MD2 Flashcards
When admitting an acutely confused patient with a head injury, which action should the nurse take?
a. Ask family members about the patient’s health history.
b. Ask leading questions to assist in obtaining health data.
c. Wait until the patient is better oriented to ask questions.
d. Obtain only the physiologic neurologic assessment data.
ANS: A
When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient’s health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information.
DIF: Cognitive Level: Apply (application) REF: 1301 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for
a. sensation on the left side of the body.
b. reasoning and problem-solving ability.
c. ability to understand written and oral language.
d. voluntary movements on the right side of the body.
ANS: C
The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.
DIF: Cognitive Level: Apply (application) REF: 1298 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?
A. Spasticity
B. Flaccidity
C.Impaired sensation
D. Hyperactive reflexes
ANS: B
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.
DIF: Cognitive Level: Understand (comprehension) REF: 1296 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Propranolol (Inderal), a β-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse monitors the patient for A dry mouth. B bradycardia. C. Constipation D. urinary retention.
ANS: B
Inhibition of the fight-or-flight response leads to a decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.
To assess the functions of the trigeminal and facial nerves (CNs V and VII), the nurse should
a. check for unilateral eyelid droop.
b. shine a light into the patient’s pupil.
c. touch a cotton wisp strand to the cornea.
d. have the patient read a magazine or book.
ANS: C
The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to evaluate function of the oculomotor nerve.
Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?
A. Assist to stand and ambulate.
B. Withhold oral fluids and food.
C. Insert an oropharyngeal airway.
D. Apply artificial tears every hour.
ANS: B
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. Balance and coordination are cerebellar functions.
An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which order should the nurse question?
a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c. Send for computed tomography (CT) scan.
d. Perform neurologic checks every 15 minutes.
ANS: B
After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, and herniation of the brain could result if lumbar puncture is performed. The other orders are appropriate.
A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to
a. enforce NPO status for 4 hours.
b. transfer the patient to radiology.
c. administer a sedative medication.
d. help the patient to a lateral position
ANS: D
For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.
During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse’s directions to move his hands and feet. The nurse will suspect A. cerebellar injury. B. a brainstem lesion. C. Frontal loba damage D. a temporal lobe lesion.
ANS: C Expressive speech (ability to express the self in language) is controlled by Broca’s area in the frontal lobe. The temporal lobe contains Wernicke’s area, which is responsible for receptive speech (ability to understand language input). The cerebellum and brainstem do not affect higher cognitive functions such as speech.
A patient has a tumor in the cerebellum. The nurse will plan interventions to A. prevent falls. B. stabilize mood. C. Avoid aspiration D. improve memory.
ANS: A
Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.
Which problem can the nurse expect for a patient who has a positive Romberg test result?
A. Pain
B. Falls
C. Aphasia
D. Confusion
ANS: B
A positive Romberg test result indicates that the patient has difficulty maintaining balance when standing with the eyes closed. The Romberg does not test for orientation, thermoregulation, or discomfort.
The nurse will anticipate teaching a patient with a possible seizure disorder about which test?
A. Cerebral angiography
B. Evoked potential studies
C. Electromyography (EMG)
D. Electroencephalography (EEG)
ANS: D
Seizure disorders are usually assessed using EEG testing. Evoked potential is used to diagnose problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.
Which nursing action will be included in the plan of care for a patient who has had cerebral angiography?
a. Monitor for headache and photophobia.
b. Keep patient NPO until gag reflex returns.
c. Check pulse and blood pressure frequently.
d. Assess orientation to person, place, and time.
ANS: C
Because a catheter is inserted into an artery (e.g., the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure that can affect pulse and blood pressure. The other nursing assessments are not needed after angiography
Which equipment will the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction? A. Sharp pin B. Tuning fork C. Reflex hammer D. Calibrated compass
ANS: B
Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination.
Which information about a 76-yr-old patient should the nurse report as uncharacteristic of normal aging?
a. Triceps reflex response graded at 1/5
b. Unintended weight loss of 15 pounds
c. 10 mm Hg orthostatic drop in systolic blood pressure
d. Patient complaint of chronic difficulty in falling asleep
ANS: B
Although changes in appetite are normal with aging, a 15-lb weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging.
The charge nurse is observing a new staff nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment?
a. The new nurse tests for light touch before testing for pain.
b. The new nurse has the patient close the eyes during testing.
c. The new nurse asks the patient if the instrument feels sharp.
d. The new nurse uses an irregular pattern to test for intact touch
ANS: C
When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.
Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider?
a. Specific gravity of 1.007
b. Protein of 65 mg/dL (0.65 g/L)
c. Glucose of 45 mg/dL (1.7 mmol/L)
d. White blood cell (WBC) count of 4 cells/μL
ANS: B
The protein level is high. The specific gravity, WBCs, and glucose values are normal.
A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans?
a. The patient is anxious about the test results.
b. The patient reports a previous allergy to shellfish.
c. The patient has back pain when lying flat for more than 4 hours.
d. The patient drank apple juice 4 hours before the scheduled procedure.
ANS: B
A contrast medium containing iodine is injected into the subarachnoid space during a myelogram. The patient’s allergy would contraindicate the use of this medium. The health care provider may need to modify the orders to prevent back pain, but this can be done after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient’s anxiety should be addressed, but procedural plans would not need to be changed.
The priority nursing assessment for a patient being admitted with a brainstem infarction is A. pupil reaction. B. respiratory rate. C. Reflex reaction time D. level of consciousness
ANS: B
Vital centers that control respiration are located in the medulla and part of the brainstem, and will require priority assessments because changes in respiratory function may be life threatening. The other information will also be obtained by the nurse but is not as urgent.
Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first?
a. A patient with a transient ischemic attack (TIA) returning from carotid duplex
studies
b. A patient with a brain tumor who has just arrived on the unit after a cerebral
angiogram
c. A patient with a seizure disorder who has just completed an
electroencephalogram (EEG)
d. A patient prepared for a lumbar puncture whose health care provider is waiting
for assistance
ANS: B
Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse, blood pressure, and the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible, but monitoring for hemorrhage after cerebral angiogram has a higher priority.
Which assessments will the nurse make to monitor a patient’s cerebellar function (select all that apply)?
a. Test for graphesthesia.
b. Observe arm swing with gait.
c. Perform the finger-to-nose test.
d. Assess heat and cold sensation.
e. Measure strength against resistance.
ANS: B,C
The cerebellum is responsible for coordination and is assessed by looking at the patient’s gait and the finger-to-nose test. The other assessments will be used for other parts of the neurologic assessment.
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 alterations in cerebral perfusion pressure.”
d. “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 of 128/68 mm Hg, 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 of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12
breaths/min
b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32
breaths/min
c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28
breaths/min
d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30
breaths/min
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 A. Flexion withdrawal. B. Localization of pain. C. Decorticate posturing. D. Decerebrate posturing.
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.
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
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 as a result of mannitol administration.
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. The nurse records the patient’s Glasgow Coma Scale score as A. 9. B. 11. C. 13 D. 15.
ANS: B
The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
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 being given. 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.
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.
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.
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 p ressure and ICP.
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.
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?
a. Coordinate the transfer of the patient to the operating room.
b. Provide discharge instructions about monitoring neurologic status.
c. Transport the patient to radiology for magnetic resonance imaging (MRI).
d. 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, and surgery are not usually indicated in a patient with a concussion.
A patient who is suspected of having an 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.
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.
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.
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.
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
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.
The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have
A. expressive aphasia.
B. impaired judgment.
C. Right-sided weakness
D. difficulty swallowing.
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.
Which statement by 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 to bed.”
c. “I do not even remember being in an accident.”
d. “I can take acetaminophen (Tylenol) for my headache.”
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.
After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to
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.
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.
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.
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.
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.
b. Immunize adolescents and college freshman.
c. Support serving healthy nutritional options in the college cafeteria.
d. Encourage adolescents and young adults to avoid crowds in the winter.
ANS: B
The Neisseria meningitides 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.
A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?
a. The patient receives a regular diet tray.
b. The bedrails on both sides of the bed are elevated.
c. Staff have turned off the lights in the patient’s room.
d. Staff have entered the patient’s room without a mask.
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.
When assessing a 53-yr-old patient with 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.
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.
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.
ANS: B
Calculate the cerebral perfusion pressure (CPP): (CPP = Mean arterial pressure [MAP] – ICP). MAP = DBP + 1/3 (Systolic 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.
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.
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.
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 has increased intracranial pressure (ICP) and is receiving hyperventilation therapy
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.
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 complaining of a headache. Which prescribed interventions 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 orally.
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.
After the emergency department nurse has received a status report on the following patients who have been admitted 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 50-yr-old patient who has an initial Glasgow Coma Scale score of 13
c. A 30-yr-old patient who lost consciousness for a few seconds after a fall
d. A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light
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.
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. Complaint of severe headache
b. Large contusion behind left ear
c. Bilateral periorbital ecchymosis
d. Temperature of 101.4° F (38.6° C)
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.
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
ANS: B
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 only require ongoing monitoring at this time.
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.
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.
A 68-yr-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?
a. Check oxygen saturation.
b. Assess pupil reaction to light.
c. Palpate the head for injuries
d. Verify Glasgow Coma Scale (GCS) score.
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.
. A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work 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.
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.
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/minute
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.
The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires rapid action by the nurse?
a. The apical pulse is slightly irregular.
b. The patient complains of a headache.
c. The patient is more difficult to arouse.
d. The blood pressure (BP) increases to 140/62 mm Hg.
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.
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.
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.
While admitting a 42-yr-old patient with a possible brain injury after a car accident 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 takes warfarin (Coumadin) daily.
b. The patient’s blood pressure is 162/94 mm Hg.
c. The patient is unable to remember the accident.
d. The patient complains of a severe dull headache.
ANS: A
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.
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.
ANS: D
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.
A patient with possible viral meningitis is admitted to the nursing unit after 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 (Rocephin) 1 g IV every 12 hours.
d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.
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.
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.
ANS: B
Epidemic encephalitis is usually spread by mosquitoes and ticks. 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 pro phylaxis 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.
Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for functional deficits?
a. “Do you have difficulty in hearing?”
b. “Are you experiencing visual problems?”
c. “Are you having any trouble with your balance?”
d. “Have you developed any weakness on one side?”
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.
56(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
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.
56(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
ANS: D
Battle’s sign (postauricular ecchymosis) and periorbital ecchymoses are associated with basilar skull fracture.
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.
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about
A. cerebral aneurysm clipping. c. oral low-dose aspirin therapy.
B. heparin intravenous infusion.
C. Oral low-dose aspirin
D. tissue plasminogen activator (tPA).
ANS: C
The patient’s symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient’s symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA
A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient reports that symptoms began with a severe headache.
d. The patient has a history of brief episodes of right-sided hemiplegia
ANS: C
A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack are not contraindications to aspirin use
