Preview Extract
Chapter 29
1. A client has experienced a subarachnoid hemorrhage and is at risk for intracranial pressure
(ICP) due to the initiation of the vasodilatory cascade. The primary risk factor for this series
of events is:
1. Cerebral tissue ischemia.
2. Cerebral edema.
3. Vasoconstriction of cerebral vessels.
4. Decreased cerebral perfusion pressure.
Answer: Cerebral tissue ischemia.
Rationale:
The vasodilatory cascade is a series of events triggered by hypoxia, with the result being
increased ICP. Vasoconstriction of cerebral blood vessels is not a cause of ICP. Depressed
cerebral perfusion pressure (CPP) is a decrease in the pressure gradient that drives cerebral
blood flow. Cerebral edema may be a result of the vasodilatory cascade but is not its cause.
2. The nurse caring for a client who has experienced a brain abscess understands the
importance of maintaining medium arterial blood pressure (MAP) since it:
1. Identifies risk for tissue ischemia.
2. Affects diastolic blood pressure.
3. Determines intracranial pressure.
4. Affects systolic blood pressure.
Answer: Identifies risk for tissue ischemia.
Rationale:
MAP is considered to be the perfusion pressure seen by organs in the body. It is believed that
a MAP that is greater than 60 mmHg is enough to sustain the organs of the average person. If
the MAP falls significantly below this number for an appreciable time, the end organ will not
get enough blood flow, and will become ischemic. MAP does not determine ICP. MAP does
not affect, but rather is affected by, systolic and diastolic blood pressure.
3. A client at risk for increased intracranial pressure (ICP) is likely to experience involuntary
compensatory mechanisms. The nurse recognizes that these alterations may include:
Select all that apply.
1. Increased absorption of cerebral spinal fluid (CSF).
2. Decreased production of cerebral spinal fluid (CSF).
3. Decreased metabolic energy needs.
4. Vasodilation of the cerebral vessels.
5. Vasoconstriction of cardiac vessels.
Answer: 1. Increased absorption of cerebral spinal fluid (CSF).
2. Decreased production of cerebral spinal fluid (CSF).
3. Decreased metabolic energy needs.
Rationale:
Increased absorption of cerebral spinal fluid (CSF). In order for the brain to maintain a
normal ICP, attempts are made to compensate for changes in any of the three components
within the brain. Initial mechanisms for ICP may include changing the volume of CSF by
decreasing production. Decreased production of cerebral spinal fluid (CSF). In order for the
brain to maintain a normal ICP, attempts are made to compensate for changes in any of the
three components within the brain. Initial mechanisms for ICP may include changing the
volume of CSF by increasing absorption. Decreased metabolic energy needs. A decrease in
metabolic energy needs is likely. Vasodilation of the cerebral vessels. Vasoconstriction of the
cerebral blood vessels will result as space becomes compressed. Vasoconstriction of cardiac
vessels. Vasoconstriction of cardiac vessels is not a normal compensatory mechanism seen for
ICP.
4. Which of the following statements made by a nurse reflects the best understanding of the
symptomology of increasing intracranial pressure (IICP)?
1. “If a client shows drowsiness or restlessness, I get concerned.”
2. “The primary focus is the client’s pupils.”
3. “Acute muscle weakness, regardless of how severe, is a red flag.”
4. “When the client reports a headache, I know we have a problem.”
Answer: “If a client shows drowsiness or restlessness, I get concerned.”
Rationale:
Alterations in the patient’s level of consciousness (LOC) are usually the first sign of
impending increase in ICP. While changes to pupil size and reactivity and decreased motor
strength are signs of possible IICP, they are usually preceded by a change in the client’s LOC.
Headaches are generally not a specific indication of IICP.
5. The nurse recognizes that a client being monitored via an external ventricular drain is
experiencing normal intracranial pressure if the reading is:
1. 14 mmHg.
2. 23 mmHg.
3. 73 mmHg.
4. 89 mmHg.
Answer: 14 mm Hg.
Rationale:
The desired range of ICP is 0 to 15 mm Hg. ICPs are considered elevated when sustained at
greater than 20 mmHg. Normal cerebral perfusion pressure (CPP) is 70 to 100 mm Hg.
6. A client with a right temporal lobe lesion is displaying Cheyne-Stokes respirations. The
nurse recognizes:
1. This client requires surgical decompression of the brain.
2. There is no medical treatment appropriate for this symptomology.
3. The next likely sign will be sluggish pupil reaction ipsilaterally.
4. This type of brain pathophysiology is usually self-limiting.
Answer: This client requires surgical decompression of the brain.
Rationale:
This client is experiencing a symptom of uncal herniation. Late signs include altered
respiratory patterns, such as Cheyne-Stokes respirations. Urgent surgical intervention to
decompress the brain is often the treatment of choice. Often, the first sign of impending uncal
herniation is a sluggishly reactive pupil on the ipsilateral (same) side of the lesion. Herniation
syndromes are life-threatening neurological emergencies that, left untreated, can progress
rapidly to death.
7. A client with increased intracranial pressure (ICP) is being repositioned. The nurse
performs this intervention incorporating which of the following?
Select all that apply.
1. Manage the repositioning with slow, smooth, and gentle movement.
2. Inform the client regarding what is going to occur during the intervention.
3. Elevate the head of the bed to 30 degrees.
4. Accompany each repositioning with passive range-of-motion exercises.
5. Reposition the client every 1 to 2 hourss.
Answer: 1. Manage the repositioning with slow, smooth, and gentle movement.
2. Inform the client regarding what is going to occur during the intervention.
3. Elevate the head of the bed to 30 degrees.
Rationale:
Manage the repositioning with slow, smooth, and gentle movement. It is especially important
that clients with increased ICP should be repositioned slowly and with smooth, gentle
movements, because rapid changes can cause the pressure to increase. Inform the client
regarding what is going to occur during the intervention. Clients should always be informed
about what is going to occur. Elevate the head of the bed to 30 degrees. The head of the bed
should be elevated. The degree depends on the reaction of the client to the position; 30
degrees is usually appropriate, but this can vary by the client. Accompany each repositioning
with passive range-of-motion exercises. Position changes should be done less frequently for
clients with ICP because turning, skin care, and passive ROM exercises can elicit involuntary
posturing, which also causes increased ICP. Reposition the client every 1 to 2 hourss. Position
changes should be done less frequently for clients with ICP because turning, skin care, and
passive ROM exercises can elicit involuntary posturing, which also causes increased ICP.
8. The nurse is monitoring the blood glucose levels of a client with a closed head injury to
maintain the client in a euglycemic state. The nurse can best accomplish this goal by:
1. Administering insulin to keep glucose blood levels between 80 and 120 mg/dl.
2. Assessing the blood glucose levels every 4 hours by glucometer testing.
3. Minimizing the client’s energy requirements by anticipating and meeting needs promptly.
4. Arranging for a diet that allows for carbohydrate loading.
Answer: Administering insulin to keep glucose blood levels between 80 and 120 mg/dl.
Rationale:
A euglycemic state refers to one where blood glucose levels are kept between 80 and 120
mg/dl. Administering insulin, which facilitates the proper utilization of glucose, will be the
most beneficial intervention in maintaining normal glucose levels (80–120 mg/dl). While
monitoring the client’s blood glucose every 4 hours is appropriate, it does not bring about
normal blood glucose levels. Minimizing energy requirements by anticipating and meeting
needs promptly is an appropriate intervention for such a client, but it will have no affect on
blood glucose control. Carbohydrate loading or the ingestion of large amounts of
carbohydrates will contribute to the elevation of blood glucose levels.
9. Which of the following statements made by a nurse shows the most informed knowledge
regarding the positioning of the head of a client being monitored for increasing intracranial
pressure (ICP) related to a brain injury that is not vascular in nature?
1. “The client’s intracranial pressure dictates how high I position the head of the bed.”
2. “I am careful to elevate the head of the client’s bed to 30 degrees.”
3. “The most controllable factor in managing intracranial pressure (ICP) is head elevation.”
4. “I elevate the client’s head when the intracranial pressure is increasing.”
Answer: “The client’s intracranial pressure dictates how high I position the head of the bed.”
Rationale:
The suggestion is that head positioning, both in terms of elevation and rotation, has a definite
effect on ICP. However, it is recommended that head position be established on an individual
basis, with the help of monitoring devices. A 30-degree elevation, while traditionally
accepted, should not be universally accepted for all clients. There are several factors that
affect the client’s intracranial pressure. Head elevation is used to minimize or prevent IICP
and should not be reserved for implementation only after an increase is observed.
10. The parent of a 2-year-old child who fell and sustained a scalp laceration that will require
suturing asks the nurse, “How serious an injury is this?” The nurse responds by stating:
1. “From the description of the fall it doesn’t appear serious, but the x-ray will tell us for
sure.”
2. “There is a lot of bleeding, but it is really a rather superficial injury.”
3. “Children this age are really resilient, but you never know until the x-rays are read.”
4. “He’ll need a few stitches and a tetanus injection, but that should do it.”
Answer: “From the description of the fall it doesn’t appear serious, but the x-ray will tell us
for sure.”
Rationale:
Scalp lacerations account for a large number of emergency department visits and are usually
not serious, but with any scalp laceration, the possibility of an underlying skull fracture must
be addressed. An accurate history of the event surrounding the injury is very important. If
there is any reason to suspect a skull fracture, a computerized tomography (CT) scan or a
plain x-ray of the skull should be obtained. Telling the parents that the wound is superficial
without the benefit of radiological confirmation is inappropriate. Stating that children are
resilient is minimizing the parent’s concern, and stating that a few stitches and a tetanus
injection is all that is needed is minimizing the potential of the injury.
11. Which of the following observations by the nurse are representative of the symptomology
of an epidural hematoma (EDH)?
Select all that apply.
1. History of unconsciousness immediately after trauma
2. Dilated pupil on the same side as the injury
3. Rapid deterioration of level of consciousness
4. Period of lucidity prior to onset of symptoms
5. Muscle weakness on the side opposite the head injury
Answer: 1. History of unconsciousness immediately after trauma
2. Dilated pupil on the same side as the injury
3. Rapid deterioration of level of consciousness
4. Period of lucidity prior to onset of symptoms
Rationale:
History of unconsciousness immediately after trauma. Classic clinical presentation of EDH is
characterized by an immediate post-traumatic period of unconsciousness, followed by a lucid
interval, which can last from minutes to hours. Dilated pupil on the same side as the injury.
Possible signs and symptoms include an enlarging pupil on the same side of the injury
(ipsilateral). Rapid deterioration of level of consciousness. A rapid deterioration in level of
consciousness may follow. Period of lucidity prior to onset of symptoms. Classic clinical
presentation of EDH is characterized by an immediate post-traumatic period of
unconsciousness, followed by a lucid interval, which can last from minutes to hours. Muscle
weakness on the side opposite the head injury. Hemiparesis (muscle weakness) of the
contralateral arm and leg (opposite side from the injury) may be present with an acute
subdural hematoma.
12. The client riding in a car that hit a tree is diagnosed with cerebral contusions resulting
from an acceleration/deceleration injury. The nurse explains this injury to the client’s
daughter as:
1. “Your dad’s brain was injured once when his head hit the windshield and again when it
rebounded against the back of his skull.”
2. “The injuries were a result of repeated contact with the dashboard of the car.”
3. “His head was traumatized by the force the car exerted against the trunk of the tree.”
4. “The brain was bruised severely several different times from the impact it suffered when
he bounced around in the car after hitting the tree.”
Answer: “Your dad’s brain was injured once when his head hit the windshield and again
when it rebounded against the back of his skull.”
Rationale:
Contusions occurring from acceleration/deceleration injuries may include motor vehicle
crashes, falls, and assault. These contusions occur as a result of the brain moving within the
skull, and bruising itself during acceleration/deceleration movement. Injuries sustained by
repeated contact with a stationary object are called deceleration injuries.
13. The nurse is caring for a client who is recovering from a lumbar puncture and is
concerned that the client may contract bacterial meningitis. The common early
symptomology that nurse should be alert to includes:
Select all that apply.
1. Headache.
2. Fever.
3. Confusion.
4. Seizures.
5. Rhinorrhea.
Answer: 1. Headache.
2. Fever.
3. Confusion.
4. Seizures.
Rationale:
Headache. Headache is a common and early symptom of meningitis. Fever. Fever is a
common and early symptom of meningitis. Confusion. Confusion is a common and early
symptom of meningitis. Seizures. Seizures are a common and early symptom of meningitis.
Rhinorrhea. Clients with skull fractures may experience rhinorrhea, which is the leaking of
cerebral spinal fluid via the nose.
14. A client is being admitted for possible meningitis. The nurse recognizes that which of the
following assessment data are significant to the confirmation of that diagnoses?
1. A history of flulike symptoms resolving 5 days ago
2. Blood pressure of 100/62
3. Sluggish pupils bilaterally
4. A cervical lymph node palpable on physical examination
Answer: A history of flulike symptoms resolving 5 days ago
Rationale:
The presence of systemic viral infections such as a “flulike” illness is significant and may
indicate the original source of the viral invasion. None of the remaining options of
hypotension, sluggish pupils, or an enlarged cervical lymph node is considered a risk factor
for meningitis.
15. The nurse is caring for a client receiving intravenous antibiotic therapy for bacterial
meningitis. The client has a history of seizures that are currently being controlled with
phenytoin (Dilantin). The nurse institutes seizure precautions for this client because:
1. Antibiotics can decrease the effect of phenytoin (Dilantin).
2. Emotional stress increases the occurrence of seizure activity.
3. Administration of drugs intravenously can initiate seizure activity.
4. Physical stress decreases the effectiveness of antiseizure medication.
Answer: Antibiotics can decrease the effect of phenytoin (Dilantin).
Rationale:
While both mental and physical stress cause changes in the body that increase the brain’s
excitability and activity, it is important to note that some antibiotics interfere with the
metabolism of other drugs, including phenytoin. This is significant because it generally
decreases the blood levels of phenytoin, leaving the patient more susceptible to seizure
activity; this is the reason for instituting seizure precautions for this client. There is no known
relationship between intravenous drug administration and seizure activity. Physical and
emotional stresses are not linked to the effectiveness of anti-seizure medications or an
increased incidence of seizures.
16. A client has been diagnosed with a grade 1 astrocytoma, an intra-axial brain tumor. When
asked what his “chances of surviving this thing are,” the nurse’s response is based on the
knowledge that:
1. Age is the greatest predictor of client survival.
2. A grade 1 is a very aggressive form of this type of tumor.
3. It depends on whether the tumor metastasizes outside the brain.
4. This type of tumor has a survival rate of 3 years.
Answer: Age is the greatest predictor of client survival.
Rationale:
The strongest predictor of survival with low-grade (grades 1 and 2) astrocytoma (a type of
glioma) is age. One study reported a mean survival time of 8.5 years for adults less than 40
years of age; this contrasts with 4.9 years for adults 40 years of age and older. Astrocytomas
(grade III) are noted to be more aggressive than lower-grade astrocytomas, with a median
survival rate of approximately 3 to 5 years. Though astrocytomas may spread into
surrounding normal brain tissue, it is rare for them to spread outside the brain and CSF
system.
17. A client has had a surgical resection of an acoustic neuroma. The nurse’s postoperative
assessment should focus on:
1. Identifying damage to cranial nerves VII, IX, X, and XII.
2. Utilization of the House/Brackmann assessment scale.
3. Documenting complaints of tinnitus and dizziness.
4. Determining the degree of hearing loss.
Answer: Identifying damage to cranial nerves VII, IX, X, and XII.
Rationale:
Surgical resection of acoustic neuromas can cause damage to cranial nerves in proximity to
the tumor. Damage to cranial nerves VII, IX, X, and XII is possible. Therefore, a thorough
cranial nerve assessment is important, both preoperatively and postoperatively. If the facial
nerve is damaged, it is important to note the degree of facial weakness exhibited using the
House/Brackmann scale. Acoustic neuromas usually are diagnosed when the patient
experiences gradual hearing loss, tinnitus, and/or dizziness.
18. A client has been diagnosed with a pituitary adenoma. Which of the following assessment
findings supports that it is a nonfunctioning form?
1. 20/40 vision using a Snellen chart
2. A protruding lower jaw
3. A round, moon-shaped face
4. Report of insomnia
Answer: 20/40 vision using a Snellen chart
Rationale:
Nonfunctioning pituitary adenomas produce symptoms caused by pressure of the tumor on
surrounding structures, such as the optic nerve. Frequently, visual loss is the presenting
symptom and it may be in the form of decreased acuity. Functioning pituitary adenomas
produce endocrine symptoms, such as acromegaly or Cushing’s syndrome. A protruding
lower jaw, moon-shaped face, and insomnia are not associated with nonfunctioning pituitary
adenomas.
19. A client diagnosed with a benign brain tumor asks, “What is a gamma knife?” The nurse
explains that “It is:
1. A method of providing a focused dose of radiation at your tumor.”
2. A radioactive seed or capsule implanted into the tumor.”
3. A robotic arm device that delivers multiple beams of radiation to the tumor.”
4. The traditional method of providing radiation to a tumor.”
Answer: A method of providing a focused dose of radiation at your tumor.”
Rationale:
Gamma knife radiosurgery is a system that uses focused radiation in a single dose.
Brachytherapy is the surgical implantation of radioactive capsules, or “seeds,” directly into
the tumor bed. Cyber knife radiosurgery is a radiosurgical system that consists of a robotic
arm used to deliver multiple beams of radiation. To say that a gamma knife is the traditional
method of providing radiation to a tumor is not accurate.
20. A client with terminal metastatic brain cancer asks, “Why should I agree to radiation
therapy?” The nurse’s response is based on the knowledge that radiation therapy:
Select all that apply
1. Provides improved quality of life.
2. Slows the growth of the tumor.
3. Helps decrease cancer-related pain.
4. Has the greatest affect on brain cancer cells.
5. Produces the least side effects of all treatment regimes.
Answer: 1. Provides improved quality of life.
2. Slows the growth of the tumor.
3. Helps decrease cancer-related pain.
Rationale:
Provides improved quality of life. The addition of radiation therapy to the treatment regimen
of brain tumor patients increases survival time and adds to the client’s quality of life. Slows
the growth of the tumor. The addition of radiation therapy to the treatment regimen of brain
tumor patients increases survival time and slows tumor growth. Helps decrease cancer-related
pain. The addition of radiation therapy to the treatment regimen of brain tumor patients adds
to the client’s comfort. Has the greatest affect on brain cancer cells. The effectiveness of the
radiation therapy depends on a variety of factors. Produces the least side effects of all
treatment regimes. Radiation therapy produces serious side effects.
21. A client diagnosed with a brain tumor is reluctant to agree to a surgical excision of the
lesion. The nurse addresses the client’s concern best by:
1. Asking the client to be more specific about what concerns him.
2. Notifying the neurosurgeon of the client’s concerns.
3. Assuring the client that the procedure is necessary.
4. Providing detailed written information on the benefits of the proposed procedure.
Answer: Asking the client to be more specific about what concerns him.
Rationale:
The nurse has a responsibility to the client to help address his concerns, but this cannot be
done until the nurse fully understands the client’s concerns. The neurosurgeon may be
notified of the concern if it is outside the nurse’s scope of responsibility. Merely assuring the
client about the necessity of the procedure does not address the client’s concerns. While
written reinforcement of the information is appropriate, the client needs personal involvement
on the part of the nurse to address specific concerns.
22. A client who has developed a seizure disorder as a result of a traumatic brain injury is
being prepared for discharge. Which of the following should the nurse include in discharge
teaching regarding the information the family/caregiver should report concerning a seizure at
home?
Select all that apply.
1. How long did the seizure last?
2. Was the client injured?
3. Did the client lose consciousness?
4. Was the client confused after the seizure?
5. Has the client been taking his seizure medication?
Answer: 1. How long did the seizure last?
2. Was the client injured?
3. Did the client lose consciousness?
4. Was the client confused after the seizure?
Rationale:
How long did the seizure last? It is important to note the duration of the seizure activity. Was
the client injured? It is important to note any injuries that resulted. Did the client lose
consciousness? It is important to note whether the client lost consciousness. Was the client
confused after the seizure? It is important to note whether the client was confused following
the event. Has the client been taking his seizure medication? Description of the event would
not include whether the client had taken medication.
23. When the daughter of a client being treated for a traumatic brain injury asks why her
mother’s blood is being tested for sodium, the nurse responses:
1. “If you mother is lacking sodium, she is at risk for serious complications.”
2. “To be sure her serum sodium level is between 135 and 145 mEg/L.”
3. “Monitoring sodium levels is routine for injuries like your mother’s.”
4. “It’s a simple diagnostic test that gives her health care provider a lot of information.”
Answer: “If you mother is lacking sodium, she is at risk for serious complications.”
Rationale:
Close monitoring of serum sodium levels is important because low levels of serum sodium,
especially less than 130 mEq/L, can facilitate cerebral edema, causing decreased levels of
consciousness, confusion, seizures, and even death. Educating the family about normal
sodium levels does not answer the question that was asked. Suggesting that the test is done
routinely for general informational purposes does not address the question effectively.
24. A client has developed postsurgical muscle weakness after the removal of a brain tumor.
To minimize this client’s risk for developing deep vein thrombosis (DVT), the nurse initially:
1. Applies antiembolism hose.
2. Instructs the client to perform leg exercises.
3. Includes regular leg massages in the client’s care plan.
4. Determines through questioning whether the client has a history of DVT.
Answer: Applies antiembolism hose.
Rationale:
If the patient is experiencing motor weakness postoperatively, great care must be taken to
avoid DVT due to immobility. The use of antiembolism hose or pneumonic stockings is
highly recommended, and they should be applied as soon as possible. The client with muscle
weakness is not capable of performing leg exercises. Massaging the legs is not an appropriate
nursing intervention and may result in serious injury to the client. Determining a history of
DVT is not an intervention.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
