Chapter 56: Acute Intracranial Problems Lewis: Medical-
Surgical Nursing, 10th Edition 100% Verified Answers
Quiz:> 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 for this situation?
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."
{{{Answer}}} (ANS: B
Short and simple explanations should be given initially to patients and family members.
The other explanations are either too complicated to be easily understood or may
increase the family members' anxiety.
DIF: Cognitive Level: Analyze (analysis))
Quiz:> Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm
Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs,
if taken 1 hour later, will be of most concern to the nurse?
a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12
breaths/min
b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32
breaths/min
c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28
breaths/min
d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30
breaths/min
{{{Answer}}} (ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory
changes represent Cushing's triad. These findings 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: Apply (application))
Quiz:> When a brain-injured patient responds to nail bed pressure with internal rotation,
adduction, and flexion of the arms, the nurse reports the response as
a. flexion withdrawal.
b. localization of pain.
,c. decorticate posturing.
d. decerebrate posturing
.{{{Answer}}} (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: Understand (comprehension))
Quiz:> The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious
patient. Which parameter should the nurse monitor to determine the medication's
effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit
{{{Answer}}} (ANS: C
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. O2 saturation
will not directly improve as a result of mannitol administration.
DIF: Cognitive Level: Apply (application))
Quiz:> A patient with a head injury opens his 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
a. 9.
b. 11.
c. 13.
d. 15.
{{{Answer}}} (ANS: B
The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best
motor response.
DIF: Cognitive Level: Apply (application))
Quiz:> An unconscious patient is admitted to the emergency department (ED) with a
head injury. The patient's spouse and teenage children stay at the patient's side and
ask many questions about the treatment being given. What action is best for the nurse
to take?
a. Call the family's pastor or spiritual advisor to take them to the chapel.
b. Ask the family to stay in the waiting room until the assessment is completed.
c. Allow the family to stay with the patient and briefly explain all procedures to them.
d. Refer the family members to the hospital counseling service to deal with their anxiety.
,{{{Answer}}} (ANS: C
The need for information about the diagnosis and care is very high in family members of
acutely ill patients. The nurse should allow the family to observe care and explain the
procedures unless they interfere with emergent care needs. A pastor or counseling
service can offer some support, but research supports information as being more
effective. Asking the family to stay in the waiting room will increase their anxiety.
DIF: Cognitive Level: Analyze (analysis))
Quiz:> A patient who is unconscious has ineffective cerebral tissue perfusion and
cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
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.
{{{Answer}}} (ANS: C
The patient with increased intracranial pressure (ICP) should be maintained in the head-
up position to help reduce ICP. Extreme flexion of the hips and knees increases
abdominal pressure, which increases ICP. Because the stimulation associated with
nursing interventions increases ICP, clustering interventions will progressively elevate
ICP. Coughing increases intrathoracic pressure and ICP.
DIF: Cognitive Level: Apply (application))
Quiz:> A 20-yr-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?
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.
{{{Answer}}} (ANS: B
Clear nasal drainage in a patient with a head injury suggests a dural tear and
cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose.
Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will
not be useful. Blowing the nose is avoided to prevent CSF leakage.
DIF: Cognitive Level: Apply (application))
Quiz:> Which action will the emergency department nurse anticipate for a patient
diagnosed with a concussion who did not lose consciousness?
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.
{{{Answer}}} (ANS: B
, A patient with a minor head trauma is usually discharged with instructions about
neurologic monitoring and the need to return if neurologic status deteriorates. MRI,
hospital admission, and surgery are not usually indicated in a patient with a concussion.
DIF: Cognitive Level: Apply (application))
Quiz:> A patient who is suspected of having an epidural hematoma is admitted to the
emergency department. Which action will the nurse expect to take?
a. Administer IV furosemide (Lasix).
b. Prepare the patient for craniotomy.
c. Initiate high-dose barbiturate therapy.
d. Type and crossmatch for blood transfusion.
{{{Answer}}} (ANS: B
The principal treatment for epidural hematoma is rapid surgery to remove the
hematoma and prevent herniation. If intracranial pressure is elevated after surgery,
furosemide or high-dose barbiturate therapy may be needed, but these will not be of
benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries,
and transfusion is usually not necessary.
DIF: Cognitive Level: Apply (application))
Quiz:> 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?
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.
{{{Answer}}} (ANS: B
Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a
nasogastric tube will increase the risk for infections such as meningitis. Turning the
patient, elevating the head, and applying cold packs are appropriate orders.
DIF: Cognitive Level: Apply (application))
Quiz:> A college athlete is seen in the clinic 6 weeks after a concussion. Which
assessment information will the nurse collect to determine whether the patient is
developing postconcussion syndrome?
a. Short-term memory
b. Muscle coordination
c. Glasgow Coma Scale
d. Pupil reaction to light
{{{Answer}}} (ANS: A
Decreased short-term memory is one indication of postconcussion syndrome. The other
data may be assessed but are not indications of postconcussion syndrome.
Surgical Nursing, 10th Edition 100% Verified Answers
Quiz:> 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 for this situation?
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."
{{{Answer}}} (ANS: B
Short and simple explanations should be given initially to patients and family members.
The other explanations are either too complicated to be easily understood or may
increase the family members' anxiety.
DIF: Cognitive Level: Analyze (analysis))
Quiz:> Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm
Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs,
if taken 1 hour later, will be of most concern to the nurse?
a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12
breaths/min
b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32
breaths/min
c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28
breaths/min
d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30
breaths/min
{{{Answer}}} (ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory
changes represent Cushing's triad. These findings 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: Apply (application))
Quiz:> When a brain-injured patient responds to nail bed pressure with internal rotation,
adduction, and flexion of the arms, the nurse reports the response as
a. flexion withdrawal.
b. localization of pain.
,c. decorticate posturing.
d. decerebrate posturing
.{{{Answer}}} (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: Understand (comprehension))
Quiz:> The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious
patient. Which parameter should the nurse monitor to determine the medication's
effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit
{{{Answer}}} (ANS: C
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. O2 saturation
will not directly improve as a result of mannitol administration.
DIF: Cognitive Level: Apply (application))
Quiz:> A patient with a head injury opens his 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
a. 9.
b. 11.
c. 13.
d. 15.
{{{Answer}}} (ANS: B
The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best
motor response.
DIF: Cognitive Level: Apply (application))
Quiz:> An unconscious patient is admitted to the emergency department (ED) with a
head injury. The patient's spouse and teenage children stay at the patient's side and
ask many questions about the treatment being given. What action is best for the nurse
to take?
a. Call the family's pastor or spiritual advisor to take them to the chapel.
b. Ask the family to stay in the waiting room until the assessment is completed.
c. Allow the family to stay with the patient and briefly explain all procedures to them.
d. Refer the family members to the hospital counseling service to deal with their anxiety.
,{{{Answer}}} (ANS: C
The need for information about the diagnosis and care is very high in family members of
acutely ill patients. The nurse should allow the family to observe care and explain the
procedures unless they interfere with emergent care needs. A pastor or counseling
service can offer some support, but research supports information as being more
effective. Asking the family to stay in the waiting room will increase their anxiety.
DIF: Cognitive Level: Analyze (analysis))
Quiz:> A patient who is unconscious has ineffective cerebral tissue perfusion and
cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
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.
{{{Answer}}} (ANS: C
The patient with increased intracranial pressure (ICP) should be maintained in the head-
up position to help reduce ICP. Extreme flexion of the hips and knees increases
abdominal pressure, which increases ICP. Because the stimulation associated with
nursing interventions increases ICP, clustering interventions will progressively elevate
ICP. Coughing increases intrathoracic pressure and ICP.
DIF: Cognitive Level: Apply (application))
Quiz:> A 20-yr-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?
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.
{{{Answer}}} (ANS: B
Clear nasal drainage in a patient with a head injury suggests a dural tear and
cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose.
Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will
not be useful. Blowing the nose is avoided to prevent CSF leakage.
DIF: Cognitive Level: Apply (application))
Quiz:> Which action will the emergency department nurse anticipate for a patient
diagnosed with a concussion who did not lose consciousness?
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.
{{{Answer}}} (ANS: B
, A patient with a minor head trauma is usually discharged with instructions about
neurologic monitoring and the need to return if neurologic status deteriorates. MRI,
hospital admission, and surgery are not usually indicated in a patient with a concussion.
DIF: Cognitive Level: Apply (application))
Quiz:> A patient who is suspected of having an epidural hematoma is admitted to the
emergency department. Which action will the nurse expect to take?
a. Administer IV furosemide (Lasix).
b. Prepare the patient for craniotomy.
c. Initiate high-dose barbiturate therapy.
d. Type and crossmatch for blood transfusion.
{{{Answer}}} (ANS: B
The principal treatment for epidural hematoma is rapid surgery to remove the
hematoma and prevent herniation. If intracranial pressure is elevated after surgery,
furosemide or high-dose barbiturate therapy may be needed, but these will not be of
benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries,
and transfusion is usually not necessary.
DIF: Cognitive Level: Apply (application))
Quiz:> 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?
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.
{{{Answer}}} (ANS: B
Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a
nasogastric tube will increase the risk for infections such as meningitis. Turning the
patient, elevating the head, and applying cold packs are appropriate orders.
DIF: Cognitive Level: Apply (application))
Quiz:> A college athlete is seen in the clinic 6 weeks after a concussion. Which
assessment information will the nurse collect to determine whether the patient is
developing postconcussion syndrome?
a. Short-term memory
b. Muscle coordination
c. Glasgow Coma Scale
d. Pupil reaction to light
{{{Answer}}} (ANS: A
Decreased short-term memory is one indication of postconcussion syndrome. The other
data may be assessed but are not indications of postconcussion syndrome.
