Nclex Care of patients post craniotomy quizlet
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
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
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.
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
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
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
Following a head injury, an unconscious 32-year-old
patient is admitted to the emergency department
(ED). The patient's spouse and children stay at
the patient's side and constantly ask about the
treatment being given.
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
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
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.
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
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
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
Following a head injury, an unconscious 32-year-old
patient is admitted to the emergency department
(ED). The patient's spouse and children stay at
the patient's side and constantly ask about the
treatment being given.
