LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)

Chapter 42 Nursing Care of Patients with Intracranial Disorders

1) A patient without a history of previous seizures experiences two tonic‒clonic seizures in succession while the nurse is in the patient's room. List in priority order the actions the nurse should take.

Choice 1. Turn the patient on his or her side.

Choice 2. Protect patient from environmental harm.

Choice 3. Start oxygen via face mask.

Choice 4. Reorientation of the patient to time, person, and place.

Page Ref: 1561-1562

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures.

MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

2) The nurse notes that a patient with damage to the diencephalon region of the cerebrum is demonstrating a breathing pattern where regular periods of deep, rapid breathing are followed by periods of apnea. How should the nurse document this breathing pattern?

1. Cheyne-Stokes respirations

2. Apneustic respirations

3. Neurogenic hyperventilation

4. Ataxic respirations

Page Ref: 1547

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation

Learning Outcome: 42.1 Describe the pathophysiology and manifestations of altered level of consciousness, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

3) The nurse is caring for a patient who will be evaluated for brain death. What should the nurse expect to be evaluated in this patient? Select all that apply.

1. Absent motor and reflex movements

2. Flat electroencephalogram (EEG) on successive EEGs

3. No spontaneous respiration

4. Pupils are equal and responsive to light

5. Criteria present for at least 15 minutes

Page Ref: 1548

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 42.1 Describe the pathophysiology and manifestations of altered level of consciousness, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with intracranial disorders.

4) The nurse is caring for a patient with an altered level of consciousness (LOC). Which intravenous fluid should the nurse expect to be prescribed for this patient?

1. Isotonic or hypertonic

2. 0.45% normal saline

3. Dextrose 5% in water

4. Dextrose 5% in 0.45% normal saline

Page Ref: 1549

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 42.1 Describe the pathophysiology and manifestations of altered level of consciousness, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

5) The nurse is caring for an unconscious patient. What should the nurse expect to be prescribed for this patient when the cough reflex disappears?

1. Continuous pulse oximetry instead of intubation

2. Frequent suctioning with a tonsil-tip suction device

3. Close observation as the patient is fed

4. Intubation and mechanical ventilation

Page Ref: 1556

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

6) The nurse is caring for a patient recovering from a craniotomy. How should the nurse position this patient?

1. Low Fowler's (head of bed up 30 degrees)

2. Flat

3. High

4. High Fowler's (head of bed up 45 degrees)

Page Ref: 1556

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

7) A patient is in the emergency department following a head injury. What should the nurse realize as being the most accurate sign of developing increased intracranial pressure (IICP)?

1. Decreasing level of consciousness

2. Elevated diastolic blood pressure

3. Decreasing respiratory rate

4. Pupils are equal

Page Ref: 1557

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with intracranial disorders.

8) A patient is described as having decerebrate posturing after a motor vehicle crash. Which position should the nurse expect to assess in this patient?

1. The arms and legs are hyperextended and arms are hyperpronated.

2. The arms are folded over the chest and spasms are rhythmic.

3. The arms are pulled inward and the head is turned to the side.

4. The arms and legs have tonic‒clonic seizure activity.

Page Ref: 1548

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 42.1 Describe the pathophysiology and manifestations of altered level of consciousness, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

9) A patient being treated for a fall has a dilated pupil on the right and a hematoma in the right temporal area. What should these findings indicate to the nurse?

1. The process affecting the pupil is occurring locally on the right side (ipsilateral pupil dilation).

2. The process affecting the pupil is occurring on the opposite side and is unrelated to the right temporal hematoma.

3. The process affecting the right pupil is temporary and soon both pupils will be equal in size.

4. The process causing the right pupil to dilate is a result of a metabolic process.

Page Ref: 1580

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 42.6 Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

10) A patient is experiencing status epilepticus. Which medication should the nurse expect to be prescribed for this patient?

1. Lorazepam (Ativan) IV

2. Oral glucose

3. Phenytoin (Dilantin) orally

4. Gabapentin (Neurontin) and lamotrigine (Lamictal)

Page Ref: 1559

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures.

MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

11) The nurse is identifying problems for a patient with a seizure disorder. Which problem should the nurse identify as being this patient's greatest psychosocial need?

1. Anxiety

2. Self-Care Deficit

3. Altered Activity: Exercise

4. Altered Body Image

Page Ref: 1562

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity: Coping Mechanisms

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures.

MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with intracranial disorders.

12) A patient has a head injury caused by a swinging bat. For which type of injury should the nurse plan care for this patient?

1. Contact

2. A deceleration

3. An acceleration-deceleration injury

4. Rotational

Page Ref: 1578

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 42.6 Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with intracranial disorders.

13) While riding in a car that hit a tree, a patient's head hit the windshield (coup) and then the brain rebounded within the skull toward the opposite side (contrecoup). For which type of traumatic brain injury should the nurse plan care for this patient?

1. Acceleration-deceleration

2. Rotational

3. Contact

4. Stationary

Page Ref: 1578

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 42.6 Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with intracranial disorders.

14) Following a fall, a patient experiences a brief loss of consciousness but is now complaining of a headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area, and is currently having a seizure. What should the nurse anticipate regarding the care of this patient?

1. This is an emergency situation that is likely due to an epidural hematoma and requires surgery.

2. This is a controlled situation once the seizure stops.

3. This is a serious situation in which a subdural hematoma is developing and requires surgery.

4. This is a typical situation seen with most patients who fall and will subside with observation.

Page Ref: 1579-1580

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 42.6 Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

15) A patient has a seizure that involves a blank stare, unresponsiveness to questions, and smacking of the lips that lasts less than a minute. How should the nurse categorize this seizure?

1. Absence

2. Partial

3. Tonic‒clonic

4. Status epilepticus

Page Ref: 1558

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures.

MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

16) A patient is having a tonic‒clonic seizure. What should the nurse make a priority when caring for this patient?

1. Protect the patient from injury.

2. Insert a bite block to prevent the patient from swallowing the tongue.

3. Ask the staff to hold the patient tightly.

4. Obtain vital signs.

Page Ref: 1559, 1561

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures.

MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

17) The nurse is caring for a patient with migraine headaches. Which medication should the nurse expect to be prescribed prophylactically for this patient?

1. Propranolol hydrochloride (Inderal)

2. Acetaminophen (Tylenol)

3. Zolmitriptan (Zomig)

4. Sumatriptan (Imitrex)

Page Ref: 1592

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 42.8 Describe the pathophysiology and manifestations of headaches, and outline the interprofessional care and nursing care of patients with headache.

MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

18) The nurse is planning a seminar about headaches for a community group. What type of headache should the nurse describe as having a strong familial connection, affects females three to one over males, and results in lost productivity?

1. Migraine

2. Cluster

3. Stress

4. Sinus

Page Ref: 1590-1591

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 42.8 Describe the pathophysiology and manifestations of headaches, and outline the interprofessional care and nursing care of patients with headache.

MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

19) The nurse is caring for a patient with a head injury involving cerebral edema and increased intracranial pressure (IICP). To prevent further transient increases from occurring, the nurse should implement what intervention?

1. Implement measures to help the patient avoid coughing and straining.

2. Position the patient in the supine position with the head of the bed at 30 degrees.

3. Initiate oxygen administration.

4. Initiate and monitor an IV with normal saline.

Page Ref: 1557

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

20) A patient is diagnosed with doll's-eye movements. What should the nurse expect to assess in this patient?

1. The eyes remain fixed as the head is turned.

2. The eyes appear to move in the direction opposite to the motion of the head, when the head is gently rotated.

3. The eyes open and close when the neck is flexed and extended.

4. The pupils remain fixed and dilated.

Page Ref: 1547

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 42.1 Describe the pathophysiology and manifestations of altered level of consciousness, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

21) The nurse is caring for a patient who had a craniotomy for a brain tumor and has developed postoperative leakage of cerebrospinal fluid (CSF) from the nose. Which action should the nurse take when caring for this patient? Select all that apply.

1. Keep patient turned on side of leakage and keep the head of the bed elevated 20 degrees.

2. Assess the patient for constant swallowing.

3. Observe for thick, yellow, odorous drainage.

4. Insert sterile packing into the area.

5. Encourage the patient to blow the nose frequently.

Page Ref: 1588-1589

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 42.7 Describe the pathophysiology and manifestations of brain tumors, and outline the interprofessional care and nursing care of patients with brain tumors.

MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

22) A patient with a brain tumor asks why a chest x-ray is needed when the tumor is in the head. What is the nurse's most appropriate response?

1. "The physician may be trying to determine if this is a metastatic brain tumor, as the most common source of these tumors is cancer of the lung."

2. "This is just a precautionary measure. The physician often prescribes chest x-rays."

3. "Don't get so upset about this! It's routine. The doctor will talk to you later."

4. "The escort is here to take you to radiology, so we'll discuss this when you return."

Page Ref: 1585

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation

Learning Outcome: 42.7 Describe the pathophysiology and manifestations of brain tumors, and outline the interprofessional care and nursing care of patients with brain tumors.

MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

23) A patient with increased intracranial pressure is prescribed mannitol (Osmitrol). What should the nurse do when providing this medication? Select all that apply.

1. Use an in-line filter for IV administration.

2. Do not administer the medication if crystals are noted in the solution.

3. Monitor central venous pressure (CVP) and pulmonary artery pressures (PAP) before and every hour throughout administration.

4. Assess patient for signs of fluid retention.

5. Discontinue the drug immediately if the patient complains of a headache.

Page Ref: 1555

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

24) The nurse instructs a patient on actions to help reduce the onset of migraine headaches. Which patient statement indicates that additional teaching is required?

1. "I will switch to red wine rather than continuing to drink white wine."

2. "Reading food labels is important since I have to avoid tyramine."

3. "I will need to drink caffeine-free soft drinks and coffee from now on."

4. "Stress management classes will be a good approach to take."

Page Ref: 1593

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning

Learning Outcome: 42.8 Describe the pathophysiology and manifestations of headaches, and outline the interprofessional care and nursing care of patients with headache.

MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

25) The nurse is caring for a patient with transient ischemic attack (TIA). Which medication should the nurse expect to be prescribed for this patient?

1. Antiplatelet agents

2. Fibrinolytic therapy

3. Anticoagulant therapy

4. Corticosteroids

Page Ref: 1569

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 42.4 Describe the pathophysiology and manifestations of stroke, and outline the interprofessional care and nursing care of patients with stroke.

MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

26) The nurse is teaching a community education class on warning signs of stroke and transient ischemic attacks (TIAs). What should be included in this presentation? Select all that apply.

1. Sudden weakness or numbness of the face, arm, or leg, especially on one side of the body

2. Sudden confusion, difficulty speaking, or difficulty understanding speech

3. Sudden trouble walking, dizziness, or loss of coordination

4. Arrival time at the hospital should be within three hours of onset for drugs to be effective

5. African Americans are a high-risk group for strokes

Page Ref: 1565

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 42.4 Describe the pathophysiology and manifestations of stroke, and outline the interprofessional care and nursing care of patients with stroke.

MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

27) The nurse is caring for a patient in the postoperative unit following carotid endarterectomy. How should the nurse position the patient?

1. On the unoperated side, either in a flat position or with the head of the bed elevated 30 degrees.

2. On the operated side with the head of the bed in semi-Fowler's position.

3. On the unoperated side with a small towel placed directly against the operative site.

4. On the operated side with a pressure dressing over the operative site.

Page Ref: 1570

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 42.4 Describe the pathophysiology and manifestations of stroke, and outline the interprofessional care and nursing care of patients with stroke.

MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

28) The nurse is completing discharge teaching to a patient following hospitalization for a seizure disorder who is being prescribed phenytoin (Dilantin). What should the nurse include in these instructions?

1. "Maintain good oral hygiene, use a soft toothbrush, massage the gums, and floss daily."

2. "Carry identification indicating the type of seizures for which you are being treated."

3. "You will need to have your sodium level monitored."

4. "If you skip a dose, make sure you double the dose the next day."

Page Ref: 1560

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures.

MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

29) The nurse is caring for a patient with an intracranial pressure monitoring device. For which potential problem should the nurse plan care for this patient?

1. Possible infection

2. Confusion

3. Changes in skin integrity

4. Changes in mobility status

Page Ref: 1557

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

30) A patient recovering from a stroke has agnosia. What should the nurse do when caring for this patient?

1. Frequently repeat the names of familiar persons and objects in the patient's room when providing care.

2. Help the patient move hands and arms through the motions of combing hair and getting dressed.

3. Speak with a normal tone of voice near the ear on the unaffected side.

4. Talk normally to the patient but allow adequate time for the patient's short responses.

Page Ref: 1567

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 42.4 Describe the pathophysiology and manifestations of stroke, and outline the interprofessional care and nursing care of patients with stroke.

MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

31) The nurse is caring for a patient with a seizure disorder who is scheduled for surgery to remove the epileptogenic focus within the cerebral cortex. Which criteria did the patient meet to be a candidate for this type of surgery? Select all that apply.

1. The patient desires to have a family.

2. There is one focal point located within the patient's brain.

3. The patient cannot afford antiseizure medication prescribed.

4. Medications have not been successful to control seizure activity.

5. The patient is unable to hold a fulltime job because of seizure activity.

Page Ref: 1561

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures.

MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

32) The nurse notes on the surgical schedule that a patient is scheduled for cranial burr holes. For which health problem does the nurse realize this type of surgical approach is indicated? Select all that apply.

1. Ischemic stroke

2. Migraine headache

3. Epidural hematoma

4. Hemorrhagic stroke

5. Acute subdural hematoma

Page Ref: 1582

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 42.6 Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the interprofessional care and nursing care of patients with this condition.

MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

33) The nurse is instructing a patient with a brain tumor about a scheduled craniotomy. What should the nurse include in this teaching? Select all that apply.

1. The tumor is excised.

2. The bone is cut between the burr holes.

3. The bone flap is returned to the opening.

4. A series of burr holes is made in the skull.

5. Plastic material is placed over the opening.

Page Ref: 1587

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 42.7 Describe the pathophysiology and manifestations of brain tumors, and outline the interprofessional care and nursing care of patients with brain tumors.

MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

34) While reviewing newly prescribed orders, the nurse begins to prepare a patient to receive plasminogen activator alteplase (tPA). What should the nurse realize about this patient's health problem? Select all that apply.

1. The patient had an ischemic stroke.

2. The patient had a hemorrhagic stroke.

3. The patient has uncontrollable seizure activity.

4. The patient had a stroke less than 3 hours ago.

5. The patient's systolic blood pressure is greater than 200 mmHg.

Page Ref: 1569-1570

Cognitive Level: Analyzing

Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 42.4 Describe the pathophysiology and manifestations of stroke, and outline the interprofessional care and nursing care of patients with stroke.

MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

35) A patient is brought for medical care with symptoms of a ruptured cerebral aneurysm. Which should the nurse expect to assess in this patient? Select all that apply.

1. Photophobia

2. Muscle cramps

3. Severe neck pain

4. Nausea and vomiting

5. Sudden excruciating headache

Page Ref: 1576

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 42.5 Describe the pathophysiology and manifestations of intracranial vascular disorders, and outline the interprofessional care and nursing care of patients with these disorders.

MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

36) A patient is diagnosed with a stable arteriovenous malformation of the right parietal lobe. What teaching should the nurse provide to this patient? Select all that apply.

1. Engage in regular exercise.

2. Limit sodium and water intake.

3. Engage in stress-reduction activities.

4. Take antiseizure medication as prescribed.

5. Take antihypertensive medication as prescribed.

Page Ref: 1577-1578

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning

Learning Outcome: 42.5 Describe the pathophysiology and manifestations of intracranial vascular disorders, and outline the interprofessional care and nursing care of patients with these disorders.

MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.