Performance
Exit
Passed
49 out of 51 questions answered correctly
Incorrect (2)
Which assessment findings would the nurse document regarding a
patient diagnosed with a right-sided brain tumor resulting in a
significantly increased intracranial pressure (ICP)? Select all that apply.
Some correct answers were not selected
Ipsilateral pupil dilation
Ipsilateral hemiparesis
Contralateral hemiparesis
Contralateral pupil dilation
Altered level of consciousness
Rationale
The level of consciousness is the most sensitive and reliable indicator of the patient's
neurologic status. Patients experiencing increased intracranial pressure will present
with varying degrees of altered levels of consciousness, depending on the degree of
pressure. Compression of cranial nerve (CN) II (optic) results in dilation of the pupil on
the same side (ipsilateral), not the opposite side (contralateral). As ICP continues to
rise, the patient will experience changes in motor response on the opposite side of the
lesion (contralateral), not the same side (ipsilateral).
pp. 1304, 1319
After performing an assessment of the oculocephalic reflex, the nurse
suspects that the patient has an intracranial lesion. Which patient
behavior supports the nurse’s assessment findings?
When flexing the neck, eye movement is in the upward direction.
Movement of the eye is in the opposite direction of the turned head.
When extending the neck, eye movement is in the downward direction.
Movement of the eye in the sideward direction occurs, with neck extension.
Rationale
Test the oculocephalic reflex by having the patient turn his or her head briskly to the
left or right while holding the eyelids open. The eye movement should be in the
opposite direction and not in the sideward direction if extending the neck. The
sideward eye movement indicates an intracranial lesion. Movement of the eye in the
opposite direction to the turning head is a normal response. Movement of eye in the
upward direction when flexing the neck is normal and does not indicate any
abnormality. When extending the neck, movement of the eye in the downward
direction indicates a normal finding.
Test-Taking Tip: Recall the procedure to assess oculocephalic reflex in a patient and
use critical knowledge to answer the question.
p. 1309
Correct (49)
Which statement by the novice nurse demonstrates understanding of
the care required for a patient admitted earlier today with a diagnosis of
post-head injury concussion?
"I can expect the pupils to be unequal in size and sluggish to respond to my
pen light."
"I will delegate keeping the patient awake for the next eight hours to my
unlicensed assistive personnel (UAP)."
"To help with post-head injury headaches, I will contact the health care
provider about prescribing morphine IV."
"I need to assess the patient's level of consciousness frequently because
changes are the first indication of complications."
Rationale
The first indication of increased intracranial pressure (ICP) is a change in the patient's
level of consciousness. Pupil changes are not an immediate assessment finding
following a concussion; in fact, pupil changes are often a late sign of neurologic
complications. Keeping the patient awake following a head injury is not necessary.
Arousing the patient frequently to assess arousal and level of consciousness is an
appropriate plan of care following a head injury. Although headache can be common
following a head injury, avoid narcotics for pain management because they can mask
the signs of impending complications, particularly alteration in level of consciousness.
p. 1315
The patient admitted with a closed head injury is awake but lethargic,
and the baseline vital signs include a BP of 120/80 mm Hg, pulse of 78
beats/min, and respirations of 20 breaths/min. Which findings indicate
deterioration of the patient’s condition two hours later?
The patient is sleeping but awakens in response to painful stimuli.
The patient does not remember what happened during the six hours prior to
the injury.
BP is 110/80 mm Hg, pulse is 78 beats/min, and respirations are 20
breaths/min.
BP is 160/74 mm Hg, pulse is 53 beats/min, and respirations are 10
breaths/min.
Rationale
Late signs of increased intracranial pressure include an increased systolic BP and
decreasing diastolic BP (widening pulse pressure), bradycardia, and decreased
respirations. The patient may also display a decreased level of consciousness, seizures,
or both. These symptoms represent the Cushing's triad and require immediate
intervention. Not remembering what happened, a sleeping patient who awakens in
response to painful stimuli, and a BP of 110/80 mm Hg, pulse of 78 beats/min, and
respirations of 20 breaths/min do not necessarily indicate deterioration in the patient's
condition.
pp. 1309, 1316
Which type of brain injury would the nurse associate with the patient
who sustained a subdural hematoma from a motor vehicle crash?
Anoxia
Primary
Cerebral
Secondary
Rationale
Primary injuries are those that occur at the time of the injury (e.g., blunt force trauma,
car accident); the subdural hematoma is itself an example of this. Secondary injuries
are those injuries resulting from the primary injury; for instance, increased intracranial
pressure may result from the hematoma. A cerebral injury is damage to the cerebrum,
and an anoxia injury results from a lack of oxygen to the brain.
p. 1300
When explaining normal intracranial pressure (ICP) balance to the
patient’s family, which three components would the nurse include?
BP, brain tissue, body mass index
Glucose level, BP, and brain tissue
BP, brain tissue, and cerebrospinal fluid
BP, brain tissue, and ventricles of the brain
Rationale
Normal ICP involves a balance of BP, brain tissue, and cerebrospinal fluid. The
ventricles of the brain, glucose level, and body mass index do not contribute to
maintaining normal ICP.
pp. 1300-1301
Which components would the nurse assess when using the Glasgow
Coma Scale (GCS) to assess a patient who sustained a head injury and
subsequently developed an increased intracranial pressure (ICP)?
Swallowing, speaking, and following verbal commands
Swallowing, pupillary response, and following verbal commands
Speaking, responding to stimuli, and following verbal commands
Responding to stimuli, swallowing, and following verbal commands
Rationale
The GSC assesses a patient’s ability to respond to stimuli, speak, and follow verbal
commands. Swallowing and pupillary response are not components of the GSC.
p. 1308
When assessing a patient’s intracranial pressure (ICP) after they
sustained a head trauma, which normative value would the nurse utilize
to compare the assessment data?
5 to 15 mm Hg
25 to 35 mm Hg
45 to 60 mm Hg
80 to 120 mm Hg
Rationale
A normal ICP reading is 5 to 15 mm Hg. Any ICP value greater than 25 mm Hg
represents a life-threatening condition requiring immediate intervention.
p. 1301
The nurse reviews the laboratory results of a patient with a cerebral
inflammatory condition and notes that glucose was absent in the
patient’s cerebrospinal fluid. The nurse recognizes that the finding is
consistent with which condition?
Encephalitis
Brain abscess
Viral meningitis
Bacterial meningitis
Rationale
The absence of glucose in cerebrospinal fluid indicates a brain abscess. The glucose
would be normal in encephalitis, would be normal or low (>40 mg/dL) in viral
meningitis, and would be decreased (5 to 40 mg/dL) in bacterial meningitis.
p. 1324
For the mechanically ventilated patient, which response would the nurse
use when family members inquire as to the benefit of maintaining the
propofol (Diprivan) drip?
Propofol facilitates efficient fluid replacement.
The treatment reduces the body’s BP.
The drug maintains electrolyte balance effectively.
The medication has a short half-life and rapid onset of action.
Rationale
The IV anesthetic propofol gained popularity in management of anxiety and agitation
because of the short half-life, which facilitates faster therapeutic action of the drug in
the body. The side effect of propofol is hypotension, which limits the use of propofol in
hypotensive patients. Propofol does not have an effect on fluid replacement or
electrolyte balance in the body.
p. 1310
For the patient with an increased intracranial pressure, who required a
tracheostomy to help to maintain adequate ventilation, which
postprocedural outcomes indicate an effective intervention? Select all
that apply.
PaO 2 of the patient is 80 mm Hg.
PaO 2 of the patient is 90 mm Hg.
PaO 2 of the patient is 110 mm Hg.
PaCO 2 of the patient is 40 mm Hg.
PaCO 2 of the patient is 30 mm Hg.
Rationale
The goal of maintaining adequate ventilation through tracheostomy is to maintain
PaO 2 of the patient greater than or equal to 100 mm Hg with PaCO 2 in the range of
35 to 45 mm Hg. Therefore the PaO 2 value of 110 mm Hg and PaCO 2 value of 40
mm Hg indicate effective treatment. A PaO 2 of less than 100 and PaCO 2 of less than
35 mm Hg indicate ineffective treatment.
p. 1307
Which position would the nurse utilize when repositioning a patient
who has an increased intracranial pressure (ICP)?
Sims'
Prone
Trendelenburg
Semi-Fowler's
Rationale
Position a patient with an increased ICP with his or her head elevated, as in semiFowler's position (typically at 30 degrees). Sims' position is side-lying with one leg
flexed, which may elevate intracranial pressure. A prone position is flat with the face
down, and the Trendelenburg position is supine with the feet higher than the head.
The head is not elevated in these positions, which is dangerous for someone with ICP.
p. 1311
While providing care for a patient with a closed head injury and
increasing intracranial pressures, which clinical manifestations
represent Cushing’s triad and require notifying the health care provider?
Select all that apply.
Bradycardia
Weak pulse
Irregular respirations
Increasing systolic BP
Decreasing systolic BP
Rationale
Cushing’s triad consists of bradycardia, irregular respiration, and a widening pulse
pressure (increasing systolic pressure). The pulse is full and bounding, not weak. The
systolic BP increases, not decreases.
p. 1303
For the patient who sustained a head trauma and has an increased
intracranial pressure, which cranial nerve (CN) would the nurse assess to
determine the patient’s papillary response?
CN X
CN V
CN III
CNXII
Rationale
CN III controls oculomotor function, so when the nurse assesses pupillary response,
he or she is checking the viability of this nerve. CN XII controls tongue movement, CN
X is the vagus nerve, and CN V is the trigeminal nerve.
p. 1309
Which assessment would the nurse perform to determine whether the
mannitol (Osmitrol) IV treatment had the desired outcome for a patient
with a head injury?
Increased BP
Decrease in body temperature
Decreased intracranial pressure
Decreased serum blood glucose
Rationale
Administering mannitol decreases intracranial pressure, so measuring this will
determine the effectiveness of the drug. Measurements of serum blood glucose, BP,
and body temperature occur, but these will not determine the effectiveness of the
mannitol.
p. 1307
When planning the care for a patient with an increased intracranial
pressure (ICP), which interventions would the nurse integrate to provide
the most comfort? Select all that apply.
Provide the patient a quiet and calm environment.
Minimize procedures that potentially produce agitation.
Facilitate an increased number of family visits to the patient.
Encourage the patient's family to increase patient interactions.
Observe the patient for signs of agitation or irritation and intervene.
Rationale
When managing the patient with increased ICP, avoid procedures that can produce
agitation. Observe the patient for signs of agitation or irritation. The environment
should be quiet and calm to provide minimal stimulation to the patient. Decrease the
stimulation levels and instruct patient's family to decrease stimulation and reduce
noise, including not visiting too frequently.
Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the
question is poor or all options are incorrect, the latter of which is more likely. Example:
If the answer you are seeking is directed to a specific treatment and all but one option deal
with signs and symptoms, you would be correct in choosing the treatment-specific option.
p. 1310
Which factors would the nurse consider prior to repositioning a patient
with an increased intracranial pressure (ICP)? Select all that apply.
Raise the head of bed above 30 degrees
Take care to prevent extreme neck flexion of patient.
Adjust body position to decrease ICP.
Rotate the patient to a side-lying position to prevent skin breakdown.
Follow protocol standards to maintain a head-up position for the patient.
Rationale
Maintaining a head-up position for the patient is important because elevation of the
head of the bed promotes drainage and decreases the vascular congestion that can
produce cerebral edema. The nurse should take care to prevent extreme neck flexion of
the patient because it can cause venous obstruction and contribute to elevated ICP.
Position the patient's body to decrease ICP and improve the cerebral perfusion
pressure (CPP). Raising the head of the bed above 30 degrees is not advisable because
it may decrease the CPP by lowering systemic BP. Rotating the patient to a side-lying
position may further increase the ICP. Special air beds can alternate skin pressures to
prevent tissue damage.
p. 1304
Which intervention would the nurse implement when providing care for
a patient experiencing an increased intracranial pressure (ICP)?
Monitor fluid and electrolyte disturbances carefully.
Position the patient in a high Fowler's position.
Administer vasoconstrictors to maintain cerebral perfusion.
Maintain physical restraints to prevent episodes of agitation.
Rationale
Monitor fluid and electrolyte disturbances vigilantly because they can have an adverse
effect on ICP. Keep the head of the patient's bed at 30 degrees in most circumstances.
Physical restraints are not applied unless necessary because agitation increases ICP. Do
not administer vasoconstrictors, typically, in the treatment of ICP.
Test-Taking Tip: Start by reading each of the answer options carefully. Usually, at least
one of them will be clearly wrong. Eliminate this one from consideration. Now you
have reduced the number of response choices by one and improved the odds.
Continue to analyze the options. If you can eliminate one more choice in a four-option
question, then you have reduced the odds to 50/50. While you are eliminating the
wrong choices, recall often occurs. One of the options may serve as a trigger that
causes you to remember what a few seconds ago had seemed completely forgotten.
pp. 1307-1308, 1310
Which intracranial pressure waveform supports the nurse’s assessment
of a compromise occurring with the patient’s intracranial compliance?
P3 wave is lower than P1 wave
P2 wave is higher than P1 wave
P2 wave is higher than P3 wave
P1, P2, and P3 resemble a staircase
Rationale
The P2 wave represents the intracranial compliance, and the P2 wave should be lower
than the P1 wave. The presence of a higher P2 wave than the P1 wave indicates
increased intracranial pressure and compromised intracranial compliance. During
normal conditions, the P3 wave is the lowest wave; the P2 wave is higher than the P3
wave; and P1, P2, and P3 waves are in order and resemble a staircase.
p. 1306
Which factors would the nurse associate with the use of hypertonic
yp
saline as a treatment for the patient with an increased intracranial
pressure (ICP)? Select all that apply.
The nurse would closely monitor the patient’s blood sugar levels.
The nurse would frequently monitor the BP and sodium levels.
Hypertonic saline treatment provides massive movement of water out of the
swollen brain cells.
Hypertonic saline treatment works similarly to mannitol (Osmitrol) when
treating increased ICP.
The nurse should ensure administration of an antacid prior to administration
to prevent gastrointestinal complications.
Rationale
Hypertonic saline provides massive movement of water out of swollen brain cells and
into blood vessels. When the patient is on this treatment, frequent monitoring of BP
and sodium levels is required because intravascular fluid volume excess can occur.
Hypertonic saline is as effective as mannitol in treating increased ICP. The treatment
does not require monitoring of blood sugar levels and does not require administration
of antacids. IV medications may be administered to prevent gastric ulcers, but not
because of the use of mannitol.
pp. 1307-1308
For the patient recovering from cranial surgery involving a bone flap,
which interventions would the nurse implement to prevent an increased
intracranial pressure (ICP)? Select all that apply.
Assess the patient's weight loss after surgery.
Frequently assess the patient's neurologic status.
Monitor the patient's serum creatinine and lipid profile.
Do not position the patient’s surgical site in a dependent position.
Closely monitor fluid and electrolyte levels and serum osmolality.
Rationale
The patient should be turned and positioned appropriately and carefully to prevent
increase in ICP. Frequent assessment of the patient's neurologic status is essential
during the first 48 hours after the cranial surgery. Closely monitor fluid and electrolyte
levels, and monitor serum osmolality to detect changes in sodium regulation, the
onset of diabetes insipidus, or severe hypovolemia. Assessing the patient's weight loss
after surgery and monitoring the patient's serum creatinine and lipid profile are not
the prime interventions after any cranial surgery because they do not affect the ICP.
STUDY TIP: Enhance your time-management abilities by designing a study program
that best suits your needs and current daily routines by considering issues such as the
following: (1) amount of time needed; (2) amount of time available; (3) "best" time to
study; and (4) time for emergencies and relaxation.
p. 1323
When the patient’s initial vital signs after a brain injury were a BP of
132/72 mm Hg, pulse 100 beats/minute, and respirations 24
breaths/minute, which subsequent vital signs would the nurse report
immediately to the health care provider?
BP 172/54 mm Hg, pulse 58 beats/minute, respirations 10 breaths/minute
BP 136/84 mm Hg, pulse 88 beats/minute, respirations 26 breaths/minute
BP 112/56 mm Hg, pulse 98 beats/minute, respirations 28 breaths/minute
BP 126/68 mm Hg, pulse 110 beats/minute, respirations 32 breaths/minute
Rationale
Fluctuations in vital signs are expected. The nurse will report a BP of 172/54 mm Hg,
pulse of 58 beats/minute, and respiration rate of 10 breaths/minute because these
values may indicate Cushing’s triad or systolic hypertension with a widening pulse
pressure, bradycardia, and irregular or low respirations. These values are indicative of
an increased intracranial pressure. BPs of 136/84, 126/68, and 112/56; pulses of 88,
110, and 98; and respiration rates of 26, 32, and 28 are not values linked to ICP when
compared to the patient’s initial vital signs.
pp. 1303, 1309, 1316
Which clinical manifestation would the nurse report immediately to the
health care provider when providing care for a patient with a traumatic
brain injury and an increased intracranial pressure (ICP)?
ICP of 20 mm Hg
Urine output of 1000 mL in one hour
Respiratory rate of 24 breaths/minute
Pulse of 100 beats/minute
Rationale
An increased urine output of 1000 mL in one hour could cause critical fluid and
electrolyte imbalance issues and needs prompt attention; this indicates a decline in the
patient’s condition. An ICP of 20 mm Hg, respiratory rate of 24 breaths/minute, and
pulse of 100 beats/minute do not indicate a need for the nurse to call the health care
provider.
p. 1310
Which intervention would the nurse implement when providing care for
a patient with an increased intracranial pressure (ICP)?
Place the patient in a supine position.
Monitor ICP continuously.
Administer D 5W IV infusions.
Withhold opiates to protect respiratory status.
Rationale
Because ICP is a dangerous condition, the nurse must monitor constantly. Patients
with ICP need to be in a semi-Fowler's, not supine, position. The administration of
D5W IV fluids will decrease serum osmolality and increase, not decrease, ICP. Opiates
such as morphine and fentanyl are rapid acting and have little effect on cerebral
perfusion; however, there is a need to monitor the patient’s respiratory status closely.
pp. 1304, 1308
For the patient admitted for observation after a minor head injury,
which assessment findings would support the nurse’s suspicion of an
increasing intracranial pressure? Select all that apply.
The patient is alert and oriented.
The patient is experiencing hemiplegia.
The patient has unilateral pupil dilation.
The patient has a regular respiratory rate of 14 breaths/min.
The patient is vomiting without preceding nausea.
Rationale
Unilateral pupil dilation, vomiting, and hemiplegia are signs of increased intracranial
pressure. A patient with increased intracranial pressure would likely have an impaired
level of consciousness rather than being alert and oriented. He or she would also have
an irregular, not regular, respiratory rate.
p. 1304
When providing a community safety presentation, which disorder would
the nurse include as a possible cause for a patient’s increased
intracranial pressure?
Sinusitis
Cor pulmonale
Diabetes insipidus
Subdural hematoma
Rationale
A subdural hematoma is a collection of blood between the brain and its covering,
which can cause intracranial pressure. Sinusitis is a respiratory disorder, which would
not cause increased intracranial pressure. Cor pulmonale is a cardiorespiratory
disorder, which would not affect intracranial pressure. Diabetes insipidus is an
endocrine disorder affecting glucose regulation, not intracranial pressure.
pp. 1313-1314
Which disorder would the nurse associate with a patient who has
meningitis with seizures, cranial nerve (CN) III palsy, and bradycardia?
Cerebral abscess
Subdural effusion
Acute cerebral edema
Increased intracranial pressure
Rationale
Acute cerebral edema is a complication of meningitis that causes seizures, CN III palsy,
and bradycardia. Cerebral abscess, subdural effusion, and increased intracranial
pressure are complications of meningitis, but they do not cause the aforementioned
symptoms.
Test-Taking Tip: Be alert to details such as most in the question stem. Recollect the
concepts and apply the appropriate ones, and re-read the options until you are strong
enough to conclude the option to be the suitable one.
p. 1325
Which inflammatory condition would the nurse associate to the
common cause of acute nonepidemic encephalitis?
St. Louis encephalitis
Eastern equine encephalitis
Western equine encephalitis
Herpes simplex virus encephalitis
Rationale
Herpes simplex virus encephalitis is the most common cause of acute nonepidemic
viral encephalitis. St. Louis encephalitis, eastern equine encephalitis, and western
equine cause epidemic encephalitis.
p. 1324
For which complication would the nurse monitor potential development
while providing care for a patient with meningitis and ventricle
adhesions that prevent the normal flow of cerebrospinal fluid?
Cerebral abscess
Acute cerebral edema
Cranial nerve irritation
Noncommunicating hydrocephalus
Rationale
Adhesions preventing the normal flow of cerebrospinal fluid lead to an obstruction of
the foramen magnum, which causes noncommunicating hydrocephalus. Cerebral
abscess is an accumulation of pus within the brain tissue. An acute cerebral edema is
an abnormal increase in water content within the extracellular fluid of the brain. The
condition occurs due to hydrocephalus. Cranial nerve irritation is caused by neurologic
dysfunctions because of increased intracranial pressure.
Test-Taking Tip: Be alert to the details such as first in the question stem. Recollect
your learning about pathophysiology of bacterial meningitis.
p. 1325
Which intervention would the nurse implement when a patient,
receiving treatment for viral meningitis since last week, arrives at the
hospital reporting a persistent severe headache?
Instruct the patient to use analgesics for the headache.
Inform the patient that headaches can occur after recovery.
Teach the patient that a headache is not a major complication.
Notify the patient that a full recovery from viral meningitis is not possible.
Rationale
Inform the patient that headaches might occur postrecovery, even though they are a
rare manifestation. Treat the patient symptomatically based on the reason for
developing the headache. A complete recovery is expected. A severe headache might
be a major complication.
Test-Taking Tip: Attention to details for words such as most in the question stem.
Recollect your learning about treatment outcomes for viral meningitis.
p. 1325
Which interventions would the nurse implement to prevent injury to the
patient with an increased intracranial pressure (ICP) and a decreased
level of consciousness in the intensive care unit? Select all that apply.
Consider administering light sedation agents.
Observe the skin area under the restraints.
Use a stimulating environment in the room.
Keep family members away from the patient.
Use effective restraints in an agitated patient.
Rationale
To prevent injury to the patient, the nurse should consider the use of light sedation
agents, as prescribed by the health care provider. Check skin area under the restraints
for signs of irritation because the irritation can increase the patient's agitation. Using
effective restraints in an agitated patient is advisable to ensure a secure outcome. The
room should not have a stimulating environment; a calm, nonstimulating
environment will help. Do not prevent family members from visiting the patient;
instead, allow a family member to visit to assist in calming the patient.
p. 1326
To determine the amount of cerebral spinal fluid to drain from a
patient’s ventricle catheter, the nurse calculates the cerebral perfusion
pressure (CPP) of an unconscious patient whose BP is 162/58 mm Hg
and intracranial pressure (ICP) is 35 mm Hg. Identify the patient’s CPP.
Record your answer using a whole number.
58
mm Hg
Rationale
The nurse calculates the CPP by subtracting the ICP from the mean arterial pressure
(MAP). The MAP is [162 + 2(58)]/3 = 193. The nurse subtracts 35 from 93 to determine
that the patient’s CPP is 58 mm Hg.
p. 1301
After assessing the breathing patterns of four assigned patients, which
patient would the nurse suspect of having a lesion in the medulla of the
brain?
The patient with cluster breathing
The patient with apneustic breathing
The patient with Cheyne-Stokes breathing
The patient with central neurogenic hyperventilation
Rationale
Lesions in the medulla may affect the breathing pattern, resulting in clustered
breathing with irregular pauses in between. Lesions on mid or lower pons cause
apneustic breathing. Bilateral hemispheric disease causes a Cheyne-Stokes pattern of
breathing. Lesions on the brainstem between lower midbrain and upper pons cause
central neurogenic hyperventilation.
Test-Taking Tip: You have at least a 25% chance of selecting the correct response in
multiple-choice items. If you are uncertain about a question, eliminate the choices that
you believe are wrong and then call on your knowledge, skills, and abilities to choose
from the remaining responses.
p. 1310
Which interventions would the nurse implement to avoid complications
associated with the corticosteroid treatment prescribed for a patient
with an increased intracranial pressure (ICP)? Select all that apply.
Monitor fluid intake and sodium levels regularly.
Monitor patient's sleep and diet routine regularly.
Perform blood glucose monitoring at least every six hours.
Avoid taking any antacids along with corticosteroid treatment.
Initiate concurrent treatment with antacids or proton pump inhibitors.
Rationale
Regularly monitor patients on corticosteroid treatment for fluid intake and sodium
levels. Perform blood glucose monitoring at least every six hours until ruling out
hyperglycemia from the steroids. Starting concurrent treatment with antacids or
proton pump inhibitors is important to prevent gastrointestinal ulcers and bleeding
because complications associated with the use of corticosteroids include
hyperglycemia, increased incidence of infections, and gastrointestinal bleeding.
Regularly monitoring the patient's sleep and diet routine does not contribute to
avoiding complications related to corticosteroid therapy. Administer antacids along
with corticosteroids to prevent gastrointestinal complications.
Test-Taking Tip: Try putting questions and answers in your own words to test your
understanding.
p. 1308
Which factors would the nurse consider when preparing to administer
the pharmacologic therapy for a patient with an increased intracranial
pressure (ICP)? Select all that apply.
Use benzodiazepines as a standalone treatment for sedation.
Monitor for hypotension when using opioids to manage anxiety.
Monitor for hypotension when using continuous IV sedatives.
Use nondepolarizing neuromuscular blocking agents alone for better
outcomes.
Use sedatives or analgesics with nondepolarizing neuromuscular blocking
agents.
Rationale
The appropriate factors to evaluate include monitoring for hypotension when using
opioids to manage anxiety and monitoring for hypotension when using continuous IV
sedatives because hypotension is a side effect. Using sedatives or analgesics with
nondepolarizing neuromuscular blocking agents is important because these agents
paralyze muscles without blocking pain or noxious stimuli. Using benzodiazepines as a
standalone treatment for sedation is not advisable due to their hypotensive effects and
long half-life. Nondepolarizing neuromuscular blocking agents paralyze muscles
without blocking pain or noxious stimuli; providers use these agents in combination
with sedatives, analgesics, or benzodiazepines.
Test-Taking Tip: Note the number of questions and the total time allotted for the test
to calculate the times at which you should be halfway and three-quarters finished with
the test. Look at the clock only every 10 minutes or so.
p. 1310
For the patient who experienced head trauma from a motor vehicle
crash, place the progressive pathophysiology steps in order from the
injury to severe increased intracranial pressure (ICP) and death.
1.
Tissue edema from initial insult
2.
Increased ICP
3.
Compression of ventricles and blood vessels
4.
Decreased cerebral blood flow
5.
Increased ICP with brainstem compression
6.
Increased ICP from increased blood volume
Rationale
After initial insult to the brain, there is tissue edema, which causes an initial increase
in ICP; then compression of ventricles and blood vessels occurs, which decreases
cerebral blood flow, thus decreasing O 2 and causing death of brain cells. Edema
occurs around this necrotic tissue, and increased ICP with compression of the
brainstem and respiratory center occurs, leading to accumulation of CO 2. Further
increases in ICP occur from increased blood volume, which leads to death.
Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the
options presented. For example, you might be asked the steps of performing a nursing
action or skill such as those involved in medication administration.
p. 1302
The initial assessment of a patient in the postanesthesia care unit
recovering from a brain tumor resection included a temperature of
100°F (37.7°C), BP of 130/76 mm Hg, pulse 64 beats/min, a urinary
catheter in place, and oxygen at a rate of 2 L/min by nasal cannula. One
hour later, which assessment finding would the nurse immediately
report to the surgeon?
Presence of a gag reflex
Urine output of 50 mL during the past hour
BP of 148/58 mm Hg and pulse 48 beats/min
Temperature of 99.8°F (37.6°C) and pulse of 96 beats/min
Rationale
Associate a BP with a widening pulse pressure, bradycardia, and irregular respirations
with an increasing intracranial pressure (ICP) known as the Cushing's triad, which
should be reported immediately. Presence of a gag reflex, urine output of 50 mL over
an hour, and temperature of 99.8°F (37.6°C) and pulse of 96 beats/min are acceptable
assessment findings in a postoperative patient.
pp. 1309, 1316
While utilizing the Glasgow Coma Scale (GCS) to assess a patient’s level
of consciousness, which potential responses would the nurse document
under best motor response? Select all that apply.
Flexion withdrawal
Localization of pain
Obedience of command
Disorganized use of words
Opening the eyes in response to sound
Rationale
Utilize flexion withdrawal, localization of pain, and obedience of command to record a
patient’s best motor response. Do not use opening of the eyes in response to stimuli
and disorganized use of words under the scale’s motor response.
p. 1308
Which interventions would the nurse implement to promote optimal
outcomes for the patient with an increased intracranial pressure (ICP)?
Select all that apply.
Maintain fluid balance and assess osmolality.
Maintain intubation and mechanical ventilation.
Lower the head of the bed and turn the patient to one side.
Wait for the respirations to improve before beginning with ventilation.
Elevate the head of the bed to 30 degrees with the head in a neutral position.
Rationale
Intubation and mechanical ventilation, maintenance of fluid balance and assessment
of osmolality, and elevation of head of bed to 30 degrees with head in a neutral
position are the appropriate actions to be performed when managing a patient with
increased intracranial pressure (ICP). Waiting for the respiration to improve may be
life-threatening. Lowering of the head of the bed and turning the patient to one side
may further increase the intracranial pressure.
pp. 1310-1311
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Which intervention would the nurse implement as the priority when
providing care for a patient with a ventriculostomy to measure increased
intracranial pressures (ICP) caused by a brain tumor?
Administer IV mannitol (Osmitrol).
Maintain hyperoxygenation through use of a ventilator.
Use strict aseptic technique with all procedural dressing changes.
Be aware of changes in ICP related to leaking cerebrospinal fluid (CSF).
Rationale
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. Administer IV mannitol or hypertonic saline as prescribed. Potential
ventilator use is to maintain oxygenation, not hyperoxygenation. CSF leaks may cause
inaccurate ICP readings, or staff may drain CSF to decrease the patient’s ICP, but strict
aseptic technique to prevent infection is the nurse's priority of care.
p. 1306
For the patient with an increased intracranial pressure (ICP), which
precautions would the nurse implement to protect the patient from
potential seizure activity? Select all that apply.
Keep suction equipment readily available at the patient’s bedside.
Provide sufficient stimulation of the patient to avoid comatose behaviors.
Implement seizure treatment only after confirming the seizure diagnosis.
Pad side rails and maintain an airway at the bedside per facility protocol.
Use prophylactic antiseizure therapy during first seven days after injury.
Rationale
Using padded side rails helps to prevent injury from falling. Keeping an airway at the
bedside and suction equipment readily available is helpful in managing seizures if they
occur. Utilize prophylactic antiseizure therapy during the first seven days after injury to
prevent seizures. Providing stimulation to the patient may aggravate the condition;
therefore the environment should be quiet. Seizure treatment should be used
prophylactically. Implement seizure treatment instead of waiting for the confirmation
of diagnosis or the seizures to occur. The nurse should administer antiseizure
treatment in this situation.
p. 1311
Which interventions would the nurse implement as a part of nutritional
therapy for the patient with an increased intracranial pressure (ICP)?
Select all that apply.
Keep the patient in a hypovolemic fluid state.
Begin parenteral nutrition if oral intake is not adequate.
Initiate nutritional replacement within three days after injury.
If comatose, wait at least seven days to begin nutritional replacement.
Evaluate the patient's urine output, fluid loss, and electrolyte balance.
Rationale
For a patient with increased ICP, begin parenteral nutrition or enteral feedings if oral
intake is not adequate. Initiate nutritional replacement within three days after injury.
Monitor the patient's urine output, fluid loss, and electrolyte balance to evaluate the
effectiveness of nutritional therapy. Do not keep the patient in a hypovolemic fluid
state; the patient needs to be in a normovolemic state. Instead of waiting, the desired
treatment is to reach full nutritional replacement within seven days after injury. Do not
confuse reducing brain edema with mannitol (Osmitrol) with the overall fluid balance
in the body.
p. 1308
After performing a patient’s assessment, which condition supports the
nurse’s intervention to decline IV administration of mannitol (Osmitrol)
to the patient?
Cerebral edema
Cerebral tissue swelling
Increased serum osmolality
Increased intracranial pressure (ICP)
Rationale
Mannitol increases the osmotic effect and may cause neurologic complications;
contraindications include administering to a patient with an increased serum
osmolality. Use mannitol to treat cerebral edema, cerebral tissue swelling, and
increased ICP because of its diuretic effect.
p. 1307
Which outcome would the nurse anticipate after administering a high
dose of prescribed barbiturates to the patient with an increased
intracranial pressure (ICP)?
The medication reduces the vasogenic edema.
Barbiturates decrease the level of cerebral metabolism.
The drug facilitates plasma expansion and an osmotic effect.
The therapy promotes massive movement of water out of brain cells.
Rationale
High doses of barbiturates decrease cerebral metabolism levels in patients with
increased ICP and helps to reduce ICP. Use corticosteroids to reduce vasogenic edema.
Mannitol (Osmitrol) acts to decrease ICP through plasma expansion and osmotic
effect. Hypertonic saline solution causes massive movement of water out of the brain
cells into the blood vessels.
Test-Taking Tip: Recall the actions and uses of barbiturates to answer this question
accurately.
p. 1304
When the unlicensed assistive personnel (UAP) reports the vital signs
(VS) of a patient with a suspected brain injury as temperature = 101.6° F
(38.7° C) orally, heart rate = 58 beats/minute, respiratory rate = 14
breaths/minute, and BP = 162/48 mm Hg, which action would the nurse
implement first?
Ask the UAP to repeat the BP.
Validate the VS by repeating the measurements.
Compare the current VS to recorded baseline VS.
Administer prescribed acetaminophen (Tylenol) for fever.
Rationale
Increasing pressure on the thalamus, hypothalamus, pons, and medulla changes a
patient’s VS. Manifestations, such as Cushing's triad (systolic hypertension with a
widening pulse pressure, bradycardia with a full and bounding pulse, and irregular
respirations), are often late signs of markedly increased intracranial pressure (ICP). The
nurse should compare the vital signs obtained with baseline vital signs recorded. If
there is a deviation from baseline, the nurse should assess the patient, including a
repeat set of VS to validate findings. More than just the BP can change with increased
intracranial pressure; therefore asking the UAP to repeat the BP only will not provide
any further data. An elevated temperature in a patient with a head injury may indicate
a hypothalamic response from injury. The nurse should gather all assessment data
before administering acetaminophen.
p. 1320
To preserve cerebral perfusion of a patient with an elevated intracranial
pressure (ICP), which cerebral perfusion pressure (CPP) would the nurse
maintain when suctioning the patient?
20 mm Hg
40 mm Hg
60 mm Hg
80 mm Hg
Rationale
Patients with elevated ICP are at risk for lower CPP during suctioning. When
suctioning, maintain the patient’s CPP above 60 mm Hg to preserve cerebral
perfusion.
p. 1301
When performing the prescribed intermittent drainage of cerebrospinal
fluid (CSF) from a previously inserted ventriculostomy system, in which
order would the intensive care unit nurse drain the fluid?
1.
Obtain the intracranial pressure (ICP) and determine whether the pressure is above
the prescribed level.
2.
Open the ventriculostomy system when ICP is greater than the prescribed pressure.
3.
Allow the CSF to drain for two to three minutes into the collection bag.
4.
Close the stopcock to return the ventriculostomy to a closed system.
Rationale
The first step is determining that the ICP is above the prescribed/desired level. If ICP is
above the indicated level, opening the ventriculostomy system at the indicated ICP is
the next step. After opening the stopcock, allow CSF to drain for two to three minutes
to relieve the pressure in the cranial vault. Closing the stopcock to return the
ventriculostomy to a closed system is the final step. Always maintain strict aseptic
techniques when performing this intervention.
pp. 1306-1307
A patient’s systemic BP is 120/60 mm Hg and the intracranial pressure
(ICP) is 24 mm Hg. After calculating the patient’s cerebral perfusion
pressure (CPP), which interpretation would the nurse apply to the
results?
High blood flow to the brain
Normal ICP
Impaired blood flow to the brain
Adequate autoregulation of blood flow
Rationale
A normal CPP is 60 to 100 mm Hg. Determine the calculated CPP by subtracting the
ICP from the mean arterial pressure (MAP).
MAP = (systolic blood pressure [SBP] + 2[diastolic blood pressure (DBP)])/3: (120 mm
Hg + 2[60 mm Hg])/3 = 120 mm Hg + 120 mm Hg = 240 mm Hg; 240/3 = 80 mm Hg.
MAP-ICP: 80 mm Hg (MAP) - 24 mm Hg (ICP) = a CPP of 56 mm Hg.
The decreased CPP (<60 mm Hg) indicates an impaired cerebral blood flow and
impaired autoregulation of the CPP. Because the ICP is 24 mm Hg, the pressure is
elevated, preventing perfusion of the brain, and requires treatment.
p. 1301
When assessing a patient’s level of consciousness, which potential
Glasgow Coma Scale (GCS) scores indicate the patient is in a comatose
state? Select all that apply.
4
5
6
9
11
Rationale
A GCS score of 8 or less generally indicates coma. Scores of 9 or 11 are greater than 8,
and do not indicate coma.
pp. 1305, 1310
Which term would the nurse use to document a patient who is
comatose from a head injury and displays flexion of the arms, wrists,
and fingers, as well as adduction of the upper extremities?
Stroke
Epileptic seizure
Decorticate posturing
Decerebrate posturing
Rationale
Decorticate posturing—described as flexion of the arms, wrists, and fingers—and
adduction of the upper extremities indicate damage to the primary motor areas of the
sensorimotor cortex, both anterior and posterior. The described assessment findings
do not specifically relate to describing a stroke or cerebrovascular accident and are not
commonly seen in patients with epileptic seizure disorders. A nurse would describe
decerebrate posturing as rigid extension of all four extremities with hyperpronation of
the forearms and flexion of the feet. Decerebrate posturing results from disruption of
motor fibers in the midbrain and brainstem and indicates serious tissue damage.
p. 1304
Which outcome would the nurse expect after administration of IV
mannitol (Osmitrol) prescribed for a patient experiencing an increased
intracranial pressure (ICP)?
Increased urine output
Decreased BP
Reduced ICP
Increased intracranial perfusion
Rationale
Mannitol is an osmotic diuretic that increases osmotic pressure in the renal tubules to
increase the uptake of water and dieresis by the kidneys, which specifically helps to
relieve cerebral edema, thereby decreasing ICP. Increased urine output, decreased BP,
and increased intracranial perfusion are secondary outcomes of administration of
mannitol. Of these, increased intracranial perfusion is most desirable because it
reduces ICP. Monitor BPs closely because an extreme decrease in BP may occur,
resulting in decreased intracranial perfusion.
pp. 1304, 1325
1 topics covered