Intracranial Regulation NCLEX Questions

Intracranial Regulation NCLEX Questions Leave the first rating Students also studied Terms in this set (25) Save Neurological NCLEX Questions 55 terms marissaxxcarol Preview ATI - Human Growth and Developm...15 terms jaysasmithPreview

NCLEX-style questions: Intracranial ...

20 terms hannahk0729Preview Schizop 17 terms Silly Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation?

• "This type of monitoring system is complex, and it is

managed by skilled staff."

• "The monitoring system helps show whether blood

flow to the brain is adequate."

• "The ventriculostomy monitoring system helps check

for changes in cerebral perfusion pressure."

• "This monitoring system has many benefits, including

the ability to drain cerebrospinal fluid."

• "The monitoring system helps show whether blood flow to the brain is

adequate." Short, simple, and accurate explanations should be given initially to patients and family members. Explaining that the system is complex, and it is managed by skilled staff or that it has multiple benefits does not address the family question about purpose for this patient. Terminology such as ventriculostomy and cerebral perfusion pressure is too complex for the initial explanation and may increase family members' anxiety.Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

• Blood pressure 154/68 mm Hg, pulse 56 beats/min,

respirations 12 breaths/min

• Blood pressure 134/72 mm Hg, pulse 90 beats/min,

respirations 32 breaths/min

• Blood pressure 148/78 mm Hg, pulse 112 beats/min,

respirations 28 breaths/min

• Blood pressure 110/70 mm Hg, pulse 120 beats/min,

respirations 30 breaths/min

• Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min

Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life- threatening process.

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?

• Flexion withdrawal
• Localization of pain
• Decorticate posturing
• Decerebrate posturing
• Decorticate posturing

Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness?

• Blood pressure
• Oxygen saturation
• Intracranial pressure
• Hemoglobin and hematocrit
• Intracranial pressure

Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve because of mannitol administration A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How should the nurse record the patient's Glasgow Coma Scale score?

• 9.
• 11.
• 13.
• 15.
• 11.

The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment. What action is best for the nurse to take?

• Call the family's pastor or spiritual advisor to take them

to the chapel.

• Ask the family to stay in the waiting room until the

assessment is completed.

• Allow the family to stay with the patient and briefly

explain all procedures to them.

• Refer the family members to the hospital counseling

service to deal with their anxiety.

• Allow the family to stay with the patient and briefly explain all procedures to

them.The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

• Encourage coughing and deep breathing.
• Position the patient with knees and hips flexed.
• Keep the head of the bed elevated to 30 degrees.
• Cluster nursing interventions to provide rest periods.
• Keep the head of the bed elevated to 30 degrees.

The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

When assessing a patient who has a right frontal lobe tumor, what finding should the nurse expect?

• Expressive aphasia
• Impaired judgment
• Right-sided weakness
• Difficulty swallowing
• Impaired judgment

The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.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 should the nurse take first?

• Document the increase in intracranial pressure.
• Ensure that the patient's neck is in neutral position.
• Notify the health care provider about the change in

pressure.

• Increase the rate of the prescribed propofol (Diprivan)

infusion.

• Ensure that the patient's neck is in neutral position.

Because suctioning will cause a transient increase in ICP, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes.Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in ICP.Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?

• A 45-yr-old patient receiving IV antibiotics for

meningococcal meningitis

• A 35-yr-old patient with intracranial pressure (ICP)

monitoring after a head injury

• A 25-yr-old patient admitted with a skull fracture and

craniotomy the previous day

• A 55-yr-old patient who is receiving hyperventilation

therapy for increased ICP

• A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis

An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The patient recovering from a craniotomy, the patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now reporting a headache. Which prescribed intervention should the nurse implement first?

• Administer IV 5% hypertonic saline.
• Draw blood for arterial blood gases (ABGs).
• Send patient for computed tomography (CT).
• Administer acetaminophen (Tylenol) 650 mg.
• Administer IV 5% hypertonic saline.

The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level.Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

After the emergency department nurse has received a status report on the following patients with head injuries, which patient should the nurse assess first?

• A 20-yr-old patient whose cranial x-ray shows a linear

skull fracture

• A 30-yr-old patient who lost consciousness for 10

seconds after a fall

• A 40-yr-old patient who has an initial Glasgow Coma

Scale score of 13

• A 50-yr-old patient whose right pupil is 10 mm and

unresponsive to light

• A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light

The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?

• Pulse of 102 beats/min
• Temperature of 101.6° F
• Intracranial pressure of 15 mm Hg
• Mean arterial pressure of 90 mm Hg
• Temperature of 101.6° F

Infection is a serious complication of ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse only require ongoing monitoring at this time.The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

• The staff nurse assesses neurologic status every hour.
• The staff nurse elevates the head of the bed to 30

degrees.

• The staff nurse suctions the patient routinely every 2

hours.

• The staff nurse administers an analgesic before turning

the patient.

• The staff nurse suctions the patient routinely every 2 hours.

Suctioning increases intracranial pressure and should only be done when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to the unlicensed assistive personnel (UAP) who regularly works in the intensive care unit?

• Document intracranial pressure every hour.
• Turn and reposition the patient every 2 hours.
• Check capillary blood glucose level every 6 hours.
• Monitor cerebrospinal fluid color and volume hourly.
• Check capillary blood glucose level every 6 hours.

Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require registered nurse (RN)- level education and scope of practice. Although repositioning patients is frequently delegated to UAP, repositioning a patient with a ventriculostomy is complex and should be supervised by the RN.