Have Some Grace :)
An unconscious patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider would the nurse question?
a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c. Send for computed tomography (CT) scan.
d. Perform neurologic checks every 15 minutes.
ANS: B
Rationale: After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure. Herniation of the brain could result if lumbar puncture is performed. The other orders are appropriate.
A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse’s first priority is to
a. Call the health care provider
b. Check the patient’s temperature
c. Measure the patient’s blood pressure
d. Elevate the head of the bed to 90 degrees
ANS: C
Rationale: A patient with a C7 spinal cord injury is at high risk for autonomic dysreflexia, a medical emergency that occurs in injuries at or above T6. The patient’s symptoms—severe headache and nausea—are classic early signs of autonomic dysreflexia, not the flu.
The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further teaching about neurologic assessment?
a. Tests for light touch before testing for pain.
b. Has the patient close the eyes during testing.
c. Asks the patient if the instrument feels sharp.
d. Uses an irregular pattern to test for intact touch.
ANS: C
Rationale: When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.
A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristics of this condition?
a. Tachycardia
b. Hypotension
c. Increased cardiac output
d. Peripheral vasoconstriction
ANS: B
Rationale: A T4 spinal cord injury can lead to neurogenic shock, which occurs due to loss of sympathetic nervous system control. Neurogenic shock = hypotension + bradycardia + vasodilation due to loss of sympathetic tone.
Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which statement by the nurse would be the best initial response for this situation?
a. “This is a complex type of monitoring system, and it is managed by skilled staff.”
b. “The system measures pressures to determine whether blood flow to the brain is adequate.”
c. “The ventriculostomy monitoring system helps check for changes in cerebral perfusion pressure.”
d. “This monitoring system has many benefits, including the ability to drain cerebrospinal fluid.”
ANS: B
Rationale: Short, simple, and accurate explanations should be given initially to patients and family members. Explaining that the system is complex, and it is managed by skilled staff or that it has multiple benefits does not address the family question about purpose for this patient. Terminology such as ventriculostomy and cerebral perfusion pressure is too complex for the initial explanation and may increase family members‘ anxiety.
The nurse is caring for a client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?
a. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
b. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
c. Decreasing temp, decreasing pulse, increasing respirations, decreasing blood pressure
d. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
ANSWER: B
Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature, widening pulse pressure, increased systolic blood pressure, and decreasing pulse and respirations. Respiratory irregularities also may occur.
Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?
a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min
b. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min
c. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respirations 28 breaths/min
d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min
ANS: A
Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing‘s triad. These findings 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.
The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures would the nurse include in planning for the client’s safety? Select all that apply. (4)
a. Padding the side rails of the bed
b. Placing an airway at the bedside
c. Placing the bed in the high position
d. Putting a padded tongue blade at the head of the bed
e. Placing oxygen and suction equipment at the bedside
f. Flushing the intravenous catheter to ensure that the site is patent
ANSWER: A, B, E, F
Rationale: Seizure precautions may vary from agency to agency, but they generally have some common features. Airway, oxygen and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure meds must be administered, and as part of the routine assessment the nurse would be checking patency of the catheter. No tongue blades.
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter would the nurse monitor to determine the medication‘s effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit
ANS: C
Rationale: 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 parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve because of mannitol administration
A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following is the priority nursing action at this time?
a. Keep neck stabilized
b. Insert nasogastric tube
c. Monitor pulse and BP frequently
d. Establish IV access and start fluid replacement
ANSWER: A
Rationale: The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out.
An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient‘s spouse and teenage children stay at the patient‘s side and ask many questions about the treatment. Which action is best for the nurse to take?
a. Call the family‘s pastor or spiritual advisor to take them to the chapel.
b. Ask the family to stay in the waiting room until the assessment is completed.
c. Allow the family to stay with the patient and briefly explain all procedures to them.
d. Refer the family members to the hospital counseling service to deal with their anxiety.
ANS: C
Rationale: The need for information about the diagnosis and care is very high in family members of acutely injured patients. The nurse would allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.
A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? Select all that apply (3)
a. Headache
b. Dilated pupils
c. Tachycardia
d. Decorticate posturing
e. Hypotension
ANSWER: A, B, D
Rationale: Headache and dilated pupils are findings associated with increased ICP.
Decorticate or decerebrate posturing is a finding associated with ICP.
*Bradycardia, not tachycardia. * Hypertension, not hypotension.
A patient who is unconscious after a head injury has cerebral edema. Which nursing intervention will be included in the plan of care?
a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods.
ANS: C
Rationale: The patient with increased intracranial pressure (ICP) would be maintained in the head-up position with the head in neutral position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.
A nurse is caring for a client who has a closed head injury with ICP readings ranging from 16 to 22mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client’s ICP? (Select all that apply) (2)
a. Suction the endotracheal tube frequently
b. Decrease the noise level in the client’s room
c. Elevate the client’s head on two pillows.
d. Administer a stool softener
e. Keep the client well hydrated
ANSWER: B, D
Rationale: Why these are not correct: Suctioning increases ICP and should be performed only when necessary. Hyperflexion of the client’s neck with pillows carries the risk of increasing ICP and should be avoided. The head of the bead should be raised to 30%, but the head should be maintained in an upright neutral position. Overhydration carries the risk of increasing ICP and should be avoided. Monitor fluids and electrolytes closely.
The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient‘s nose. Which admission order would the nurse question?
a. Keep the head of bed elevated.
b. Insert nasogastric tube to low suction.
c. Turn patient side to side every 2 hours.
d. Apply cold packs intermittently to face.
ANS: B
Rationale: Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.
A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor?
a. Hyperglycemia
b. Hyponatremia
c. Hypervolemia
d. Oliguria
ANSWER: B
Rationale: Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances such as hyponatremia. **Hyperglycemia is not correct. **Hypovolemia and polyuria are the adverse effects of mannitol.
A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action would the nurse take first?
a. Document the BP and ICP in the patient‘s record.
b. Report the BP and ICP to the health care provider.
c. Elevate the head of the patient‘s bed to 60 degrees.
d. Continue to monitor the patient‘s vital signs and ICP.
ANS: B
Rationale: Calculate the cerebral perfusion pressure (CPP): (CPP = Mean arterial pressure [MAP] – ICP). MAP = DBP + 1/3 (Systolic blood pressure [SBP] – Diastolic blood pressure [DBP]). Therefore, the MAP is 70, and the CPP is 56 mm Hg, which are below the normal values of 60 to 100 mm Hg and are approaching the level of ischemia and neuronal death. Immediate changes in the patient‘s therapy such as fluid infusion or vasopressor administration are needed to improve the CPP. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.
A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment?
a. Glasgow Coma Scale
b. Cranial Nerve Function
c. Oxygen Saturation
d. Pupillary Response
ANSWER: C
Rationale: Using the ABC priority setting framework, assessment of oxygen saturation is the priority action. Brain tissue can only survive without perfusion for about 3 minutes before permanent damage occurs. **The others are important but not the priority.
After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action would the nurse take first?
a. Document the increase in intracranial pressure.
b. Ensure that the patient‘s neck is in neutral position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprivan) infusion.
ANS: B
Rationale: Because suctioning will cause a transient increase in ICP, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in ICP.
A head injury client has HR 48, BP 198/62, irregular respirations. Interpretation?
a. Improving
b. Hypovolemia
c. Cushing's Triad
d. Medication side effect
Answer: C
Rationale: These are classic signs of Cushing's Triad.
A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor. Which action will the nurse take first?
a. Check oxygen saturation.
b. Palpate the head for injuries.
c. Assess pupil reaction to light.
d. Verify Glasgow Coma Scale (GCS) score
ANS: A
Rationale: Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.
A nurse is caring for a client with a head injury. Which finding is the earliest indication of increased intracranial pressure (ICP)?
A. Bradycardia
B. Decreased level of consciousness
C. Widening pulse pressure
D. Fixed, dilated pupils
ANSWER: B.
Rationale:
B (Correct): The earliest and most sensitive sign of increased ICP is a change in LOC (restlessness, confusion, decreased responsiveness).
A: Bradycardia is part of late ICP (Cushing’s triad).
C: Widening pulse pressure is also a late sign.
D: Fixed, dilated pupils indicate brain herniation, a very late and severe sign.
Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?
a. Intracranial pressure of 15 mm Hg
b. Cerebrospinal fluid (CSF) drainage of 25 mL/hr
c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg
d. Cardiac monitor shows sinus tachycardia at 120 beats/min
ANS: C
Rationale: The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hr. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.
A client with TBI becomes increasingly restless and confused. What is the nurse’s priority action?
A. Administer pain medication
B. Reassess neurologic status
C. Notify the provider immediately
D. Apply restraints
ANSWER: B
Rationale:
B (Correct): Always assess before acting and compare to baseline.
A: Pain meds could mask neurological changes.
C: Notifying provider may be needed after reassessment confirms decline.
D: Applying restraints is not appropriate without further assessment.
While admitting a patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?
a. The patient reports a severe dull headache.
b. The patient takes an anticoagulant drug daily.
c. The patient‘s blood pressure is 162/94 mm Hg.
d. The patient is unable to remember the accident
ANS: B
Rationale: The use of anticoagulants increases the risk for intracranial hemorrhage and would be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.