ECCO Caring for Patients with Neurologic Disorders: Part 1 Questions and Answers 100% Pass

ECCO Caring for Patients with Neurologic Disorders: Part 1 Questions and Answers 100% Pass What vital sign assessments herald impending brainstem herniation? Increased SBP w/widening pulse pressure, changes in respirations, and bradycardia A patient is admitted after sustaining traumatic brain injury in a motorcycle crash. The patent's GCS score on admission is E 2, M 3, V 1T = 6T. Which of the following should the nurse perform to prepare the patient for ICP monitoring? Prior to placement of an ICP monitoring catheter, a neurologic assessment is performed in order to have a baseline assessment to compare to the postinsertion assessment. A patient is admitted following a drug overdose. The patient does not open eyes upon verbal request but localizes to a trapezius muscle squeeze without opening eyes. The nurse should document the patient's mental status as: Responsive to painful stimuli You are caring for an unconscious patient with traumatic brain injury from a motor vehicle crash. His alcohol and toxicology screen are negative, he has no facial fractures, and he's not receiving pain or sedation medication. Vital signs: BP 100/70 (80), HR 86 sinus rhythm, SpO2 95% with endotracheal tube secured. Upon application of painful stimuli with supraorbital notch pressure, the patient clenches fists, holds legs straight out, and bends arms inward toward the body. Fingers are bent and held on the chest. The nurse should document this response as: Abnormal flexor posturing In a patient with a subarachnoid hemorrhage, what is the purpose of a transcranial Doppler (TCD) test? Measure blood flow velocity to assess for vasospasm. Transcranial Doppler (TCD) uses ultrasound technology to evaluate cerebral blood flow and arterial narrowing in the major cerebral vessels. If arterial passages have narrowed, as in vasospasm, blood flow velocity is increased. Which of the following patients should the nurse anticipate as most likely to develop hyponatremia and hypo-osmolality? A patient: Two days post severe traumatic brain injury A nurse finds that a patient does not move spontaneously or follow commands. To assess the patient's motor function, the nurse applies a central pain stimulus, without response. What is the nurse's next step? Apply peripheral pain stimulus In determining LOC, a nurse finds that a patient post multisystem trauma does not respond to loud questions, statements, or a light shoulder touch. What should be the nurse's next step? Assess a central pain stimulus response Which of the following may result in a decreased supply of oxygen to the brain? Hypotension and hypoxia are the primary systemic causes of decreased oxygen supply. In assessing an unconscious patient who is noted to have new-onset sluggish pupillary light reflex, deficits in what other cranial nerve reflexes can indicate brainstem compression? Deficits in pupil reactivity to light and the basic protective reflexes (e.g., gag, cough, corneal) in an unconscious patient can indicate brainstem compression. Report new-onset or previously unknown deficits immediately to the provider. Which of the following should the nurse perform immediately after insertion of the ICP monitoring device is completed? Assess neurologic status and compare to assessment before insertion. Which of the following central pain stimuli should the nurse use to assess motor function in a patient who is unconscious and who has facial fractures? Use the trapezius squeeze as a central pain stimulus in patients who have facial injuries. A patient is admitted after an unwitnessed cardiac arrest at home. Review the EMR. What criterion is anticipated as part of the decision-making process to support declaration of death by neurologic criteria? The PaCO2 increases to 68 when off ventilator for 8 minutes. During an apnea test, patients without brainstem function will remain apneic even when the PaCO2 reaches very high levels. A patient with an EVD in place suddenly develops disorientation to place, and ICP suddenly increases from 15 to 22 mm Hg. EVD drainage system troubleshooting indicates no visible blockages and no CSF fluid fluctuation, and the EVD is no longer draining. Which of the following interventions is the highest priority? Inform the provider of the assessment and EVD status Your patient blinks and can move eyes up and down. Respirations are irregular with periods of apnea; gag reflex and motor movement of extremities are absent. What is your highest priority intervention? Secure the airway A patient is admitted with a subarachnoid hemorrhage. She is restless and agitated, and complaining of an ongoing headache 10/10. Which of the following changes in signs and symptoms requires an immediate call to the provider? Unresponsiveness to physical stimuli and sluggish pupillary response When a nurse asks a patient's name, The patient replies with the name of the town where the hospital is located. When asked what day it is, he replies "house." Shown a hairbrush and asked to name it, he replies "dog." What other step(s) should the nurse take to evaluate the patient's language functioning? Ask the patient to raise one arm slowly. Patients who demonstrate components of aphasia need to be assessed for their ability to follow commands to help differentiate the type of aphasia. Avoid providing cues to the patient when asking them to follow commands. A patient with an external ventricular drain is noted to have a damped ICP waveform on the monitor. Which of the following is indicated? Check for air bubbles or debris in the drainage system A patient with a massive cerebral hemorrhage is admitted. The patient is comatose. Pupils have become dilated and no longer react to light. The breathing pattern has become irregular. Vital signs: BP 170/66 (101), HR 40 and irregular, RR 16 and irregular. Administration of which of the following should the nurse anticipate? Mannitol (Osmitrol) On a patient's ICP waveform, the P2 wave is higher and more rounded than the P1 wave. What is the significance of this finding? Decreased intracranial compliance; patient may be unable to compensate for intracranial volume changes. On the ICP waveform, P2 higher than P1 indicates the patient may be unable to compensate for small changes in intracranial volume. A nurse finds no CSF in a patient's EVD collection chamber. Assessment reveals the drain stopcock is open to drain. What two other assessment should the nurse perform? Assess for pulsations or fluctuations in the tubing; Assess drain tubing for presence of visible blockages. To evaluate EVD functionality, check that the system is properly set up and leveled at the foramen of Monro, evaluate for a damped waveform, check the tubing to assess for debris, lower the drainage system briefly to assess for fluctuation, and notify the provider if there is no drainage or fluctuation. What should the nurse do to assess orientation in a patient who is post-cardiopulmonary bypass? AO questions After evaluating LOC and mental status for a patient 6 hours past stroke, a nurse should complete the patient's neurologic exam by evaluating which other functions? Pupil size and assessment; Orientation and basic communication; Motor function Serial neurologic exams are performed more frequently than comprehensive exams and include: LOC, mental status, motor exam, and pupil size and reactivity. A patient with traumatic brain injury is receiving norepinephrine to maintain CPP between 60 - 70 mm Hg. The patient's ICP waveform changes from P1 higher than P2 higher than P3, to P2 higher than P1 and P3. Which of the following interventions is most likely to affect the change in ICP waveform? Ensure the patient's neck is in neutral alignment. A skier who collided with a tree is placed in a cervical collar and admitted for head injury. What potential cause of increased ICP should the nurse observe for? Compression on the jugular veins due to cervical collar tightness A patient with a large brain tumor is admitted. She initially reported a headache and suddenly became unresponsive to all stimuli. Pupils are no longer reactive to light. The heart rate is decreasing, and the SBP is elevated with a widened pulse pressure. The provider has been notified and is on the way to the bedside. Which of the following is immediately indicated to temporarily reduce increased ICP? Hyperventilation causes cerebral arterial vasoconstriction, decreasing cerebral blood flow, intracranial blood volume, and ICP. A patient with a lumbar drain has zero drainage for the last hour. Which of the following actions should the nurse implement? Assess the tubing for a kink or a clot