A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

1.Blowing the nose

2.Isometric exercises

3.Coughing vigorously

4.Exhaling during repositioning

4.Exhaling during repositioning

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate?

1.Insert nasal packing.

2Document the findings.

3.Contact the primary health care provider (PHCP).

4.Monitor the client's blood pressure and check for signs of increased intracranial pressure.

3.Contact the primary health care provider (PHCP).

Members of the family of an unconscious client with increased intracranial pressure from a head injury are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation?

1.It is possible the client can hear the family.

2.The family needs immediate crisis intervention.

3.The client might have wanted a visit from the hospital chaplain.

4.The family could benefit from a conference with the primary health care provider.

1.It is possible the client can hear the family.

The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional?

1.A psychologist

2.A social worker

3.A neuropsychologist

4.A vocational rehabilitation specialist

3.A neuropsychologist

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse would place the client in which position postoperatively?

1.Head of bed flat, head and neck midline

2.Head of bed flat, head turned to the nonoperative side

3.Head of bed elevated 30 to 45 degrees, head and neck midline

4.Head of bed elevated 30 to 45 degrees, head turned to the operative side

3.Head of bed elevated 30 to 45 degrees, head and neck midline

The nurse is assessing fluid balance in a client with a head injury who has undergone a craniotomy. The nurse would assess for which finding as a sign of overhydration, which would aggravate cerebral edema?

1.Unchanged weight

2.Shift intake 950 mL, output 900 mL

3.Blood urea nitrogen (BUN) 10 mg/dL (3.6 mmol/L)

4.Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)

4.Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction?

1.Sounds will not be heard clearly unless they are loud.

2.Obtain assistance with ambulation if the client is light-headed.

3Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed.

4.Use a check-off system for administering anticonvulsant medications to avoid missing doses.

1.Sounds will not be heard clearly unless they are loud.

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition would the nurse document?

1.The intracranial pressure reading is normal.

2The intracranial pressure reading is elevated.

3The intracranial pressure reading is borderline.

4An intracranial pressure reading of 8 mm Hg is low.

1.The intracranial pressure reading is normal.

The nurse in the neurological unit is monitoring a client with a head injury for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item?

1.Blood pressure

2.Motor response

3.Pupillary response

4.Level of consciousness

1.Blood pressure

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client?

1.Dilated pupils

2.Lumbar trauma

3.A cervical spinal cord injury

4.Altered level of consciousness

3.A cervical spinal cord injury

The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client who sustained a head injury. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How would the nurse document these findings?

1.Normal

2.Abnormal

3.Insignificant

4.Inconclusive

2.Abnormal

The nurse in the neurological unit is caring for a client with a supratentorial lesion from a brain injury. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction?

1.Temperature

2.Blood pressure

3Ability to speak

4.Level of consciousness

4.Level of consciousness

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP?

1.Confusion

2.Bradycardia

3.Sluggish pupils

4.A widened pulse pressure

1.Confusion

The nurse is planning discharge teaching for a client started on acetazolamide for a supratentorial lesion from a head injury. Which information about the primary action of the medication would be included in the client's education?

1.It will prevent hypertension.

2.It will prevent hyperthermia.

3.It decreases cerebrospinal fluid production.

4.It maintains adequate blood pressure for cerebral perfusion.

3.It decreases cerebrospinal fluid production.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area?

1.The left side of the body

2.The right side of the body

3.Both sides of the body equally

4.Cranial nerves only, such as speech and pupillary response

1.The left side of the body

The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client who sustained a head injury. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation?

1.Brain death

2.A cerebral lesion

3.A temporal lesion

4.An intact brainstem

4.An intact brainstem

The nurse is caring for a client with a head injury who has an intracranial pressure (ICP) monitoring device. The nurse would become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding?

1.5 mm Hg

2.8 mm Hg

3.14 mm Hg

4.22 mm Hg

4.22 mm Hg

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges?

1.Pao₂ 60 to 100 mm Hg, Paco₂ 25 to 30 mm Hg

2.Pao₂ 60 to 100 mm Hg, Paco₂ 30 to 35 mm Hg

3.Pao₂ 80 to 100 mm Hg, Paco₂ 25 to 30 mm Hg

4.Pao₂ 80 to 100 mm Hg, Paco₂ 35 to 38 mm Hg

4.Pao₂ 80 to 100 mm Hg, Paco₂ 35 to 38 mm Hg

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even-tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem?

1.Intracranial pressure changes

2.A long-term sequela of the injury

3.A worsening of the original injury

4.A short-term problem that will resolve in about 1 month

2.A long-term sequela of the injury

A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that family members need further teaching if they verbalize to call the primary health care provider (PHCP) for which client sign or symptom?

1.Vomiting

2.Minor headache

3.Difficulty speaking

4.Difficulty awakening

2.Minor headache

The nurse is performing an assessment on a client with a head injury and notes that the client is assuming this posture. The nurse contacts the primary health care provider and reports that the client is exhibiting which posture? Refer to figure.

1.Opisthotonos

2.Decorticate rigidity

3.Decerebrate rigidity

4.Flaccid quadriplegia

2.Decorticate rigidity

A client with a traumatic brain injury is able, with eyes closed, to identify a set of keys placed in their hands. On the basis of this assessment finding, the nurse determines that there is appropriate function of which lobe of the brain?

1.Frontal

2.Parietal

3.Occipital

4.Temporal

2.Parietal

A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment?

1.Taste

2.Smell

3.Vision

4.Hearing

3.Vision

The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly?

1.Thalamus

2.Hypothalamus

3.Limbic system

4.Reticular activating system

2.Hypothalamus

A client with chronic obstructive pulmonary disease who sustained a head injury has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2?

1.It will cause arteriovenous shunting.

2.It will cause vasodilation of blood vessels in the brain.

3.It will cause blood vessels in the circle of Willis to collapse.

4.It will cause hyperresponsiveness of blood vessels in the brain.

2.It will cause vasodilation of blood vessels in the brain.

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse would place the client with an incision in the anterior or middle fossa in which position?

1.15 degrees of Trendelenburg's

2.Side-lying with the head of the bed flat

3.With the head of the bed elevated at least 30 degrees

4.With the head of the bed elevated no more than 10 degrees

3.With the head of the bed elevated at least 30 degrees

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention would the nurse plan to implement?

1.Check cranial nerve functioning.

2.Determine the cause of the accident.

3.Draw blood for arterial blood gas analysis.

4.Perform a pulmonary wedge pressure measurement.

3.Draw blood for arterial blood gas analysis.

The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse would plan to place the client in which position?

1.Prone

2.Supine

3.Side-lying

4.Semi-Fowler's

4.Semi-Fowler's

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home?

1."When did the injury occur?"

2."Was the client awake and talking right after the injury?"

3."What medications has the client received since the fall?"

4."What was the client's level of consciousness before the injury?"

2."Was the client awake and talking right after the injury?"

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific primary health care provider prescriptions, the nurse would place the client in which positions? Select all that apply.

1.Head midline

2.Neck in neutral position

3.Flat, with head turned to the side

4.Head of bed elevated 30 to 45 degrees

5.Head of bed elevated with the neck extended

1.Head midline

2.Neck in neutral position

4.Head of bed elevated 30 to 45 degrees

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How would the nurse document the Glasgow Coma Scale (GCS) score?

1.GCS = 3

2.GCS = 6

3.GCS = 9

4.GCS = 11

3.GCS = 9

The nurse is positioning a client who has increased intracranial pressure as a result of a head injury. Which position would the nurse plan to avoid?

1.Head midline

2.Head turned to the side

3.Neck in neutral position

4.Head of bed elevated 30 to 45 degrees

2.Head turned to the side

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client?

1.Take and record vital signs every 4 to 8 hours.

2Prophylactically hyperventilate during the first 24 hours.

3Treat a central fever with the administration of antipyretic medications such as acetaminophen.

4.Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

4.Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client would most likely be maintained in which position?

1.Prone position

2.Supine position

3.Semi-Fowler's position

4.Dorsal recumbent position

3.Semi-Fowler's position

1.Eye opening

2.Reflex response

3.Best verbal response

4.Best motor response

5.Pupil size and reaction

1.Eye opening

3.Best verbal response

4.Best motor response

A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply.

1.Fever

2.Seizures

3.Hypoxia

4.Ischemia

5.Hypotension

6.Increased intracranial pressure (ICP)

3.Hypoxia

4.Ischemia

5.Hypotension

6.Increased intracranial pressure (ICP)

The nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim who is unresponsive. A layperson is attempting to perform resuscitative measures. The nurse would intervene if which action by the layperson is noted?

1.Use of the head tilt–chin lift

2.Checking the scene for safety

3.Use of the jaw thrust maneuver

4.Moving the client away from traffic

1.Use of the head tilt–chin lift

A client with a probable minor head injury resulting from a motor vehicle crash is admitted to the hospital for observation. The nurse leaves the cervical collar applied to the client in place until when?

1.The family comes to visit.

2The nurse needs to do physical care.

3.The primary health care provider makes rounds.

4.The results of spinal radiography are known.

4.The results of spinal radiography are known.

Which interventions would be included in the care of a client with a head injury and a subarachnoid bolt? Select all that apply.

1.Monitor vital signs.

2.Monitor neurological status.

3.Monitor the dressing for signs of infection.

4.Monitor for signs of increased intracranial pressure.

5.Drain cerebrospinal fluid when the intracranial pressure is elevated.

1.Monitor vital signs.

2.Monitor neurological status.

3.Monitor the dressing for signs of infection.

4.Monitor for signs of increased intracranial pressure.

The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition?

1.Concussion

2.Skull fracture

3.Subdural hematoma

4.Epidural hematoma

4.Epidural hematoma

A client has a closed head injury with increased intracranial pressure (ICP). The increased ICP is being managed by mannitol 25 g by the intravenous (IV) route every 2 hours. The nurse is planning to administer this medication via IV pump in what manner?

1.Mixed in solution with the IV antibiotics

2.Giving it slowly over 30 to 90 minutes

3.Piggybacked into the packed red blood cells

4.Giving it rapidly over 5 minutes by IV bolus

2.Giving it slowly over 30 to 90 minutes

The nurse is monitoring ongoing care for a potential organ donor who has been diagnosed with brain death following a severe head injury. Which finding indicates to the nurse that the standard for ongoing care has been maintained?

1.Pao₂ 70 mm Hg

2.Urine output 100 mL/hr

3.Heart rate 52 beats/min

4.Blood pressure 90/48 mm Hg

2.Urine output 100 mL/hr

A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation?

1.Assessing lung sounds

2.Monitoring temperature

3.Administering intravenous (IV) fluids

4.Performing range-of-motion exercises to the extremities

3.Administering intravenous (IV) fluids

The nurse is performing a neurological assessment on a client with a head injury. The nurse would use which technique to assess the plantar reflex?

1.Stroking the foot from the heel to the toe

2.Gently inserting a gloved finger in the rectum

3.Directing a flashlight onto the pupils of the eyes

4.Using a tongue depressor and stimulating the back of the throat

1.Stroking the foot from the heel to the toe

A client has a cerebellar lesion. The nurse would plan to obtain which item for use by the client?

1.Walker

2.Slider board

3.Raised toilet seat

4.Adaptive eating utensils

1.Walker

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

1.Obtain a court order for the surgical procedure.

2Ask the EMS team to sign the informed consent.

3.Transport the victim to the operating room for surgery.

4.Call the police to identify the client and locate the family.

3.Transport the victim to the operating room for surgery.

The nurse prepares to teach a client with subarachnoid hemorrhage about the effects of nimodipine. The nurse plans to explain which information about the type and action of this medication?

1.Vasodilator that has an affinity for cerebral blood vessels

2.Beta-adrenergic blocker that will decrease blood pressure

3.Diuretic that will decrease blood pressure by decreasing fluid volume

4.Calcium channel blocker that will decrease spasm in cerebral blood vessels

4.Calcium channel blocker that will decrease spasm in cerebral blood vessels

The client with a traumatic brain injury (TBI) has begun to excrete copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 mL. The nurse expects that the primary health care provider will prescribe which medication?

1.Mannitol

2.Desmopressin

3.Ethacrynic acid

4.DexamethasoneSubmit

2.Desmopressin

A client with a subarachnoid hemorrhage needs to have surgery delayed until a stable clinical condition is achieved. The nurse prepares to administer which medication as prescribed to prevent clot breakdown and dissolution?

1.Alteplase

2.Heparin sodium

3.Warfarin sodium

4.Aminocaproic acid

4.Aminocaproic acid

The client with a head injury is experiencing signs of increased intracranial pressure (ICP), and mannitol is prescribed. The nurse administering this medication expects which as intended effects of this medication? Select all that apply.

1.Reduced ICP

2.Increased diuresis

3.Increased osmotic pressure of glomerular filtrate

4.Reduced tubular reabsorption of water and solutes

5.Reabsorption of sodium and water in the loop of Henle

1.Reduced ICP

2.Increased diuresis

3.Increased osmotic pressure of glomerular filtrate

4.Reduced tubular reabsorption of water and solutes

The nurse has a prescription to give dexamethasone by the intravenous (IV) route to a client with cerebral edema. How would the nurse prepare this medication?

1.Diluting the medication in 500 mL of 5% dextrose

2.Preparing an undiluted direct injection of the medication

3.Diluting the medication in 1 mL of lactated Ringer's solution for direct injection

4.Diluting the medication in 10% dextrose in water and administering it as a direct injection

2.Preparing an undiluted direct injection of the medication

Dexamethasone intravenously is prescribed for the client with cerebral edema. The nurse prepares the medication for administration and plans to perform which action?

1.Administer the medication by direct injection.

2Mix the medication in 1000 mL of 5% dextrose.

3.Mix the medication in 100 mL of lactated Ringer's solution.

4.Dilute the medication in lactated Ringer's solution and administer as a direct injection.

1.Administer the medication by direct injection.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

1.Obtain a court order for the surgical procedure.

2.Ask the EMS team to sign the informed consent.

3.Transport the victim to the operating room for surgery.

4.Call the police to identify the client and locate the family.

3.Transport the victim to the operating room for surgery.

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse would use which technique to test the client's peripheral response to pain?

1.Sternal rub

2.Pressure on nail beds

3.Pressure on the orbital rim

4.Squeezing of the sternocleidomastoid muscle

2.Pressure on nail beds

The nurse is caring for a client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?

1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure

2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure

4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

1.Blowing the nose

2.Isometric exercises

3.Coughing vigorously

4.Exhaling during repositioning

4.Exhaling during repositioning

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

1.Fluid is clear and tests negative for glucose.

2Fluid is grossly bloody in appearance and has a pH of 6.

3.Fluid clumps together on the dressing and has a pH of 7.

4.Fluid separates into concentric rings and tests positive for glucose.

4.Fluid separates into concentric rings and tests positive for glucose.

The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure

2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure

4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure