Chapter 34- Patient Management- Nervous System.rtf (47 kb) My Nursing Test Banks

 

1.

A nurse is monitoring a patient recently admitted to the critical care unit with an acute brain injury. She is aware that intracranial hypertension is a major risk associated with brain injury. Which of the following findings would definitively indicate that the patient has intracranial hypertension?

A)

Cerebral perfusion pressure (CPP) of 75 mm Hg

B)

Intracranial pressure (ICP) of 25 mm Hg

C)

Mean arterial pressure (MAP) of 150 mm Hg

D)

Systolic pressure of 110 mm Hg

2.

A patient is demonstrating increased pulse pressure, decreased pulse, and irregular respiration. The nurse recognizes these symptoms of increased intracranial pressure and understands that the patients autoregulation of cerebral blood flow in the brain has failed. Which of the following findings would be consistent with a failure of autoregulation of blood flow in the brain? Select all that apply.

A)

Cerebral perfusion pressure of 40 mm Hg

B)

Mean arterial pressure of 170 mm Hg

C)

Systolic pressure of 120 mm Hg

D)

Intracranial pressure of 35 mm Hg

3.

A nurse is working with a patient with acute head trauma. The nurse understands that the cerebral blood flow in this patient is decreased to compensate for the cerebral edema caused by the trauma. What other compensatory mechanisms should the nurse be aware of that are likely occurring in this patient to maintain a constant intracranial pressure? Select all that apply.

A)

Expansion of cisterns and ventricles

B)

Increased cerebrospinal fluid (CSF) production

C)

Increased CSF absorption

D)

Shunting of CSF into the spinal subarachnoid space

4.

A patient in the ICU with severe head trauma remains stable for the first 24 hours after admission, with no indication of intracranial hypertension. Suddenly, however, the patient begins showing signs of Cushings triad. The nurse recognizes that this occurrence indicates that the patients compensatory mechanisms have become exhausted. What physiological change occurs as part of this exhaustion of compensatory mechanisms? Select all that apply.

A)

Decrease in volume of contents of the intracranial compartment

B)

Decrease in intracranial pressure

C)

Decrease in cerebral perfusion

D)

Decrease in compliance within the intracranial compartment

5.

Two patients, a husband and wife, are admitted to the ICU after sustaining traumatic head injuries in a motor vehicle accident. The husband is in a coma but shows no abnormalities on a CT scan. He is 45 years old and has a systolic blood pressure of 85 mm Hg. The wife, 42 years old, is not comatose and has a normal CT scan, but shows signs of brain injury, and has a systolic blood pressure of 80 mm Hg. The nurse recognizes that intracranial pressure monitoring is indicated for which of these patients?

A)

Both the husband and wife

B)

Neither the husband nor the wife

C)

The husband only

D)

The wife only

6.

A patient recently admitted to the ICU for head trauma has a Glasgow Coma Scale score of 4 and a hematoma apparent on CT scan of the head. This patient has multiple fractures in her skull and an intracranial pressure (ICP) of 30 mm Hg. Which ICP monitoring device would be contraindicated for this patient?

A)

Intraventricular

B)

Intraparenchymal

C)

Lumbar/subarachnoid

D)

Subdural

7.

A patient with head trauma requires intracranial pressure (ICP) monitoring. The physician insists that the most accurate monitoring device feasible should be used for this patient. This patient also requires frequent draining of cerebrospinal fluid (CSF) while being monitored. The nurse recognizes that which ICP monitoring device would be best for this patient?

A)

Intraventricular

B)

Subarachnoid

C)

Subdural

D)

Epidural

8.

A patient with head trauma is being monitored with an intraventricular catheter device (IVC). The patients intracranial pressure (ICP) had been staying around 20 mm Hg, but moments ago, it spiked up to 55 mm Hg. What complication related to the monitoring device itself would best explain this dramatic increase in ICP?

A)

Infection at the catheter access site

B)

Obstruction of the catheter

C)

Hemorrhage

D)

Misplacement of catheter

9.

A patient with a brain injury is receiving IV mannitol to reduce cerebral edema and intracranial pressure (ICP) during the early resuscitation phase. The patient is rapidly becoming hypovolemic. What intervention should the nurse make to help correct the hypovolemia?

A)

Administer crystalloid solution.

B)

Administer morphine.

C)

Discontinue mannitol.

D)

Administer propofol.

10.

A patient with severe and refractory elevated intracranial pressure (ICP) has been in an induced barbiturate coma for 48 hours. Over the first 24 hours, the patients ICP decreased from 30 to 14 mm Hg and her systolic blood pressure decreased from 130 to 80 mm Hg. These changes were sustained in the second 24 hours. The nurse recognizes that which of the following is the appropriate intervention for this patient?

A)

Administer IV solution.

B)

Discontinue barbiturate therapy.

C)

Initiate hypothermia therapy.

D)

Administer a sedative.

11.

A patient with a brain injury is undergoing intracranial pressure (ICP) monitoring and cerebrospinal fluid (CSF) drainage, along with mannitol therapy, to relieve ICP. What other intervention can the nurse make to aid in relieving this patients ICP?

A)

Extend and rotate the patients head.

B)

Flex the patients hips to greater than 90 degrees.

C)

Elevate the head of the patients bed to 20 degrees.

D)

Perform frequent blood draws.

12.

Regulation of intracranial pressure is explained by the Monro-Kellie doctrine. Based on this doctrine, under normal circumstances, if a patients brain volume increases, what compensatory change does the nurse expect?

A)

Reduction of cerebral blood volume

B)

Increased cerebrospinal fluid volume

C)

Increased cerebrospinal fluid production

D)

Elevation of systemic blood pressure

13.

A patient with a head injury is being monitored with an intracranial pressure monitor. What nursing assessment best indicates intracranial hypertension?

A)

Intracranial pressure 8 mm Hg

B)

Glasgow Coma Scale score 3

C)

Intracranial pressure 25 mm Hg

D)

Glasgow Coma Scale score 15

14.

The patient has undergone intracerebral surgery. Knowing that interruption of the skull interferes with the brains ability to autoregulate, what nursing assessment information most clearly indicates the highest patient risk?

A)

Pulmonary adventitious sounds

B)

Capillary refill less than 2 seconds

C)

Blood pressure consistently elevated

D)

Pain at 8 on 0-to-10 scale

15.

The patient is in a critical care unit after an acute head injury and has developed respiratory and ventilatory failure and hypotension. What effect will this development have on the patients cerebral perfusion pressure?

A)

Elevated above 100 mm Hg

B)

Reduced below 60 mm Hg

C)

Will make it very labile

D)

Will have very little effect

16.

Intracranial pressure monitoring can be a valuable diagnostic tool but also has significant complications. In what patient with a severe head injury would the nurse question the use of intracranial pressure monitoring?

A)

Glasgow Coma Scale score of 3

B)

Declared brain dead

C)

Subarachnoid hematoma

D)

Severe stroke

17.

The patient has elevated intracranial pressure secondary to overproduction of cerebrospinal fluid. During therapy, an intracranial pressure monitor is placed. What type of monitor should be used if withdrawal of cerebrospinal fluid is also desired?

A)

Intraventricular

B)

Epidural

C)

Intraparenchymal

D)

Subdural

18.

The patient is being monitored with an intracranial pressure monitor. What nursing assessment most indicates the development of a complication of intracranial pressure monitoring?

A)

Purulent drainage around monitor access site

B)

Intracranial pressure 12 mm Hg at rest

C)

Intracranial pressure 20 mm Hg during suctioning

D)

Development of slight respiratory alkalosis

19.

The patient has an intracranial pressure monitor. After the patient returns from a computed tomography (CT) scan of the head, the nurse notices that the patients intracranial pressure is significantly lower than before the scan. What nursing action is most likely to identify a cause of this change?

A)

Take vital signs.

B)

Flush monitor tubing toward patient.

C)

Relevel the transducer.

D)

Drain cerebrospinal fluid.

20.

A patient who is on an intracranial pressure monitor after an acute head injury has an intracranial pressure of 10 mm Hg at rest. When the patient is being suctioned, the intracranial pressure rises briefly to 20 mm Hg but returns quickly to 10 mm Hg once the suctioning has ceased. What is the most appropriate nursing intervention?

A)

Administer intravenous sedation

B)

Suction no longer than 15 seconds each time

C)

Drain 10 mL cerebrospinal fluid

D)

Return to supine position

21.

Seven days after a traumatic head injury, a patient has elevated intracranial pressure that is refractory to sedation, paralysis, cerebrospinal fluid drainage, and osmotic diuretics. The patients arterial blood gas results are pH 7.45, PaCO2 33, and bicarbonate ion 18. What is the best nursing decision?

A)

Reduce respiratory rate

B)

Administer intravenous bicarbonate

C)

Increase intravenous sedation

D)

Continue with current plan of care

22.

A patient with an acute brain injury is receiving IV mannitol, an osmotic diuretic. If this medication is effective, what does the nurse expect?

A)

Increased cerebral perfusion pressure

B)

Increased serum osmolarity above 320 mOsm

C)

Reduction of Glasgow Coma Scale values

D)

Development of fixed and dilated pupils

Answer Key

1.

B

2.

A, B, D

3.

C, D

4.

C, D

5.

A

6.

C

7.

A

8.

B

9.

A

10.

B

11.

C

12.

A

13.

C

14.

C

15.

B

16.

B

17.

A

18.

A

19.

C

20.

B

21.

D

22.

A

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