QUESTIONS CHAPTER 57 TEST #1 ANSWER KEY

1. When family members ask the nurse about the purpose of the ventriculostomy system being used for
intracranial pressure monitoring for a patient, which response by the nurse is best?

a. "This type of monitoring system is complex and highly skilled staff are needed."
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 to patients and family members. The other explanations
are either too complicated to be easily understood or may increase the family member's anxiety.

2. A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and
respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the
nurse?

a. Blood pressure 156/60, pulse 55, respirations 12

b. Blood pressure 130/72, 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
Cushing's triad and 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.

3. When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient
responds with internal rotation, adduction, and flexion of the arms. The nurse documents this 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.

4. Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol
(Osmitrol) has been effective for an unconscious patient?

a. Hematocrit
b. Blood pressure
c. Oxygen saturation
d. Intracranial pressure

ANS: D
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.

5. A 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 remove a painful stimulus. The nurse records
the patient's 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. Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department
(ED). The patient's spouse and children stay at the patient's side and constantly ask 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. Call the family's pastor or spiritual advisor to support them while initial care is given.
d. Refer the family members to the hospital counseling service to deal with their anxiety.
ANS: B
The need for information about the diagnosis and care is very high in family members of acutely ill
patients, and the nurse should allow the family to observe care and explain the procedures. 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.

7. An unconscious patient 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. Keep the head of the bed elevated to 30 degrees.

b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.

ANS: A
The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to
help reduce ICP. 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.

8. After noting that a patient with a head injury has clear nasal drainage, which action should the nurse
take?

a. Have the patient blow the nose.

b. Check the nasal drainage for glucose.
c. Assure the patient that rhinorrhea is normal 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. A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to
take?

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) of the brain.
d. Arrange to admit the patient to the neurologic unit for observation for 24 hours.

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
indicated in a patient with a concussion.

10. A 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. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.

ANS: D
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. While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the
patient's nose. Which of these admission orders should the nurse question?

a. Insert nasogastric tube.

b. Turn patient every 2 hours.
c. Keep the head of bed elevated.
d. Apply cold packs for facial bruising.

ANS: A
Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a
nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the
head, and applying cold pack are appropriate orders.

12. Which assessment information will the nurse collect to determine whether a patient is developing
postconcussion syndrome?

a. Muscle resistance
b. Short-term memory
c. Glasgow coma scale
d. Pupil reaction to light

ANS: B
Decreased short-term memory is one indication of postconcussion syndrome. The other data may be
assessed but are not indications of postconcussion syndrome.

13. When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find

a. judgment changes.
b. expressive aphasia.
c. right-sided weakness.
d. difficulty swallowing.

ANS: A
The frontal lobes control 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 patient who is being discharged from the emergency department (ED) after a
head injury 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 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 patient has a nursing diagnosis of
impaired physical mobility related to decreased level of consciousness and weakness. An appropriate
nursing intervention is to

a. position the bed flat and log roll the patient.

b. cluster nursing activities to allow longer rest periods.
c. turn and reposition the patient side to side every 2 hours.
d. perform range-of-motion (ROM) exercises every 4 hours.
ANS: D
ROM exercises will help to 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 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 community health nurse is developing a program to decrease the incidence of meningitis in
adolescents and young adults. Which nursing action is most important?

a. Vaccinate 11- and 12-year-old children against Haemophilus influenzae.

b. Emphasize the importance of hand washing to prevent spread of infection.
c. Immunize adolescents and college freshman against Neisseria meningitides.
d. Encourage adolescents and young adults to avoid crowded areas in the winter.

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.

18. While caring for a patient who has just been admitted with meningococcal meningitis, the RN
observes all of the following. Which one requires action by the RN?

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 nursing assistant goes into the patient's room without a mask.
d. The lights in the patient's room are turned off and the blinds are shut.

ANS: C
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 food 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.

19. When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which
finding should be reported immediately to the health care provider?

a. The patient has a positive Kernig's sign.

b. The patient complains of having a stiff neck.
c. The patient's temperature is 101° F (38.3° C).
d. The patient's blood pressure is 86/42 mm Hg.

ANS: D
Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for
interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with
bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life
threatening as the hypotension.

20. A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which
action should the nurse take first?

a. Elevate the head of the patient's bed to 60 degrees.

b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP.

ANS: C
The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and
approaching the level of ischemia and neuronal death. Immediate changes in the patient's 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 also will be done, but they are not the first actions that the
nurse should take.

21. After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head
injury has increased from 14 to 16 mm Hg. Which action should the nurse take first?
a. Document the increase in intracranial pressure.
b. Assure that the patient's neck is not in a flexed position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprovan) infusion.

ANS: B
Since 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 of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to
an RN who has floated from the medical unit?

a. A 44-year-old receiving IV antibiotics for meningococcal meningitis

b. A 23-year-old who had a skull fracture and craniotomy the previous day
c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago
d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy

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.

23. A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a
decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed
interventions should the nurse implement first?

a. Draw blood for arterial blood gases (ABGs).

b. Administer 5% hypertonic saline intravenously.
c. Administer acetaminophen (Tylenol) 650 mg orally.
d. Send patient for computed tomography (CT) of the head.

ANS: B
The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the
nurse's 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 intra-cranial pressure (ICP).
Drawing ABGs and obtaining a CT scan may add 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 patient whose cranial x-ray shows a linear skull fracture

b. A patient who has an initial Glasgow Coma Scale score of 13
c. A patient who lost consciousness for a few seconds after a fall
d. A 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.

25. Which assessment finding in a patient who was admitted the previous day with a basilar skull
fracture is most important to report to the health care provider?

a. Bruising under both eyes

b. Complaint of severe headache
c. Large ecchymosis behind one ear
d. Temperature of 101.5° 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. When a patient's 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. Oral temperature 101.6° F

b. Apical pulse 102 beats/min
c. Intracranial pressure 15 mm Hg
d. Mean arterial pressure 90 mm Hg

ANS: A
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.

DIF: Cognitive Level: Application REF: 1438-1440



27. The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a
craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to
intervene?

a. The staff nurse suctions the patient every 2 hours.

b. The staff nurse assesses neurologic status every hour.
c. The staff nurse elevates the head of the bed to 30 degrees.
d. The staff nurse administers a mild analgesic before turning the patient.

ANS: A
Suctioning increases intracranial pressure and is done only when the patient's respiratory condition
indicates it is needed. The other actions by the staff nurse are appropriate.

DIF: Cognitive Level: Application REF: 1430-1431



28. A patient is brought to the emergency department (ED) by ambulance after being found unconscious
on the bathroom floor by the spouse. Which action will the nurse take first?

a. Obtain oxygen saturation.

b. Check pupil reaction to light.
c. Palpate the head for hematoma.
d. Assess Glasgow Coma Scale (GCS).

ANS: A
Airway patency and breathing are the most vital functions and should be assessed first. The neurologic
assessments should be accomplished next and the health and medication history last.

DIF: Cognitive Level: Application REF: 1435-1437



29. The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes
the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP)
who regularly work in the intensive care unit?

a. Monitor cerebrospinal fluid color hourly.

b. Document intracranial pressure every hour.
c. Turn and reposition the patient every 2 hours.
d. Check capillary blood glucose level every 6 hours.
ANS: D
Experienced NAP 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 RN-level education and scope of practice. Although repositioning patients is frequently delegated
to NAP, repositioning a patient with a ventriculostomy is complex and should be done by the RN.

DIF: Cognitive Level: Application REF: 1442



30. Which information about a 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 15 mL/hour
c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg
d. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/min

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.

DIF: Cognitive Level: Application REF: 1430-1432



31. When caring for a patient who has had a head injury, which assessment information requires the
most rapid action by the nurse?

a. The patient is more difficult to arouse.

b. The patient's pulse is slightly irregular.
c. The patient's blood pressure increases from 120/54 to 136/62 mm Hg.
d. The patient complains of a headache at pain level 5 of a 10-point scale.

ANS: A
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 is not unusual in a
patient after a head injury. A slightly irregular apical pulse is not unusual.

DIF: Cognitive Level: Application REF: 1431-1433



32. The nurse obtains these assessment findings for a patient who has a head injury. Which finding
should be reported rapidly to the health care provider?

a. Urine output of 800 mL in the last hour

b. Intracranial pressure of 16 mm Hg when patient is turned
c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour
d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg

ANS: A
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.

DIF: Cognitive Level: Application REF: 1434-1435



33. When admitting a patient with a possible coup-contracoup injury after a car accident to the
emergency department, 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 patient's 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 to the ED.

DIF: Cognitive Level: Application REF: 1437-1438



34. A patient admitted with bacterial meningitis and a temperature of 102° F (38.8° C) has orders for all
of these collaborative interventions. Which action should the nurse take first?

a. Administer ceftizoxime (Cefizox) 1 g IV.

b. Use a cooling blanket to lower temperature.
c. Swap the nasopharyngeal mucosa for cultures.
d. Give acetaminophen (Tylenol) 650 mg PO.
ANS: C
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.

DIF: Cognitive Level: Application REF: 1440-1441



35. An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an
intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as
____________________.

ANS:
72 mm Hg
The formula for calculation of cerebral perfusion pressure is [(Systolic pressure + Diastolic blood pressure
2)/3] = intracranial pressure.

DIF: Cognitive Level: Application REF: 1452-1453



36. Identify two ways the following three-volume components of intracranial pressure (ICP) can be
changed to adapt to small increases in intracranial pressure.

a. Cerebrospinal fluid (CSF)

b. Brain Tissue
c. Blood tissue

a. Increased absorption, decreased production, displacement into spinal canal

b. herniation, lesion, edema, collapse of veins and dural sinuses, increased venous outflow and
decreased blood flow
c. distention of dura, slight compression of tissue



37. The earliest signs of increased ICP the nurse should assess for include

a. Cushing's triad
b. unexpected vomiting
c. decreasing level of consciousness (LOC)
d. dilated pupil with sluggish response to light
C.
One of the most sensitive signs of increased intracranial pressure (ICP) is a decreasing LOC. A decrease in
LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur



38. The nurse recognizes the presence of Cushing's triad in the patient with

a. Increased pulse, irregular respiration, increased BP

b. decreased pulse, irregular respiration, increased pulse pressure
c. increased pulse, decreased respiration, increased pulse pressure
d. decreased pulse, increased respiration, decreased systolic BP

B.
Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the
hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is
usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a
bradycardia with a full and bounding pulse, and irregular respirations.



39. Increased ICP in the left cerebral cortex, caused by intracranial bleeding causes displacement of brain
tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to as

a. uncal herniation
b. tentorial herniation
c. cingulate herniation
d. temporal lobe herniation

C.
Cingulate herniation- the dural structures that separate the two hemispheres and the cerebral
hemispheres from the cerebellum influence the patterns of cerebral herniation. A cingulated herniation
occurs where there is lateral displacement of brain tissue beneath the falx cerebri.



40. A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the
patient is

a. aseptic technique to prevent infection

b. constant monitoring of ICP waveforms
c. removal of CSF to maintain normal ICP
d. sampling CSF to determine abnormalities
A.
Aseptic technique to prevent infection- An intraventricular catheter is a fluid coupled system that can
provide direct access for microorganisms to enter the ventricles of the brain, and aseptic technique is a
very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not
usually necessary, and removal of CSF for sampling or to maintain normal ICP is done only when
specifically ordered



41. Metabolic and nutritional needs of the patient with increased ICP are best met with

a. enteral feedings that are low in sodium

b. the simple glucose available in D5W IV solutions
c. a fluid restriction that promotes a moderate dehydration
d. balanced, essential nutrition in a form that the patient can tolerate

D.
A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose
to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes
cerebral edema, and if a patient cannot take oral nutrition, other means of providing nutrition should be
used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional
requirements, and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity.
Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as
urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.



42. A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal
response except moaning and muttering when stimulated, and flexes his arm in response to painful
stimuli. The nurse records the patients GCS score as

a. 6
b. 7
c. 9
d. 11

B.
no opening of eyes = 1
incomprehensible words= 2
flexion withdrawal = 4
Total = 7


43. When assessing the body function of a patient with increased ICP, the nurse should initially assess

a. corneal reflex testing

b. extremity strength testing
c. pupillary reaction to light
d. circulatory and respiratory status

D.
Of the body functions that should be assessed in an unconscious patient, cardiopulmonary status is the
most vital function and gives priorities to the ABCs (airway, breathing, and circulation).



44. CN III originating in the midbrain is assessed by the nurse for an early indication of pressure on the
brainstem by

a. assessing for nystagmus

b. testing the corneal reflex
c. testing pupillary reaction to light
d. testing for oculocephalic (doll's eye) reflex

C.
One of the functions of CN III, the oculomotor nerve, is pupillary constriction, and testing for pupillary
constriction is important to identify patients at risk for brainstem herniation caused by increased ICP. The
corneal reflex is used to assess the functions of CN V and VII, and the oculocephalic reflex tests all cranial
nerves involved with eye movement. Nystagmus is commonly associatted with specific lesions or
chemical toxicities and is not a definitive sign of ICP.



45. A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral
edema. An appropriate nursing intervention for the patient is

a. avoiding positioning the patient with neck and hip flexion

b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg
c. clustering nursing activities to provide periods of uninterrupted rest
d. routine suctioning to prevent accumulation of respiratory secretions

A.
Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities,
and noxious stimuli; they should be avoided or performed as little as possible in the patient with
increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP; the
PaCO2 should be maintained at 30 to 35 mm Hg.


46. An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the health
care provider when arterial blood gas measurement results reveal a

a. pH of 7.43
b. SaO2 of 94%
c. PaO2 of 50 mm Hg
d. PaCO2 of 30 mm Hg

C.
A PaO2 of 50 mm Hg reflects a hypoxemia that may lead to further decreased cerebral perfusion and
hypoxia and must be corrected. The pH of SaO2 are within normal range, and a PaCO2 of 30 mm Hg
reflects acceptable value for the patient with increased ICP



47. The nurse is monitoring a patient for increased ICP following a head injury. Which of the following
manifestations indicate an increased ICP (select all that apply)

a. fever
b. oriented to name only
c. narrowing pulse pressure
d. dilated right pupil > left pupil
e. decorticate posturing to painful stimulus

A, B, D, E
The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil,
changes in motor response such as posturing, and fever, which may indicate pressure on the
hypothalamus. Changes in vital signs would be an increased systolic BP with widened pulse pressure and
bradycardia.



48. While the nurse performs ROM on an unconscious patient with increased ICP, the patient
experiences severe decerebrate posturing reflexes. The nurse should

a. use restraints to protect the patient from injury

b. administer CNS depressants to lightly sedate the patient
c. perform the exercises less frequently because posturing can increase ICP
d. continue the exercises because they are necessary to maintain musculoskeletal function

C.
If reflex posturing occurs during ROM or positioning of the patient, these activities should be done less
frequently until the patient's condition stabilizes, because posturing can case increases in ICP. Neither
restraints nor CNS depressants would be indicated.



49. A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present
in the drainage, the nurse

a. examines the tympanic membrane for a tear

b. tests the fluid for a halo sign on a white dressing
c. tests the fluid with a glucose identifying strip or stick
d. collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis

B.
Testing clear drainage for CSF in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip,
but if blood is present, the glucose in the blood will produce and unreliable result. To test bloody
drainage, the nurse should test the fluid for a halo or ring that occurs when a yellowish ring encircles
blood dripped onto a white pad or towel



50. The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences

a. failure to regain consciousness following a head injury

b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury
c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months
d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a
decrease in LOC

D.
An arterial epidural hematoma is the most acute neurologic emergency, and the typical symptoms
include unconsciousness at the scene, with a brief lucid interval followed by a decrease in LOC. An acute
subdural hematoma manifests signs within 48 hours of an injury; a chronic subdural hematoma develops
over weeks or months



51. Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal
fracture with a subdural hematoma in a patient admitted to the emergency department following an
automobile accident. In planning care for the patient, the nurse anticipates that

a. the patient will receive life-support measures until the condition stabilizes
b. immediate burr holes will be made to rapidly decompress the intracranial activity
c. the patient will be treated conservatively with close monitoring for changes in neurologic condition
d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of
the cranium

D.
When there is a depressed fracture and fractures with loose fragments, a craniotomy is indicated to
elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of acute
subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be
used in an extreme emergency for rapid decompression, but with a depressed fracture, surgery would be
the treatment of choice



52. When a patient is admitted to the emergency department following a head injury, the nurse's first
priority in management of the patient once a patent airway is confirmed is

a. maintaining cervical spine precautions

b. determining the presence of increased ICP
c. monitoring for changes in neurologic status
d. establishing IV access with a large-bore catheter

A.
In addition to monitoring for a patent airway during emergency care of the patient with a head injury,
the nurse must always assume that a patient with a head injury may have a cervical spine injury.
Maintaining cervical spine precautions in all assessment and treatment activities with the patient is
essential to prevent additional neurologic damage.



53. A 54-year old man is recovering from a skull fracture with a subacute subdural hematoma. He has
return of motor control and orientation but appears apathetic and has reduced awareness of his
environment. When planning discharge or the patient, the nurse explains to the patient and the family
that

a. continuous improvement in the patient's condition should occur until he has returned to pre trauma
status
b. the patient's complete recovery may take years, and the family should plan for his long term
dependent care
c. the patient is likely to have long term emotional and mental changes that may require continued
professional help
d. role changes in family members will be necessary because the patient will be dependent on his family
for care and support

C.
Residual mental and emotional changes of brain trauma with personality changes are often the most
incapacitating problems following head injury and are common in patients who have been comatose
longer than 6 hours. Families must be prepared for changes in the patient's behavior to avoid family-
patient friction and maintain family functioning, and professional assistance may be required. There is no
indication he will be dependent on others for care, but he likely will not return to pre trauma status

54. Assisting the family to understand what is happening to the patient is an especially important role of
the nurse when the patient has a tumor of the

a. ventricles
b. frontal lobe
c. parietal lobe
d. occipital lobe

B.
Frontal lobe tumors often lead to loss of emotional control, confusion, memory loss, disorientation, and
personality changes that are very disturbing and frightening to the family. Physical symptoms, such as
blindness, disturbances in sensation and perception, and even seizures, that occur with other tumors are
more likely to be understood and accepted by the family

55. For the patient undergoing a craniotomy, the nurse provides information about the use of wigs and
hairpieces or other methods to disguise hair loss

a. during pre operative teaching

b. in the patient asks about their use
c. in the immediate postoperative period
d. when the patient expresses negative feelings about his or her appearance

A.
The prevent undue concern and anxiety about hair loss and postoperative self-esteem disturbances, a
patient undergoing cranial surgery should be informed pre operatively that the head is usually shaved in
surgery while the patient is anesthetized and that methods can be used after the dressings are removed
postoperatively to disguise the hair loss. In the immediate postoperative period, the patient is very ill,
and the focus is on maintaining neurologic function, bur preoperatively the nurse should anticipate the
patient's postoperative need for self-esteem and maintenance of appearance.

56. Successful achievement of patient outcomes for the patient with cranial surgery would be best
indicated by the
a. ability to return home in 6 days
b. ability to meet all self-care needs
c. acceptance of residual neurologic deficits
d. absence of signs and symptoms of increased ICP

D.
The primary goal after cranial surgery is prevention of increased ICP, and interventions to prevent ICP
and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and
ultimate function of the patient depend on the reason for surgery, the postoperative course, and the
patient's general state of health

57. A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment,
the nurse questions the patient about a recent history of

a. mosquito or tick bites

b. chickenpox or measles
c. cold sores or fever blisters
d. an upper respiratory infection

D.
Meningitis is often a result of an upper respiratory infection or middle ear infection, where organisms
gain entry to the CNS. Epidemic encephalitis is transmitted by ticks and mosquitoes, and nonepidemic
encephalitis may occur as a complication of measles, chickenpox, or mumps. Encephalitis caused by the
herpes simplex virus carries a high fatality rate

58. Classic symptoms of bacterial meningitis include

a. papilledema and psychomotor seizures

b. high fever, nuchal rigidity, and severe headache
c. behavioral changes with memory loss and lethargy
d. positive Kernig's and Brudzinski's signs and hemiparesis

B.
High fever, severe headache, nuchal rigidity, and positive Brudzinski's and Kernig's signs are such classic
symptoms of meningitis that they are usually considered diagnostic for meningitis. Other symptoms,
such as papilledema, generalized seizures, hemiparesis, and decreased LOC, may occur as complications
of increased ICP and cranial nerve dysfunction.
59. On physical examination of a patient with headache and fever, the nurse would suspect a brain
abscess when the patient has

a. seizures
b. nuchal rigidity
c. focal symptoms
d. signs of increased ICP

C.
The symptoms of brain abscess closely resemble those of meningitis and encephalitis, including fever,
headache, and increased ICP, except the patient also usually has some focal symptoms that reflect the
local are of the abscess.

60. The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The
nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which
complications (select all that apply)?

A. Vision loss
B. Cerebral edema
C. Pituitary dysfunction
D. Parathyroid dysfunction
E. Focal neurologic deficits

A,B,C,E
Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including
vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to
dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure
(ICP) and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the
pituitary gland.

61. A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation
should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak?

A. A halo sign on the nasal drip pad

B. Decreased blood pressure and urinary output
C. A positive reading for glucose on a Test-tape strip
D. Clear nasal drainage along with the bloody discharge

A
When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes
the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo
effect. The presence of glucose would be unreliable for determining the presence of CSF because blood
also contains glucose. Decreased blood pressure and urinary output would not be indicative of a CSF
leak.

62. The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What
indicates the presence of this sign of meningeal irritation?

A. Tonic spasms of the legs

B. Curling in a fetal position
C. Arching of the neck and back
D. Resistance to flexion of the neck

D
Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive
flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and
arching of the neck and back are not related to meningeal irritation.

63. The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle
accident. Which change in vital signs would the nurse interpret as a manifestation of increased
intracranial pressure (ICP)?

A. Tachypnea
B. Bradycardia
C. Hypotension
D. Narrowing pulse pressure

B
Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with
increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia
with a full and bounding pulse, and irregular respirations.

64. The nurse is providing care for a patient who has been admitted to the hospital with a head injury
and who requires regular neurologic and vital sign assessment. Which assessments will be components
of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)?

A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best verbal response
E. Best motor response
F. Cranial nerve function

B,D,E
The three dimensions of the GCS are eye opening, best verbal response, and best motor response.
Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

65. What nursing intervention should be implemented in the care of a patient who is experiencing
increased ICP?

A. Monitor fluid and electrolyte status carefully.

B. Position the patient in a high Fowler's position.
C. Administer vasoconstrictors to maintain cerebral perfusion.
D. Maintain physical restraints to prevent episodes of agitation.

A
Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly.
The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical
restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in
the treatment of ICP.

66. Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The
nurse should recognize that the patient will most likely need which treatment modality?

A. Surgery
B. Chemotherapy
C. Radiation therapy
D. Biologic drug therapy

A
Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy
are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance.
Radiation therapy may be used as a follow-up measure after surgery.

67. A patient has a systemic blood pressure of 120/60 and an ICP of 24 mm Hg. After calculating the
patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results?
A. High blood flow to the brain
B. Normal intracranial pressure
C. Impaired blood flow to the brain
D. Adequate autoregulation of blood flow

C
Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP.
MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP - ICP: 80mm Hg - 24 mm Hg =
56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that
autoregulation is impaired. Because the ICP is 24, it is elevated and requires treatment.

68. Decerebrate posture is documented in the chart of the patient that the nurse will be caring for. The
nurse should know that the patient may have elevated ICP causing serious disruption of motor fibers in
the midbrain and brainstem and will expect the patient's posture to look like which posture represented
below?

B
Decerebrate posture is all four extremities in rigid extension with hyperpronation of the forearms and
plantar flexion of feet. Decorticate posture is internal rotation and adduction of the arms with flexion of
the elbows, wrists, and fingers from interruption of voluntary motor tracts in the cerebral cortex.
Decorticate response on one side of the body and decerebrate response on the other side of the body
may occur depending on the damage to the brain. Opisthotonic posture is decerebrate posture with the
neck and back arched posteriorly and may be seen with traumatic brain injury.

69. The patient with increased ICP from a brain tumor is being monitored with a ventriculostomy. What
nursing intervention is the priority in caring for this patient?

A. Administer IV mannitol (Osmitrol).

B. Ventilator use to hyperoxygenate the patient
C. Use strict aseptic technique with dressing changes.
D. Be aware of changes in ICP related to leaking CSF.

C
The priority nursing intervention is to use strict aseptic technique with dressing changes and any
handling of the insertion site to prevent the serious complication of infection. IV mannitol (Osmitrol) or
hypertonic saline will be administered as ordered. Ventilators may be used to maintain oxygenation. CSF
leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic
technique to prevent infection is the nurse's priority of care.
70. A male patient suffered a diffuse axonal injury from a traumatic brain injury (TBI). He has been
maintained on IV fluids for 2 days. The nurse seeks enteral feeding for this patient based on what
rationale?

A. Free water should be avoided.

B. Sodium restrictions can be managed.
C. Dehydration can be better avoided with feedings.
D. Malnutrition promotes continued cerebral edema.

D
A patient with diffuse axonal injury is unconscious and, with increased ICP, is in a hypermetabolic,
hypercatabolic state that increases the need for fuel for healing. Malnutrition promotes continued
cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid
and electrolytes will be monitored to maintain balance with the enteral feedings.

71. In planning long-term care for a patient after a craniotomy, what must the nurse include when
teaching the patient, family, and caregiver?

A. Seizure disorders may occur in weeks or months.

B. The family will be unable to cope with role reversals.
C. There are often residual changes in personality and cognition.
D. Referrals will be made to eliminate residual deficits from the damage.

C
In long-term care planning, the nurse must include the family and caregiver when teaching about
potential residual changes in personality, emotions, and cognition as these changes are most difficult for
the patient and family to accept. Seizures may or may not develop. The family and patient may or may
not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals,
they may be improved.

72. The physician orders intracranial pressure (ICP) readings every hour for a 23-year-old male patient
with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is
most important for the nurse to take which action?

A. Document the ICP reading in the chart.

B. Determine if the patient has a headache.
C. Assess the patient's level of consciousness.
D. Position the patient with head elevated 60 degrees.
C
The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and
reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to
determine the degree of impaired consciousness.

73. A 19-year-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Clear
fluid is draining from the patient's nose. What action by the nurse is most appropriate?

A. Apply a loose gauze pad under the patient's nose.

B. Place the patient in a modified Trendelenburg position.
C. Ask the patient to gently blow the nose to clear the drainage.
D. Gently insert a catheter in the nares and suction the drainage.

A
Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal
skull fracture. If CSF rhinorrhea occurs, the nurse should inform the physician immediately. A loose
collection pad may be placed under the nose. The head of the bed may be raised to decrease the CSF
pressure so that a tear can seal. The nurse should not place a dressing or tube in the nasal cavity, and the
patient should not sneeze or blow the nose.

74. The nurse prepares to administer temozolomide (Temodar) to a 59-year-old white male patient with
a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the
medication?

A. Serum potassium and serum sodium levels

B. Urine osmolality and urine specific gravity
C. Absolute neutrophil count and platelet count
D. Cerebrosprinal fluid (CSF) pressure and cell count

C
Temozolomide causes myelosuppression. The nurse should assess the absolute neutrophil count and the
platelet count. The absolute neutrophil count should be >1500/μL and platelet count >100,000/μL.

75. A 32-year-old female patient is diagnosed with diabetes insipidus after transsphenoidal resection of a
pituitary adenoma. What should the nurse consider as a sign of improvement?

A. Serum sodium of 120 mEq/L

B. Urine specific gravity of 1.001
C. Fasting blood glucose of 80 mg/dL
D. Serum osmolality of 290 mOsm/kg

D
Laboratory findings in diabetes insipidus include an elevation in serum osmolality and serum sodium and
a decrease in urine specific gravity. Normal serum osmolality is 275 to 295 mOsm/kg, normal serum
sodium is 135 to 145 mEq/L, and normal specific gravity is 1.003 to 1.030. Elevated blood glucose levels
occur with diabetes mellitus.

76. A 68-year-old man with suspected bacterial meningitis has just had a lumbar puncture in which
cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first?

A. Codeine
B. Phenytoin (Dilantin)
C. Ceftriaxone (Rocephin)
D. Acetaminophen (Tylenol)

C
Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g.,
ceftriaxone) is instituted immediately after the collection of specimens for cultures, and even before the
diagnosis is confirmed. Dexamethasone may also be prescribed before or with the first dose of
antibiotics. The nurse should collaborate with the health care provider to manage the headache (with
codeine), fever (with acetaminophen), and seizures (with phenytoin).

77. Vasogenic cerebral edema increases intracranial pressure by

A. Shifting fluid in the gray matter

B. Altering the endothelial lining of the cerebral capillaries
C. Leaking molecules from the intercellular fluid to the capillaries
D. Altering the osmotic gradient flow into the intravascular component

Correct answer: b
Rationale: Vasogenic cerebral edema occurs mainly in the white matter. It is caused by changes in the
endothelial lining of cerebral capillaries.

78. A patient with intracranial pressure monitoring has a pressure of 12mm Hg. The nurse understands
that this pressure reflects

a. A severe decrease in cerebral perfusion pressure

b. An alteration in the production of cerebrospinal fluid
c. The loss of autoregulatory control of intracranial pressure
d. A normal balance between brain tissue, blood and cerebrospinal fluid

Correct answer: d
Rationale: Normal intracranial pressure (ICP) is 5 to 15 mm Hg. A sustained pressure above the upper
limit is considered abnormal.

79. A nurse plans care for the patient with increased intracranial pressure with the knowledge that the
best way to position the patient is to

a. Keep the head of the bed flat

b. Elevate the HOB by 30 degrees
c. Maintain pt on the left side with the head supported on a pillow
d. Use a continuous rotation bed to continuously change patient position

Correct answer: b
Rationale: The nurse should maintain the patient with abnormal ICP in the head-up position. Elevation of
the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral
edema. The nurse should position the patient to prevent extreme neck flexion, which can cause venous
obstruction and contribute to elevation in ICP. Elevation of the head of the bed also reduces sagittal sinus
pressure, promotes drainage from the head through the valveless venous system and jugular veins, and
decreases the vascular congestion that can produce cerebral edema. However, raising the head of the
bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood
pressure. The effects of elevation of the head of the bed on the ICP and CPP must be evaluated carefully.

80. The nurse is alerted to a possible acute subdural hematoma in the patient who

a. Has linear skull fracture crossing a major artery

b. Has focal symptoms of brain damage with no recollection of a head injury
c. Develops decreased level of consciousness and a headache within 48 hrs of a head injury
d. Has an immediate loss of consciousness with brief lucid interval followed by dereasing level of
consciousness

Correct answer: c
Rationale: An acute subdural hematoma manifests within 24 to 48 hours of the injury. The signs and
symptoms are similar to those associated with brain tissue compression in elevated ICP and include
decreasing level of consciousness and headache
81. During admission of a patient with a severe head injury to the emergency department the nurse
places the highest priority on assessment for

a. Patency of airway
b. Presence of neck injury
c. Neurologic status with Glasgow coma scale
d. Cerebrospinal fluid leakage from the ears or nose

Correct answer: a
Rationale: The nurse's initial priority in the emergency management of a patient with a severe head
injury is to ensure that the patient has a patent airway.

82. A patient is suspected of having a brain tumor. The s/s include: memory deficits, visual disturbances,
weakness of right upper and lower extremities and personality changes. The nurse recognizes that the
tumor is most likely located in the

a. Frontal lobe
b. Parietal lobe
c. Occipital lobe
d. Temporal lobe

Correct answer: a
Rationale: A unilateral frontal lobe tumor may result in the following signs and symptoms: unilateral
hemiplegia, seizures, memory deficit, personality and judgment changes, and visual disturbances. A
bilateral frontal lobe tumor may cause symptoms associated with a unilateral frontal lobe tumor and an
ataxic gait.

83. Nursing management of a patient with a brain tumor includes (select all that apply):

a. discussing with the patient methods to control inappropriate behavior.

b. using diversion techniques to keep the patient stimulated and motivated.
c. assisting and supporting the family in understanding any changes in behavior.
d. limiting self-care activities until the patient has regained maximum physical functioning.
e. planning for seizure precautions and teaching the patient and the caregiver about anti seizure drugs.

Correct answers: c, e
Rationale: Nursing interventions should be based on a realistic appraisal of the patient's condition and
prognosis after cranial surgery. The nurse should provide support and education to the caregiver and
family about the patient's behavioral changes. The nurse should be prepared to manage seizures and
teach the caregiver and family about antiseizure medications and how to manage a seizure. An overall
goal is to foster the patient's independence for as long as possible and to the highest degree possible.
The nurse should decrease stimuli in the patient's environment to prevent increases in intracranial
pressure.

84. The nurse on clinical unit is assigned to four patients. Which patient should she assess first?

a. Patient with a skull fracture whose nose is bleeding

b. Older patient with a stroke who is confused and whose daughter is present
c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10 scale
d. Patient who had a craniotomy for a brain tumor who now 3 days postoperative had had continued
vomiting

Correct answer: c
Rationale: The patient with meningitis should be seen first; patients with meningitis must be observed
closely for manifestations of elevated ICP, which is thought to result from swelling around the dura and
increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in
behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who
has undergone cranial surgery should be seen second; although nausea and vomiting are common after
cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics.
The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nose bleed and
should be seen third. Confusion after a stroke may be expected; the patient should have a family
member present.

85. A nursing measure that is indicated to reduce the potential for seizures and increased intracranial
pressure in the patient with bacterial meningitis is

a. Administering codeine for relief of head and neck pain

b. Controlling fever with prescribed drugs and cooling techniques
c. Keeping the room dark and quiet to minimize environmental stimulation
d. Maintain the patient on strict bed rest with the head of the bed slightly elevated

Correct answer: b
Rationale: Fever must be vigorously managed because it increases cerebral edema and the frequency of
seizures. Neurologic damage may result from an extremely high temperature over a prolonged period.
Acetaminophen or aspirin may be used to reduce fever; other measures, such as a cooling blanket or
tepid sponge baths with water, may be effective in lowering the temperature