Chapter 45 - Care of Critically Ill Patients with Neurologic Problems

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Chapter 45 - Care of Critically Ill Patients with Neurologic Problems
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1

A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)?

  1. Assessing for Grey Turner’s sign
  2. Maintaining neutral head position
  3. Placing the client in the
  4. Trendelenburg position Suctioning the client frequently

B. Maintaining neutral head position

2

A client is considering treatments for a malignant brain tumor. Which statement by the client indicates a need for further instruction by the nurse?

  1. “A combination of treatments might be necessary.”
  2. “In a craniotomy, holes are cut in the skull to access the tumor.”
  3. “I can go home the day of my craniotomy.”
  4. “The goal is to decrease tumor size and improve survival time.”

C. “I can go home the day of my craniotomy.”

3

A client hospitalized for hypertension presses the call light and reports “feeling funny.” When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first?

  1. Assesses airway, breathing, and circulation
  2. Calls the provider
  3. Performs a neurologic check
  4. Assists the client to a sitting position

A. Assesses airway, breathing, and circulation

4

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client?

  1. Achieving the highest level of functioning
  2. Increasing cerebral perfusion
  3. Preventing further injury
  4. Preventing skin breakdown

A. Achieving the highest level of functioning

5

The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range?

  1. Dexamethasone (Decadron)
  2. Hydrochlorothiazide (HydroDIURIL)
  3. Mannitol (Osmitrol)
  4. Phenytoin (Dilantin)

C. Mannitol (Osmitrol)

6

A client with a traumatic brain injury from a motor vehicle crash is monitored for signs/symptoms of increased intracranial pressure (ICP). Which sign/symptoms does the nurse monitor for?

  1. Changes in breathing pattern
  2. Dizziness
  3. Increasing level of consciousness
  4. Reactive pupils

A. Changes in breathing pattern

7

The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign/symptom is the nurse most concerned about?

  1. Amnesia
  2. Asymmetric pupils
  3. Headache
  4. Head laceration

B. Asymmetric pupils

8

A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client?

  1. Calling the Stroke Team
  2. Establishing an IV
  3. Positioning the client to prevent aspiration
  4. Preparing for thrombolytic administration

C. Positioning the client to prevent aspiration

9

An alert and oriented person is admitted to the emergency department with a GCS of 10, indicating a moderate brain injury. Which assessment finding will the nurse report immediately to the health care provider?

  1. Photophobia accompanied by headache
  2. New onset of dizziness when lying quietly in bed
  3. A brisk pupillary reaction to light
  4. New difficulty in responsiveness or sudden drowsiness

D. New difficulty in responsiveness or sudden drowsiness

10

A client returns from the postanesthesia care unit (PACU) after a craniotomy for removal of a left parietal lobe tumor. How will the nurse position the client after surgery?

  1. Flex the client's knees to decrease intra-abdominal pressure and cerebral hypertension.
  2. Keep the client on the left side to prevent surgical site bleeding or cerebrospinal fluid leakage.
  3. Elevate the client's head to at least 30 degrees to promote cerebral venous drainage.
  4. Hyperextend the client's neck to maintain the airway and prevent aspiration regardless of supine or side-lying positioning.

C. Elevate the client's head to at least 30 degrees to promote cerebral venous drainage.