Med Surg - Exam 2 - Ch 57 (Acute Intracranial Probs) Flashcards
Which components are able to change to adapt to small increases in intracranial pressure (ICP) (select all that apply)?
a. Blood
b. Skull bone
c. Brain tissue
d. Scalp tissue
e. Cerebrospinal fluid (CSF)
a. Blood
c. Brain tissue
e. Cerebrospinal fluid (CSF)
Blood adapts to increased venous outflow, decreased cerebral blood flow (CBF), and collapse of veins and dural sinuses. Brain tissue adapts with distention of the dura, slight compression of tissue, or herniation. Cerebrospinal fluid (CSF) adapts with increased absorption, decreased production, and displacement into the spinal canal. Skull bone and scalp tissue do not adapt to changes in intracranial pressure (ICP).
The cerebral perfusion pressure (CPP) is the presure needed to ensure blood flow to the brain. Normal CPP is 60 to 100 mm Hg. Calculate the CPP of a patient whose blood pressure (BP) is 106/52 mm Hg and ICP is 14 mm Hg.
_______ mm Hg
56 mm Hg
Mean arterial pressure (MAP) diastolic blood pressure (DBP) + 1/2 (systolic blood pressure [SBP] - DBP) = 52 + 18 = 70
Cerebral perfusion pressure (CPP) = MAP - ICP = 70 - 14 = 56
Calculate the CPP for the patient with an ICP of 24 mm Hg and a systemic BP of 108/64 mm Hg.
_______ mm Hg
45 mm Hg
MAP = DBP + 1/3 (SBP - DBP) = 64 + 15 = 79 CPP = MAP - ICP = 79 - 34 = 45
Which factors decrease cerebral blood flow (select all that apply)?
a. Increased ICP
b. PaO2 of 45 mm Hg
c. PaCO2 of 30 mm Hg
d. Arterial blood pH of 7.3
e. Decreased mean arterial pressure (MAP)
c. PaCO2 of 30 mm Hg
e. Decreased mean arterial pressure (MAP)
Cerebral blood flow is decreased when the MAP and the PaCO2 are decreased. The other options increase cerebral blood flow.
What are the causes of vasogenic cerebral edema (select all that apply)?
a. Hydrocephalus
b. Ingested toxins
c. Destructive lesions or trauma
d. Local disruption of cell membranes
e. Fluid flowing from intravascular to extravascular space
b. Ingested toxins
e. Fluid flowing from intravascular to extravascular space
Which events cause increased ICP (select all that apply)?
a. Vasodilation
b. Necrotic tissue edema
c. Blood vessel compression
d. Edema from initial brain insult
e. Brainstem compression and herniation
a. Vasodilation
b. Necrotic tissue edema
d. Edema from initial brain insult
An early sign of increased ICP that the nurse should assess for is
a. Cushing’s triad.
b. unexpected vomiting.
c. decreasing level of consciousness (LOC).
d. dilated pupil with sluggish response to light.
c. decreasing level of consciousness (LOC).
The nurse recognizes that the presence of Cushing’s triad in the patient with which vital sign changes?
a. Increased pulse, irregular respiration, increased BP
b. Decreased pulse, increased respiration, decreased systolic BP
c. Decreased pulse, irregular respiration, widened pulse pressure
d. Increased pulse, decreased respiration, widened pulse pressure
c. Decreased pulse, irregular respiration, widened pulse pressure
Increased ICP in the left cerebral cortex caused by intracranial bleeding causes displacement of brain tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to as what?
a. Uncal herniation
b. Tentorial herniation
c. Cingulate herniation
d. Temporal lobe herniation
c. Cingulate herniation
A patient has ICP monitoring with an intraventricular catheter. What is a priority nursing intervention for the patient?
a. Aseptic technique to prevent infection
b. Constant monitoring of ICP waveforms
c. Removal of CSF to maintain normal ICP
d. Sampling CSF to determine abnormalities
a. Aseptic technique to prevent infection
When using intraventricular ICP monitoring, what should the nurse be aware of to prevent inaccurate readings?
a. The P2 wave is higher than the P1 wave.
b. CSF is leaking around the monitoring device.
c. The transducer of the ventriculostomy monitor is at the level of the upper ear.
d. The drain of the CSF drainage device was closed for 6 minutes before taking the reading.
b. CSF is leaking around the monitoring device.
The patient is being monitored long-term with a brain tissue oxygenation catheter. What range for the pressure of oxygen in brain tissue (PbtO2) will maintain cerebral oxygen supply and demand?
a. 55% to 75%
b. 20 to 40 mm Hg
c. 70 to 150 mm Hg
d. 80 to 100 mm Hg
b. 20 to 40 mm Hg
The normal pressure of oxygen in brain tissue (PbtO2) is 20 to 40 mm Hg. The normal jugular venous oxygen saturation (SjvO2) is 55% to 75% and indicates total venous brain tissue extraction of oxygen; this is used for short-term monitoring. The MAP of 70 to 150 mm Hg is needed for effective autoregulation of CBF. The normal range for PaO2 is 80 to 100 mm Hg.
Which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid?
a. Oxygen administration
b. Pentobarbital (Nembutal)
c. Mannitol (Osmitrol) (25%)
d. Dexamethasone (Decadron)
c. Mannitol (Osmitrol) (25%)
Mannitol (Osmitrol) (25%) is an osmotic diuretic that expands plasma and causes fluid to move from tissues into the blood vessels. Hypertonic saline reduces brain swelling by moving water out of brain tissue. Oxygen administration is done to maintain brain function. Pentobarbitol (Nembutal) and other barbiturates are used to reduce cerebral metabolism. The corticosteroid dexamethasone (Decadron) is used to treat vasogenic edema to stabilize cell membranes and improve neuronal function by improving CBF and restoring autoregulation.
How are the metabolic and nutritional needs of the patient with increased ICP best met?
a. Enteral feedings that are low in sodium
b. Simple glucose available in D5W IV solutions
c. Fluid restriction that promotes a moderate dehydration
d. Balanced, essential nutrition in a form that the patient can tolerate
d. Balanced, essential nutrition in a form that the patient can tolerate
A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema and if a patient cannot take oral nutrition, other means of providing nutrition should be used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional requirements and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity. Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.
Why is the Glasgow Coma Scale (GCS) used?
a. To quickly assess the LOC
b. To assess the patient’s ability to communicate
c. To assess the patient’s ability to respond to commands
d. To assess the patient’s coordination with motor responses
a. To quickly assess the LOC
The Glasgow Coma Scale (GCS) is used to quickly assess the LOC with a standardized system. The three areas assessed are the patient’s ability to speak, obey commands, and open eyes to verbal or painful stimulus. Although best motor response is an indicator, it is not used to assess coordination.
A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. What should the nurse record as the patient’s GCS score?
a. 6
b. 7
c. 9
d. 11
b. 7
No opening of the eyes = 1; incomprehensible words = 2; flexion withdrawal = 4. Total = 7
When assessing the body functions of a patient with increased ICP, what should the nurse assess first?
a. Corneal reflex testing
b. Pupillary reaction to light
c. Extremity strength testing
d. Circulatory and respiratory status
d. Circulatory and respiratory status
Of the body functions that should be assessed in an unconscious patient, cardiopulmonary status is the most vital function and gives priorities to the ABCs (airway, breathing, and circulation).
How is cranial nerve (CN) III, originating in the midbrain, assessed by the nurse for an early indication of pressure on the brainstem?
a. Assess for nystagmus
b. Test the corneal reflex
c. Test pupillary reaction to light
d. Test for oculocephalic (doll’s eyes) reflex
c. Test pupillary reaction to light
One of the functions of cranial nerve (CN) III, the oculomotor nerve, is pupillary constriction and testing for pupillary constriction is important to identify patients at risk for brainstem herniation caused by increased ICP. The corneal reflex is used to assess the functions of CN V and VII and the oculocephalic reflex tests all cranial nerves involved with eye movement. Nystagmus is commonly associated with specific lesions or chemical toxicities and is not a definitive sign of ICP.
A patient has a nursing diagnosis of risk of ineffective cerebral tissue perfusion related to cerebral edema. What is an appropriate nursing intervention for the patient?
a. Avoid positioning the patient with neck and hip flexion.
b. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg.
c. Cluster nursing activities to provide periods of uninterrupted rest.
d. Routinely suction to prevent accumulation of respiratory secretions.
a. Avoid positioning the patient with neck and hip flexion.
Nursing care activities that increase ICP are hip and neck flexion, suctioning, clustering care activities, and noxious stimuli. They should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP.
An unconscious patient with an increased ICP is on ventilatory support. The nurse notifies the health care provider when arterial blood gas (ABG) measurement results reveal what?
a. pH of 7.43
b. SaO2 of 94%
c. PaO2 of 70 mm Hg
d. PaCO2 of 35 mm Hg
c. PaO2 of 70 mm Hg
A PaO2 of 70 mm Hg reflects hypoxemia that may lead to further decreased cerebral perfusion. PaO2 should be maintained at greater than or equal to 100 mm Hg. The pH and SaO2 are within normal range and a PaCO2 of 35 mm Hg reflects a normal value.
The nurse is monitoring a patient for increased ICP following a head injury. What are manifestations of increased ICP (select all that apply)?
a. Fever
b. Oriented to name only
c. Narrowing pulse pressure
d. Right pupil dilated greater than left pupil
e. Decorticate posturing to painful stimulus
a. Fever
b. Oriented to name only
d. Right pupil dilated greater than left pupil
e. Decorticate posturing to painful stimulus
The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate pressure on the hypothalamus. Changes in vital signs would be an increased SBP with widened pulse pressure and bradycardia.
While the nurse performs range of motion (ROM) on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. What should the nurse do first?
a. Use restraints to protect the patient from injury.
b. Perform the exercises less frequently because posturing can increase ICP.
c. Administer central nervous system (CNS) depressants to lightly sedate the patient.
d. Continue the exercises because they are necessary to maintain musculoskeletal function.
b. Perform the exercises less frequently because posturing can increase ICP.
If reflex posturing occurs during range of motion (ROM) or positioning of the patient, these activities should be done less frequently until the patient’s condition stabilizes because posturing can cause increases in ICP and may indicate herniation. Neither restraints nor central nervous system (CNS) depressants would be indicated.
The patient has been diagnosed with a cerebral concussion. What should the nurse expect to see in this patient?
a. Deafness, loss of taste, and CSF otorrhea
b. CSF otorrhea, vertigo, and Battle’s sign with a dural tear
c. Boggy temporal muscle because of extravasation of blood
d. Headache, retrograde amnesia, and transient reduction in LOC
d. Headache, retrograde amnesia, and transient reduction in LOC
A cerebral concussion may include a brief disruption in LOC, retrograde amnesia, and a headache, all of short duration. A basilar skull fracture may have a dural tear with CSF or brain otorrhea, rhinorrhea, hearing difficulty, vertigo, and Battle’s sign. A temporal fracture would have a boggy temporal muscle because of extravasation of blood, Battle’s sign, or CSF otorrhea.
The patient comes to the emergency department (ED) with cortical blindness and visual field defects. Which type of head injury does the nurse suspect?
a. Cerebral contusion
b. Orbital skull fracture
c. Posterior fossa fracture
d. Frontal lobe skull fracture
c. Posterior fossa fracture
The posterior fossa fracture causes occipital bruising resulting in cortical blindness or visual field defects. A cerebral contusion is bruising of brain tissue within a focal area. An orbital skull fracture would cause periorbital ecchymosis (racoon eyes) and possible optic nerve injury. A frontal lobe skull fracture would expose the brain to contaminants through the frontal air sinus and the patient would have CSF rhinorrhea or pneumocranium.
The patient has a depressed skull fracture and scalp lacerations with communication to the intracranial cavity. Which type of injury does the nurse record?
a. Linear skull fracture
b. Depressed skull fracture
c. Compound skull fracture
d. Comminuted skull fracture
c. Compound skull fracture
The compound skull fracture is a depressed skull fracture and scalp lacerations with communicating pathway(s) to the intracranial cavity. A linear skull fracture is a straight break in the bone without alteration in the fragments. A depressed skull fracture is an inward indentation of the skull that may cause pressure on the brain. A comminuted skull fracture has multiple linear fractures with bone fragmented into many pieces.
A patient with a head injury has bloody drainage from the ear. What should the nurse do to determine is CSF is present in the drainage?
a. Examine the tympanic membrane for a tear.
b. Test the fluid for a halo sign on a white dressing.
c. Test the fluid with a glucose-identifying strip or stick.
d. Collect 5 mL of fluid in a test tube and send it to the laboratory for analysis.
b. Test the fluid for a halo sign on a white dressing.
Testing clear drainage for CSF in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip but if blood is present, the glucose in the blood will produce an unreliable result. To test bloody drainage, the nurse should test the fluid for a “halo” or “ring” that occurs when a yellowish ring encircles blood dripped onto a white pad or towel within a few minutes.
The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences
a. failure to regain consciousness following a head injury.
b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury.
c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months.
d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC.
d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC.
An arterial epidural hematoma is the most acute neurologic emergency and typical symptoms include unconsciousness at the scene with a brief lucid interval followed by a decrease in LOC. An acute subdural hematoma manifests within 48 hours of an injury. A chronic subdural hematoma develops over weeks or months.
Skull x-rays and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the ED following an automobile accident. In planning care for the patient, what should the nurse anticipate?
a. The patient will receive life support measures until condition stabilizes.
b. Immediate burr holes will be made to rapidly decompress the intracranial cavity.
c. The patient will be treated conservatively with close monitoring for changes in neurologic status.
d. The patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium.
d. The patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium.
When there is a depressed fracture or a fracture with loose fragments, a craniotomy is indicated to elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be used an in extreme emergency for rapid decompression or to aid in removing a bone flap but with a depressed fracture, surgery would be the treatment of choice.
When a patient is admitted to the ED following a head injury, what should be the nurse’s first priority in management of the patient once a patent airway is confirmed?
a. Maintain cervical spine precautions.
b. Monitor for changes in neurologic status.
c. Determine the presence of increased ICP.
d. Establish IV access with a large-bore catheter.
a. Maintain cervical spine precautions.
In addition to monitoring for a patent airway during emergency care of the patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.
A 54-year-old man is recovering from a skull fracture with a subacute subdural hematoma that caused consciousness. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge of the patient, what should the nurse explain to the patient and family?
a. The patient is likely to have long-term emotional and mental changes that may require professional help.
b. Continuous improvement in the patient’s condition should occur until he has returned to pretrauma status.
c. The patient’s complete recovery may take years and the family should plan for his long-term dependent care.
d. Role changes in family members will be necessary because the patient will be dependent on his family for care and support.
a. The patient is likely to have long-term emotional and mental changes that may require professional help.
Residual mental and emotional changes of brain trauma with personality changes are often the most incapacitating problems following head injury and are common in patients who have been comatose for longer than 6 hours. Families must be prepared for changes in the patient’s behavior to avoid family-patient friction and maintain family functioning and professional assistance may be required. There is no indication the patient will be dependent on others for care but he likely will not return to pretrauma status.
The patient is suspected of having a new brain tumor. Which test will the nurse expect to be ordered to detect a small tumor?
a. CT scan
b. Angiography
c. Electroencephalography (EEG)
d. Positron emission tomography (PET) scan
d. Positron emission tomography (PET) scan
The positron emission tomography (PET) scan or magnetic resonance imaging (MRI) are used to reliably detect very small tumors. The computed tomography (CT) and brain scans are used to identify the location of a lesion. Angiography could be used to determine blood flow to the tumor and further localize it. Electroencephalography (EEG) would be used to rule out seizures.
Assisting the family to understand what is happening to the patient is an especially important role of the nurse when the patient has a tumor in which part of the brain?
a. Ventricles
b. Frontal lobe
c. Parietal lobe
d. Occipital lobe
b. Frontal lobe
Frontal lobe tumors often lead to loss of emotional control, confusion, memory loss, disorientation, seizures, and personality and judgment changes that are very disturbing and frightening to the family. Physical symptoms, such as blindness, speech disturbances, or disturbances in sensation and perception that occur with other tumors, are more likely to be understood and accepted by the family.
Which cranial surgery would require the patient to learn how to protect the surgical area from trauma?
a. Burr holes
b. Craniotomy
c. Cranioplasty
d. Craniectomy
d. Craniectomy
A craniectomy is excision of cranial bone without replacement, so the patient will need to protect the brain from trauma in this surgical area. Burr holes are opened into the cranium with a drill to remove blood and fluid. A craniotomy is opening the cranium with removal of a bone flap to open the dura. The replaced bone flap is wired or sutured after surgery. A cranioplasty replaces part of the cranium with an artificial plate.
What is the best explanation of stereotactic radiosurgery?
a. Radioactive seeds are implanted in the brain.
b. Very precisely focused radiation destroys tumor cells.
c. Tubes are placed to redirect CSF from one area to another.
d. The cranium is opened with removal of a bone flap to open the dura.
b. Very precisely focused radiation destroys tumor cells.
A stereotactic radiosurgery technique uses precisely focused radiation to destroy tumor cells. The radiation is computer and imagery guided. Radioactive seeds are used to deliver radiation. Ventricular shunts are used to redirect CSF from one area to another. A craniotomy is done by first making burr holes then opening the cranium by connecting the holes to remove a flap of bone to expose the dura mater.
For the patient undergoing the craniotomy, when should the nurse provide information about the use of wigs and hairpieces or other methods to disguise hair loss?
a. During preoperative teaching
b. If the patient asks about their use
c. In the immediate postoperative period
d. When the patient expresses negative feelings about his or her appearance
a. During preoperative teaching
To prevent undue concern and anxiety about hair loss and postoperative self-esteem disturbances, a patient is undergoing cranial surgery should be informed preoperatively that the head is usually shaved in surgery while the patient is anesthetized and that a turban, scarf, or cap may be used after the dressings are removed postoperatively and a wig may also be used after the incision has healed to disguise the hair loss. In the immediate postoperative period the patient is very ill and the focus is on maintaining neurologic function but preoperatively the nurse should anticipate the patient’s postoperative need for self-esteem and the maintenance of appearance.
Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by what?
a. Ability to return home in 6 days
b. Ability to meet all self-care needs
c. Acceptance of residual neurologic deficits
d. Absence of signs and symptoms of increased ICP
d. Absence of signs and symptoms of increased ICP
The primary goal after cranial surgery is prevention of increased ICP and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient’s general state of health.
On physical examination of a patient with headache and fever, the nurse should suspect a brain abscess when the patient has
a. seizures.
b. nuchal rigidity.
c. focal symptoms.
d. signs of increased ICP.
c. focal symptoms.
The symptoms of brain abscess closely resemble those of meningitis and encephalitis, including fever, headache, nausea, vomiting, and increased ICP, except that the patient also may have some focal symptoms that reflect the local area of the abscess.
Which of the following descriptions are characteristic of encephalitis (select all that apply)?
a. CSF production is increased
b. Almost always has a viral cause
c. Is an inflammation of the brain
d. Most frequently caused by bacteria
e. May be transmitted by insect vectors
f. Involves inflammation of tissues surrounding the brain and spinal cord
b. Almost always has a viral cause
c. Is an inflammation of the brain
e. May be transmitted by insect vectors
Encephalitis is usually caused by a virus that inflames the brain and can be transmitted by ticks and mosquitoes. The other options are characteristics of meningitis.
A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment, the nurse questions the patient about a recent history of what?
a. Mosquito or tick bites
b. Chickenpox or measles
c. Cold sores or fever blisters
d. An upper respiratory infection
d. An upper respiratory infection
Meningitis is often a result of an upper respiratory infection or a penetrating wound of the skull, where organisms gain entry to the CNS. Epidemic encephalitis is transmitted by ticks and mosquitoes and nonepidemic encephalitis may occur as a complication of measles, chickenpox, or mumps. Encephalitis caused by the herpes simplex virus carries a high fatality rate.
What are the key manifestations of bacterial meningitis?
a. Papilledema and psychomotor seizures
b. High fever, nuchal rigidity, and severe headache
c. Behavioral changes with memory loss and lethargy
d. Jerky eye movements, loss of corneal reflex, and hemiparesis
b. High fever, nuchal rigidity, and severe headache
High fever, severe headache, nuchal rigidity, nausea, and vomiting are key signs of meningitis. Other symptoms, such as papilledema, generalized seizures, hemiparesis, and decreased LOC, and cranial nerve dysfunction may occur as complications of increased ICP in meningitis.
Vigorous control of fever in the patient with meningitis is required to prevent complications of increased cerebral edema, seizure frequency, neurologic damage, and fluid loss. What nursing care should be included?
a. Administer analgesics as ordered.
b. Monitor LOC related to increased brain metabolism.
c. Rapidly decrease temperature with a cooling blanket.
d. Assess for peripheral edema from rapid fluid infusion.
b. Monitor LOC related to increased brain metabolism.
LOC must be monitored because it will decrease with the increased brain metabolism that the fever causes. Analgesics will not aid in lowering the body temperature, although acetaminophen will be used as an antipyretic. Rapid cooling may lead to shivering that increases metabolism. Monitoring cerebral edema will be done. Peripheral edema is unrelated and there will not be a rapid fluid infusion for the fever. Fluid replacement will be calculated with 800 mL/day for respiratory losses and 100 mL for each degree of temperature above 100.4F (38C).
Vasogenic cerebral edema increases intracranial pressure by
a. shifting fluid in the gray matter.
b. altering the endothelial lining of cerebral capillaries.
c. leaking molecules from the intracellular fluid the capillaries.
d. altering the osmotic gradient flow into the intravascular component.
b. altering the endothelial lining of cerebral capillaries.
Vasogenic cerebral edema occurs mainly in the white matter. It is caused by changes in the endothelial lining of cerebral capillaries.
A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects
a. a severe decrease in cerebral perfusion pressure.
b. an alteration in the production of cerebrospinal fluid.
c. the loss of autoregulatory control of intracranial pressure.
d. a normal balance between brain tissue, blood, and cerebrospinal fluid.
d. a normal balance between brain tissue, blood, and cerebrospinal fluid.
Normal intracranial pressure (ICP) is 5 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal.
A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to
a. keep the head of the bed flat.
b. elevate the head of the bed to 30 degrees.
c. maintain patient on the left side with the head support on a pillow.
d. use a continuous-rotation bed to continuously change patient position.
b. elevate the head of the bed to 30 degrees.
The nurse should maintain the patient with abnormal ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. The nurse should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevation in ICP. Elevation of the head of the bed also reduces sagittal sinus pressure, promotes drainage from the head through the valveless venous system and jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood pressure. The effects of elevation of the head of the bed on the ICP and CPP must be evaluated carefully.
The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)?
a. Tachypnea
b. Bradycardia
c. Hypotension
d. Narrowing pulse pressure
b. Bradycardia
Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing’s triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.
During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for
a. patency of airway.
b. presence of a neck injury.
c. neurologic status with the Glasgow Coma Scale.
d. cerebrospinal fluid leakage from the ears or nose.
a. patency of airway.
The nurse’s initial priority in the emergency management of a patient with a severe head injury is to ensure that the patient has a patent airway.
A patient is suspected of having a brain tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the
a. frontal lobe.
b. parietal lobe.
c. occipital lobe.
d. temporal lobe.
a. frontal lobe.
A unilateral frontal lobe tumor may result in the following signs and symptoms: unilateral hemiplegia, seizures, memory deficit, personality and judgment changes, and visual disturbances. A bilateral frontal lobe tumor may cause symptoms associated with a unilateral frontal lobe tumor and an ataxic gait.
Nursing management of a patient with a brain tumor includes (select all that apply)
a. discussing with the patient methods to control inappropriate behavior.
b. using diversion techniques to keep the patient stimulated and motivated.
c. assisting and supporting the family in understanding any changes in behavior.
d. limiting self-care activities until the patient has regained maximum physical functioning.
e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.
c. assisting and supporting the family in understanding any changes in behavior.
e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.
Nursing interventions should be based on a realistic appraisal of the patient’s condition and prognosis after cranial surgery. The nurse should provide support and education to the caregiver and family about the patient’s behavioral changes. The nurse should be prepared to manage seizures and teach the caregiver and family about antiseizure medications and how to manage a seizure. An overall goal is to foster the patient’s independence for as long as possible and to the highest degree possible. The nurse should decrease stimuli in the patient’s environment to prevent increases in intracranial pressure.
The nurse on the clinical unit is assigned to four patients. Which patient should the nurse assess first?
a. Patient with skull fracture whose nose is bleeding
b. Older patient with a stroke who is confused and whose daughter is present
c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale
d. Patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued vomiting
c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale
The patient with meningitis should be seen first; patients with meningitis must be observed closely for manifestations of elevated ICP, which is thought to result from swelling around the dura and increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who has undergone cranial surgery should be seen second; although nausea and vomiting are common after cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics. The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nose bleed and should be seen third. Confusion after a stroke may be expected; the patient should have a family member present.
A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is
a. administering codeine for relief of head and neck pain.
b. controlling fever with prescribed drugs and cooling techniques.
c. keeping the room dark and quiet to minimize environmental stimulation.
d. maintaining the patient on strict bed rest with the head of the bed slightly elevated.
b. controlling fever with prescribed drugs and cooling techniques.
Fever must be vigorously managed because it increases cerebral edema and the frequency of seizures. Neurologic damage may result from an extremely high temperature over a prolonged period. Acetaminophen or aspirin may be used to reduce fever; other measures, such as a cooling blanket or tepid sponge baths with water, may be effective in lowering the temperature.
The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which complications (select all that apply)?
a. Vision loss
b. Cerebral edema
c. Pituitary dysfunction
d. Parathyroid dysfunction
e. Focal neurologic deficits
a. Vision loss
b. Cerebral edema
c. Pituitary dysfunction
e. Focal neurologic deficits
Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure (ICP) and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.
A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak?
a. A halo sign on the nasal drip pad
b. Decreased blood pressure and urinary output
c. A positive reading for glucose on a Test-tape strip
d. Clear nasal drainage along with the bloody discharge
a. A halo sign on the nasal drip pad
When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose. Decreased blood pressure and urinary output would not be indicative of a CSF leak.
The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation?
a. Tonic spasms of the legs
b. Curling in a fetal position
c. Arching of the neck and back
d. Resistance to flexion of the neck
d. Resistance to flexion of the neck
Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.
The nurse is providing care for a patient who has been admitted to the hospital with a head injury and who requires regular neurologic and vital sign assessment. Which assessments will be components of the patient’s score on the Glasgow Coma Scale (GCS) (select all that apply)?
a. Judgment
b. Eye opening
c. Abstract reasoning
d. Best verbal response
e. Best motor response
f. Cranial nerve function
b. Eye opening
d. Best verbal response
e. Best motor response
The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.
What nursing intervention should be implemented in the care of a patient who is experiencing increased ICP?
a. Monitor fluid and electrolyte status carefully.
b. Position the patient in a high Fowler’s position.
c. Administer vasoconstrictors to maintain cerebral perfusion.
d. Maintain physical restraints to prevent episodes of agitation.
a. Monitor fluid and electrolyte status carefully.
Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient’s bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.
Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse should recognize that the patient will most likely need which treatment modality?
a. Surgery
b. Chemotherapy
c. Radiation therapy
d. Biologic drug therapy
a. Surgery
Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.
A patient has a systemic blood pressure of 120/60 and an ICP of 24 mm Hg. After calculating the patient’s cerebral perfusion pressure (CPP), how does the nurse interpret the results?
a. High blood flow to the brain
b. Normal intracranial pressure
c. Impaired blood flow to the brain
d. Adequate autoregulation of blood flow
c. Impaired blood flow to the brain
Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP - ICP: 80mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24, it is elevated and requires treatment.
The patient with increased ICP from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient?
a. Administer IV mannitol (Osmitrol).
b. Ventilator use to hyperoxygenate the patient
c. Use strict aseptic technique with dressing changes.
d. Be aware of changes in ICP related to leaking CSF.
c. Use strict aseptic technique with dressing changes.
The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol (Osmitrol) or hypertonic saline will be administered as ordered. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse’s priority of care.
How to calculate CPP
CPP = MAP - ICP
MAP = DBP + 1/3(SBP - DBP) or = [SBP + 2(DBP)]/3
Normal range of CPP: 60-100 mmHg
A male patient suffered a diffuse axonal injury from a traumatic brain injury (TBI). He has been maintained on IV fluids for 2 days. The nurse seeks enteral feeding for this patient based on what rationale?
a. Free water should be avoided.
b. Sodium restrictions can be managed.
c. Dehydration can be better avoided with feedings.
d. Malnutrition promotes continued cerebral edema.
d. Malnutrition promotes continued cerebral edema.
A patient with diffuse axonal injury is unconscious and, with increased ICP, is in a hypermetabolic, hypercatabolic state that increases the need for fuel for healing. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings.
In planning long-term care for a patient after a craniotomy, what must the nurse include when teaching the patient, family, and caregiver?
a. Seizure disorders may occur in weeks or months.
b. The family will be unable to cope with role reversals.
c. There are often residual changes in personality and cognition.
d. Referrals will be made to eliminate residual deficits from the damage.
c. There are often residual changes in personality and cognition.
In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.
Types of head injuries
- Scalp lacerations
- Skull fractures
- Head trauma
Two methods of testing to determine if fluid leaking from nose/ear is CSF
- Test leaking fluid to see if leaking fluid is present. CSF gives positive reading for glucose. If blood is present, test is unreliable.
- Look for halo or ring sign - allow leaking fluid to drip onto white gauze pad or towel, and observe drainage. Within few minutes, blood coalesces into center, with a yellowish ring encircling blood if CSF is present.
- Both tests can give false positive results
Scalp lacerations
- Easily recognized type of external head trauma
- Associated with profuse bleeding
- Major complications are blood loss or infection
Skull fractures
- Can be described in several ways: (1) linear or depressed; (2) simple, comminuted, or compound; (3) closed or open
- Location of fracture determines clinical manifestations
- Manifestations evolve over course of several hours
- May include cranial nerve deficits, Battle’s sign (postauricular ecchymosis), and periorbital ecchymosis (racoon eyes).
- Generally associated with tear in dura and subsequent leakage of CSF
- Rhinorrhea (CSF leakage from nose) or otorrhea (CSF leakage from ear) confirms fracture has transversed dura - risk of meningitis is high w/CSF leak, antibiotics should be administered preventatively
- Potential complications: intracranial infections, hematoma, and meningeal and brain tissue damage
Head trauma
- Categorized as diffuse (generalized) or focal (localized)
- Brain injury can be classified as minor (GCS 13-15), moderate (9-12), severe (3-8)
- Diffuse:
o Concussion - brief disruption of LOC, retrograde amnesia, and headache. Very brief manifestations
o Diffuse axonal injury - may include decreased LOC, increased ICP, decortication or decerebration, and global cerebral edema. Approx 90% w/DAI remain in persistent vegetative state. - Focal:
o Lacerations - tearing of brain tissue and often occur in association with depressed and open fractures and penetrating injuries.
o Contusion - bruising of brain tissue with focal area, usually associated with closed head injury.
o Epidural hematoma - bleeding between the dura and inner surface of the skull - neurological emergency. Classic signs of epidural hematoma: initial period of unconsciousness at scene, with brief lucid interval followed by a decrease in LOC; headache, nausea, or vomiting; other focal findings.
o Subdural hematoma - bleeding between dura mater and arachnoid layer of meninges. May be acute (24-48 hrs after injury), subacute (48 hr-2 wk), or chronic (weeks or months, usually >20 days). S/S similar to increased ICP - incl. decreasing LOC and headache.
o Intracerebral hematoma - occurs from bleeding w/i brain tissue in ~16% brain injuries - occurs within frontal and temporal lobes
Brain tumors - age/race prevalence
- Whites have higher incidence of malignant brain tumors than African Americans
- White males have highest incidence of malignant brain tumors
- African Americans have higher incidence of benign brain tumors (e.g., meningiomas) than whites
Indications for cranial surgery
Brain abscess - excision or drainage of abscess
Hydrocephalus - placement of ventriculoatrial or ventriculoperitoneal shunt
Brain tumors - excision or partial resection of tumor
Intracranial bleeding - surgical evacuation through burr holes or craniotomy
Skull fractures - debridement of fragments and necrotic tissue, elevation and realignment of bone fragments
Arteriovenous (AV) malformation - excision of malformation
Aneurysm repair - dissection and clipping or coiling of aneurysm
Manifestations of frontal lobe tumor
- Unilateral hemiplegia
- Seizures
- Memory deficit
- Personality and judgment changes
- Visual disturbances
- (Ataxic gait also with bilateral vs unilateral)
Manifestations of parietal lobe tumor
- Speech disturbance (if tumor is in the dominant hemisphere)
- Inability to write
- Spatial disorders
- Unilateral neglect
Manifestations of occipital lobe tumor
- Vision disturbances
- Seizures
Manifestations of temporal lobe tumor
- Few symptoms
- Seizures
- Dysphagia
Manifestations of brainstem tumors
- Headache on awakening
- Drowsiness
- Ataxic gait
- Facial muscle weakness
- Hearing loss
- Dysphagia
- Disarthria
- “Crossed eyes” or other visual changes
- Hemiparesis
When being assessed for airway and breathing, the client presenting with increased intracranial pressure would most likely exhibit which of the following vital signs?
A. BP 190/84, HR 150, and an irregular respiratory pattern
B. BP 80/50, HR 50, and Kussmaul respiration
C. BP 80/50, HR 150, and Cheyne-Stokes respirations
D. BP 190/84, HR 50, and an irregular respiratory pattern
D. BP 190/84, HR 50, and an irregular respiratory pattern
Which of the symptoms listed below indicate early , later, and very late stages of increased intracranial pressure (ICP)
- Altered level of consciousness
- Absence of motor function
- Sluggish pupil reaction
- Headache
- Decreased systolic BP
- Vomiting
- Decreased pulse rate
- Increased systolic BP
- Decorticate posturing
- Increased pulse rate
- Decreased visual acuity
- Pupils dilated and fixed
Early:
- Altered level of consciousness
- Sluggish pupil reaction
- Headache
- Vomiting
- Decreased visual acuity
Later:
- Decreased pulse rate
- Increased systolic BP
- Decorticate posturing
Very late:
- Absence of motor function
- Decreased systolic BP
- Increased pulse rate
- Pupils dilated and fixed
The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse choose?
- Flexion of the hips
- Head turned to the side
- Neck in neutral position
- Trendelenburg’s position
- Neck in neutral position
The nurse is caring for a client who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider? 1. Complaint of severe headache 2. Large contusion behind left ear 3, Bilateral periorbital ecchymosis 4. Temperature of 101.4°F (38.6°C)
- Temperature of 101.4°F (38.6°C)
While admitting a client with a basal skull fracture, the nurse notes clear drainage from the client’s nose. Which of these admission orders should the nurse question?
- Insert nasogastric tube
- Check the nasal drainage for glucose
- Keep the head of bed elevated
- Apply cold packs for facial bruising
- Insert nasogastric tube
After having a craniectomy and left anterior fossae incision, a client has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to
- Position the bed flat and log roll the client.
- Cluster nursing activities to allow longer rest periods.
- Turn and reposition the client side to side every 2 hours.
- Perform range-of-motion (ROM) exercises every 4 hours.
- Perform range-of-motion (ROM) exercises every 4 hours.
When assessing a 53-year-old client with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?
- The client exhibits nuchal rigidity.
- The client has a positive Kernig’s sign.
- The client’s temperature is 101° F (38.3° C).
- The client’s blood pressure is 88/42 mm Hg.
- The client’s blood pressure is 88/42 mm Hg.
This is the question that we had debate about in section 1. After checking the original resource, the correct answer should be 4, not 3. The first three symptoms are expected as the characteristics of Meningitis. But hypotension requires immediate attention.
Which assessment data would support the client’s diagnosis of bacterial meningitis?
- Assess the client’s answer to date, time and place.
- Assess the client’s bilateral grip strength.
- Assess the client’s deep tendon reflexes.
- Assess the client’s ability to bend the chin to the chest.
- Assess the client’s ability to bend the chin to the chest.
A sign of bacterial meningitis is nuchal rigidity secondary to inflammation of the meninges. If the client has pain in the neck when touching the chin to the chest, this is called nuchal rigidity.
The client who has had a gunshot wound to the head assumes decerebrate posturing when the nurse applies painful stimuli. Which assessment data obtained 3 hours later would indicate the client’s condition is worsening?
- Purposeless movement in response to painful stimuli
- Flaccid paralysis in all four extremities
- Decorticate posturing when painful stimuli are applied
- Pupils that are 6 mm in size and nonreactive on painful stimuli
- Flaccid paralysis in all four extremities
Flaccidity would indicate a worsening of the client’s condition. Flaccidity indicates there is no brainstem function and is the worst response to painful stimuli.
Which expected outcome is most appropriate for the nurse to identify for the client diagnosed with encephalitis?
- The client will have intact neurological function.
- The client will have 2+ deep tendon reflexes.
- The client will have a urine output of 30 mL an hour.
- The client will have no impaired skin integrity.
- The client will have intact neurological function.
Clients diagnosed with encephalitis have neurological deficits while the inflammation is present. The therapeutic plan is to treat the disease process, decrease the edema, and return the client to an optimal level of wellness with the neurological system intact.
The client diagnosed with septic meningitis who just had a lumbar puncture is admitted to the medical floor. Which intervention is the nurse’s priority?
- Administer the intravenous fluid at 150 mL/hr.
- Keep the client’s head of the bed flat.
- Assess the client’s lumbar puncture site.
- Provide a quiet, calm, and dark room.
- Keep the client’s head of the bed flat.
The client head of the bed should be kept flat to prevent a spinal headache, so this is the priority intervention. Spinal headaches are very painful and could result in a blood patch if not resolved.
