UNIT 9

Question 1

A nurse is monitoring a patient recently admitted to the critical care unit with an acute brain injury. She is aware that intracranial hypertension is a major risk associated with brain injury. Which of the following findings would definitively indicate that the patient has intracranial hypertension?

A) Cerebral perfusion pressure (CPP) of 75 mm Hg

B) Intracranial pressure (ICP) of 25 mm Hg

C) Mean arterial pressure (MAP) of 150 mm Hg

D) Systolic pressure of 110 mm Hg

Answer 1

B

Question 2

A patient is demonstrating increased pulse pressure, decreased pulse, and irregular respiration. The nurse recognizes these symptoms of increased intracranial pressure and understands that the patients autoregulation of cerebral blood flow in the brain has failed. Which of the following findings would be consistent with a failure of autoregulation of blood flow in the brain? Select all that apply.

A) Cerebral perfusion pressure of 40 mm Hg

B) Mean arterial pressure of 170 mm Hg

C) Systolic pressure of 120 mm Hg

D) Intracranial pressure of 35 mm Hg

Answer 2

A B D

Question 3

A nurse is working with a patient with acute head trauma. The nurse understands that the cerebral blood flow in this patient is decreased to compensate for the cerebral edema caused by the trauma. What other compensatory mechanisms should the nurse be aware of that are likely occurring in this patient to maintain a constant intracranial pressure? Select all that apply.

A) Expansion of cisterns and ventricles

B) Increased cerebrospinal fluid (CSF) production

C) Increased CSF absorption

D) Shunting of CSF into the spinal subarachnoid space

Answer 3

C D

Question 4

A patient in the ICU with severe head trauma remains stable for the first 24 hours after admission, with no indication of intracranial hypertension. Suddenly, however, the patient begins showing signs of Cushings triad. The nurse recognizes that this occurrence indicates that the patients compensatory mechanisms have become exhausted. What physiological change occurs as part of this exhaustion of compensatory mechanisms? Select all that apply.

A) Decrease in volume of contents of the intracranial compartment

B) Decrease in intracranial pressure

C) Decrease in cerebral perfusion

D) Decrease in compliance within the intracranial compartment

Answer 4

C D

Question 5

Two patients, a husband and wife, are admitted to the ICU after sustaining traumatic head injuries in a motor vehicle accident. The husband is in a coma but shows no abnormalities on a CT scan. He is 45 years old and has a systolic blood pressure of 85 mm Hg. The wife, 42 years old, is not comatose and has a normal CT scan, but shows signs of brain injury, and has a systolic blood pressure of 80 mm Hg. The nurse recognizes that intracranial pressure monitoring is indicated for which of these patients?

A) Both the husband and wife

B) Neither the husband nor the wife

C) The husband only

D) The wife only

Answer 5

A

Question 6

A patient recently admitted to the ICU for head trauma has a Glasgow Coma Scale score of 4 and a hematoma apparent on CT scan of the head. This patient has multiple fractures in her skull and an intracranial pressure (ICP) of 30 mm Hg. Which ICP monitoring device would be contraindicated for this patient?

A) Intraventricular

B) Intraparenchymal

C) Lumbar/subarachnoid

D) Subdural

Answer 6

C

Question 7

A patient with head trauma requires intracranial pressure (ICP) monitoring. The physician insists that the most accurate monitoring device feasible should be used for this patient. This patient also requires frequent draining of cerebrospinal fluid (CSF) while being monitored. The nurse recognizes that which ICP monitoring device would be best for this patient?

A) Intraventricular

B) Subarachnoid

C) Subdural

D) Epidural

Answer 7

A

Question 8

A patient with head trauma is being monitored with an intraventricular catheter device (IVC). The patients intracranial pressure (ICP) had been staying around 20 mm Hg, but moments ago, it spiked up to 55 mm Hg. What complication related to the monitoring device itself would best explain this dramatic increase in ICP?

A) Infection at the catheter access site

B) Obstruction of the catheter

C) Hemorrhage

D) Misplacement of catheter

Answer 8

B

Question 9

A patient with a brain injury is receiving IV mannitol to reduce cerebral edema and intracranial pressure (ICP) during the early resuscitation phase. The patient is rapidly becoming hypovolemic. What intervention should the nurse make to help correct the hypovolemia?

A) Administer crystalloid solution.

B) Administer morphine.

C) Discontinue mannitol.

D) Administer propofol.

Answer 9

A

Question 10

. A patient with severe and refractory elevated intracranial pressure (ICP) has been in an induced barbiturate coma for 48 hours. Over the first 24 hours, the patients ICP decreased from 30 to 14 mm Hg and her systolic blood pressure decreased from 130 to 80 mm Hg. These changes were sustained in the second 24 hours. The nurse recognizes that which of the following is the appropriate intervention for this patient?

A) Administer IV solution.

B) Discontinue barbiturate therapy.

C) Initiate hypothermia therapy.

D) Administer a sedative

Answer 10

B

Question 11

A patient with a brain injury is undergoing intracranial pressure (ICP) monitoring and cerebrospinal fluid (CSF) drainage, along with mannitol therapy, to relieve ICP. What other intervention can the nurse make to aid in relieving this patients ICP?

A) Extend and rotate the patients head.

B) Flex the patients hips to greater than 90 degrees.

C) Elevate the head of the patients bed to 20 degrees.

D) Perform frequent blood draws.

Answer 11

C

Question 12

Regulation of intracranial pressure is explained by the Monro-Kellie doctrine. Based on this doctrine, under normal circumstances, if a patients brain volume increases, what compensatory change does the nurse expect?

A) Reduction of cerebral blood volume

B) Increased cerebrospinal fluid volume

C) Increased cerebrospinal fluid production

D) Elevation of systemic blood pressure

Answer 12

A

Question 13

A patient with a head injury is being monitored with an intracranial pressure monitor. What nursing assessment best indicates intracranial hypertension?

A) Intracranial pressure 8 mm Hg

B) Glasgow Coma Scale score 3

C) Intracranial pressure 25 mm Hg

D) Glasgow Coma Scale score 15

Answer 13

C

Question 14

. The patient has undergone intracerebral surgery. Knowing that interruption of the skull interferes with the brains ability to autoregulate, what nursing assessment information most clearly indicates the highest patient risk?

A) Pulmonary adventitious sounds

B) Capillary refill less than 2 seconds

C) Blood pressure consistently elevated

D) Pain at 8 on 0-to-10 scale

Answer 14

C

Question 15

The patient is in a critical care unit after an acute head injury and has developed respiratory and ventilatory failure and hypotension. What effect will this development have on the patients cerebral perfusion pressure?

A) Elevated above 100 mm Hg

B) Reduced below 60 mm Hg

C) Will make it very labile

D) Will have very little effect

Answer 15

B

Question 16

Intracranial pressure monitoring can be a valuable diagnostic tool but also has significant complications. In what patient with a severe head injury would the nurse question the use of intracranial pressure monitoring?

A) Glasgow Coma Scale score of 3

B) Declared brain dead

C) Subarachnoid hematoma

D) Severe stroke

Answer 16

B

Question 17

The patient has elevated intracranial pressure secondary to overproduction of cerebrospinal fluid. During therapy, an intracranial pressure monitor is placed. What type of monitor should be used if withdrawal of cerebrospinal fluid is also desired?

A) Intraventricular

B) Epidural

C) Intraparenchymal

D) Subdural

Answer 17

A

Question 18

The patient is being monitored with an intracranial pressure monitor. What nursing assessment most indicates the development of a complication of intracranial pressure monitoring?

A) Purulent drainage around monitor access site

B) Intracranial pressure 12 mm Hg at rest

C) Intracranial pressure 20 mm Hg during suctioning

D) Development of slight respiratory alkalosis

Answer 18

A

Question 19

The patient has an intracranial pressure monitor. After the patient returns from a computed tomography (CT) scan of the head, the nurse notices that the patients intracranial pressure is significantly lower than before the scan. What nursing action is most likely to identify a cause of this change?

A) Take vital signs.

B) Flush monitor tubing toward patient.

C) Relevel the transducer.

D) Drain cerebrospinal fluid

Answer 19

C

Question 20

A patient who is on an intracranial pressure monitor after an acute head injury has an intracranial pressure of 10 mm Hg at rest. When the patient is being suctioned, the intracranial pressure rises briefly to 20 mm Hg but returns quickly to 10 mm Hg once the suctioning has ceased. What is the most appropriate nursing intervention?

A) Administer intravenous sedation

B) Suction no longer than 15 seconds each time

C) Drain 10 mL cerebrospinal fluid

D) Return to supine position

Answer 20

B

Question 21

Seven days after a traumatic head injury, a patient has elevated intracranial pressure that is refractory to sedation, paralysis, cerebrospinal fluid drainage, and osmotic diuretics. The patients arterial blood gas results are pH 7.45, PaCO2 33, and bicarbonate ion 18. What is the best nursing decision?

A) Reduce respiratory rate

B) Administer intravenous bicarbonate

C) Increase intravenous sedation

D) Continue with current plan of care

Answer 21

D

Question 22

A patient with an acute brain injury is receiving IV mannitol, an osmotic diuretic. If this medication is effective, what does the nurse expect?

A) Increased cerebral perfusion pressure

B) Increased serum osmolarity above 320 mOsm

C) Reduction of Glasgow Coma Scale values

D) Development of fixed and dilated pupils

Answer 22

A

Question 23

A patient who was in a motor vehicle accident struck her forehead on the windshield of her car after crashing into the back of another car. Given this mechanism of injury, which regions of the brain are most likely to be injured? Select all that apply.

A) Frontal lobes

B) Parietal lobes

C) Occipital lobes

D) Temporal lobes

E) Diencephalon

F) Medulla oblongata

Answer 23

A C

Question 24

A patient was involved in a fight in which he was struck in the back of the head with a blunt object. Scalp laceration is immediately evident. The nurse suspects cerebral edema and ischemia. On CT scan, it appears that he has contusions and a fractured skull. On neurological assessment, the nurse finds evidence of concussion, as the patient demonstrates short-term memory impairment. Of these findings, which are secondary brain injuries? Select all that apply.

A) Scalp laceration

B) Cerebral edema

C) Ischemia

D) Contusions

E) Fractured skull

F) Concussion

Answer 24

B C

Question 25

Following cerebral angiography, a patient is found to have carotid artery dissection. What critical complication associated with this injury should the nurse be most concerned about because it could lead to stroke?

A) Concussion

B) Hemorrhage

C) Diffuse axonal injury

D) Coma

Answer 25

B

Question 26

A patient with traumatic brain injury is experiencing cerebral edema, which has led to severely elevated intracranial pressure. He has increased pulse pressure, decreased heart rate, and an irregular respiratory pattern. He has lost consciousness and demonstrates bilateral pupillary dilation. The nurse recognizes that these symptoms point to which condition?

A) Central herniation syndrome

B) Uncal herniation syndrome

C) Cerebrovascular injury

D) Diffuse axonal injury

Answer 26

A

Question 27

A patient with traumatic brain injury is being assessed. This patient demonstrates gross defects in visual acuity on reading a Snellen eye chart. Which cranial nerve is most likely damaged?

A) Cranial nerve I

B) Cranial nerve II

C) Cranial nerve III

D) Cranial nerve IV

Answer 27

B

Question 28

A comatose patient with a traumatic brain injury is being tested for cranial nerve damage. The nurse passes a wisp of cotton over the lower conjunctiva of each eye. The patients lower eyelid in each eye twitches when the cotton makes contact with the cornea. The nurse recognizes that this result indicates which of the following?

A) The trigeminal nerve is functioning properly but the facial nerve is not

B) The facial nerve is functioning properly but the trigeminal nerve is not

C) Neither the trigeminal nerve nor the facial nerve is functioning properly

D) Both the trigeminal and the facial nerves are functioning properly

Answer 28

D

Question 29

A patient with traumatic brain injury is found to have bilateral lesions deep in the cerebral hemispheres. What respiratory pattern should the nurse most expect to find in this patient?

A) Alternating hyperpneic and apneic phases (Cheyne-Stokes breathing)

B) Sustained, regular, rapid, and deep hyperventilation (neurogenic hyperventilation)

C) Long pause at full inspiration or full expiration (apneustic breathing)

D) Gasping breaths with irregular pauses (cluster breathing)

Answer 29

A

Question 30

A patient is suspected of having injury to his carotid artery following trauma to his neck after engaging in a fight during a hockey game. Which diagnostic test would be most effective in investigating this injury?

A) Computed tomography (CT)

B) Magnetic resonance imaging (MRI)

C) Electroencephalogram (EEG)

D) Cerebral angiography

Answer 30

D

Question 31

An inexperienced nurse who is new to the ICU is examining the eyes of a comatose patient with traumatic brain injury who is on a ventilator. In doing so, she turns the patients head sharply to one side. After she is finished, she leaves the patients head turned to the side. A more experienced nurse sees this and cautions the new nurse not to turn the patients head so sharply or leave it in that position. What is the best rationale for the more experienced nurses admonition?

A) Compression of the jugular vein leading to increased intracranial pressure

B) Lack of a patent airway

C) Lack of dignity for the patient

D) Cramping of neck muscles

Answer 31

A

Question 32

A nurse is caring for a patient with a traumatic brain injury who is paralyzed. The nurse must decide how best to meet the nutritional needs of this patient. What intervention is best to support the nutritional needs of the patient?

A) Replace 140% of the patients resting energy expenditure via parenteral nutrition.

B) Meet metabolic demands of the patient within 8 to 10 days of the injury.

C) Collaborate with a nutrition support team to meet the patients nutritional needs.

D) Maintain the patients blood sugar level at 300 mg/dL.

Answer 32

C

Question 33

A patient has experienced a traumatic brain injury. During initial assessment, the nurse determines that the mechanism of injury was accelerationdeceleration. What is the best rationale for this nursing assessment?

A) Helps to predict nature of internal injuries

B) Satisfied the nurses curiosity

C) Required on admission form

D) May be part of legal evidence

Answer 33

A

Question 34

A patient with a traumatic brain injury is at high risk for a secondary brain injury. What is the best nursing explanation of a secondary brain injury?

A) Result of a repeated assault incident

B) From a penetrating gunshot wound

C) Trauma inflicted by another person

D) Cerebral edema and ischemia

Answer 34

D

Question 35

The patient has a depressed skull fracture resulting in a tear of the dura mater. What nursing intervention is most directed at preventing a significant complication of this particular injury?

A) Elevating the head of the bed to 15 degrees

B) Giving supplemental oxygen by mask

C) Ensuring compliance with hand hygiene protocols

D) Obtaining consent for surgical repair of fracture

Answer 35

C

Question 36

A patient with a skull fracture has a positive halo sign. What does this sign indicate?

A) Fracture of the anterior fossa

B) Presence of a basilar skull fracture

C) Impingement of cranial nerves

D) Cerebrospinal fluid leak

Answer 36

D

Question 37

A patient with a suspected skull fracture is observed to have raccoon eyes, or bilateral periorbital bruising. What other symptom does the nurse expect?

A) Positive Battles sign

B) Cerebrospinal fluid rhinorrhea

C) Cerebrospinal fluid otorrhea

D) Maxillarycranial separation

Answer 37

B

Question 38

About 6 weeks after a concussion injury, the patient is complaining of headaches, decreased attention span, and short-term memory impairment. The patient expresses extreme frustration and anxiety. What is the best nursing intervention?

A) Obtain an order for a repeat computed tomography (CT) scan

B) Admit the patient for a complete neurologic evaluation

C) Provide emotional support and explanations

D) Refer to psychiatry for evaluation and treatment

Answer 38

C

Question 39

The patient has an acute subdural hematoma from an acute head injury. What is the most typical symptom that the nurse would expect during the first 2 days after the injury?

A) Decreasing level of consciousness

B) Labile blood pressure

C) Cardiac dysrhythmias

D) Impingement of cranial nerve 8

Answer 39

A

Question 40

The nurse is evaluating the cognitive function of a patient with impaired neurologic functioning after an acute brain injury. What is the best nursing approach for evaluation of orientation to person, place, and time?

A) Ask exactly the same questions each time.

B) Ask if the patient knows where he is.

C) Vary the questions slightly each time.

D) Ask the family to corroborate information

Answer 40

C

Question 41

The nurse is assessing a patients level of arousal. Since the patient is unresponsive to verbal and touch stimulation, the nurse decides to try a central pain stimulus. What technique would the nurse be least likely to use?

A) Squeeze the trapezius muscle.

B) Apply pressure over the supraorbital notch.

C) Apply pressure to closed eyelids.

D) Perform a sternal rub.

Answer 41

C

Question 42

A patient with a traumatic brain injury is given IV phenytoin to prevent seizures. Three days after the drug is started, the patient develops a red, vesicular rash on her trunk. What is the most appropriate collaborative intervention?

A) Administer an antihistamine.

B) Discontinue phenytoin.

C) Evaluate for contact dermatitis.

D) Place in contact isolation.

Answer 42

B

Question 43

A patient with a neurologic deficit following traumatic brain injury is making very slow progress toward normal. The family expresses distress and worry about financial and other matters to the nurse. What is the nurses best response?

A) Referral for nursing home placement

B) Questions about insurance status

C) Referral to psychiatry for evaluation

D) Referral to multidisciplinary rehabilitation team

Answer 43

D

Question 44

A teenaged boy jumped from a two-story building and landed on his feet, injuring his spine, and is now in the ICU. The nurse recognizes his injury as which of the following?

A) Rotational injury

B) Axial loading

C) Hyperflexion

D) Hyperextension

Answer 44

B

Question 45

The nurse is assessing a patient with a spinal cord injury in the ICU. The patient is completely paralyzed from the waist down but has sensation in his shoulders, chest, arms, and hands. He has no control of his bowel or bladder. Which of the following are possible sites for this patients injury, given his loss of function? Select all that apply.

A) C4

B) C7

C) T3

D) T7

E) T12

F) L4

Answer 45

D E

Question 46

A patient presents to the ICU with a spinal cord injury at C3 and the following: loss of position sense, light touch, and vibratory sense below the level of the injury. However, the patient has retained all motor function and pain and temperature sensation. The nurse suspects that the injury has occurred on what portion of the spinal cord?

A) Central

B) Lateral

C) Anterior

D) Posterior

Answer 46

D

Question 47

A patient involved in a snowmobile accident struck a tree and sustained a fractured vertebra at C4. She demonstrates signs of ischemic areas near the injury, along with hypoperfusion, microscopic hemorrhage, and edema. The nurse observes signs of concussion, including loss of consciousness. Which of the following are considered secondary injuries? Select all that apply.

A) Fractured vertebra

B) Cord ischemia

C) Hypoperfusion

D) Microscopic hemorrhage

E) Edema

F) Concussion

Answer 47

B C D E

Question 48

A patient with a mild spinal cord injury becomes light-headed every time she attempts to rise from her bed. At rest, her heart rate and blood pressure are normal. All of her motor, sensory, reflex, and autonomic functions are intact. The nurse recognizes which condition in this patient?

A) Spinal shock

B) Neurogenic shock

C) Orthostatic hypotension

D) Central cord syndrome

Answer 48

C

Question 49

A patient with a spinal cord injury has been stabilized in the ICU and now must undergo diagnostic testing. Which test would be most appropriate for detecting a fracture of the vertebra?

A) Magnetic resonance imaging (MRI)

B) Blood urea nitrogen (BUN)

C) Glasgow coma scale (GCS)

D) Computed tomography (CT)

Answer 49

D

Question 50

A patient is recovering from a lumbar spine injury and requires an immobilization device for this region. Which device would be most appropriate for this patient?

A) Halo vest

B) Aspen collar

C) Minerva brace

D) Jewett brace

Answer 50

D

Question 51

A nurse is monitoring a patient with spinal cord injury for respiratory complications. Which of the following findings would indicate that the patient should be intubated?

A) Respiratory rate of 20 breaths/minute

B) Vital capacity of 30 mL/kg

C) PaO2 of 90 mm Hg

D) PaCO2 of 60 mm Hg

Answer 51

D

Question 52

After failing to effectively clear a patients airway by having him cough, the nurse is now suctioning his airway. What complication related to suctioning should the nurse be aware of?

A) Bradycardia

B) Tachycardia

C) Hyperglycemia

D) Hypertension

Answer 52

A

Question 53

A patient with a spinal cord injury and who smokes is at risk for developing deep vein thrombosis (DVT). The nurse provides the patient with antiembolism stockings and encourages her to stop smoking, as it contributes to vasoconstriction in the periphery and thus to DVT. What other measure would be appropriate to help prevent DVT in this patient?

A) Administration of atropine sulfate

B) Administration of heparin

C) Administration of reserpine

D) Administration of methyldopa

Answer 53

B

Question 54

A patient is admitted to the emergency department after a near-drowning accident. The patient dove head-first into shallow water and has a high blood-alcohol level. Cardiopulmonary resuscitation was used at the scene. The patient is awake and alert. Considering the mechanism of injury, what is the highest nursing priority?

A) Check vital signs often.

B) Obtain an order for radiography studies.

C) Monitor pulse oximetry closely.

D) Provide cervical spine stability

Answer 54

D

Question 55

A patient is in critical care recovering from a spinal cord injury. As part of shift report, the nurse is told that the patients injury is between C1 and C4 and involves the entire cord. The patient is on a mechanical ventilator. What is the best nursing action to provide for patient safety?

A) Be sure all side rails are up at all times.

B) Keep the bed in low position when unattended.

C) Verify that a functioning bag-mask resuscitator is at the bedside.

D) Place the call light in the patients hand.

Answer 55

C

Question 56

A patient was struck in the jaw and had hyperextension of the cervical spine. If the patient has central cord syndrome, what would the nurse most expect?

A) Full loss of motor function below the lesion

B) Ipsilateral increased cutaneous pain at the lesion

C) Arm paralysis with intact motor function in the legs

D) Full motor paralysis and loss of touch sensation below the lesion

Answer 56

C

Question 57

Patients with spinal cord injury may experience both spinal shock and neurogenic shock, and differentiating between the two is essential. What symptoms are unique to neurogenic shock?

A) Loss of motor and sensory function

B) Flaccid paralysis below the lesion

C) Presence of poikilothermia

D) Hypotension and bradycardia

Answer 57

D

Question 58

During the initial assessment of patient with a probable spinal cord injury, the nurse performs a digital rectal examination. What is the best rationale for this examination?

A) Part of routine admission physical

B) Checks for fecal impaction

C) Assesses for sensation or movement

D) Preliminary for rectal medications

Answer 58

C

Question 59

A patient involved in a motor vehicle accident has a high risk of spinal cord injury. At the scene, what is the priority patient assessment?

A) Level of consciousness

B) Respiratory rate

C) Independent mobility

D) Peripheral sensation

Answer 59

B

Question 60

A patient with a cervical spine fracture has been fitted with a halo vest and is to ambulate for the first time today. What is the priority nursing action?

A) Put rubber corks on the ends of the pins.

B) Pad the edges of the vest to prevent chafing.

C) Have the patient sit on the side of the bed for several minutes.

D) Teach about loss of peripheral vision

Answer 60

C

Question 61

A patient has a C7-C8 spinal cord injury. During recovery, what is the nursing priority of care?

A) Encourage the patient to do incentive spirometry exercises.

B) Monitor neurologic status every 4 hours.

C) Collaborate with physical therapy for exercises.

D) Refer to social services for financial assistance.

Answer 61

A

Question 62

A patient with a spinal cord lesion at C6-C7 has developed pneumonia and is placed on kinetic therapy producing constant lateral rotation to 40 degrees bilaterally. What is a nursing priority of care for this patient relative to the kinetic therapy?

A) Measure intake and output hourly.

B) Provide nutrition with adequate protein.

C) Auscultate bowel sounds every 4 hours.

D) Inspect skin surfaces every 4 hours

Answer 62

D

Question 63

The patient has a spinal cord lesion at T1-T2. About an hour after being turned, the patient experiences a sudden throbbing headache accompanied by extreme blood pressure elevation and profound bradycardia. The patient has a very flushed face. What is the nursing priority?

A) Administer pain medication immediately.

B) Give intravenous beta-antagonist medication.

C) Turn on a fan.

D) Check Foley catheter for twisting or kinks.

Answer 63

D

Question 64

A patient recovering from a partial spinal cord lesion is experiencing muscle spasticity. Relative to this complication, what is the nursing priority?

A) Monitor neurologic status every 4 hours

B) Ensure compliance with exercise program

C) Medicate often for pain and discomfort

D) Emphasize nutritional balance

Answer 64

B