Chapter 56: Acute Intracranial Problems
Lewis: Medical-Surgical Nursing, 10th
Edition
A 20-yr-antique male affected person is admitted with a head harm after a collision while playing
soccer. After noting that the affected person has advanced clear nasal drainage, which
movement need to the nurse take?
A. Have the patient gently blow the nose.
B. Check the drainage for glucose content material.
C. Teach the affected person that rhinorrhea is expected after a head damage.
D. Obtain a specimen of the fluid to send for culture and sensitivity. - ANS-ANS: B
Clear nasal drainage in a affected person with a head harm shows a dural tear and
cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it'll test high-quality for glucose. Fluid
leaking from the nose could have everyday nasal flora, so tradition and sensitivity will now not
be useful. Blowing the nostril is avoided to save you CSF leakage.
DIF: Cognitive Level: Apply (application)
A 68-year-vintage male patient is delivered to the emergency department (ED) by ambulance
after being discovered subconscious on the rest room ground with the aid of his spouse. Which
action will the nurse take first?
A. Check oxygen saturation.
B. Assess scholar response to mild.
C. Palpate the top for accidents
d. Verify Glasgow Coma Scale (GCS) score. - ANS-ANS: A
Airway patency and breathing are the maximum vital functions and need to be assessed first.
The neurologic tests need to be completed next and extra assessment after that.
DIF: Cognitive Level: Analyze (analysis)
A university athlete is seen inside the medical institution 6 weeks after a concussion. Which
assessment records will the nurse collect to determine whether or not the patient is developing
postconcussion syndrome?
A. Short-time period reminiscence
b. Muscle coordination
c. Glasgow Coma Scale
d. Pupil response to light - ANS-ANS: A
Decreased quick-time period reminiscence is one indication of postconcussion syndrome. The
other information may be assessed however are not indicators of postconcussion syndrome.
, DIF: Cognitive Level: Apply (application)
A male affected person who has feasible cerebral edema has a serum sodium stage of 116
mEq/L (116 mmol/L) and a lowering degree of consciousness (LOC). He is now complaining of
a headache. Which prescribed interventions ought to the nurse put into effect first?
A. Administer IV five% hypertonic saline.
B. Draw blood for arterial blood gases (ABGs).
C. Send patient for computed tomography (CT).
D. Administer acetaminophen (Tylenol) 650 mg orally. - ANS-ANS: A
The affected person's low sodium suggests that hyponatremia can be causing the cerebral
edema. The nurse's first motion have to be to accurate the low sodium degree. Acetaminophen
(Tylenol) could have minimum effect on the headache due to the fact it's far resulting from
cerebral edema and multiplied intracranial strain (ICP). Drawing ABGs and acquiring a CT scan
might also offer a few beneficial information, but the low sodium stage can also lead to seizures
unless it's far addressed fast.
DIF: Cognitive Level: Analyze (analysis)
A patient admitted with a diffuse axonal injury has a systemic blood stress (BP) of 106/fifty two
mm Hg and an intracranial strain (ICP) of 14 mm Hg. Which action should the nurse take first?
A. Document the BP and ICP inside the patient's record.
B. Report the BP and ICP to the fitness care issuer.
C. Elevate the head of the patient's mattress to 60 levels.
D. Continue to display the affected person's critical symptoms and ICP. - ANS-ANS: B
Calculate the cerebral perfusion strain (CPP): (CPP = Mean arterial stress [MAP] - ICP). MAP =
DBP + 1/three (Systolic blood strain [SBP] - Diastolic blood stress [DBP]). Therefore the MAP is
70, and the CPP is fifty six mm Hg, which can be below the regular values of 60 to a hundred
mm Hg and are approaching the extent of ischemia and neuronal dying. Immediate
modifications in the affected person's remedy which includes fluid infusion or vasopressor
administration are needed to improve the CPP. Adjustments within the head elevation have to
best be accomplished after consulting with the health care company. Continued tracking and
documentation may also be achieved, however they're now not the first actions that the nurse
need to take.
DIF: Cognitive Level: Analyze (evaluation)
A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a
intense headache. Which order must the nurse put into effect first?
A. Administer ceftizoxime (Cefizox) 1 g IV.
B. Give acetaminophen (Tylenol) 650 mg PO.
C. Use a cooling blanket to lower temperature.
D. Swab the nasopharyngeal mucosa for cultures. - ANS-ANS: D
Antibiotic therapy ought to be instituted hastily in bacterial meningitis, but cultures have to be
performed before antibiotics are commenced. As soon as the cultures are carried out, the
antibiotic have to be began. Hypothermia remedy and acetaminophen management are
appropriate however may be started after the alternative movements are implemented.
Lewis: Medical-Surgical Nursing, 10th
Edition
A 20-yr-antique male affected person is admitted with a head harm after a collision while playing
soccer. After noting that the affected person has advanced clear nasal drainage, which
movement need to the nurse take?
A. Have the patient gently blow the nose.
B. Check the drainage for glucose content material.
C. Teach the affected person that rhinorrhea is expected after a head damage.
D. Obtain a specimen of the fluid to send for culture and sensitivity. - ANS-ANS: B
Clear nasal drainage in a affected person with a head harm shows a dural tear and
cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it'll test high-quality for glucose. Fluid
leaking from the nose could have everyday nasal flora, so tradition and sensitivity will now not
be useful. Blowing the nostril is avoided to save you CSF leakage.
DIF: Cognitive Level: Apply (application)
A 68-year-vintage male patient is delivered to the emergency department (ED) by ambulance
after being discovered subconscious on the rest room ground with the aid of his spouse. Which
action will the nurse take first?
A. Check oxygen saturation.
B. Assess scholar response to mild.
C. Palpate the top for accidents
d. Verify Glasgow Coma Scale (GCS) score. - ANS-ANS: A
Airway patency and breathing are the maximum vital functions and need to be assessed first.
The neurologic tests need to be completed next and extra assessment after that.
DIF: Cognitive Level: Analyze (analysis)
A university athlete is seen inside the medical institution 6 weeks after a concussion. Which
assessment records will the nurse collect to determine whether or not the patient is developing
postconcussion syndrome?
A. Short-time period reminiscence
b. Muscle coordination
c. Glasgow Coma Scale
d. Pupil response to light - ANS-ANS: A
Decreased quick-time period reminiscence is one indication of postconcussion syndrome. The
other information may be assessed however are not indicators of postconcussion syndrome.
, DIF: Cognitive Level: Apply (application)
A male affected person who has feasible cerebral edema has a serum sodium stage of 116
mEq/L (116 mmol/L) and a lowering degree of consciousness (LOC). He is now complaining of
a headache. Which prescribed interventions ought to the nurse put into effect first?
A. Administer IV five% hypertonic saline.
B. Draw blood for arterial blood gases (ABGs).
C. Send patient for computed tomography (CT).
D. Administer acetaminophen (Tylenol) 650 mg orally. - ANS-ANS: A
The affected person's low sodium suggests that hyponatremia can be causing the cerebral
edema. The nurse's first motion have to be to accurate the low sodium degree. Acetaminophen
(Tylenol) could have minimum effect on the headache due to the fact it's far resulting from
cerebral edema and multiplied intracranial strain (ICP). Drawing ABGs and acquiring a CT scan
might also offer a few beneficial information, but the low sodium stage can also lead to seizures
unless it's far addressed fast.
DIF: Cognitive Level: Analyze (analysis)
A patient admitted with a diffuse axonal injury has a systemic blood stress (BP) of 106/fifty two
mm Hg and an intracranial strain (ICP) of 14 mm Hg. Which action should the nurse take first?
A. Document the BP and ICP inside the patient's record.
B. Report the BP and ICP to the fitness care issuer.
C. Elevate the head of the patient's mattress to 60 levels.
D. Continue to display the affected person's critical symptoms and ICP. - ANS-ANS: B
Calculate the cerebral perfusion strain (CPP): (CPP = Mean arterial stress [MAP] - ICP). MAP =
DBP + 1/three (Systolic blood strain [SBP] - Diastolic blood stress [DBP]). Therefore the MAP is
70, and the CPP is fifty six mm Hg, which can be below the regular values of 60 to a hundred
mm Hg and are approaching the extent of ischemia and neuronal dying. Immediate
modifications in the affected person's remedy which includes fluid infusion or vasopressor
administration are needed to improve the CPP. Adjustments within the head elevation have to
best be accomplished after consulting with the health care company. Continued tracking and
documentation may also be achieved, however they're now not the first actions that the nurse
need to take.
DIF: Cognitive Level: Analyze (evaluation)
A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a
intense headache. Which order must the nurse put into effect first?
A. Administer ceftizoxime (Cefizox) 1 g IV.
B. Give acetaminophen (Tylenol) 650 mg PO.
C. Use a cooling blanket to lower temperature.
D. Swab the nasopharyngeal mucosa for cultures. - ANS-ANS: D
Antibiotic therapy ought to be instituted hastily in bacterial meningitis, but cultures have to be
performed before antibiotics are commenced. As soon as the cultures are carried out, the
antibiotic have to be began. Hypothermia remedy and acetaminophen management are
appropriate however may be started after the alternative movements are implemented.
