.A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?

Headache

Infection

Aphasia

Hypertension

Place client in a “cannonball” position.

Answer and Explanation

The Correct Answer is B

An intraventricular catheter (ventriculostomy) is a device used to monitor intracranial pressure (ICP) and drain excess cerebrospinal fluid (CSF) in clients with severe brain injury. While it provides valuable real-time data on ICP, it also carries a significant risk of infection because it involves direct access to the brain's ventricles. Meningitis or ventriculitis can occur if strict aseptic technique is not maintained. Nurses must closely observe for signs of infection, such as fever, change in mental status, or purulent drainage from the catheter site.

Rationale for Correct Answer:
B. Infection: Ventriculostomy catheters provide a direct route for pathogens into the central nervous system. This places the client at risk for life-threatening infections like meningitis or ventriculitis, which require immediate recognition and intervention.

Rationale for Incorrect Answers:

A. Headache: While headaches can occur with increased ICP or CSF drainage, they are not specific to ventriculostomy-related complications. Headaches are common and nonspecific and not considered a direct complication of the catheter itself.

C. Aphasia: Aphasia is a neurologic deficit related to brain injury, particularly in the dominant hemisphere, but it is not a complication of ventriculostomy. It reflects damage from the trauma itself, not the monitoring device.

D. Hypertension: Hypertension may occur as a compensatory response to increased ICP (as part of Cushing’s triad), but it is not a direct complication of the ventriculostomy catheter. It signals a systemic or neurologic response, not an issue with the catheter.

Key Takeaways:
• Infection is the most serious and common complication of ventriculostomy use.
• Nurses must maintain sterile technique and monitor closely for signs of CNS infection.
• Other symptoms like headache or hypertension may relate to the injury, not the catheter itself.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A myelogram is an invasive diagnostic procedure used to visualize the spinal cord, nerve roots, and surrounding subarachnoid space using contrast dye injected into the spinal canal via lumbar puncture. Because of this, the preparation and positioning for a myelogram closely resemble those of a lumbar puncture, including obtaining informed consent, checking for allergies to contrast dye, and proper positioning during and after the procedure.

Rationale for Correct Answer:

A. Lumbar puncture: A myelogram requires injection of contrast dye into the subarachnoid space through a lumbar puncture. Therefore, preparation (e.g., client positioning, sterile technique, consent, allergy screening) and aftercare (e.g., monitoring for headache or CSF leak) are very similar to a standard lumbar puncture.

Rationale for Incorrect Answers:
B. MRI: MRI is a noninvasive imaging procedure that uses magnetic fields and does not involve puncturing the spinal canal or injecting contrast into the CSF unless performed with special contrast protocols.
C. Cerebral angiography: This procedure involves injection of contrast dye into cerebral arteries, typically via a femoral catheter, and does not involve accessing the spinal canal.
D. EEG: EEG is noninvasive and involves placement of electrodes on the scalp to monitor electrical activity in the brain. It does not use contrast dye or invasive techniques.

Key Takeaways:
• Myelogram preparation is most similar to a lumbar puncture due to shared technique and spinal access.
• Contrast dye is used in both procedures, requiring allergy assessment and informed consent.
• Other tests like EEG, MRI, and cerebral angiography differ significantly in terms of invasiveness and preparation.

A. Potassium B. Chloride C. Magnesium D. Sodium

Correct Answer is D

Explanation

Mannitol is an osmotic diuretic commonly used in clients with increased intracranial pressure (ICP) to reduce cerebral edema by drawing fluid from the brain into the vascular system. However, this diuresis can cause significant fluid and electrolyte imbalances, particularly affecting sodium levels. Hypernatremia or hyponatremia may develop depending on the patient's fluid status, so sodium must be closely monitored to prevent neurological deterioration or worsening cerebral edema.

Rationale for Correct Answer:
D. Sodium: Mannitol causes osmotic diuresis, which may result in hypernatremia if excessive water loss occurs or hyponatremia if free water replacement is inadequate. Either imbalance can worsen neurologic status, making sodium the most critical electrolyte to monitor in these patients.

Rationale for Incorrect Answers:

Potassium: Although mannitol can cause some renal electrolyte losses, potassium disturbances are less common and less urgent than sodium changes in the context of mannitol therapy.
Chloride: Chloride may be altered as it accompanies sodium loss or retention, but it is not typically the primary concern in mannitol administration.
Magnesium: Magnesium levels can be affected by diuretics, but neurologic implications of sodium imbalance take priority in clients with increased ICP.

Key Takeaways:
• Sodium is the priority electrolyte to monitor when administering mannitol due to the risk of diuresis-induced imbalances.
• Both hypernatremia and hyponatremia can worsen neurologic status and must be addressed promptly.
• While other electrolytes are also monitored, sodium directly affects cerebral fluid balance and ICP.

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.A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is scheduled for a myelogram and the nurse explains to the client that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests?

Correct Answer is A

Explanation

The critical care nurse provides care for a client who is admitted for the treatment of head trauma and prescribed mannitol to reduce intracranial pressure (ICP). Which electrolyte is the priority for the nurse to monitor?

Correct Answer is D

Explanation

.A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?

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