Chapter 57: Nursing Management: Acute Intracranial Problems

Chapter 57: Nursing Management: Acute Intracranial Problems

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE
1. When family members ask the nurse about the purpose of the ventriculostomy system
being used for intracranial pressure monitoring for a patient, which response by the nurse
is best?
a. “This type of monitoring system is complex and highly skilled staff are needed.”
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.”
ANS: B
Short and simple explanations should be given to patients and family members. The other
explanations are either too complicated to be easily understood or may increase the
family member’s anxiety.
DIF: Cognitive Level: Application REF: 1438
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
2. A patient with a head injury has admission vital signs of blood pressure 128/68, pulse
110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will
be of most concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes
represent Cushing’s triad and indicate that the intracranial pressure (ICP) has increased,
and brain herniation may be imminent unless immediate action is taken to reduce ICP.
The other vital signs may indicate the need for changes in treatment, but they are not
indicative of an immediately life-threatening process.
DIF: Cognitive Level: Application REF: 1429-1430
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the
patient responds with internal rotation, adduction, and flexion of the arms. The nurse
documents this as
a. flexion withdrawal.
Test Bank 57-2
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing.
ANS: C
Internal rotation, adduction, and flexion of the arms in an unconscious patient is
documented as decorticate posturing. Extension of the arms and legs is decerebrate
posturing. Because the flexion is generalized, it does not indicate localization of pain or
flexion withdrawal.
DIF: Cognitive Level: Comprehension REF: 1429-1430
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. Which parameter is best for the nurse to monitor to determine whether the prescribed IV
mannitol (Osmitrol) has been effective for an unconscious patient?
a. Hematocrit
b. Blood pressure
c. Oxygen saturation
d. Intracranial pressure
ANS: D
Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure.
It may initially reduce hematocrit and increase blood pressure, but these are not the best
parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not
directly improve as a result of mannitol administration.
DIF: Cognitive Level: Application REF: 1432-1433 TOP: Nursing Process:
Evaluation
MSC: NCLEX: Physiological Integrity
5. A 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 remove a painful
stimulus. The nurse records the patient’s Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15.
ANS: B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best
motor response.
DIF: Cognitive Level: Application REF: 1434
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity