Chapter 48. Nursing Care of Patients With Central Nervous System Disorders

Chapter 48. Nursing Care of Patients With Central Nervous System Disorders

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____     1.   The nurse is caring for a patient brought to the emergency department after an automobile accident. The patient is fully conscious. For what early signs of increased intracranial pressure (ICP) should the nurse be alert?

____     2.   The vital signs for a client with a possible head injury were on admission: blood pressure 128/72 mm Hg, pulse 90 beats/min, and respirations 66 breaths/min. Which vital sign assessment conducted four hours later most likely indicates the presence of increased intracranial pressure (ICP)?

____     3.   A patient who was in an industrial accident has had a sudden increase in intracranial pressure and is being prepared for placement of an emergency subarachnoid bolt. Which action should the nurse make a priority at this time?

____     4.   A patient with a severe headache due to viral meningitis requests an opioid analgesic. What explanation about opioids should the nurse provide?

____     5.   The nurse concludes that a patient’s meningitis is improving. What activity did the patient perform for the nurse to come to this conclusion?

MULTIPLE CHOICE

1. ANS:  D

Initial symptoms of increased ICP include restlessness, irritability, and decreased level of consciousness, because cerebral cortex function is impaired. If not intubated, the patient may hyperventilate, causing vasoconstriction as the body attempts to compensate. As the pressure increases, the oculomotor nerve may be compressed on the side of the impairment. C. Compression of the outermost fibers of the oculomotor nerve results in diminished reactivity and dilation of the pupil. As the fibers become increasingly compressed, the pupil stops reacting to light. If the compression continues, and the brain tissue exerts pressure on the opposite side of the brain from the injury, both pupils become fixed and dilated. B. Hypothermia is not a sign of IICP. A. Vital sign changes are a late indication of increasing ICP.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

2. ANS:  A

Vital sign changes are a late indication of increasing ICP. Cushing’s response is a classic late sign of increased ICP. Cushing’s response (or Cushing’s triad) is characterized by bradycardia, bradypnea, and arterial hypertension (increasing systolic blood pressure while diastolic blood pressure remains the same), resulting in widening pulse pressure. B. These vital signs indicate tachycardia. C. These vital signs indicate tachypnea. C. These vital signs indicate both tachycardia and tachypnea.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis|

3. ANS:  C

The patient is unlikely to be able to sign a consent form, and it must be signed for surgery to begin. B. Bathing is not a priority. A. D. Belongings and further questioning can be taken care of after the patient is in surgery.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level: Application

4. ANS:  B

Opioids are habit forming and are used only as a last resort for headaches. A. C. They do not increase intracranial pressure, and they are not contraindicated for other reasons. D. Tylenol is much less effective than an opioid.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

5. ANS:  C

Ability to touch the chin to the chest indicates improvement in nuchal rigidity. A. B. D. An improvement in the patient’s condition is not associated with the ability to dorsiflex the feet, sit up, drink water, or maintain a side-lying position in bed.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Evaluation