Chapter 57 Nursing Management Acute Intracranial Problems
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 Cushing’s 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.
DIF: Cognitive Level: Apply (application)
REF:
1360
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
3. When a
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 Cushing’s 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.
DIF: Cognitive Level: Apply (application)
REF:
1360
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
3. When a