TBIICP NCLEX Questions

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Unit 4:

64 terms sav In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?a.) Complete set of vital signs b.) Palpation and auscultation of the abdomen c.) Brief neurologic assessment d.) Initiation of pulse oximetry c.) Brief neurologic assessment

Rationale:

A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.A pediatric client is admitted to the neuro ICU with a closed-head injury sustained after falling out of a tree house. The mechanisms of injury this young client most

likely sustained would be:

a.) Acceleration b.) Penetrating c.) Rotational d.) Deceleration d.) Deceleration

Rationale:

Deceleration injury occurs when the brain stops rapidly in the cranial vault. As the skull ceases movement, the brain continues to move until it hits the skull. The force of deceleration causes injury at the site of impact. An example of this is a victim of a fall.A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make?A.) Observe the color of the fingers B.) Palpate the radial pulse under the cast C.) Check the cast for odor and drainage D.) Evaluate the response to analgesics D.) Evaluate the response to analgesics

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?a.) Vomiting continues b.) Intracranial pressure (ICP) is increased c.) The client needs mechanical ventilation d.) Blood is anticipated in the cerebralspinal fluid (CSF) b.) Intracranial pressure (ICP) is increased

Rationale:

Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?a.) To reduce intraocular pressure b.) To prevent acute tubular necrosis c.) To promote osmotic diuresis to decrease ICP d.) To draw water into the vascular system to increase blood pressure c.) To promote osmotic diuresis to decrease ICP

Rationale:

Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?a.) Urine output increases b.) Pupils are 8 mm and nonreactive c.) Systolic blood pressure remains at 150 mm Hg d.) BUN and creatinine levels return to normal a.) Urine output increases

Rationale:

Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.Which of the following signs and symptoms of increased ICP after head trauma would appear first?a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure c.) Restlessness and confusion

Rationale:

The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.Problems with memory and learning would relate to which of the following lobes?a.) Frontal b.) Occipital c.) Parietal d.) Temporal d.) Temporal

Rationale:

The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily functions with sensory function.

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional?a.) Frontal b.) Occipital c.) Parietal d.) Temporal c.) Parietal

Rationale:

The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?a.) Sternal rub b.) Pressure on the orbital rim c.) Squeezing the sternocleidomastoid muscle d.) Nail bed pressure d.) Nail bed pressure

Rationale:

Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The

nurse understands that this indicates the client has:

a.) A cerebral lesion b.) A temporal lesion c.) An intact brainstem d.) Brain death c.) An intact brainstem

Rationale:

Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?a.) Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.c.) Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.d.) Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

Rationale:

A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of

surgery if the client exhibits:

a.) A positive Brudzinski's sign b.) A negative Kernig's sign c.) Absence of nuchal rigidity d.) A Glascow Coma Scale score of 15 a.) A positive Brudzinski's sign

Rationale:

Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.A client with a head injury is being monitored for increased intracranial pressure (ICP). His mean arterial pressure (MAP) is 70 and the ICP is 18 mmHg; therefore

his cerebral perfusion pressure (CPP) is:

a.) 52 mm Hg b.) 88 mm Hg c.) 48 mm Hg d.) 68 mm Hg a.) 52 mm Hg

Rationale:

CCP=MAP-ICP

70-18=52

CCP=52

CCP is maintained above 60 mm Hg For a male client with suspected increased intracranial

pressure (ICP), a most appropriate respiratory goal is to:

a.) Prevent respiratory alkalosis.b.) Lower arterial pH.c.) Promote carbon dioxide elimination.d.) Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg c.) Promote carbon dioxide elimination.

Rationale:

The goal in treatment is to prevent acidemia by eliminating carbon dioxide.A patient is admitted with a subacute subdural hematoma.The nurse realizes this patient will most likely be treated

with:

a.) Emergency craniotomy.b.) Elective draining of the hematoma.c.) Burr holes to remove the hematoma.d.) Removal of the affected cranial lobe.b.) Elective draining of the hematoma.A patient with a traumatic brain injury is in need of fluid replacement therapy to maintain a systole blood pressure of at least 90 mm Hg. The nurse realizes that the best

fluid replacement for this patient would be:

a.) Normal saline.b.) D5W c.) D5 1/2 0.9% NS d.) 0.45% NS a.) Normal saline.

Rationale:

A systolic blood pressure less than 90 mm Hg in a patient with a traumatic brain injury is a predictor of a poor outcome. Initial management usually involves assuring that the patient is hydrated. Isotonic crystalloids such as 0.9% saline or Ringer's solution are most commonly used. Normal Saline is preferred because it is inexpensive, iso-osmolar and has no free water.#2 and #4 are not correct. In general, the use of hypotonic crystalloids, such as D5W or 0.45% normal saline is avoided because of the potential for worsening cerebral edema.#3 is not correct. D51/2 NS is hypertonic and will draw fluid from the cells & interstial tissue into the vascular space. This could worsen cerebral edema.