Chapter 57 Nursing Supervision Acute Intracranial Problems

Chapter 57: Nursing Management: Acute Intracranial Problems

Test out Bank


1 ) Family members of any patient who may have a traumatic brain injury ask the nurse regarding the purpose

with the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best?

a. " This sort of monitoring strategy is complex in fact it is managed simply by skilled personnel. ” m. " The monitoring program helps present whether blood circulation to the mental faculties are adequate. ” c. " The ventriculostomy monitoring system helps look for alterations in cerebral perfusion pressure. ”

d. " This monitoring system provides multiple benefits including facilitation of cerebrospinal fluid drainage. ”


Short and simple details should be offered initially to patients and family members. The other answers are either too difficult to be quickly understood or perhaps may raise the family members' anxiety.

DIF: Cognitive Level: Apply (application)



TOP: Medical Process: Setup

MSC: NCLEX: Psychosocial Honesty

2 . Entrance vital indicators for a brain-injured patient are blood pressure 128/68, pulse 128, and

respirations 26. Which usually set of vital signs, in the event taken 1 hour after admission, will be on most concern to the nurse?

a. Blood pressure 154/68, pulse 56, respirations doze

b. Blood pressure 134/72, heartbeat 90, respirations 32

c. Blood pressure 148/78, pulse 112, respirations 28

d. Stress 110/70, heartbeat 120, respirations 30


Systolic hypertension with widening heart beat pressure, bradycardia, and breathing changes signify Cushing's triad. These conclusions indicate the intracranial pressure (ICP) has grown, and head herniation can be imminent unless of course immediate action is taken to reduce ICP. The additional vital symptoms may reveal the need for within treatment, but are not a sign of an right away life-threatening process.

DIF: Intellectual Level: Apply (application)



BEST: Nursing Process: Assessment

MSC: NCLEX: Physical Integrity

a few. When a brain-injured patient responds to nail bed pressure with internal rotation, adduction,

and flexion with the arms, the nurse reports the response as

a. flexion drawback.

b. localization of discomfort.

c. decorticate posturing.

deb. decerebrate posturing.



Internal rotation, adduction, and flexion in the arms within an unconscious patient is noted as decorticate posturing. Extension of the arms and legs is decerebrate posturing. For the reason that flexion is definitely generalized, will not indicate localization of soreness or flexion withdrawal. DIF: Cognitive Level: Understand (comprehension)

REF: 1360

TOP: Nursing jobs Process: Evaluation

MSC: NCLEX: Physiological Ethics

4. The nurse provides administered recommended IV mannitol (Osmitrol) for an unconscious patient.

Which variable should the health professional monitor to look for the medication's effectiveness? a. Stress

b. O2 saturation

c. Intracranial pressure

d. Hemoglobin and hematocrit


Mannitol can be an osmotic diuretic and definitely will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and maximize blood pressure, but these are not the best parameters pertaining to evaluation with the effectiveness in the drug. Oxygen saturation will not likely directly improve as a result of mannitol administration.

DIF: Cognitive Level: Apply (application)



TOP: Nursing Process: Analysis

MSC: NCLEX: Physiological Honesty

5. A 46-year-old patient with a mind injury opens the eyes to verbal stimulation, curses when

triggered, and does not react to a spoken command to go but efforts to push aside a painful stimulus. The health professional records the patient's Glasgow Coma Scale score as being a. 9.

n. 11.

c. 13.

m. 15.


You will have a credit score of 3 pertaining to eye starting, 3 for best verbal response, and 5 for best engine response.

DIF: Cognitive Level: Apply (application)



TOP: Breastfeeding Process: Evaluation

MSC: NCLEX: Physiological Ethics

6. An...



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