Med Surg - Exam 2 - Ch 57 (Acute Intracranial Probs) Flashcards

Question

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

Answer 1

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.

Answer 2

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.

Answer 3

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.

Answer 4

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.

Answer 5

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.

Answer 6

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.

Answer 7

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.

Answer 8

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.

Answer 9

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.

Answer 10

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.

Answer 11

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.

Answer 12

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.

Answer 13

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.

Answer 14

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.

Answer 15

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.

Answer 16

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.

Answer 17

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).

Answer 18

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.

Answer 19

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.

Answer 20

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.

Answer 21

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.

Answer 22

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.

Answer 23

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.

Answer 24

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.

Answer 25

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.

Answer 26

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.

Answer 27

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.

Answer 28

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.

Answer 29

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.

Answer 30

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.

Answer 31

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.

Answer 32

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.

Answer 33

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.

Answer 34

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.

Answer 35

CPP = MAP - ICP MAP = DBP + 1/3(SBP - DBP) or = [SBP + 2(DBP)]/3 Normal range of CPP: 60-100 mmHg

Answer 36

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.

Answer 37

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.

Answer 38

- Scalp lacerations - Skull fractures - Head trauma

Answer 39

- 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

Answer 40

- Easily recognized type of external head trauma - Associated with profuse bleeding - Major complications are blood loss or infection

Answer 41

- 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

Answer 42

- 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

Answer 43

- 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

Answer 44

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

Answer 45

- Unilateral hemiplegia - Seizures - Memory deficit - Personality and judgment changes - Visual disturbances - (Ataxic gait also with bilateral vs unilateral)

Answer 46

- Speech disturbance (if tumor is in the dominant hemisphere) - Inability to write - Spatial disorders - Unilateral neglect

Answer 47

- Vision disturbances | - Seizures

Answer 48

- Few symptoms - Seizures - Dysphagia

Answer 49

- Headache on awakening - Drowsiness - Ataxic gait - Facial muscle weakness - Hearing loss - Dysphagia - Disarthria - "Crossed eyes" or other visual changes - Hemiparesis

Answer 50

D. BP 190/84, HR 50, and an irregular respiratory pattern

Answer 51

Early: 1. Altered level of consciousness 3. Sluggish pupil reaction 4. Headache 6. Vomiting 11. Decreased visual acuity Later: 7. Decreased pulse rate 8. Increased systolic BP 9. Decorticate posturing Very late: 2. Absence of motor function 5. Decreased systolic BP 10. Increased pulse rate 12. Pupils dilated and fixed

Answer 52

3. Neck in neutral position

Answer 53

4. Temperature of 101.4°F (38.6°C)

Answer 54

1. Insert nasogastric tube

Answer 55

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

Answer 56

4. 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.

Answer 57

4. 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.

Answer 58

2. 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.

Answer 59

1. 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.

Answer 60

2. 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.