Test Bank For Medical-Surgical Nursing in Canada 4th Edition by Sharon L. Lewis, Linda Bucher, Margaret M. Heitkemper, Mariann M. Harding :Chapter 59 Nursing Management: Acute Intracranial Problems

Chapter 59: Nursing Management: Acute Intracranial Problems MULTIPLE CHOICE 1. A patient has a systemic blood pressure of 120 /60 mm Hg and an intracran ial pressure (ICP) of 24 mm Hg. What does the nurse determine that the cerebr al perfus ion pressure (CPP) of this patient indicates? a. High blood flow to the brain b. Normal ICP c. Impaired b lood flow to the brain d. Adequa te autoregulation of cereb ral blood flow ANS: C The patient’s CPP is 56 mm Hg, be low the normal of 70 to 100 mm Hg and appro aching the level of ischemia and neuronal death. PTS: 1 DIF: Cognitive Level: Application REF: page 1636 OBJ: 2 TOP: Nursing Proce ss: Assessment MSC: CRNE: CH-6 2. ICP monitoring is instituted for a patient with a head injury. The patient’s arterial blood pressure is 92/50 mm Hg, and her ICP is 18 mm Hg. Which nurs ing action is most appropr iate? a. Document and con tinue to monitor the par ameters. b. Elevate the head of the patient’s bed. c. Notify the physician about the asse ssments. d. Check the pa tient’s pup illary response to light. ANS: C The patient’s CPP is only 46 mm Hg, wh ich w ill rapidly lead to cereb ral ischemia and neuron al death unless rap id action is taken to reduce ICP and increase ar terial blood pressure, so the most appropr iate action is to contact the physician. PTS: 1 DIF: Cognitive Level: Analysis REF: page 1636, Table 59-1 OBJ: 3 TOP: Nursing Proce ss: Implementation MSC: CRNE: CH-27 3. Patient manifestations of a headache, CSF leakage, and cran ial nerve deficit are signs of which one of the fo llowing indications for cran ial surgery? a. Brain tumour b. Skull fracture c. Hydroceph alus d. Intracranial infection ANS: B Patient manifestations of a headache, CSF leakage, and cran ial nerve deficit indicate a sku ll fracture, wh ich requires cran ial surgery. PTS: 1 DIF: Cognitive Level: Application REF: page 1661, Table 59-12 OBJ: 8 TOP: Nursing Proce ss: Assessment MSC: CRNE: CH-8 4. A patient with a ser um sodium level of 115 mmol/L has a decreas ing level of consc iousness (LOC) and complains of a headac he. Which of the fo llowing orders shou ld be the priority? a. Administer ac etaminophen (Tylenol) 650 mg orally. b. Administer 5% hypertonic saline intravenous ly. c. Draw b lood for ar terial blood gases (A BGs). d. Send the patient to the rad iology depa rtment for computed tomography of the head. ANS: B The patient’s low sod ium indicates that hyponatremia may be causing the cerebr al edema, and the nurse’s first action shou ld be to correct the low sodium level. PTS: 1 DIF: Cognitive Level: Application REF: page 1643 OBJ: 3 TOP: Nursing Proce ss: Implementation MSC: CRNE: CH-22 5. The wife of a pa tient who is in a c oma is optimistic about her husband’s recove ry because he opens h is eyes and appears to be awake. What is the most appropr iate response to the wife’s comment? a. “Your husband ’s behav iour is only a reflex and does not really show improvement in his cond ition.” b. “Sleep–wake cycles are encourag ing signs of reco very, and you shou ld be optimistic about your husband’s cond ition.” c. “You are right to be op timistic. When pa tients beg in to recover from a coma, the first behav iours seen are those of wakefu lness.” d. “Your husband may show s leep–wake patterns if the part of the brain respons ible for arousal is not injured, but these patterns do not reflect activity of the higher brain centres.” ANS: D Arousal is con trolled by the re ticular ac tivating system in the bra instem and will allow the patient to maintain wakefu lness even though the damage to the ce rebral cortex is severe. PTS: 1 DIF: Cognitive Level: Application REF: page 1645, Table 59-5 OBJ: 3 TOP: Nursing Proce ss: Implementation MSC: CRNE: HW-26 6. When assessing a patient with a head injury, what will the nurse recog nize as an ear ly indication of increased IC P? a. Vomiting b. Headac he c. Change in the LOC d. Sluggish pup illary respo nse to light ANS: C LOC is the most sensitive indicator of the pa tient’s neuro logical status and po ssible changes in ICP. PTS: 1 DIF: Cognitive Level: Comprehens ion REF: page 1638 OBJ: 3 TOP: Nursing Proce ss: Assessment MSC: CRNE: CH-8 7. A patient is admitted to the hospital with a head injury resulting fr om an automobile accident. On a dmission, the pa tient’s vital signs are temperature 37°C, b lood pressure 128 /68 mm Hg, pulse 110 bea ts/min, and resp iration 26 brea ths/min. One hour af ter admission, which of the following vital signs does the nurse no te indicates the presence of Cushing’s triad?