Chapter 61 Management of Patients With Neurologic Dysfunction
Multiple Choice
1. The nurse caring for a patient with cerebral edema following an acute head injury would
expect to administer which of the following priority medications to reduce cerebral edema? A)
Hydrochlorothiazide (HydroDIURIL)
B) Furosemide (Lasix) C) Mannitol (Osmitrol)
D) Spironolactone (Aldactone) Ans: C
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-2
Feedback: The osmotic diuretic (mannitol) is given to dehydrate the brain tissue and reduce
cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid.
Spironolactone, Lasix, and hydrochlorothiazide are used in the treatment of congestive heart
failure (CHF) and hypertension.
2. The nurse caring for a patient exhibiting clinical manifestations of increased intracranial
pressure (ICP) knows that which of the following diagnostic studies would be contraindicated in
this patient?
A) CT scan
B) Lumbar puncture
C) MRI
D) Venous Doppler studies
Ans: B
,Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Patient Needs: A-1
Feedback: A lumbar puncture in a patient with increased intracranial pressure (ICP) may cause
the brain to herniate due to the withdrawal of fluid and change in pressure during the procedure.
Herniation of the brain is a dire and frequently fatal event. A CT scan, MRI, and Venous Doppler
are considered non-invasive procedures and do not affect the intracranial pressure itself.
3. A patient admitted to the neurological intensive care unit with a brain stem herniation is
exhibiting an altered level of consciousness. The nurse has determined that the patient's mean
arterial pressure (MAP) is 60 with an intracranial pressure (ICP) reading of 5 mm Hg. The nurse
would be correct in determining the cerebral perfusion pressure (CPP) as which of the following
values?
A) Normal
B) High
C) Low
D) Compensating
Ans: C
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 3
Patient Needs: D-3
Feedback: The CPP is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg.
Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. A lower
than normal CPP indicates that the cardiac output is insufficient to maintain adequate cerebral
perfusion.
4. The nurse is completing a plan of care on a postoperative craniotomy patient with a diagnosis
of risk for imbalanced fluid volume related to osmotic diuretic use. An appropriate intervention
for this diagnosis would consist of which of the following?
A) Changing the patient's position as indicated
B) Monitoring serum electrolytes
C) Maintaining NPO status
D) Monitoring arterial blood gas (ABG) values
, Ans: B
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Patient Needs: A-1
Feedback: When a patient is receiving osmotic diuretics, it is important to monitor serum
electrolytes, specifically potassium. Also, a patient receiving osmotic diuretics should have a
serum osmolality drawn to assess hydration status. Patients receiving mannitol should have an
indwelling urinary catheter to monitor urinary output and manage the resulting diuresis. Changing
the patient's position, maintaining an NPO status, and monitoring ABG values do not relate to the
nursing diagnosis of risk for imbalanced fluid volume.
5. A craniotomy patient has just returned from surgery. The nurse completing the initial
assessment notes fluids leaking from the patient's nose. An appropriate initial nursing intervention
to complete at this time would include which of the following?
A) Prepare for a lumbar puncture.
B) Test the leaking fluid with a Dextrostix.
C) Document the abnormal find as the only intervention. D) Pack the patient's nose to prevent
leakage.
Ans: B
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Patient Needs: A-1
Feedback: Nursing management of leakage of cerebrospinal fluid (CSF) focuses on
differentiating CSF from mucus. The nurse should collect the fluid on a Dextrostix. If CSF is
present, the indicator will have a positive reaction, as CSF contains glucose. Refer to Chart 61-2,
page 1869. The patient would not be prepared for a lumbar puncture at this time, nor would his
nose be packed; this could lead to increased intracranial pressure. A loose dressing may be
applied to absorb the drainage initially.
6. A head-injured patient is presenting with a generalized seizure. An appropriate nursing
intervention during the seizure would include which of the following?
A) Restrain the patient to prevent injury.
B) Open the patient's jaws to insert an oral airway.
Multiple Choice
1. The nurse caring for a patient with cerebral edema following an acute head injury would
expect to administer which of the following priority medications to reduce cerebral edema? A)
Hydrochlorothiazide (HydroDIURIL)
B) Furosemide (Lasix) C) Mannitol (Osmitrol)
D) Spironolactone (Aldactone) Ans: C
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-2
Feedback: The osmotic diuretic (mannitol) is given to dehydrate the brain tissue and reduce
cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid.
Spironolactone, Lasix, and hydrochlorothiazide are used in the treatment of congestive heart
failure (CHF) and hypertension.
2. The nurse caring for a patient exhibiting clinical manifestations of increased intracranial
pressure (ICP) knows that which of the following diagnostic studies would be contraindicated in
this patient?
A) CT scan
B) Lumbar puncture
C) MRI
D) Venous Doppler studies
Ans: B
,Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Patient Needs: A-1
Feedback: A lumbar puncture in a patient with increased intracranial pressure (ICP) may cause
the brain to herniate due to the withdrawal of fluid and change in pressure during the procedure.
Herniation of the brain is a dire and frequently fatal event. A CT scan, MRI, and Venous Doppler
are considered non-invasive procedures and do not affect the intracranial pressure itself.
3. A patient admitted to the neurological intensive care unit with a brain stem herniation is
exhibiting an altered level of consciousness. The nurse has determined that the patient's mean
arterial pressure (MAP) is 60 with an intracranial pressure (ICP) reading of 5 mm Hg. The nurse
would be correct in determining the cerebral perfusion pressure (CPP) as which of the following
values?
A) Normal
B) High
C) Low
D) Compensating
Ans: C
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 3
Patient Needs: D-3
Feedback: The CPP is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg.
Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. A lower
than normal CPP indicates that the cardiac output is insufficient to maintain adequate cerebral
perfusion.
4. The nurse is completing a plan of care on a postoperative craniotomy patient with a diagnosis
of risk for imbalanced fluid volume related to osmotic diuretic use. An appropriate intervention
for this diagnosis would consist of which of the following?
A) Changing the patient's position as indicated
B) Monitoring serum electrolytes
C) Maintaining NPO status
D) Monitoring arterial blood gas (ABG) values
, Ans: B
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Patient Needs: A-1
Feedback: When a patient is receiving osmotic diuretics, it is important to monitor serum
electrolytes, specifically potassium. Also, a patient receiving osmotic diuretics should have a
serum osmolality drawn to assess hydration status. Patients receiving mannitol should have an
indwelling urinary catheter to monitor urinary output and manage the resulting diuresis. Changing
the patient's position, maintaining an NPO status, and monitoring ABG values do not relate to the
nursing diagnosis of risk for imbalanced fluid volume.
5. A craniotomy patient has just returned from surgery. The nurse completing the initial
assessment notes fluids leaking from the patient's nose. An appropriate initial nursing intervention
to complete at this time would include which of the following?
A) Prepare for a lumbar puncture.
B) Test the leaking fluid with a Dextrostix.
C) Document the abnormal find as the only intervention. D) Pack the patient's nose to prevent
leakage.
Ans: B
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Patient Needs: A-1
Feedback: Nursing management of leakage of cerebrospinal fluid (CSF) focuses on
differentiating CSF from mucus. The nurse should collect the fluid on a Dextrostix. If CSF is
present, the indicator will have a positive reaction, as CSF contains glucose. Refer to Chart 61-2,
page 1869. The patient would not be prepared for a lumbar puncture at this time, nor would his
nose be packed; this could lead to increased intracranial pressure. A loose dressing may be
applied to absorb the drainage initially.
6. A head-injured patient is presenting with a generalized seizure. An appropriate nursing
intervention during the seizure would include which of the following?
A) Restrain the patient to prevent injury.
B) Open the patient's jaws to insert an oral airway.
