Question 1

Which finding for a patient who has a head injury should the nurse report immediately to the health care provider?

Accepted Answer

A)   Intracranial pressure is 16 mm Hg when patient is turned.
B)   Pale yellow urine output is 1200 mL over the last 2 hours.
C)   LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
D)   Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours. B

Question 2

The nurse is admitting a patient with a basal skull fracture.The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose.Which admission order should the nurse question?

Accepted Answer

A)   Keep the head of bed elevated.
B)   Insert nasogastric tube to low suction.
C)   Turn patient side to side every 2 hours
D)   Apply cold packs intermittently to face. B

Question 3

A 68-year-old male patient is brought to the emergency department (ED)by ambulance after being found unconscious on the bathroom floor by his spouse.Which action will the nurse take first?

Accepted Answer

A)   Check oxygen saturation.
B)   Assess pupil reaction to light.
C)   Verify Glasgow Coma Scale (GCS)  score.
D)   Palpate the head for hematoma or bony irregularities. A

Question 4

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP)of 106/52 mm Hg and an intracranial pressure (ICP)of 14 mm Hg.Which action should the nurse take first?

Accepted Answer

A)   Document the BP and ICP in the patient's record.
B)   Report the BP and ICP to the health care provider.
C)   Elevate the head of the patient's bed to 60 degrees.
D)   Continue to monitor the patient's vital signs and ICP.

Question 5

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department.Which action prescribed by the health care provider should the nurse question?

Accepted Answer

A)   Elevate the head of the bed 20 degrees.
B)   Restrict oral fluids to 1000 mL daily.
C)   Administer ceftriaxone (Rocephin)  1 g IV every 12 hours.
D)   Give ibuprofen (Motrin)  400 mg every 6 hours as needed for headache.

Question 6

The nurse has administered prescribed IV mannitol (Osmitrol)to an unconscious patient.Which parameter should the nurse monitor to determine the medication's effectiveness?

Accepted Answer

A)   Blood pressure
B)   Oxygen saturation
C)   Intracranial pressure
D)   Hemoglobin and hematocrit

Question 7

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?

Accepted Answer

A)   "This type of monitoring system is complex and it is managed by skilled staff."
B)   "The monitoring system helps show whether blood flow to the brain is adequate."
C)   "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure."
D)   "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

Question 8

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have

Accepted Answer

A)   expressive aphasia.
B)   impaired judgment.
C)   right-sided weakness.
D)   difficulty swallowing.

Question 9

A patient has increased intracranial pressure and a ventriculostomy after a head injury.Which action can the nurse delegate to unlicensed assistive personnel (UAP)who regularly work in the intensive care unit?

Accepted Answer

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

Question 10

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg,and an intracranial pressure (ICP)of 20 mm Hg.The nurse will calculate the cerebral perfusion pressure (CPP)as ____ mm Hg.

Accepted Answer

The answer of An unconscious patient with a traumatic head...

Question 11

A 42-year-old patient who has bacterial meningitis is disoriented and anxious.Which nursing action will be included in the plan of care?

Accepted Answer

A)   Encourage family members to remain at the bedside.
B)   Apply soft restraints to protect the patient from injury.
C)   Keep the room well-lighted to improve patient orientation.
D)   Minimize contact with the patient to decrease sensory input.

Question 12

A 46-year-old patient with a head injury opens the 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.The nurse records the patient's Glasgow Coma Scale score as

Accepted Answer

A)   9.
B)   11.
C)   13.
D)   15.

Question 13

After endotracheal suctioning,the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg.Which action should the nurse take first?

Accepted Answer

A)   Document the increase in intracranial pressure.
B)   Ensure that the patient's neck is in neutral position.
C)   Notify the health care provider about the change in pressure.
D)   Increase the rate of the prescribed propofol (Diprivan)  infusion.

Question 14

When assessing a 53-year-old patient with bacterial meningitis,the nurse obtains the following data.Which finding should be reported immediately to the health care provider?

Accepted Answer

A)   The patient exhibits nuchal rigidity.
B)   The patient has a positive Kernig's sign.
C)   The patient's temperature is 101° F (38.3° 
C)  .
D)   The patient's blood pressure is 88/42 mm Hg.

Question 15

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department.Which action will the nurse plan to take?

Accepted Answer

A)   Administer IV furosemide (Lasix) .
B)   Prepare the patient for craniotomy.
C)   Initiate high-dose barbiturate therapy.
D)   Type and crossmatch for blood transfusion.

Question 16

During change-of-shift report,the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation.Which positioning shown in the accompanying figure will the nurse expect to observe?

Accepted Answer

A)   1
B)   2
C)   3
D)   4

Question 17

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling.Which nursing intervention will be included in the plan of care?

Accepted Answer

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

Question 18

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

Accepted Answer

A)   Coordinate the transfer of the patient to the operating room.
B)   Provide discharge instructions about monitoring neurologic status.
C)   Transport the patient to radiology for magnetic resonance imaging (MRI) .
D)   Arrange to admit the patient to the neurologic unit for 24 hours of observation.

Question 19

A 20-year-old male patient is admitted with a head injury after a collision while playing football.After noting that the patient has developed clear nasal drainage,which action should the nurse take?

Accepted Answer

A)   Have the patient gently blow the nose.
B)   Check the drainage for glucose content.
C)   Teach the patient that rhinorrhea is expected after a head injury.
D)   Obtain a specimen of the fluid to send for culture and sensitivity.

Question 20

Which statement by a 40-year-old patient who is being discharged from the emergency department (ED)after a concussion indicates a need for intervention by the nurse?

Accepted Answer

A)   "I will return if I feel dizzy or nauseated."
B)   "I am going to drive home and go to bed."
C)   "I do not even remember being in an accident."
D)   "I can take acetaminophen (Tylenol)  for my headache."

Exam 53: Nursing Management: Acute Intracranial Problems