Nokea
The nurse is caring for a patient with increased intracranial pressure (IICP). Which of the following are late signs of IICP? (Select all that apply.)
- A. Unilateral hemiparesis
- B. Papilledema
- C. Decorticate posturing
- D. Decerebrate posturing
- E. Hyperthermia
Correct Answer: C,D,E
Rationale: Late signs of IICP include decerebrate posturing, decorticate posturing, and hyperthermia. Unilateral hemiparesis and papilledema are early signs when the compensatory mechanism is intact.
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The nurse is caring for a patient who has a head injury and is diagnosed with a concussion. Which of the following actions should the nurse plan to take?
- A. Coordinate the transfer of the patient to the operating room.
- B. Provide discharge instructions about monitoring neurological status.
- C. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain.
- D. Arrange to admit the patient to the neurological unit for observation for 24 hours.
Correct Answer: B
Rationale: A patient with a minor head trauma is usually discharged with instructions about neurological monitoring and the need to return if neurological status deteriorates. MRI, hospital admission, or surgery is not indicated in a patient with a concussion.
The nurse is caring for a patient with possible cerebral edema who has a serum sodium level of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache. Which of the following prescribed interventions should the nurse implement first?
- A. Draw blood for arterial blood gases (ABGs).
- B. Administer 5% hypertonic saline intravenously.
- C. Administer acetaminophen 650 mg orally.
- D. Send patient for computed tomography (CT) of the head.
Correct Answer: B
Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.
A patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which of the following nursing interventions should be included in the plan of care?
- A. Keep the head of the bed elevated to 30 degrees.
- B. Position the patient with the knees and hips flexed.
- C. Encourage coughing and deep breathing to improve oxygenation.
- D. Cluster nursing interventions to provide uninterrupted rest periods.
Correct Answer: A
Rationale: The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.
The nurse is caring for a patient following a craniectomy and left anterior fossae incision who has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. Which of the following is an appropriate nursing intervention?
- A. Position the bed flat and log roll the patient.
- B. Cluster nursing activities to allow longer rest periods.
- C. Turn and reposition the patient side to side every 2 hours.
- D. Perform range-of-motion ( ROM) exercises every 4 hours.
Correct Answer: D
Rationale: ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.
The nurse is admitting a patient who has a tumour of the right frontal lobe. Which of the following findings should the nurse expect to observe?
- A. Judgement changes
- B. Expressive aphasia
- C. Right-sided weakness
- D. Difficulty swallowing
Correct Answer: A
Rationale: The frontal lobes control intellectual activities such as judgement. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumour. Swallowing is controlled by the brain stem.