Chapter 57: Nursing Management: Acute Intracranial Problems
1. Family members of a patient who has a traumatic brain injury ask the nurse about the purpose
of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best?
a. “This type of monitoring system is complex and it is managed by skilled staff.”
b. “The monitoring system helps show whether blood flow to the brain is adequate.”
c. “The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure.”
d. “This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage.”
Short and simple explanations should be given initially to patients…show more content…
What action is best for the nurse to take?
a. Ask the family to stay in the waiting room until the initial assessment is completed.
b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Refer the family members to the hospital counseling service to deal with their anxiety. d. Call the family’s pastor or spiritual advisor to take them to the chapel while care is given. ANS: B
The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
7. A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue
perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods.
The patient with increased intracranial