Exam 10: Care of the Patient Experiencing an Intracranial Dysfunction

A patient experiencing a fever, stiff neck, and change in mental status has a positive Kernig's sign. What should these findings suggest to the nurse?

The nurse prepares to conduct an hourly neurologic assessment on a patient in the intensive care unit. What is included in this assessment?

What should the nurse do when assessing the motor function of a patient with a head injury?

A patient demonstrates neurologic changes consistent with increasing intracranial pressure. For which primary cause of this pressure increase should the nurse assess at this time? Select all that apply.

A patient with a severe head injury has a pO₂ of 88 and a pCO₂ of 48. What should be done to support this patient?

The nurse is assigned to a patient with an intracranial pressure monitoring device. What is a priority when caring for this patient?

A patient with meningitis develops hypotension and tachycardia. What action should the nurse take? Select all that apply.

A patient with a traumatic brain injury being mechanically ventilated is prescribed propofol. What should the nurse identify as an advantage of using this medication? Select all that apply.

The nurse prepares to assist with the assessment of a patient's oculovestibular reflex. What should be done before this reflex is assessed?

The nurse identifies interventions to address the potential problem of increasing intracranial pressure for a victim of a house fire. For which secondary causes is the nurse planning care for this patient? Select all that apply.

A patient with a penetrating traumatic head injury has a Glasgow Coma Scale of 9. Which of the following will the nurse realize is most likely to be implemented for this patient?

A patient's mean arterial pressure (MAP) decreases to 50 while his ICP is 20. What should the nurse realize that the drop in MAP could lead to?

A patient is admitted with a head injury from an acceleration/deceleration motor vehicle crash. Which type of injury did this patient most likely experience?

A patient diagnosed with a subdural hematoma has an intracranial pressure of 14 mm Hg. What body effect should the nurse expect if this pressure increases? Select all that apply.

The nurse assesses a patient's corneal reflex. Which cranial nerve is being assessed?

When providing care to a patient with increased intracranial pressure, the nurse should be concerned about which clinical finding because it can result in an additional increase in intracranial pressure?

A patient with a traumatic brain injury is diagnosed with an acute subdural hematoma. What should the nurse expect to assess in this patient? Select all that apply.

A patient in the neurologic intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating should this patient have for verbal response?