N4 - test - Neuro ICP - Chapter 55

Med Surg Book
NCLEX Examination Review Questions Chapter 55

1. Vasogenic cerebral edema increases intracranial pressure by
A. shifting fluid in the gray matter.
B. altering the endothelial lining of cerebral capillaries.
C. leaking molecules from the intracellular fluid to the capillaries.
D. altering the osmotic gradient flow into the intravascular component.

2. A patient with intracranial pressure monitoring has pressure of 12 mm 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.

3. The 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 head of the bed to 30 degrees.
C. maintain patient on left side with head supported on pillow.
D. use a continuous-rotation bed to continuously change patient position.

4. The nurse is alerted to a possible acute subdural hematoma in the patient who
A. has a 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 hours of a head injury.
D. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

5. 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 a neck injury.
C. neurologic status with the Glasgow Coma Scale.
D. cerebrospinal fluid leakage from the ears or nose.

6. A patient is suspected of having a cranial tumor. The signs and symptoms 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.

7. Nursing management of a patient with a brain tumor includes
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.

8. The primary goal of nursing care after a craniotomy is
A. preventing infection.
B. ensuring patient comfort.
C. avoiding the need for secondary surgery.
D. preventing increased intracranial pressure.

9. 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 darkened and quiet to minimize environmental stimulation.
D. maintaining the patient on strict bed rest with the head of the bed slightly elevated.