Lewis: Medical-Surgical Nursing, 9th Edition

Chapter 57
Rationales for Bridge to NCLEX Examination questions
1. Correct answer: b
Rationale: Vasogenic cerebral edema occurs mainly in the white matter. It is
caused by changes in the endothelial lining of cerebral capillaries.
2. Correct answer: d
Rationale: Normal intracranial pressure (ICP) is 5 to 15 mm Hg. A sustained
pressure above the upper limit is considered abnormal.
3. Correct answer: b
Rationale: The nurse should maintain the patient with abnormal ICP in the
head-up position. Elevation of the head of the bed to 30 degrees enhances
respiratory exchange and aids in decreasing cerebral edema. The nurse
should position the patient to prevent extreme neck flexion, which can cause
venous obstruction and contribute to elevation in ICP. Elevation of the head
of the bed also reduces sagittal sinus pressure, promotes drainage from the
head through the valveless venous system and jugular veins, and decreases
the vascular congestion that can produce cerebral edema. However, raising
the head of the bed above 30 degrees may decrease the cerebral perfusion
pressure (CPP) by lowering systemic blood pressure. The effects of elevation
of the head of the bed on the ICP and CPP must be evaluated carefully.
4. Correct answer: c
Rationale: An acute subdural hematoma manifests within 24 to 48 hours of
the injury. The signs and symptoms are similar to those associated with brain
tissue compression in elevated ICP and include decreasing level of
consciousness and headache.
5. Correct answer: a
Rationale: The nurse's initial priority in the emergency management of a
patient with a severe head injury is to ensure that the patient has a patent
airway.
6. Correct answer: a
Rationale: A unilateral frontal lobe tumor may result in the following signs
and symptoms: unilateral hemiplegia, seizures, memory deficit, personality
and judgment changes, and visual disturbances. A bilateral frontal lobe
tumor may cause symptoms associated with a unilateral frontal lobe tumor
and an ataxic gait.
7. Correct answers: c, e

Rationale: Nursing interventions should be based on a realistic appraisal of

the patients condition and prognosis after cranial surgery. The nurse should
provide support and education to the caregiver and family about the
patients behavioral changes. The nurse should be prepared to manage
seizures and teach the caregiver and family about antiseizure medications
and how to manage a seizure. An overall goal is to foster the patients
independence for as long as possible and to the highest degree possible. The
nurse should decrease stimuli in the patients environment to prevent
increases in intracranial pressure.
8. Correct answer: c
Rationale: The patient with meningitis should be seen first; patients with
meningitis must be observed closely for manifestations of elevated ICP,
which is thought to result from swelling around the dura and increased
cerebrospinal fluid (CSF) volume. Sudden change in the level of
consciousness or change in behavior along with a sudden severe headache
may indicate an acute elevation of ICP. The patient who has undergone
cranial surgery should be seen second; although nausea and vomiting are
common after cranial surgery, it can result in elevations of ICP. Nausea and
vomiting should be treated with antiemetics. The patient with a skull fracture
needs to be evaluated for CSF leakage occurring with the nose bleed and
should be seen third. Confusion after a stroke may be expected; the patient
should have a family member present.
9. Correct answer: b
Rationale: Fever must be vigorously managed because it increases cerebral
edema and the frequency of seizures. Neurologic damage may result from an
extremely high temperature over a prolonged period. Acetaminophen or
aspirin may be used to reduce fever; other measures, such as a cooling
blanket or tepid sponge baths with water, may be effective in lowering the
temperature.