Medical-Surgical Nursing Assessment and Management of Clinical Problems 9e Chapter 57

Chapter 57: Nursing Management: Acute Intracranial Problems
Test Bank
MULTIPLE CHOICE
1. Family members of a patient who has a traumatic brain injury ask the nurse about the purpose
of the ventriculostomy system being used for intracranial pressure monitoring. Which
response by the nurse is best?
a. This type of monitoring system is complex and it is managed by skilled staff.
b. The monitoring system helps show whether blood flow to the brain is adequate.
c. The ventriculostomy monitoring system helps check for alterations in cerebral
perfusion pressure.
d. This monitoring system has multiple benefits including facilitation of
cerebrospinal fluid drainage.
ANS: B
Short and simple explanations should be given initially to patients and family members. The
other explanations are either too complicated to be easily understood or may increase the
family members anxiety.
DIF: Cognitive Level: Apply (application) REF: 1361

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
2. Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and
respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most
concern to the nurse?
a. Blood pressure 154/68, pulse 56, respirations 12
b. Blood pressure 134/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes
represent Cushings triad. These findings indicate that the intracranial pressure (ICP) has
increased, and brain herniation may be imminent unless immediate action is taken to reduce
ICP. The other vital signs may indicate the need for changes in treatment, but they are not
indicative of an immediately life-threatening process.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. When a brain-injured patient responds to nail bed pressure with internal rotation, adduction,
and flexion of the arms, the nurse reports the response as
a. flexion withdrawal.
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing.
ANS: C
Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented
as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the
flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
DIF: Cognitive Level: Understand (comprehension) REF: 1360

4. The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient.

Which parameter should the nurse monitor to determine the medications effectiveness?
a.Blood pressure
b.Oxygen saturation
c.Intracranial pressure
d.Hemoglobin and hematocrit
ANS: C
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.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
5. A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when
stimulated, and does not respond to a verbal command to move but attempts to push away a
painful stimulus. The nurse records the patients Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15.
ANS: B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor
response.

6. An unconscious 39-year-old male patient is admitted to the emergency department (ED) with
a head injury. The patients spouse and teenage children stay at the patients side and ask many
questions about the treatment being given. What action is best for the nurse to take?
a. Ask the family to stay in the waiting room until the initial assessment is
completed.
b. Allow the family to stay with the patient and briefly explain all procedures to
them.
c. Refer the family members to the hospital counseling service to deal with their
anxiety.
d. Call the familys pastor or spiritual advisor to take them to the chapel while care is
given.
ANS: B
The need for information about the diagnosis and care is very high in family members of
acutely ill patients. The nurse should allow the family to observe care and explain the
procedures unless they interfere with emergent care needs. A pastor or counseling service can
offer some support, but research supports information as being more effective. Asking the
family to stay in the waiting room will increase their anxiety.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
7. A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue
perfusion related to cerebral tissue swelling. Which nursing intervention will be included in
the plan of care?
a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods.
ANS: C
The patient with increased intracranial pressure (ICP) should be maintained in the head-up
position to help reduce ICP. Extreme 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.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
8. A 20-year-old male patient is admitted with a head injury after a collision while playing
football. After noting that the patient has developed clear nasal drainage, which action should
the nurse take?
a. Have the patient gently blow the nose.
b. Check the drainage for glucose content.
c. Teach the patient that rhinorrhea is expected after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity.
ANS: B
Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal
fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from
the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing
the nose is avoided to prevent CSF leakage.

9. Which action will the emergency department nurse anticipate for a patient diagnosed with a
concussion who did not lose consciousness?
a. Coordinate the transfer of the patient to the operating room.
b. Provide discharge instructions about monitoring neurologic status.
c. Transport the patient to radiology for magnetic resonance imaging (MRI).
d. Arrange to admit the patient to the neurologic unit for 24 hours of observation.
ANS: B
A patient with a minor head trauma is usually discharged with instructions about neurologic
monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission,
or surgery are not usually indicated in a patient with a concussion.
DIF: Cognitive Level: Apply (application) REF: 1369-1370

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
10. A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the
emergency department. Which action will the nurse plan to take?
a.Administer IV furosemide (Lasix).
b.Prepare the patient for craniotomy.
c.Initiate high-dose barbiturate therapy.
d.Type and crossmatch for blood transfusion.
ANS: B
The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and
prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-
dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma
is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not
necessary.

11. The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses
around both eyes and clear drainage from the patients nose. Which admission order should
the nurse question?
a. Keep the head of bed elevated.
b. Insert nasogastric tube to low suction.
c. Turn patient side to side every 2 hours
d. Apply cold packs intermittently to face.
ANS: B
Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage. Insertion of a
nasogastric tube will increase the risk for infections such as meningitis. Turning the patient,
elevating the head, and applying cold packs are appropriate orders.
DIF: Cognitive Level: Apply (application) REF: 1369 | 1374

12. A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment
information will the nurse collect to determine whether a patient is developing postconcussion
syndrome?
a. Short-term memory
b. Muscle coordination
c. Glasgow Coma Scale
d. Pupil reaction to light
ANS: A
Decreased short-term memory is one indication of postconcussion syndrome. The other data
may be assessed but are not indications of postconcussion syndrome.
13. The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may
have
a. expressive aphasia.
b. impaired judgment.
c. right-sided weakness.
d. difficulty swallowing.
ANS: B
The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the
parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor.
Swallowing is controlled by the brainstem.

14. Which statement by a 40-year-old patient who is being discharged from the emergency
department (ED) after a concussion indicates a need for intervention by the nurse?
a. I will return if I feel dizzy or nauseated.
b. I am going to drive home and go to bed.
c. I do not even remember being in an accident.
d. I can take acetaminophen (Tylenol) for my headache.
ANS: B
Following a head injury, the patient should avoid driving and operating heavy machinery.
Retrograde amnesia is common after a concussion. The patient can take acetaminophen for
headache and should return if symptoms of increased intracranial pressure such as dizziness or
nausea occur.

15. After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a
nursing diagnosis of impaired physical mobility related to decreased level of consciousness
and weakness. An appropriate nursing intervention is to
a. cluster nursing activities to allow longer rest periods.
b. turn and reposition the patient side to side every 2 hours.
c. position the bed flat and log roll to reposition the patient.
d. perform range-of-motion (ROM) exercises every 4 hours.
ANS: D
ROM exercises will help 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.

16. A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing
action will be included in the plan of care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Keep the room well-lighted to improve patient orientation.
d. Minimize contact with the patient to decrease sensory input.
ANS: A
Patients with meningitis and disorientation will be calmed by the presence of someone
familiar at the bedside. Restraints should be avoided because they increase agitation and
anxiety. The patient requires frequent assessment for complications. The use of touch and a
soothing voice will decrease anxiety for most patients. The patient will have photophobia, so
the light should be dim.

17. The public health nurse is planning a program to decrease the incidence of meningitis in
adolescents and young adults. Which action is most important?
a. Encourage adolescents and young adults to avoid crowds in the winter.
b. Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
c. Immunize adolescents and college freshman against Neisseria meningitides.
d. Emphasize the importance of hand washing to prevent the spread of infection.
ANS: C
The Neisseria meningitides vaccination is recommended for children ages 11 and 12,
unvaccinated teens entering high school, and college freshmen. Hand washing may help
decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with
Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are
in school or the workplace, avoiding crowds is not realistic.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
18. A patient has been admitted with meningococcal meningitis. Which observation by the nurse
requires action?
a. The bedrails at the head and foot of the bed are both elevated.
b. The patient receives a regular diet from the dietary department.
c. The lights in the patients room are turned off and the blinds are shut.
d. Unlicensed assistive personnel enter the patients room without a mask.
ANS: D
Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain
respiratory isolation as well as standard precautions. Because the patient may be confused and
weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the
room decrease pain caused by photophobia. Nutrition is an important aspect of care in a
patient with meningitis.

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
19. When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the
following data. Which finding should be reported immediately to the health care provider?
a. The patient exhibits nuchal rigidity.
b. The patient has a positive Kernigs sign.
c. The patients temperature is 101 F (38.3 C).
d. The patients blood pressure is 88/42 mm Hg.
ANS: D
Shock is a serious complication of meningitis, and the patients low blood pressure indicates
the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive
Kernigs sign are expected with bacterial meningitis. The nurse should intervene to lower the
temperature, but this is not as life threatening as the hypotension.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
20. A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52
mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take
first?
a. Document the BP and ICP in the patients record.
b. Report the BP and ICP to the health care provider.
c. Elevate the head of the patients bed to 60 degrees.
d. Continue to monitor the patients vital signs and ICP.
ANS: B
Calculate the cerebral perfusion pressure (CPP): (CPP = mean arterial pressure [MAP] ICP).
MAP = DBP + 1/3 (systolic blood pressure [SBP] diastolic blood pressure [DBP]).
Therefore the (MAP) is 70 and the CPP is 56 mm Hg, which is below the normal of 60 to 100
mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the
patients therapy such as fluid infusion or vasopressor administration are needed to improve
the cerebral perfusion pressure. Adjustments in the head elevation should only be done after
consulting with the health care provider. Continued monitoring and documentation will also
be done, but they are not the first actions that the nurse should take.
DIF: Cognitive Level: Analyze (analysis) REF: 1357

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
21. After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a
traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take
first?
a. Document the increase in intracranial pressure.
b. Ensure that the patients neck is in neutral position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprivan) infusion.
ANS: B
Because suctioning will cause a transient increase in intracranial pressure, the nurse should
initially check for other factors that might be contributing to the increase and observe the
patient for a few minutes. Documentation is needed, but this is not the first action. There is no
need to notify the health care provider about this expected reaction to suctioning. Propofol is
used to control patient anxiety or agitation. There is no indication that anxiety has contributed
to the increase in intracranial pressure.

22. Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a
registered nurse (RN) who has floated from the medical unit?
a. A 45-year-old receiving IV antibiotics for meningococcal meningitis
b. A 25-year-old admitted with a skull fracture and craniotomy the previous day
c. A 55-year-old who has increased intracranial pressure (ICP) and is receiving
hyperventilation therapy
d. A 35-year-old with ICP monitoring after a head injury last week
ANS: A
An RN who works on a medical unit will be familiar with administration of IV antibiotics and
with meningitis. The postcraniotomy patient, patient with an ICP monitor, and the patient on a
ventilator should be assigned to an RN familiar with the care of critically ill patients.

OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
23. A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116
mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a
headache. Which prescribed interventions should the nurse implement first?
a. Administer IV 5% hypertonic saline.
b. Draw blood for arterial blood gases (ABGs).
c. Send patient for computed tomography (CT).
d. Administer acetaminophen (Tylenol) 650 mg orally.
ANS: A
The patients low sodium indicates that hyponatremia may be causing the cerebral edema. The
nurses first action should be to correct the low sodium level. Acetaminophen (Tylenol) 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 provide some useful
information, but the low sodium level may lead to seizures unless it is addressed quickly.

24. 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 20-year-old patient whose cranial x-ray shows a linear skull fracture
b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13
c. A 40-year-old patient who lost consciousness for a few seconds after a fall
d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light
ANS: D
The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased
intracranial pressure. The other patients are not at immediate risk for complications such as
herniation.
DIF: Cognitive Level: Analyze (analysis) REF: 1366

OBJ: Special Questions: Prioritization; Multiple Patients
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
25. The nurse is caring for a patient who was admitted the previous day with a basilar skull
fracture after a motor vehicle crash. Which assessment finding is most important to report to
the health care provider?
a. Complaint of severe headache
b. Large contusion behind left ear
c. Bilateral periorbital ecchymosis
d. Temperature of 101.4 F (38.6 C)
ANS: D
Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature
should be reported to the health care provider. The other findings are typical of a patient with
a basilar skull fracture.

26. After evacuation of an epidural hematoma, a patients intracranial pressure (ICP) is being
monitored with an intraventricular catheter. Which information obtained by the nurse is most
important to communicate to the health care provider?
a. Pulse 102 beats/min
b. Temperature 101.6 F
c. Intracranial pressure 15 mm Hg
d. Mean arterial pressure 90 mm Hg
ANS: B
Infection is a serious consideration with ICP monitoring, especially with intraventricular
catheters. The temperature indicates the need for antibiotics or removal of the monitor. The
ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing
monitoring at this time.

27. The charge nurse observes an inexperienced staff nurse caring for a patient who has had a
craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires
the charge nurse to intervene?
a. The staff nurse assesses neurologic status every hour.
b. The staff nurse elevates the head of the bed to 30 degrees.
c. The staff nurse suctions the patient routinely every 2 hours.
d. The staff nurse administers an analgesic before turning the patient.
ANS: C
Suctioning increases intracranial pressure, and should only be done when the patients
respiratory condition indicates it is needed. The other actions by the staff nurse are
appropriate.

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation
28. A 68-year-old male patient is brought to the emergency department (ED) by ambulance after
being found unconscious on the bathroom floor by his spouse. Which action will the nurse
take first?
a. Check oxygen saturation.
b. Assess pupil reaction to light.
c. Verify Glasgow Coma Scale (GCS) score.
d. Palpate the head for hematoma or bony irregularities.
ANS: A
Airway patency and breathing are the most vital functions, and should be assessed first. The
neurologic assessments should be accomplished next and additional assessment after that.

29. A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which
action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in
the intensive care unit?
a. Document intracranial pressure every hour.
b. Turn and reposition the patient every 2 hours.
c. Check capillary blood glucose level every 6 hours.
d. Monitor cerebrospinal fluid color and volume hourly.
ANS: C
Experienced UAP can obtain capillary blood glucose levels when they have been trained and
evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and
intracranial pressure (ICP) require registered nurse (RN)level education and scope of
practice. Although repositioning patients is frequently delegated to UAP, repositioning a
patient with a ventriculostomy is complex and should be supervised by the RN.

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
30. Which information about a 30-year-old 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 25 mL/hour
c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg
d. Cardiac monitor shows sinus tachycardia at 128 beats/minute
ANS: C
The PbtO2 should be 20 to 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 to
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.

31. The nurse is caring for a patient who has a head injury and fractured right arm after being
assaulted. Which assessment information requires the most rapid action by the nurse?
a. The apical pulse is slightly irregular.
b. The patient complains of a headache.
c. The patient is more difficult to arouse.
d. The blood pressure (BP) increases to 140/62 mm Hg.
ANS: C
The change in level of consciousness (LOC) is an indicator of increased intracranial pressure
(ICP) and suggests that action by the nurse is needed to prevent complications. The change in
BP should be monitored but is not an indicator of a need for immediate nursing action.
Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.

32. Which finding for a patient who has a head injury should the nurse report immediately to the
health care provider?
a. Intracranial pressure is 16 mm Hg when patient is turned.
b. Pale yellow urine output is 1200 mL over the last 2 hours.
c. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
d. Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours.
ANS: B
The high urine output indicates that diabetes insipidus may be developing, and interventions
to prevent dehydration need to be rapidly implemented. The other data do not indicate a need
for any change in therapy.

33. When admitting a 42-year-old patient with a possible brain injury after a car accident to the
emergency department (ED), the nurse obtains the following information. Which finding is
most important to report to the health care provider?
a. The patient takes warfarin (Coumadin) daily.
b. The patients blood pressure is 162/94 mm Hg.
c. The patient is unable to remember the accident.
d. The patient complains of a severe dull headache.
ANS: A
The use of anticoagulants increases the risk for intracranial hemorrhage and should be
immediately reported. The other information would not be unusual in a patient with a head
injury who had just arrived in the ED.

34. A patient being admitted with bacterial meningitis has a temperature of 102.5 F (39.2 C) and
a severe headache. Which order for collaborative intervention should the nurse implement
first?
a. Administer ceftizoxime (Cefizox) 1 g IV.
b. Give acetaminophen (Tylenol) 650 mg PO.
c. Use a cooling blanket to lower temperature.
d. Swab the nasopharyngeal mucosa for cultures.
ANS: D
Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be
done before antibiotics are started. As soon as the cultures are done, the antibiotic should be
started. Hypothermia therapy and acetaminophen administration are appropriate but can be
started after the other actions are implemented.

35. A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture
was performed in the emergency department. Which action prescribed by the health care
provider should the nurse question?
a. Elevate the head of the bed 20 degrees.
b. Restrict oral fluids to 1000 mL daily.
c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours.
d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.
ANS: B
The patient with meningitis has increased fluid needs, so oral fluids should be encouraged.
The other actions are appropriate. Slight elevation of the head of the bed will decrease
headache without causing leakage of cerebrospinal fluid from the lumbar puncture site.
Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal
fluid analysis.

36. Which action will the public health nurse take to reduce the incidence of epidemic
encephalitis in a community?
a. Encourage the use of effective insect repellents during mosquito season.
b. Remind patients that most cases of viral encephalitis can be cared for at home.
c. Teach about the importance of prophylactic antibiotics after exposure to
encephalitis.
d. Arrange for screening of school-age children for West Nile virus during the school
year.
ANS: A
Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent is
effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in
an intensive care unit during the initial stages. Antibiotic prophylaxis is not used to prevent
encephalitis because most encephalitis is viral. West Nile virus is most common in adults over
age 50 during the summer and early fall.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
37. To assess for functional deficits, which question will the nurse ask a patient who has been
admitted for treatment of a benign occipital lobe tumor?
a.Do you have difficulty in hearing?
b.Are you experiencing visual problems?
c.Are you having any trouble with your balance?
d.Have you developed any weakness on one side?
ANS: B
Because the occipital lobe is responsible for visual reception, the patient with a tumor in this
area is likely to have problems with vision. The other questions will be better for assessing
function of the temporal lobe, cerebellum, and frontal lobe.

38. During change-of-shift report, the nurse learns that a patient with a head injury has decorticate
posturing to noxious stimulation. Which positioning shown in the accompanying figure will
the nurse expect to observe?
a. 1
b. 2
c. 3
d. 4
ANS: A
With decorticate posturing, the patient exhibits internal rotation and adduction of the arms
with flexion of the elbows, wrists, and fingers. The other illustrations are of decerebrate,
mixed decorticate/decerebrate posturing, and opisthotonic posturing.

39. Which is the correct point on the accompanying figure where the nurse will assess for
ecchymosis when admitting a patient with a basilar skull fracture?
a. A
b. B
c. C
d. D
ANS: D
Point D, the periorbital and postauricular areas, should be selected. Battles sign and
periorbital ecchymoses are associated with basilar skull fracture.

COMPLETION
1. An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg,
and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral
perfusion pressure (CPP) as ____ mm Hg.
ANS:
74
Calculate the CPP: (CPP = mean arterial pressure [MAP] ICP). MAP = DBP + 1/3 (systolic
blood pressure [SBP] diastolic blood pressure [DBP]). The MAP is 94. The CPP is 74.
DIF: Cognitive Level: Apply (application)


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Chapter 57: Nursing Management: Acute Intracranial Problems

DIF: Cognitive Level: Apply (application) REF: 1361

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4. The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient.

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DIF: Cognitive Level: Apply (application) REF: 1382

DIF: Cognitive Level: Apply (application) REF: 1383

DIF: Cognitive Level: Apply (application) REF: 1384

DIF: Cognitive Level: Apply (application) REF: 1376

DIF: Cognitive Level: Understand (comprehension) REF: 1360

DIF: Cognitive Level: Understand (comprehension) REF: 1369

DIF: Cognitive Level: Apply (application)

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