LEWIS Med/Surg Chapter 56
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of
care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?
A) Change the patients position as indicated.
B) Monitor serum electrolytes.
C) Maintain NPO status.
D) Monitor arterial blood gas (ABG) values.
B
Feedback:
The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on
an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte
values, along with fluid intake and output. Fluids may have to be restricted in patients with cerebral
edema. Changing the patients position, maintaining an NPO status, and monitoring ABG values do not
relate to the nursing diagnosis of deficient fluid volume
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing
diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse
would document for this diagnosis?
A. Copes with sensory deprivation.
B. Registers normal body temperature.
C. Pays attention to grooming.
D. Obeys commands with appropriate motor responses.
D
Feedback:
An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased
intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals
signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory
deprivation would relate to the nursing diagnosis of disturbed sensory perception. The outcome of
,registers normal body temperature relates to the diagnosis of potential for ineffective
thermoregulation. Body image disturbance would have a potential outcome of pays attention to
grooming.
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is
admitted to the ED. The physician determines the patients injury is causing increased intracranial
pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool?
A. Monro-Kellie hypothesis
B. Glasgow Coma Scale
C. Cranial nerve function
D. Mental status examination
B
Feedback:
LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma
Scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that
because of the limited space for expansion within the skull, an increase in any one of the components
(blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve
function and the mental status examination would be part of the neurologic examination for this
patient, but would not be the priority in evaluating LOC.
A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent
assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would
be correct in suspecting the presence of what complication?
A) Encephalitis
B) CSF leak
C) Meningitis
D) Catheter occlusion
C
, Feedback:
Complications of a ventriculostomy include ventricular infectious meningitis and problems with the
monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are
not suggestive of encephalitis, a CSF leak, or an occluded catheter.
The nurse is participating in the care of a patient with increased ICP. What diagnostic test is
contraindicated in this patients treatment?
A) Computed tomography (CT) scan
B) Lumbar puncture
C) Magnetic resonance imaging (MRI)
D) Venous Doppler studies
B
Feedback:
A lumbar puncture in a patient with increased ICP may cause the brain to herniate from the withdrawal
of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and
frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they
would not affect the ICP itself.
The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan
should specify monitoring for what early sign of increased ICP?
A) Disorientation and restlessness
B) Decreased pulse and respirations
C) Projectile vomiting
D) Loss of corneal reflex
A
Feedback:
Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and
respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of
care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?
A) Change the patients position as indicated.
B) Monitor serum electrolytes.
C) Maintain NPO status.
D) Monitor arterial blood gas (ABG) values.
B
Feedback:
The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on
an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte
values, along with fluid intake and output. Fluids may have to be restricted in patients with cerebral
edema. Changing the patients position, maintaining an NPO status, and monitoring ABG values do not
relate to the nursing diagnosis of deficient fluid volume
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing
diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse
would document for this diagnosis?
A. Copes with sensory deprivation.
B. Registers normal body temperature.
C. Pays attention to grooming.
D. Obeys commands with appropriate motor responses.
D
Feedback:
An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased
intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals
signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory
deprivation would relate to the nursing diagnosis of disturbed sensory perception. The outcome of
,registers normal body temperature relates to the diagnosis of potential for ineffective
thermoregulation. Body image disturbance would have a potential outcome of pays attention to
grooming.
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is
admitted to the ED. The physician determines the patients injury is causing increased intracranial
pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool?
A. Monro-Kellie hypothesis
B. Glasgow Coma Scale
C. Cranial nerve function
D. Mental status examination
B
Feedback:
LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma
Scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that
because of the limited space for expansion within the skull, an increase in any one of the components
(blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve
function and the mental status examination would be part of the neurologic examination for this
patient, but would not be the priority in evaluating LOC.
A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent
assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would
be correct in suspecting the presence of what complication?
A) Encephalitis
B) CSF leak
C) Meningitis
D) Catheter occlusion
C
, Feedback:
Complications of a ventriculostomy include ventricular infectious meningitis and problems with the
monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are
not suggestive of encephalitis, a CSF leak, or an occluded catheter.
The nurse is participating in the care of a patient with increased ICP. What diagnostic test is
contraindicated in this patients treatment?
A) Computed tomography (CT) scan
B) Lumbar puncture
C) Magnetic resonance imaging (MRI)
D) Venous Doppler studies
B
Feedback:
A lumbar puncture in a patient with increased ICP may cause the brain to herniate from the withdrawal
of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and
frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they
would not affect the ICP itself.
The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan
should specify monitoring for what early sign of increased ICP?
A) Disorientation and restlessness
B) Decreased pulse and respirations
C) Projectile vomiting
D) Loss of corneal reflex
A
Feedback:
Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and
respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.
