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 flowto
the brain is adequate."
c. "The ventriculostomy monitoring system helps checkfor
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 flowto
the brain is adequate."
c. "The ventriculostomy monitoring system helps checkfor
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.
