Chapter 59: Nursing Management: Acute Intracranial Problems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. Family members ask the nurse about the purpose of the ventriculostomy system being
used for intracranial pressure monitoring for a client. Which of the following responses by
the nurse is best?
a. “This type of monitoring system is complex and highly skilled staff are needed.”
b. “The monitoring system helps show whether blood flow to the brain is adequate.”
c. “The ventriculostomy monitoring system helps check for alterations in cerebral
perfusion pressure.”
d. “This monitoring system has multiple benefits including facilitation of
cerebro-spinal fluid drainage.”
ANS: B
Short and simple explanations should be given to clients and family members. The other
explanations are either too complicated to be easily understood or may increase the family
member’s anxiety.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
2. The nurse is caring for a client with a head injury and has admission vital signs of blood
pressure 128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute. Which of
these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes
represent Cushing’s triad and 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.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse is assessing a client who is unconscious and applies a painful stimulus to the
nail beds. The client responds with internal rotation, adduction, and flexion of the arms.
Which of the following terms should the nurse use when documenting the findings?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing
ANS: C
, Internal rotation, adduction, and flexion of the arms in an unconscious client is
documented as decorticate posturing. Extension of the arms and legs is decerebrate
posturing. Because the flexion is generalized, it does not indicate localization of pain or
flexion withdrawal.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
4. Which of the following parameters is best for the nurse to monitor to determine whether
the prescribed IV mannitol has been effective for an unconscious client?
a. Hematocrit
b. Blood pressure
c. Oxygen saturation
d. Intracranial pressure
ANS: D
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 the best
parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not
directly improve as a result of mannitol administration.
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
5. A client with a head injury opens his or her eyes to verbal stimulation, curses when
stimulated, and does not respond to a verbal command to move but attempts to remove a
painful stimulus. Which of the following Glasgow Coma Scale scores should the nurse
document?
a. 9
b. 11
c. 13
d. 15
ANS: B
The client has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor
response.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
6. The nurse is admitting a client to the emergency department (ED) who is unconscious
following a head injury. The client’s spouse and children stay at the client’s side and
constantly ask about the treatment being given. What of the following actions is best for
the nurse to take?
a. Ask the family to stay in the waiting room until the initial assessment is completed.
b. Allow the family to stay with the client and briefly explain all procedures to them.
c. Call the family’s pastor or spiritual advisor to support them while initial care is
given.
d. Refer the family members to the hospital counselling service to deal with their
anxiety.
ANS: B
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. Family members ask the nurse about the purpose of the ventriculostomy system being
used for intracranial pressure monitoring for a client. Which of the following responses by
the nurse is best?
a. “This type of monitoring system is complex and highly skilled staff are needed.”
b. “The monitoring system helps show whether blood flow to the brain is adequate.”
c. “The ventriculostomy monitoring system helps check for alterations in cerebral
perfusion pressure.”
d. “This monitoring system has multiple benefits including facilitation of
cerebro-spinal fluid drainage.”
ANS: B
Short and simple explanations should be given to clients and family members. The other
explanations are either too complicated to be easily understood or may increase the family
member’s anxiety.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
2. The nurse is caring for a client with a head injury and has admission vital signs of blood
pressure 128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute. Which of
these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes
represent Cushing’s triad and 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.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse is assessing a client who is unconscious and applies a painful stimulus to the
nail beds. The client responds with internal rotation, adduction, and flexion of the arms.
Which of the following terms should the nurse use when documenting the findings?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing
ANS: C
, Internal rotation, adduction, and flexion of the arms in an unconscious client is
documented as decorticate posturing. Extension of the arms and legs is decerebrate
posturing. Because the flexion is generalized, it does not indicate localization of pain or
flexion withdrawal.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
4. Which of the following parameters is best for the nurse to monitor to determine whether
the prescribed IV mannitol has been effective for an unconscious client?
a. Hematocrit
b. Blood pressure
c. Oxygen saturation
d. Intracranial pressure
ANS: D
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 the best
parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not
directly improve as a result of mannitol administration.
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
5. A client with a head injury opens his or her eyes to verbal stimulation, curses when
stimulated, and does not respond to a verbal command to move but attempts to remove a
painful stimulus. Which of the following Glasgow Coma Scale scores should the nurse
document?
a. 9
b. 11
c. 13
d. 15
ANS: B
The client has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor
response.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
6. The nurse is admitting a client to the emergency department (ED) who is unconscious
following a head injury. The client’s spouse and children stay at the client’s side and
constantly ask about the treatment being given. What of the following actions is best for
the nurse to take?
a. Ask the family to stay in the waiting room until the initial assessment is completed.
b. Allow the family to stay with the client and briefly explain all procedures to them.
c. Call the family’s pastor or spiritual advisor to support them while initial care is
given.
d. Refer the family members to the hospital counselling service to deal with their
anxiety.
ANS: B
