Quiz 4 Flashcards
A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?
A. Extension of the extremities
B. External rotation of the lower extremities
C. Pronation of the hands
D. Plantar flexion of the legs
D. Plantar flexion of the legs
Rationale: In decorticate posturing, the lower extremities typically exhibit plantar flexion. Additionally, the upper extremities show flexion of the arms, wrists, and fingers with adduction of the arms.
A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?
A. Administer a vasodilator medication.
B. Elevate the head of the bed to 30°.
C. Apply a cold compress to the forehead.
D. Decrease the oxygen flow rate.
B. Elevate the head of the bed to 30°.
Reason: This choice is correct because elevating the head of the bed to 30° may help to improve the venous drainage and decrease the ICP. ICP is the pressure exerted by the brain tissue, cerebrospinal fluid (CSF), and blood within the cranial cavity. A normal ICP range is 5 to 15 mm Hg, and an elevated ICP (>20 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, positioning the client in a semi-Fowler’s position (30° angle) or high- Fowler’s position (60° to 90° angle) can facilitate breathing and prevent further complications.
A nurse is caring for a client who has a closed head injury. In which of the following positions should the nurse place the client?
A. Sims
B. Modified Trendelenburg
C. Semi-Fowler’s
D. Prone
C. Semi-Fowler’s
Choice C: This is correct because semi-Fowler’s position is used for clients who have increased intracranial pressure, respiratory distress, or head trauma. It elevates the head and chest to reduce cerebral edema and facilitate breathing.
A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse that the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)
A. Pupillary changes
B. Disorientation
C. Headache
D. Slurred speech
E. Neck pain and stiffness
A. Pupillary changes
B. Disorientation
C. Headache
D. Slurred speech
A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)
A. Slurred speech.
B. Bradycardia with a bounding pulse.
C. Confusion.
D. Hypertension with an increasing pulse pressure.
E. Nonreactive dilated pupils.
F. Hypotension with a decreasing pulse pressure.
B. Bradycardia with a bounding pulse.
D. Hypertension with an increasing pulse pressure.
E. Nonreactive dilated pupils.
NGN
What will the nurse suspect?
Monitor?
Cushing’s triad
monitor:
- dilated pupils
- bradycardia
- hypotension
- increased RR
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?
A. The client needs total nursing care.
B. The client has a stable neurologic status
C. The client is alert and oriented.
D. The client has a mild brain injury but requires extensive care
A. The client needs total nursing care.
A nurse is caring for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
A. Place suction equipment at the client’s bedside.
B. Avoid the use of warm water to wash the client’s face.
C. Provide range of motion exercises to the client’s neck and shoulders.
D. Apply an eye patch to the client’s right eye.
A. Place suction equipment at the client’s bedside.
Choice A reason: Placing suction equipment at the client’s bedside is a necessary action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Acoustic neuroma is a noncancerous tumor that develops on the vestibulocochlear nerve, which is responsible for hearing and balance. It can also affect the adjacent cranial nerves, such as the glossopharyngeal (CN IX) and the vagus (CN X) nerves, which are involved in swallowing and gagging. A client with acoustic neuroma may have difficulty swallowing and clearing secretions, which can increase the risk of aspiration and respiratory infections. The nurse should have suction equipment ready to remove any excess saliva or mucus from the client’s mouth or throat.
A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?
A. Ask the client to shrug his shoulders against passive resistance
B. Instruct the client to look up and down without moving his head
C. Observe the client’s ability to smile and frown
D. Have the client stand with his eyes closed and touch his nose
B. Instruct the client to look up and down without moving his head
Choice B: Instruct the client to look up and down without moving his head is an assessment that will give the nurse information about the function of cranial nerve III. Cranial nerve III is the oculomotor nerve, which innervates four of the six extraocular muscles that control eye movements. The oculomotor nerve also controls pupil size and lens shape. By instructing the client to look up and down without moving his head, the nurse can assess the ability of the oculomotor nerve to move the eyes vertically and adjust to different distances.
A nurse is assessing a client’s cranial nerve VII. Which of the following responses should the nurse expect?
A. The client’s pupils constrict in response to light.
B. The client’s tongue is in a midline position:
C. The client has a symmetrical smile.
D. The client turns their head against resistance.
C. The client has a symmetrical smile.
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?
A. Localization of pain
B. Decorticate posturing
C. Decerebrate posturing
D. Flexion withdrawal
B. Decorticate posturing
Fill in the blank GCS
11
A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?
A. Flex the client’s hip.
B. Hyperextend the client’s neck.
C. Provide warming measures for the client.
D. Adjust the client’s head of bed.
D. Adjust the client’s head of bed.
Rationale: Adjust the client’s head of bed is correct. Elevating the head of the bed helps reduce ICP and improves cerebral perfusion by promoting venous outflow.
A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings?
A. Elevated temperature
B. Pupils reactive to light
C. Widened pulse pressure
D. Nuchal rigidity
C. Widened pulse pressure
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 would 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.
b. Ensure that the patient‘s neck is in neutral position.
