Lewis Chapter 57 - Acute Intracranial Problems (Pre-test, Bridge NCLEX, NCLEX Review)

Lewis Chapter 57 - Acute Intracranial Problems (Pre-test, Bridge NCLEX, NCLEX Review) Leave the first rating Students also studied Terms in this set (26) Science MedicineNursing Save ReXPN Exam Review 772 terms Kaitlyn_Mossey Preview Med-Surg: Lewis: Chapter 57: Acute ...68 terms gvilleshirleyPreview ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview Lewis C 57 terms mic The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which complications (select all that apply)?

• Vision loss
• Cerebral edema
• Pituitary dysfunction
• Parathyroid dysfunction
• Focal neurologic deficits

A,B,C,E

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.A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak?

• A halo sign on the nasal drip pad
• Decreased blood pressure and urinary output
• A positive reading for glucose on a Test-tape strip
• Clear nasal drainage along with the bloody discharge

A 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.

The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation?

• Tonic spasms of the legs
• Curling in a fetal position
• Arching of the neck and back
• Resistance to flexion of the neck

D 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.The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)?

• Tachypnea
• Bradycardia
• Hypotension
• Narrowing pulse pressure

B 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.The nurse is providing care for a patient who has been admitted to the hospital with a head injury and who requires regular neurologic and vital sign assessment.Which assessments will be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)?

• Judgment
• Eye opening
• Abstract reasoning
• Best verbal response
• Best motor response
• Cranial nerve function

B,D,E 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.What nursing intervention should be implemented in the care of a patient who is experiencing increased ICP?

• Monitor fluid and electrolyte status carefully.
• Position the patient in a high Fowler's position.
• Administer vasoconstrictors to maintain cerebral

perfusion.

• Maintain physical restraints to prevent episodes of

agitation.A 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.Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse should recognize that the patient will most likely need which treatment modality?

• Surgery
• Chemotherapy
• Radiation therapy
• Biologic drug therapy

A 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.

A patient has a systemic blood pressure of 120/60 and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results?

• High blood flow to the brain
• Normal intracranial pressure
• Impaired blood flow to the brain
• Adequate autoregulation of blood flow

C 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.Decerebrate posture is documented in the chart of the patient that the nurse will be caring for. The nurse should know that the patient may have elevated ICP causing serious disruption of motor fibers in the midbrain and brainstem and will expect the patient's posture to look like which posture represented below?B Decerebrate posture is all four extremities in rigid extension with hyperpronation of the forearms and plantar flexion of feet. Decorticate posture is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers from interruption of voluntary motor tracts in the cerebral cortex. Decorticate response on one side of the body and decerebrate response on the other side of the body may occur depending on the damage to the brain. Opisthotonic posture is decerebrate posture with the neck and back arched posteriorly and may be seen with traumatic brain injury.The patient with increased ICP from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient?

• Administer IV mannitol (Osmitrol).
• Ventilator use to hyperoxygenate the patient
• Use strict aseptic technique with dressing changes.
• Be aware of changes in ICP related to leaking CSF.

C 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.A male patient suffered a diffuse axonal injury from a traumatic brain injury (TBI). He has been maintained on IV fluids for 2 days. The nurse seeks enteral feeding for this patient based on what rationale?

• Free water should be avoided.
• Sodium restrictions can be managed.
• Dehydration can be better avoided with feedings.
• Malnutrition promotes continued cerebral edema.

D 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.In planning long-term care for a patient after a craniotomy, what must the nurse include when teaching the patient, family, and caregiver?

• Seizure disorders may occur in weeks or months.
• The family will be unable to cope with role reversals.
• There are often residual changes in personality and

cognition.

• Referrals will be made to eliminate residual deficits

from the damage.C 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.

The physician orders intracranial pressure (ICP) readings every hour for a 23-year-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action?

• Document the ICP reading in the chart.
• Determine if the patient has a headache.
• Assess the patient's level of consciousness.
• Position the patient with head elevated 60 degrees.

C The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness.The Glasgow Coma Scale may be used to determine the degree of impaired consciousness.A 19-year-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Clear fluid is draining from the patient's nose. What action by the nurse is most appropriate?

• Apply a loose gauze pad under the patient's nose.
• Place the patient in a modified Trendelenburg position.
• Ask the patient to gently blow the nose to clear the

drainage.

• Gently insert a catheter in the nares and suction the

drainage.A Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. If CSF rhinorrhea occurs, the nurse should inform the physician immediately. A loose collection pad may be placed under the nose. The head of the bed may be raised to decrease the CSF pressure so that a tear can seal. The nurse should not place a dressing or tube in the nasal cavity, and the patient should not sneeze or blow the nose.The nurse prepares to administer temozolomide (Temodar) to a 59-year-old white male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication?

• Serum potassium and serum sodium levels
• Urine osmolality and urine specific gravity
• Absolute neutrophil count and platelet count
• Cerebrosprinal fluid (CSF) pressure and cell count

C Temozolomide causes myelosuppression. The nurse should assess the absolute neutrophil count and the platelet count. The absolute neutrophil count should be >1500/μL and platelet count >100,000/μL.A 32-year-old female patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary adenoma. What should the nurse consider as a sign of improvement?

• Serum sodium of 120 mEq/L
• Urine specific gravity of 1.001
• Fasting blood glucose of 80 mg/dL
• Serum osmolality of 290 mOsm/kg

D Laboratory findings in diabetes insipidus include an elevation in serum osmolality and serum sodium and a decrease in urine specific gravity. Normal serum osmolality is 275 to 295 mOsm/kg, normal serum sodium is 135 to 145 mEq/L, and normal specific gravity is 1.003 to 1.030. Elevated blood glucose levels occur with diabetes mellitus.A 68-year-old man with suspected bacterial meningitis has just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first?

• Codeine
• Phenytoin (Dilantin)
• Ceftriaxone (Rocephin)
• Acetaminophen (Tylenol)

C Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted immediately after the collection of specimens for cultures, and even before the diagnosis is confirmed.Dexamethasone may also be prescribed before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).