ICP
Select the main structures below that play a role in altering intracranial pressure:
A. Brain
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Periosteum
F. Dura Mater
The answers are A, C, and D. Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid and blood.
A client presents with a head injury after being in a motor vehicle accident and diagnosed with a brain contusion with a coup-contrecoup injury. The client is stabilized and sent home, but the healthcare provider instructs the client to return in 3 days for a repeat MRI. Which explains the rationale for repeat MRI?
A. The MRI will be repeated to determine the cause of the clients injuries.
B. It can take hours to days for contusions to form from a coup-contrecoup injury.
B. It can take hours to days for contusions to form a coup-contrecoup injury.
Brain contusions are classified as coup or contrecoup. Individuals can also have a contre-coup injury. It can take a few hours to a few days to determine the full extent of the injury.
Which patient below is most at risk for developing a condition called autonomic dysreflexia?
A. A 24 y/o male patient with a traumatic brain injury.
B. A 15 y/o female patient with a spinal cord injury at C7
C. A 35 y/o male patient with a spinal cord injury at L6.
D. A 42 y/o male patient recovering from hemorrhagic stroke.
The answer is B. Patients who are at MOST risk for developing autonomic dysreflexia are patients who have experienced a spinal chord injury at T6 or higher... this includes C7.
Myasthenia gravis occurs when antibodies attack the _________ receptors at the neuromuscular junction leading to ______________.
A. Metabotropic: muscle weakness
B. Nicotinic acetylcholine; muscle weakness
C. Dopaminergic adrenergic: muscle contraction
D. Nicotinic adrenergic; muscle contraction
The answer is B. In myasthenia gravis, either the nicotinic acetylcholine receptors are attacked by antibodies created by the immune system (hence why this disease is considered autoimmune) or antibodies are inhibiting the function of muscle-specific kinase (which is a receptor tyrosine kinase that helps with maintaining and building the neuromuscular junction.)
True or False: Gillian-Barre Syndrome occurs when the body's immune system attacks the myelin sheath on the nerves in the central nervous system.
A. True
B. False
FASLE - Gillian-Barre Syndrome is an autoimmune neuro condition where the immune system attacks the nerves (myelin sheath) in the peripheral nervous system and cranial nerves.
A patient is being treated for increased intracranial pressure. Which activities should the patient avoid.
A. Coughing
B. Sneezing
C. Talking
D. Valsalva Maneuver
E. Vomiting
F. Keeping the head of the bead between 30-35 degrees.
The answers are A, B, D, and E. These activities can increase ICP.
The nurse is caring for an adolescent who presents with headache, memory loss, and blurred vision after sustaining an injury playing football. The healthcare provider diagnoses the client with a concussion and instructs the client to refrain from sports for a minimum of 4 weeks to prevent a second impact syndrome (SIS). Which statement indicates the understanding of the instructions provided.
A. I should stay away from any type of sports activity for a month.
B. I should avoid playing all sports until the headaches dissipate.
A. When the adolescent states that they should away from any type of sports activity for a month, this indicates an understanding of instructions provided. Waiting for headaches to dissipate does indicate that full healing has occurred.
Your patient, who has a spinal chord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action?
A. Perform a bladder scan.
B. Perform a rectal digital examination.
C. Assess the patient's blood pressure.
D. Administer a PRN medication to alleviate pain and provide a dark, calm environment.
The answer is C. This is the nurse's NEXT action. The patient is at risk for developing autonomic dysreflexia because of their spinal cord injury at T3 (remember patients who have a SCI at T6 or higher are at MOST risk. If a patient with this type of injury states they have a headache the nurse should next assess BP. If elevated the nurse would check bladder (A bladder issue is the most common cause of AD.)
Your educating a patient about the pathophysiology of myasthenia gravis. While explaining the involvement of the thymus gland is located. You state it is located?
A. Behind the thyroid gland
B. Within the adrenal glands
C. Behind the sternum in between the lungs
D. Anterior to the hypothalamus
The answer is C. The thymus is located anteriorly in the upper part of the chest behind the sternum in between the lungs.
You're assessing a patient's health history for risk factors associated with developing Guillain-Barre Syndrome. Select all the risk factors below:
A. Recent upper respiratory infection
B. Patient's age: 3 years old
C. Positive stool culture Campylobacter Jejuni
D. Hyperthermia
E. Epstein-Barr
F. Diabetes
G. Myasthenia Gravis
The answers are: A, C and E. Risk factors for developing Guillain-Barr Syndrome include: experiencing upper respiratory infection, GI infection (especially from Campylobacter Juni, Epstein-Barr infection, HIV/AIDS, vaccination (flu or Swine flu) etc.
Your providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "what is a normal cerebral perfusion pressure level?" Your response is:
A. 5-15 mmHg
B. 60-100 mmHg
C. 30-45 mmHg
D. >160 mmHg
The answer is B. This is a normal CPP. A represents a normal intracranial pressure.
Which information regarding post concussion syndrome and signs to report should the nurse provide to the client who sustained a concussion? (Select all that apply.)
A. Rash or hives
B. Personality changes.
C. Sensitivity to light and noise
D. Insomnia
E. Nausea
Signs of post concussion syndrome include nausea, insomnia, headaches, personality changes, light and noise sensitivity, memory problems, dizziness and fatigue.
Your performing a head to toe assessment on a patient with a spinal cord injury at T6. The patient is restless, sweaty, and extremely flushed. You assess the patient's blood pressure and heart rate. 140/98 HR 52. You look at the patient's chart and find that their base line is 106/76 and HR is 72. What action should the nurse take FIRST?
A. Reassess the patient's BP.
B. Check the patient's blood glucose.
C. Position the patient at 90 degrees and lower the legs.
D. Provide cooling blankets for patient.
The answer is C. Based on the patient's findings and how the patient has a spinal cord injury at T6 they are experiencing autonomic dysreflexia. Patients with this condition may have a BP that is 20-40mmHg higher than their baseline and may experience bradycardia.
You're preparing to help the neurologist with conducting a Tensilon test. Which antidote will you have on a hand in case of an emergency?
A. Atropine
B. Protamine Sulfate
C. Narcan
D. Leucovorin
The answer is A. Atropine will help reverse the effects of the drug given a Tensilon test, which is Edrophonium, in case an emergency arises. Edrophonium is a short-acting cholinergic drug, while atropine is an anticholinergic.
Which tests below can be ordered to help the physician diagnose Guillain-Barre Syndrome. Select all that apply:
A. Edrophonium Test
B. Sweat Test
C. Lumbar puncture
D. Electromyography
E. Nerve Conduction Studies
The answers are C, D, and E. These are the tests that can be ordered to help the MD determine if the patient is experiencing GBS.
Which patient below is at MOST risk for increased intracranial pressure?
A. A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brain injury.
C. A patient who experienced a myocardial infarction.
D. A patient post-op from eye surgery.
The answer is B. Remember head trauma, cerebral hemorrhage, hematoma, hydrocephalus, tumor, encephalitis, etc. can all increase ICP.
A client is seen in an urgent care center with signs of a mild traumatic brain injury (TBI). Which clinical manifestation would indicate a need to see a neurologist?
A. Unequal pupils
B. Racoon eyes
C. Irritability
D. Tinnitus
A. Unequal pupils indicate that a traumatic brain injury (TBI) was more severe than was actually diagnosed. This would require further follow up from neurologist to determine possible cranial nerve damage or damage to ocular portion of the brain. Tinnitus, irritability, and raccoon eyes are mild manifestations of a mild traumatic brain injury.
Your providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select all the most common causes you will discuss during your in-service.
A. Hypoglycemia
B. Distended bladder
C. Sacral pressure injury
D. Fecal Impaction
E. Urinary Tract Infection
The answer is B,C,D and E. Anything that can cause an irritating stimulus below the site of the spinal injury (T6 or higher) can lead to autonomic dysreflexia, which causes an exaggerated sympathetic reflex response and parasympathetic system is unable to oppose it. This will lead to severe hyperetnsion.
Which meal option would be the most appropriate for a patient with my myasthenia gravis?
A. Roasted potatoes and cubed steak
B. Hamburger with baked fries
C. Clam chowder with mashed potatoes
D. Fresh veggie tray with sliced cheese cubes
The answer is C. Patients with MG have weak muscles and this can include the muscles that are used for chewing and swallowing. The patient should choose meal options that require the least amount of chewing and that are easy to swallow.
You're about to send a patient for a lumbar puncture to help rule out Guillian-Barre Syndrome. Before sending the patient you will have the patient?
A. Clean the back with antiseptic
B. Drink contrast dye
C. Void
D. Wash their hair.
The answer is C. The patient will need to void and the empty the bladder before going for a LP. This will help decrease the chances of the bladder becoming punctured during the procedure.
A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65. Temperature 101.6F, respirations 14, oxygen saturation 95%. ICP reading is 21 mmHg. Based on these findings you would?
A. Administer PRN dose of vasopressor
B. Administer 2 L of oxygen
C. Remove extra blankets and give patient a cool bath
D. Perform suctioning
The answer is C. It is important to monitor the patient for hyperthermia (a fever), A fever increases ICP and cerebral blood volume, and metabolic needs of the patient. The nurse can administer antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath or use a cooling system. Remember it is important to prevent shivering (this also increases metabolic needs and ICP),
The nurse is caring for a client who reports being hot over the head by their significant other. Which assessment finding should lead the nurse to suspect that the client has a skull fracture? (Select all that apply.)
A. Loss of consciousness
B. Dysphagia
C. Raccoon eyes
D. Clear drainage from the nares.
E. Battle sign
A client with a skull fracture would present with battle sign, which is bruising behind the ear. Other signs include raccoon eyes, which is bruising of the eye and periorbital area. Leakage of cerebrospinal fluid would be noted from the ears or the nares.
What is the BEST position for patient experiencing autonomic dysreflexia?
A. High Fowler's with legs lowered.
B. Low Fowler's with legs lowered.
C. Semi-Fowler's with legs at heart level
D. Prone.
The answer is A. The patient should be in High Fowler's (90 degrees) with legs lowered. This will allow gravity to cause blood to pool in the lower extremities and decrease blood pressure.
Select all the signs and symptoms below that can present in myasthenia gravis:
A. Respiratory failure
B. Increased salivation
C. Diplopia
D. Ptosis
E. Slurred speech
F. Restlessness
G. Mask-like appearance of looking sleepy
H. Difficulty swallowing
The answers are A, C, D, E, F (restlessness from hypoxia, which is experienced with respiratory failure). G and H.
The patient's lumbar puncture results are back. Which finding below correlates with Guillain-Barre Syndrome?
A. High glucose with normal white blood cells
B. High protein with normal white blood cells
C. High protein with low white blood cells
D. Low protein with high white blood cells.
The answer is B