NUR 2520 - Unit I - Nervous System/Acute Intracranial
Problems Questions With Complete Solutions
A 19-year-old woman is hospitalized for a frontal skull fracture
from a blunt force head injury. Clear fluid is draining from the
patient's nose. What action by the nurse is most appropriate?
a. Apply a loose gauze pad under the patient's nose.
b. Place the patient in a modified Trendelenburg position.
c. Ask the patient to gently blow the nose to clear the drainage.
d. Gently insert a catheter in the nares and suction the drainage.
Correct Answers a. Apply a loose gauze pad under the patient's
nose.
Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage
from the nose) may occur with a frontal skull fracture. If CSF
rhinorrhea occurs, the nurse should inform the physician
immediately. A loose collection pad may be placed under the
nose. The head of the bed may be raised to decrease the CSF
pressure so that a tear can seal. The nurse should not place a
dressing or tube in the nasal cavity, and the patient should not
sneeze or blow the nose.
A 32-year-old female patient is diagnosed with diabetes
insipidus after transsphenoidal resection of a pituitary adenoma.
What should the nurse consider as a sign of improvement?
a. Serum sodium of 120 mEq/L
b. Urine specific gravity of 1.001
c. Fasting blood glucose of 80 mg/dL
,d. Serum osmolality of 290 mOsm/kg Correct Answers d.
Serum osmolality of 290 mOsm/kg
Laboratory findings in diabetes insipidus include an elevation in
serum osmolality and serum sodium and a decrease in urine
specific gravity. Normal serum osmolality is 275 to 295
mOsm/kg, normal serum sodium is 135 to 145 mEq/L, and
normal specific gravity is 1.003 to 1.030. Elevated blood
glucose levels occur with diabetes mellitus.
A 68-year-old man with suspected bacterial meningitis has just
had a lumbar puncture in which cerebrospinal fluid was obtained
for culture. Which medication should the nurse administer first?
a. Codeine
b. Phenytoin (Dilantin)
c. Ceftriaxone (Rocephin)
d. Acetaminophen (Tylenol) Correct Answers c. Ceftriaxone
(Rocephin)
Bacterial meningitis is a medical emergency. When meningitis
is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted
immediately after the collection of specimens for cultures, and
even before the diagnosis is confirmed. Dexamethasone may
also be prescribed before or with the first dose of antibiotics.
The nurse should collaborate with the health care provider to
manage the headache (with codeine), fever (with
acetaminophen), and seizures (with phenytoin).
A male patient suffered a diffuse axonal injury from a traumatic
brain injury (TBI). He has been maintained on IV fluids for 2
, days. The nurse seeks enteral feeding for this patient based on
what rationale?
a. Free water should be avoided.
b. Sodium restrictions can be managed.
c. Dehydration can be better avoided with feedings.
d. Malnutrition promotes continued cerebral edema. Correct
Answers d. Malnutrition promotes continued cerebral edema.
A patient with diffuse axonal injury is unconscious and, with
increased ICP, is in a hypermetabolic, hypercatabolic state that
increases the need for fuel for healing. Malnutrition promotes
continued cerebral edema, and early feeding may improve
outcomes when begun within 3 days after injury. Fluid and
electrolytes will be monitored to maintain balance with the
enteral feedings.
A nurse plans care for the patient with increased intracranial
pressure with the knowledge that the best way to position the
patient is to
a. keep the head of the bed flat
b. elevate the head of the bed to 30 degrees
c. maintain patient on the left side with the head supported by a
pillow
d. use a continuous-rotation bed to continuously change patient
postion Correct Answers b. elevate the head of the bed to 30
degrees
Rationale: The nurse should maintain the patient with abnormal
ICP in the head-up position. Elevation of the head of the bed to
Problems Questions With Complete Solutions
A 19-year-old woman is hospitalized for a frontal skull fracture
from a blunt force head injury. Clear fluid is draining from the
patient's nose. What action by the nurse is most appropriate?
a. Apply a loose gauze pad under the patient's nose.
b. Place the patient in a modified Trendelenburg position.
c. Ask the patient to gently blow the nose to clear the drainage.
d. Gently insert a catheter in the nares and suction the drainage.
Correct Answers a. Apply a loose gauze pad under the patient's
nose.
Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage
from the nose) may occur with a frontal skull fracture. If CSF
rhinorrhea occurs, the nurse should inform the physician
immediately. A loose collection pad may be placed under the
nose. The head of the bed may be raised to decrease the CSF
pressure so that a tear can seal. The nurse should not place a
dressing or tube in the nasal cavity, and the patient should not
sneeze or blow the nose.
A 32-year-old female patient is diagnosed with diabetes
insipidus after transsphenoidal resection of a pituitary adenoma.
What should the nurse consider as a sign of improvement?
a. Serum sodium of 120 mEq/L
b. Urine specific gravity of 1.001
c. Fasting blood glucose of 80 mg/dL
,d. Serum osmolality of 290 mOsm/kg Correct Answers d.
Serum osmolality of 290 mOsm/kg
Laboratory findings in diabetes insipidus include an elevation in
serum osmolality and serum sodium and a decrease in urine
specific gravity. Normal serum osmolality is 275 to 295
mOsm/kg, normal serum sodium is 135 to 145 mEq/L, and
normal specific gravity is 1.003 to 1.030. Elevated blood
glucose levels occur with diabetes mellitus.
A 68-year-old man with suspected bacterial meningitis has just
had a lumbar puncture in which cerebrospinal fluid was obtained
for culture. Which medication should the nurse administer first?
a. Codeine
b. Phenytoin (Dilantin)
c. Ceftriaxone (Rocephin)
d. Acetaminophen (Tylenol) Correct Answers c. Ceftriaxone
(Rocephin)
Bacterial meningitis is a medical emergency. When meningitis
is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted
immediately after the collection of specimens for cultures, and
even before the diagnosis is confirmed. Dexamethasone may
also be prescribed before or with the first dose of antibiotics.
The nurse should collaborate with the health care provider to
manage the headache (with codeine), fever (with
acetaminophen), and seizures (with phenytoin).
A male patient suffered a diffuse axonal injury from a traumatic
brain injury (TBI). He has been maintained on IV fluids for 2
, days. The nurse seeks enteral feeding for this patient based on
what rationale?
a. Free water should be avoided.
b. Sodium restrictions can be managed.
c. Dehydration can be better avoided with feedings.
d. Malnutrition promotes continued cerebral edema. Correct
Answers d. Malnutrition promotes continued cerebral edema.
A patient with diffuse axonal injury is unconscious and, with
increased ICP, is in a hypermetabolic, hypercatabolic state that
increases the need for fuel for healing. Malnutrition promotes
continued cerebral edema, and early feeding may improve
outcomes when begun within 3 days after injury. Fluid and
electrolytes will be monitored to maintain balance with the
enteral feedings.
A nurse plans care for the patient with increased intracranial
pressure with the knowledge that the best way to position the
patient is to
a. keep the head of the bed flat
b. elevate the head of the bed to 30 degrees
c. maintain patient on the left side with the head supported by a
pillow
d. use a continuous-rotation bed to continuously change patient
postion Correct Answers b. elevate the head of the bed to 30
degrees
Rationale: The nurse should maintain the patient with abnormal
ICP in the head-up position. Elevation of the head of the bed to
