Chapter 41: Critical Care of Patients with
Neurologic Emergencies
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is caring for a client who had a hemorrhagic stroke. Which assessment
finding is the earliest sign of increasing intracranial pressure (ICP) for this client?
a. Projectile vomiting
b. Dilated and nonreactive pupils
c. Severe hypertension
d. Decreased level of consciousness
ANS: D
The earliest sign of increasing ICP is decreased level of consciousness. The other
signs occur later.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Complications MSC: Client Needs Category:
Physiological Integrity: Reduction of Risk Potential
2. A client is admitted with a traumatic brain injury. What is the nurse’s priority
assessment?
a. Complete neurologic assessment
b. Comprehensive pain assessment
c. Airway and breathing assessment
d. Functional assessment
, ANS: C
Although the client has a brain injury, the most important assessment is to assess the
client’s ABCs, which includes airway, breathing, and circulation. The other
assessments are performed later after the client is stabilized.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Assessment MSC: Client Needs Category:
Physiological Integrity: Physiological Adaptation
3. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury.
The patient’s spouse is very frustrated, stating that the patient’s personality has
changed and the situation is very difficult. What response by the nurse is most
appropriate?
a. Explain that personality changes are common following brain injuries.
b. Ask the client why he or she is acting out and behaving differently.
c. Refer the client and spouse to a head injury support group.
d. Tell the spouse that this is expected and he or she will have to learn to cope.
ANS: A
Personality and behavior often change permanently after head injury. The nurse will
explain this to the spouse. Asking the client about his or her behavior isn’t useful
because the patient probably cannot help it. A referral might be a good idea, but the
nurse needs to do something in addition to just referring the couple. Telling the
spouse to learn to cope belittles his or her concerns and feelings.
DIF: Applying TOP: Integrated Process: Communication and
Documentation KEY: Traumatic brain injury, Therapeutic
communication, Coping MSC: Client Needs Category: Psychosocial
Integrity
4. The nurse is caring for four clients with traumatic brain injuries. Which client would
the nurse assess first?
, a. Client with amnesia for the incident
b. Client who has a Glasgow Coma Scale score of 12
c. Client with a PaCO2 of 36 mm Hg and on a ventilator
d. Client who has a temperature of 102° F (38.9° C)
ANS: D
A fever is a poor prognostic indicator in patients with brain injuries. The nurse should
see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia
for the incident are all either expected or positive findings.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment
KEY: Traumatic brain injury, Assessment MSC: Client Needs
Category: Safe and Effective Care Environment: Management of Care
5. A client with a severe traumatic brain injury has an organ donor card in his wallet.
Which nursing action is appropriate?
a. Request a directive form the client’s primary health care provider.
b. Ask the family if they agree to organ donation for the client.
c. Wait until brain death is determined before acting on organ donation.
d. Contact the local organ procurement organization as soon as possible.
ANS: D
The appropriate nursing action is to respect the client’s desire to be an organ donor
and contact the local organ procurement organization even if family members do not
agree. In most agencies, the primary health care provider does not have to write an
order or directive to approve the organ donation. Family consent is not required.
DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and
Implementation KEY: Traumatic brain injury, Brain death MSC:
Client Needs Category: Physiological Integrity: Physiological Adaptation
Neurologic Emergencies
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is caring for a client who had a hemorrhagic stroke. Which assessment
finding is the earliest sign of increasing intracranial pressure (ICP) for this client?
a. Projectile vomiting
b. Dilated and nonreactive pupils
c. Severe hypertension
d. Decreased level of consciousness
ANS: D
The earliest sign of increasing ICP is decreased level of consciousness. The other
signs occur later.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Complications MSC: Client Needs Category:
Physiological Integrity: Reduction of Risk Potential
2. A client is admitted with a traumatic brain injury. What is the nurse’s priority
assessment?
a. Complete neurologic assessment
b. Comprehensive pain assessment
c. Airway and breathing assessment
d. Functional assessment
, ANS: C
Although the client has a brain injury, the most important assessment is to assess the
client’s ABCs, which includes airway, breathing, and circulation. The other
assessments are performed later after the client is stabilized.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Assessment MSC: Client Needs Category:
Physiological Integrity: Physiological Adaptation
3. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury.
The patient’s spouse is very frustrated, stating that the patient’s personality has
changed and the situation is very difficult. What response by the nurse is most
appropriate?
a. Explain that personality changes are common following brain injuries.
b. Ask the client why he or she is acting out and behaving differently.
c. Refer the client and spouse to a head injury support group.
d. Tell the spouse that this is expected and he or she will have to learn to cope.
ANS: A
Personality and behavior often change permanently after head injury. The nurse will
explain this to the spouse. Asking the client about his or her behavior isn’t useful
because the patient probably cannot help it. A referral might be a good idea, but the
nurse needs to do something in addition to just referring the couple. Telling the
spouse to learn to cope belittles his or her concerns and feelings.
DIF: Applying TOP: Integrated Process: Communication and
Documentation KEY: Traumatic brain injury, Therapeutic
communication, Coping MSC: Client Needs Category: Psychosocial
Integrity
4. The nurse is caring for four clients with traumatic brain injuries. Which client would
the nurse assess first?
, a. Client with amnesia for the incident
b. Client who has a Glasgow Coma Scale score of 12
c. Client with a PaCO2 of 36 mm Hg and on a ventilator
d. Client who has a temperature of 102° F (38.9° C)
ANS: D
A fever is a poor prognostic indicator in patients with brain injuries. The nurse should
see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia
for the incident are all either expected or positive findings.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment
KEY: Traumatic brain injury, Assessment MSC: Client Needs
Category: Safe and Effective Care Environment: Management of Care
5. A client with a severe traumatic brain injury has an organ donor card in his wallet.
Which nursing action is appropriate?
a. Request a directive form the client’s primary health care provider.
b. Ask the family if they agree to organ donation for the client.
c. Wait until brain death is determined before acting on organ donation.
d. Contact the local organ procurement organization as soon as possible.
ANS: D
The appropriate nursing action is to respect the client’s desire to be an organ donor
and contact the local organ procurement organization even if family members do not
agree. In most agencies, the primary health care provider does not have to write an
order or directive to approve the organ donation. Family consent is not required.
DIF: Understanding TOP: Integrated Process: Nursing Process: Planning and
Implementation KEY: Traumatic brain injury, Brain death MSC:
Client Needs Category: Physiological Integrity: Physiological Adaptation
