Nokea
A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?
- A. Encephalitis
- B. CSF leak
- C. Meningitis
- D. Catheter occlusion
Correct Answer: C
Rationale: Nuchal rigidity and photophobia are signs of meningitis, a potential ventriculostomy complication. Encephalitis, CSF leak, and catheter occlusion present differently.
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A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient?
- A. Rizatriptan (Maxalt)
- B. Naratriptan (Amerge)
- C. Sumatriptan succinate (Imitrex)
- D. Zolmitriptan (Zomig)
Correct Answer: C
Rationale: Sumatriptan and other triptans can cause chest pain and are contraindicated in ischemic heart disease. All listed medications are triptans, but sumatriptan is specifically noted for this risk.
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care?
- A. Monitoring of pulse oximetry
- B. Administration of a low-protein diet
- C. Administration of thorough oral hygiene
- D. Fluid restriction as ordered
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, making thorough oral hygiene essential. Pulse oximetry, low-protein diet, and fluid restriction are not related to phenytoin's adverse effects.
A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?
- A. Hemiplegia
- B. Dry mucous membranes
- C. Signs of internal bleeding
- D. Loss of brain stem reflexes
Correct Answer: D
Rationale: Loss of brain stem reflexes (e.g., pupillary, corneal) signals impending death in severe head injury. Hemiplegia, dry membranes, and bleeding are not specific to this outcome.
The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient?
- A. Position the patient supine.
- B. Maintain head of bed (HOB) elevated at 30 to 45 degrees.
- C. Position patient in prone position.
- D. Maintain bed in Trendelenberg position.
Correct Answer: B
Rationale: HOB elevation at 30-45 degrees reduces ICP in supratentorial craniotomy patients. Supine, prone, or Trendelenberg positions increase ICP risk.
The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patients admission orders? Select all that apply.
- A. Transcranial Doppler flow study
- B. Cerebral angiography
- C. MRI
- D. Cranial radiography
- E. Electromyelography
Correct Answer: A,B,C
Rationale: CT, MRI, cerebral angiography, and transcranial Doppler assess brain masses. Cranial radiography and EMG are not diagnostic for intracranial masses.