Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?

Beware of changes in ICP related to leaking cerebrospinal fluid (CSF)

Maintain hyper-oxygenation through use of a ventilator

Use strict aseptic technique with all procedural dressing changes

Administer IV mannitol (Osmitrol)

Answer and Explanation

The Correct Answer is C

A.   Monitoring for CSF leakage is crucial to avoid infection and to maintain ICP accuracy.
B.   Hyper-oxygenation may be used in certain cases but is not the priority.
C.   Aseptic technique for all procedures and dressing changes is critical to prevent infection.
D.   Administering IV mannitol can be important, but aseptic technique is the priority to prevent infection.

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Correct Answer is D

Explanation

A. BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B. BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C. BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D. The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

A. Poor judgment B. Intellectual impairment C. Loss of depth perception D. Impaired sense of humor

Correct Answer is B

Explanation

A. Poor judgment: Poor judgment is more likely to be seen with a stroke in the right hemisphere.
B. Intellectual impairment: A stroke in the left hemisphere can cause cognitive and intellectual deficits, especially in language and reasoning.
C. Loss of depth perception: Loss of depth perception is typically seen with right-sided strokes, not left- sided.
D. Impaired sense of humor: This is more common in right-sided strokes affecting the emotional and social aspects of the brain.

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Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Correct Answer is D

Explanation

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct Answer is B

Explanation

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Which interventions would the nurse include in the plan of care for a patient with a diagnosis of bacterial meningitis?

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A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Which intervention would the nurse implement to provide relief of the patient's discomfort when presenting to the clinic with a red, swollen, circumscribed, acutely, tender area near the eye and in the lid margin?

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