28 breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min

Answer 2

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.

Question 3

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?

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

Answer 3

ANS: C
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.

Question 4

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication’s effectiveness?

a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit

Answer 4

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. O2 saturation will not directly improve because of mannitol administration.

Question 5

A patient with a head injury opens his 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. How should the nurse record the patient’s Glasgow Coma Scale score?

a. 9.
b. 11.
c. 13.
d. 15.

Answer 5

ANS: B
The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

Question 6

An unconscious 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. What action is best for the nurse to take?

a. Call the family’s pastor or spiritual advisor to take them to the chapel.
b. Ask the family to stay in the waiting room until the assessment is completed.
c. Allow the family to stay with the patient and briefly explain all procedures to
them.
d. Refer the family members to the hospital counseling service to deal with their
anxiety.

Answer 6

ANS: C
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.

Question 7

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

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

Answer 7

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.

Question 8

A 20-yr-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?

a. Have the patient gently blow the nose.
b. Check the drainage for glucose content.
c. Teach the patient that rhinorrhea is expected after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity.

Answer 8

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.

Question 9

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

a. Coordinate the transfer of the patient to the operating room.
b. Provide discharge instructions about monitoring neurologic status.
c. Arrange to admit the patient to the neurologic unit for observation.
d. Transport the patient to radiology for magnetic resonance imaging (MRI).

Answer 9

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, and surgery are not usually indicated in a patient with a concussion.

Question 10

A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take?

a. Administer IV furosemide (Lasix).
b. Prepare the patient for craniotomy.
c. Initiate high-dose barbiturate therapy.
d. Type and crossmatch for blood transfusion.

Answer 10

ANS: B
The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure 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 patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient’s nose. Which admission order should the nurse question?

a. Keep the head of bed elevated.
b. Insert nasogastric tube to low suction.
c. Turn patient side to side every 2 hours.
d. Apply cold packs intermittently to face.

Answer 11

ANS: B
Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.

Question 12

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome?

a. Short-term memory
b. Muscle coordination
c. Glasgow Coma Scale
d. Pupil reaction to light

Answer 12

ANS: A
Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.

Question 13

When assessing a patient who has a right frontal lobe tumor, what finding should the nurse expect?

a. Expressive aphasia
b. Impaired judgment
c. Right-sided weakness
d. Difficulty swallowing

Answer 13

ANS: B
The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.

Question 14

Which statement by a patient who is being discharged from the emergency department (ED) after a concussion 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 right to bed.”
c. “I do not even remember being in an accident today.”
d. “I can take acetaminophen (Tylenol) for my headache.”

Answer 14

ANS: B
After a head injury, the patient should avoid driving and operating heavy machinery.
Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.

Question 15

After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has weakness, impaired physical mobility, and a decreased level of consciousness. Which nursing action will be included in the plan of care?

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

Answer 15

ANS: D
ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.

Question 16

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?

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

Answer 16

ANS: A
Patients with meningitis 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 patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

Question 17

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?

a. Emphasize the importance of hand washing before meals.
b. Encourage immunization for adolescents and college freshmen.
c. Tell adolescents and young adults to avoid crowds in the winter.
d. Support serving healthy nutritional options in the college cafeteria.

Answer 17

ANS: B
The Neisseria meningitidis vaccination is recommended for children ages 11 and 12 years,
unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria and good nutrition may increase resistance to infection, but those are not as effective as immunization. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.

Question 18

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

a. The patient received a regular diet tray.
b. Staff turned off the lights in the patient’s room.
c. The bedrails on both sides of the bed are elevated.
d. Staff have entered the patient’s room without a mask.

Answer 18

ANS: D
Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient 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 patient with meningitis.

Question 19

When assessing an adult who has bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention?

a. The patient exhibits nuchal rigidity.
b. The patient has a positive Kernig’s sign.
c. The patient’s temperature is 101° F (38.3° C).
d. The patient’s blood pressure is 88/42 mm Hg.

Answer 19

ANS: D
Shock is a serious complication of meningitis, and the patient’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

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

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

Answer 20

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

Calculate the cerebral perfusion pressure (CPP): (CPP = Mean arterial pressure [MAP] – ICP). MAP = DBP + 1/3 (Sytolic blood pressure [SBP] - Diastolic blood pressure [DBP]).
Therefore, the MAP is 70, and the CPP is 56 mm Hg, which are below the normal values of 60 to 100 mm Hg and are approaching the level of ischemia and neuronal death. Immediate changes in the patient’s therapy such as fluid infusion or vasopressor administration are needed to improve the CPP. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.

Question 21

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?

a. Document the increase in intracranial pressure.
b. Ensure that the patient’s neck is in neutral position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprivan) infusion.

Answer 21

ANS: B
Because suctioning will cause a transient increase in ICP, the nurse should initially check for other factors that might be contributing to the increase and observe the patient 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 patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in ICP.

Question 22

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?

a. A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis
b. A 35-yr-old patient with intracranial pressure (ICP) monitoring after a head injury
c. A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day
d. A 55-yr-old patient who is receiving hyperventilation therapy for increased ICP

Answer 22

ANS: A
An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The patient recovering from a craniotomy, the patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.

Question 23

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now reporting a headache. Which prescribed intervention should the nurse implement first?

a. Administer IV 5% hypertonic saline.
b. Draw blood for arterial blood gases (ABGs).
c. Send patient for computed tomography (CT).
d. Administer acetaminophen (Tylenol) 650 mg.

Answer 23

ANS: A
The patient’s low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse’s first action should be to correct the low sodium level. Acetaminophen (Tylenol) 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 provide 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 patients with head injuries, which patient should the nurse assess first?

a. A 20-yr-old patient whose cranial x-ray shows a linear skull fracture
b. A 30-yr-old patient who lost consciousness for 10 seconds after a fall
c. A 40-yr-old patient who has an initial Glasgow Coma Scale score of 13

d. A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light

Answer 24

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

Question 25

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

a. Report of severe headache
b. Large contusion behind left ear
c. Bilateral periorbital ecchymosis
d. Temperature of 101.4° F (38.6° C)

Answer 25

ANS: D
Patients 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 patient with a basilar skull fracture.

Question 26

After evacuation of an epidural hematoma, a patient’s intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?

a. Pulse of 102 beats/min
b. Temperature of 101.6° F
c. Intracranial pressure of 15 mm Hg
d. Mean arterial pressure of 90 mm Hg

Answer 26

ANS: B
Infection is a serious complication of 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 only require ongoing monitoring at this time.

Question 27

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

a. The staff nurse assesses neurologic status every hour.
b. The staff nurse elevates the head of the bed to 30 degrees.
c. The staff nurse suctions the patient routinely every 2 hours.
d. The staff nurse administers an analgesic before turning the patient.

Answer 27

ANS: C
Suctioning increases intracranial pressure and should only be done when the patient’s respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.

Question 28

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?

a. Check oxygen saturation.
b. Palpate the head for injuries.
c. Assess pupil reaction to light.
d. Verify Glasgow Coma Scale (GCS) score.

Answer 28

ANS: A
Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.

Question 29

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to the unlicensed assistive personnel (UAP) who regularly works in the intensive care unit?

a. Document intracranial pressure every hour.
b. Turn and reposition the patient every 2 hours.
c. Check capillary blood glucose level every 6 hours.
d. Monitor cerebrospinal fluid color and volume hourly.

Answer 29

ANS: C
Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require registered nurse (RN)–level education and scope of practice. Although repositioning patients is frequently delegated to UAP, repositioning a patient with a ventriculostomy is complex and should be supervised by the RN.

Question 30

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

a. Intracranial pressure of 15 mm Hg
b. Cerebrospinal fluid (CSF) drainage of 25 mL/hr
c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg
d. Cardiac monitor shows sinus tachycardia at 120 beats/min

Answer 30

ANS: C
The PbtO2 should be 20 to 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 to 30 mL/hr. 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 patient who has a head injury and fractured right arm. Which assessment information requires rapid action by the nurse?

a. The patient reports a headache.
b. The apical pulse is slightly irregular.
c. The patient is more difficult to arouse.
d. The blood pressure increases to 140/62 mm Hg.

Answer 31

ANS: C
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 and a slightly irregular apical pulse are not unusual in a patient after a head injury.

Question 32

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions?

a. Pale yellow urine output of 1200 mL over the past 2 hours.
b. Ventriculostomy drained 40 mL of fluid in the past 2 hours.
c. Intracranial pressure spikes to 16 mm Hg when patient is turned.
d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.

Answer 32

ANS: 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

While admitting a 42-yr-old patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?

a. The patient reports a severe dull headache.
b. The patient takes warfarin (Coumadin) daily.
c. The patient’s blood pressure is 162/94 mm Hg.
d. The patient is unable to remember the accident.

Answer 33

ANS: B
The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.

Question 34

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first?

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

Answer 34

ANS: D
Antibiotic therapy should be started quickly in bacterial meningitis, but cultures must be done before antibiotics are started. After 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.

Question 35

A patient with possible viral meningitis is admitted to the nursing unit after a lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question?

a. Restrict oral fluids to 1000 mL/day.
b. Elevate the head of the bed 20 degrees.
c. Administer ceftriaxone 1 g IV every 12 hours.
d. Give ibuprofen 400 mg every 6 hours as needed for headache.

Answer 35

ANS: A
The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis.

Question 36

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?

a. Teach about prophylactic antibiotics after exposure to encephalitis.
b. Encourage the use of effective insect repellent during mosquito season.
c. Remind patients that most cases of viral encephalitis can be cared for at home.
d. Arrange to screen school-age children for West Nile virus during the school year.

Answer 36

ANS: B
Mosquitoes and ticks usually spread epidemic encephalitis. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an intensive care unit during the initial stages. Antibiotic prophylaxis is not used to prevent encephalitis because most encephalitis is viral. West Nile virus is most common in adults over age 50 during the summer and early fall.

Question 37

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for related functional deficits?

a. “Do you have any difficulty in hearing?”
b. “Are you experiencing vision problems?”
c. “Are you having any trouble with your balance?”
d. “Have you developed any weakness on one side?”

Answer 37

ANS: B
Because the occipital lobe is responsible for visual reception, the patient with a tumor in this area is likely to have problems with vision. The other questions will be better for assessing function of the temporal lobe, cerebellum, and frontal lobe.

Question 38

During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe?

a. 1
b. 2
c. 3
d. 4

Answer 38

ANS: A

With decorticate posturing, the patient exhibits internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers. The other illustrations are of decerebrate, mixed decorticate and decerebrate posturing, and opisthotonic posturing.

Question 39

Which is the correct point on the accompanying figure where the nurse will assess for ecchymosis when admitting a patient with a basilar skull fracture?

a. A
b. B
c. C
d. D

Answer 39

ANS: D
Battle’s sign (postauricular ecchymosis) and periorbital ecchymoses are associated with basilar skull fracture.