Reason: The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain.
The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements
needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.
02.Answer A.
Reason: Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure,which refl ects the additional pressure needed to perfuse the
brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
03. Answer A.
Reason: Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal
flaring are more characteristic of respiratory distress or hypoxia.
04. Answer B.
Reason: It is best for the client to wear mitts, which help prevent the client from pulling on the I.V.without causing additional agitation. Using a jacket or wrist restraint or tucking the client’s arms and
hands under the drawsheet restrict movement and add to feelings of being confi ned, all of which would increase her agitation and increase ICP.
05. Answer B.
Reason: After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fl uid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.
06. Answer C.
Reason: Temperatures are not assessed orally with a glass thermometer because the thermometer could break and cause injury if a seizure occurred. The client can perform personal hygiene. There is no clinical reason to discourage the client from wearing his own clothes. As long as there are no other limitations, the client should be encouraged to be out of bed.
07. Answer B.
Reason:. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing.
Because the client had a bleed in the occipital lobe,which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another
bleed ensues. The nurse should notify the physician immediately so that treatment can begin before respirations cease. The client is not obtaining suffi cient oxygen and the depth of breathing is assisted by
the ventilator. The health care provider will determine changes in the ventilator settings.
08. Answer A
.Reason: The nurse should expect a client in the postictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron fi ring and tonic-clonic motor response. An inability to move a muscle part is not expected after a tonic-clonic seizure because a lack of motor function would be related to a complication,such as a lesion, tumor, or stroke, in the correlating brain tissue. A change in sensation would not be expected because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the central nervous system.
Hypotension is not typically a problem after a seizure.
09. Answer C.
Reason: A priority for the client in the postictal phase (after a seizure) is to assess the client’s breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to
the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client’s level of sleepiness
is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent
10. Answer C.
Reason: Control of blood pressure is critical during the fi rst 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identifi ed by the physician and specifi c to the client’s ischemic tissue
needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.
11. Answer B.
Reason: Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing
positions as long as the client is maintained in anatomically neutral positions and her limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to
avoid injury to himself or herself or the client. Having the client help lift herself off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown.
12. Answer B.
Reason: Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.
13. Answer B.
Reason: The fi rst sign of Parkinson’s disease is usually tremors. The client commonly is the fi rst to notice this sign because the tremors may be minimal at fi rst. Rigidity is the second sign, and bradykinesia
is the third sign. Akinesia is a later stage of bradykinesia.
14. Answer B.
Reason: Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson’s disease.
15. Answer B.
Reason: With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone
and tremors are common symptoms of MS.
16. Answer B.
Reason:When the blink refl ex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client
wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artifi cial tears instilled once per shift are not frequent enough for preventing dryness.
17. Answer C.
Reason: Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in the unconscious client who becomes restless. The most accurate method for determining the presence of hypoxia is to evaluate the pulse oximeter value or arterial blood gas values. Cyanosis and decreased respirations are late indicators of hypoxia. Hypertension, not hypotension, is a sign of hypoxia.
18. Answer B.
Reason: It is essential that the nurse document the client’s response to pain medication on a routine, systematic basis. Reassuring the client that pain will be relieved is often not realistic. A client who continually
presses the PCA button may not be getting adequate pain relief, but through careful assessment and documentation, the effectiveness of pain relief interventions can be evaluated and modified. Pain medication is not titrated until the client is free from pain but rather until an acceptable level of pain management is reached.
19. Answer C.
Reason: Clients with Parkinson’s disease can experience dysphagia. Thickening liquids assists with
swallowing, preventing aspiration. Hyperextending the neck opens the airway and can increase risk of aspiration. Pressing the chin fi rmly on the chest makes swallowing more diffi cult. The chin should
be slightly tucked to promote swallowing. The nurse should suggest a speech therapy consult for evaluation of the client’s ability to swallow.
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