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Which of the following assessment findings should the nurse report immediately to the health care provider when caring for a patient with increased intracranial pressure?
- A. CPP 38 mm Hg
- B. MAP 92 mm Hg
- C. PaO2 110 mm Hg
- D. BP 140/82
Correct Answer: A
Rationale: A cerebral perfusion pressure (CPP) of 38 mm Hg is critically low, below the normal range of 70-100 mm Hg, indicating inadequate cerebral perfusion and a risk of ischemia. This should be reported immediately to the health care provider. MAP, BP, and PaO2 values listed are within normal limits and do not require immediate action.
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After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first?
- A. A patient whose cranial radiograph shows a linear skull fracture
- B. A patient who has an initial Glasgow Coma Scale score of 13
- C. A patient who lost consciousness for a few seconds after a fall
- D. A patient whose right pupil is 10 mm and unresponsive to light
Correct Answer: D
Rationale: The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage, brain herniation, and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.
Which of the following information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?
- A. Intracranial pressure of 15 mm Hg.
- B. Cerebrospinal fluid (CSF) drainage of 15 mL/hour
- C. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg.
- D. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/minute
Correct Answer: C
Rationale: The PbtO2 should be 20-40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20-30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.
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.
A nurse is providing care for an unconscious patient with a head injury prescribed IV mannitol. Which of the following parameters is best for the nurse to monitor to determine if the mannitol has been effective?
- A. Hematocrit
- B. Blood pressure
- C. Oxygen saturation
- D. Intracranial pressure
Correct Answer: D
Rationale: Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.
After receiving change of shift report, which of the following patients should the nurse assess first?
- A. A 44-year-old receiving IV antibiotics for meningococcal meningitis
- B. A 23-year-old who had a skull fracture and craniotomy the previous day
- C. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago
- D. A 61-year-old who has increased ICP and is receiving hyperventilation therapy
Correct Answer: D
Rationale: The patient that should be seen first is the one that requires the closest monitoringâ??the patient with ICP and receiving hyperventilation therapy. The postcraniotomy patient, patient with an ICP monitor, and the patient on IV antibiotics should be assessed as well but the priority would be the most critically ill patients.