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Questions and Answers
What does the nurse concur from the positive Dextrostix test in a patient with clear nasal discharge after head trauma?
What does the nurse concur from the positive Dextrostix test in a patient with clear nasal discharge after head trauma?
For which potential complication should the nurse evaluate a patient with a head injury?
For which potential complication should the nurse evaluate a patient with a head injury?
Why will the nurse question an order for a benzodiazepine prescribed for a patient with increased intracranial pressure?
Why will the nurse question an order for a benzodiazepine prescribed for a patient with increased intracranial pressure?
Which symptoms would the nurse expect to find in a patient with a brain abscess in the occipital lobe? (Select all that apply)
Which symptoms would the nurse expect to find in a patient with a brain abscess in the occipital lobe? (Select all that apply)
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Which statements made by the caregiver indicate the need for further teaching after a patient with a head injury is discharged? (Select all that apply)
Which statements made by the caregiver indicate the need for further teaching after a patient with a head injury is discharged? (Select all that apply)
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Which condition indicates to the nurse to maintain closure of the patient's eyes after a traumatic brain injury?
Which condition indicates to the nurse to maintain closure of the patient's eyes after a traumatic brain injury?
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What actions should the nurse plan to perform to provide the most comfort for the patient with increased intracranial pressure (ICP)? (Select all that apply)
What actions should the nurse plan to perform to provide the most comfort for the patient with increased intracranial pressure (ICP)? (Select all that apply)
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What is the patient's cerebral perfusion pressure (CPP) if blood pressure is 162/58 mm Hg and ICP is 35 mm Hg?
What is the patient's cerebral perfusion pressure (CPP) if blood pressure is 162/58 mm Hg and ICP is 35 mm Hg?
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Which patient does the nurse suspect may have a lesion in the medulla of brain?
Which patient does the nurse suspect may have a lesion in the medulla of brain?
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Which possible responses could be scored under best motor response on the Glasgow Coma Scale (GCS)? (Select all that apply)
Which possible responses could be scored under best motor response on the Glasgow Coma Scale (GCS)? (Select all that apply)
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Which causes of fixed pupils should the nurse consider during assessment? (Select all that apply)
Which causes of fixed pupils should the nurse consider during assessment? (Select all that apply)
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What outcome does the nurse anticipate after administering high doses of barbiturates for increased ICP?
What outcome does the nurse anticipate after administering high doses of barbiturates for increased ICP?
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What components are involved in maintaining normal intracranial pressure (ICP)?
What components are involved in maintaining normal intracranial pressure (ICP)?
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Which actions should the nurse perform to promote optimal outcomes for a patient with increased ICP? (Select all that apply)
Which actions should the nurse perform to promote optimal outcomes for a patient with increased ICP? (Select all that apply)
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How can the findings of flexion of the arms, wrists, and fingers in a comatose head-injured patient be described?
How can the findings of flexion of the arms, wrists, and fingers in a comatose head-injured patient be described?
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Which factors should the nurse consider when administering pharmacologic therapy for a patient with increased ICP? (Select all that apply)
Which factors should the nurse consider when administering pharmacologic therapy for a patient with increased ICP? (Select all that apply)
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What actions should the nurse perform to avoid complications during corticosteroid treatment for increased ICP? (Select all that apply)
What actions should the nurse perform to avoid complications during corticosteroid treatment for increased ICP? (Select all that apply)
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What finding indicates deterioration in the condition of a patient with a closed head injury?
What finding indicates deterioration in the condition of a patient with a closed head injury?
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How must cerebral perfusion pressure (CPP) be maintained during suctioning to preserve cerebral perfusion?
How must cerebral perfusion pressure (CPP) be maintained during suctioning to preserve cerebral perfusion?
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What is the priority nursing intervention when caring for a patient with increased ICP?
What is the priority nursing intervention when caring for a patient with increased ICP?
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What outcome does the nurse expect after administering mannitol for increased ICP?
What outcome does the nurse expect after administering mannitol for increased ICP?
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What does a CPP of 56 mm Hg indicate for a patient with elevated intracranial pressure (ICP)?
What does a CPP of 56 mm Hg indicate for a patient with elevated intracranial pressure (ICP)?
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Which findings would indicate shunt malfunction related to increased ICP? (Select all that apply)
Which findings would indicate shunt malfunction related to increased ICP? (Select all that apply)
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Which cranial nerve's functioning is evaluated through pupillary response in a patient with head trauma?
Which cranial nerve's functioning is evaluated through pupillary response in a patient with head trauma?
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What behavior after assessing the oculocephalic reflex indicates an intracranial lesion?
What behavior after assessing the oculocephalic reflex indicates an intracranial lesion?
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What is the initial action a nurse should take for a patient with head trauma who has a urine output of 300 mL/hr and dry skin?
What is the initial action a nurse should take for a patient with head trauma who has a urine output of 300 mL/hr and dry skin?
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Which indicator is the most reliable for assessing a patient's neurologic status following a head injury?
Which indicator is the most reliable for assessing a patient's neurologic status following a head injury?
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When assessing surgery outcomes in a patient with a brain tumor, which factors should be considered? (Select all that apply)
When assessing surgery outcomes in a patient with a brain tumor, which factors should be considered? (Select all that apply)
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Which symptoms should a nurse instruct a patient with a head injury to report immediately? (Select all that apply)
Which symptoms should a nurse instruct a patient with a head injury to report immediately? (Select all that apply)
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What must the nurse include in long-term care planning for a patient following craniotomy?
What must the nurse include in long-term care planning for a patient following craniotomy?
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Which patient assignment is appropriate for a nurse reassigned to a neurologic intermediate care unit?
Which patient assignment is appropriate for a nurse reassigned to a neurologic intermediate care unit?
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In a patient with cerebral edema, what finding is likely if they report a headache and disturbed consciousness?
In a patient with cerebral edema, what finding is likely if they report a headache and disturbed consciousness?
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What will be the Glasgow Coma Scale score for a patient with a moderate head injury?
What will be the Glasgow Coma Scale score for a patient with a moderate head injury?
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What type of brain herniation is indicated by lateral displacement of brain tissue beneath the falx cerebri?
What type of brain herniation is indicated by lateral displacement of brain tissue beneath the falx cerebri?
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What is the surgical procedure for redirecting cerebrospinal fluid (CSF) in a patient preparing for cranial surgery?
What is the surgical procedure for redirecting cerebrospinal fluid (CSF) in a patient preparing for cranial surgery?
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Which type of brain tumor is associated with a patient with AIDS who reports uncontrolled urination and excessive thirst?
Which type of brain tumor is associated with a patient with AIDS who reports uncontrolled urination and excessive thirst?
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Which aspect of a patient with intracranial pressure (ICP) monitoring requires follow-up by the nurse?
Which aspect of a patient with intracranial pressure (ICP) monitoring requires follow-up by the nurse?
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Which complications can result from brain tumors? (Select all that apply)
Which complications can result from brain tumors? (Select all that apply)
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Which tumor growth is most commonly associated with acquired immunodeficiency syndrome (AIDS)?
Which tumor growth is most commonly associated with acquired immunodeficiency syndrome (AIDS)?
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What are primary goals when planning care for a patient with a brain tumor? (Select all that apply)
What are primary goals when planning care for a patient with a brain tumor? (Select all that apply)
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Before administering temozolomide, which factors should the nurse evaluate? (Select all that apply)
Before administering temozolomide, which factors should the nurse evaluate? (Select all that apply)
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What diagnostic test helps localize a brain tumor and detect blood flow?
What diagnostic test helps localize a brain tumor and detect blood flow?
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Which statement made by a newly licensed nurse caring for a patient with a ventricular shunt requires immediate intervention?
Which statement made by a newly licensed nurse caring for a patient with a ventricular shunt requires immediate intervention?
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What surgical procedure does a patient with hydrocephalus prepare for?
What surgical procedure does a patient with hydrocephalus prepare for?
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A patient with a brain tumor presents symptoms of visual disturbances and seizures. Which area of the brain is this tumor most likely located in?
A patient with a brain tumor presents symptoms of visual disturbances and seizures. Which area of the brain is this tumor most likely located in?
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Study Notes
Increased Intracranial Pressure (ICP) Overview
- ICP management is critical for patient comfort; minimize agitation by avoiding stimulating procedures.
- Maintain a quiet environment and closely monitor for agitation signs.
- Offer family guidance on limiting stimulation and visit frequency.
Cerebral Perfusion Pressure (CPP)
- CPP is calculated by subtracting ICP from the mean arterial pressure (MAP).
- MAP formula: (systolic + 2 × diastolic) / 3.
- Normal CPP is above 60 mm Hg; lower CPP indicates impaired blood flow to the brain.
Breathing Patterns and Brain Lesions
- Cluster breathing suggests a possible lesion in the medulla.
- Different breathing patterns correlate with specific brain abnormalities:
- Apneustic breathing indicates mid or lower pons lesions.
- Cheyne-Stokes is associated with bilateral hemispheric disease.
- Central neurogenic hyperventilation is linked to disruptions in the brainstem.
Glasgow Coma Scale (GCS) Best Motor Response
- Valid responses under best motor response include:
- Flexion withdrawal
- Localization of pain
- Obedience to command
- Eye-opening and disorganized speech are not categorized under motor response.
Fixed Pupils and Their Causes
- Fixed pupils unresponsive to light may result from:
- Previous eye surgery
- Increased ICP
- Direct injury to cranial nerve III (CN III)
- Administration of diuretics and raised intraocular pressure do not typically cause fixed pupils.
Pharmacologic Management of ICP
- High-dose barbiturates decrease cerebral metabolism, aiding in ICP reduction.
- Mannitol acts as an osmotic diuretic that effectively reduces ICP by increasing urine output.
- Use of sedatives or analgesics alongside neuromuscular blockers is crucial for pain management during procedures.
Monitoring and Interventions
- Continuous ICP monitoring is essential for patients with ICP.
- Maintain fluid balance and assess osmolality.
- Elevate head of the bed to 30 degrees; avoid supine position.
Signs of ICP Deterioration
- Late signs of ICP include widening pulse pressure, bradycardia, and decreased respirations.
- Blood pressure and heart rate changes are key indicators of neurological deterioration.
Shunt Malfunction Symptoms
- Indications of a shunt malfunction may include:
- Blurred vision
- Headaches and vomiting
- Decreased level of consciousness
Assessment of Neurologic Function
- Test pupillary response to assess cranial nerve III function; relevant for detecting ICP impact.
- Oculocephalic reflex used to identify intracranial lesions; incorrect eye movement suggests a lesion.
Diabetes Insipidus Related to Head Injury
- High urine output and dry mucous membranes indicate possible diabetes insipidus post-head trauma.
- Evaluation of urine specific gravity is a priority to assess hydration status.
General Nursing Considerations
- Compare current vital signs with baseline to detect changes associated with ICP.
- Monitor patients following head injuries for any deviations in normal neurological responses.
- Anticipate potential complications and prepare for necessary interventions.### Neurological Assessments and Conditions
- Level of Consciousness: Key indicator of neurologic status; changes may indicate increased intracranial pressure (ICP).
- Dim Vision: Can result from cranial nerve dysfunction; important to monitor in neuro patients.
- Papilledema: Swelling of the optic disc due to increased ICP; observed during retinal examination.
- Body Temperature: Changes may occur due to ICP's effects on the hypothalamus.
Post-Surgical Considerations in Brain Tumor Patients
- Surgery can reduce tumor mass, relieve symptoms, and extend survival time but does not usually provide a complete cure.
- Post-operative assessment should focus on symptom relief and monitoring ICP.
Head Injury Patient Education
- Caregivers should be alerted to report seizures, stiff neck, and increased drowsiness immediately.
- Symptoms like sneezing and constipation are typically less concerning and may have alternative explanations.
Long-Term Care After Craniotomy
- Expect emotional and cognitive changes; education on these is critical for family coping strategies.
- Patients may develop seizures weeks to months post-surgery.
Appropriate Nursing Assignments
- A nurse from a medical-surgical unit should monitor an alert patient with viral encephalitis rather than critical post-operative patients or unconscious ones.
Findings Related to Cerebral Edema
- Vasogenic Edema: Characterized by increased extracellular fluid volume, typically linked to permeability issues of the blood-brain barrier.
- Hypoxia indicates cytotoxic edema, distinct from hydrocephalus caused by interstitial edema.
Glasgow Coma Scale (GCS)
- A score of 10 indicates moderate head injury; GCS range for moderate injuries is 9-12.
Types of Herniation
- Cingulate Herniation: Occurs with lateral brain displacement beneath the falx cerebri.
Surgical Procedures for CSF Management
- Shunt placement is the typical procedure for redirecting cerebrospinal fluid when absorption is impaired.
Brain Tumor Symptoms Associated with AIDS
- Primary Central Nervous System Lymphoma: Linked with AIDS; may cause diabetes insipidus symptoms like excessive thirst and urination.
Goals in Brain Tumor Management
- Primary goals include tumor mass reduction, identifying tumor type and location, and managing ICP effectively.
Temozolomide Medication Considerations
- Evaluate for myelosuppression; the drug effectively crosses the blood-brain barrier and directly affects tumor growth.
Diagnostic Tests for Tumor Localization
- Angiography: Used to help localize brain tumors and assess blood flow; not to be confused with EEG or lumbar punctures.
Ventricular Shunt Care
- Gradual positioning is crucial to avoid rapid ICP changes; infection prevention measures should be strictly adhered to.
Hydrocephalus Surgical Interventions
- Ventriculoatrial Shunt Placement: Effective for draining excess cerebrospinal fluid related to hydrocephalus.
Symptoms of Occipital Lobe Tumors
- Common symptoms include visual disturbances, headaches, and seizures.
CSF Rhinorrhea
- A positive Dextrostix test indicates cerebrospinal fluid is leaking, a critical finding in head injury assessments.
Complications Related to Head Injuries
- Monitor for increased intracranial pressure as a significant complication following cerebral hemorrhage and edema.
Benzodiazepine Use in ICP Patients
- Caution against benzodiazepines due to potential hypotensive effects that can worsen ICP management.
Symptoms Associated with Brain Abscesses
- Headaches, fever, nausea, and potential visual impairment are typical in cases of an occipital lobe abscess.
Caregiver Education After Head Injury
- Caregivers must understand when to report symptoms indicating mental status deterioration and avoid practices that may exacerbate swelling.
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Description
This quiz focuses on nursing care strategies for patients experiencing increased intracranial pressure (ICP). It covers key actions nurses should take to ensure patient comfort and minimize agitation. Test your knowledge on the best practices in managing ICP effectively.
