Chapter 10 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 10

Question 1

Type: MCSA

A patient with a head injury has a pO2 of 88 and a pCO2 of 58. The nurse realizes that which physiologic process will occur in this patient?

1. Cerebral blood vessels will constrict.

2. Cerebral blood vessels will dilate.

3. Blood flow to the cerebral cortex will slow.

4. Blood will be shunted from the cerebral cortex.

Correct Answer: 2

Rationale 1: This is not an expected physiologic response to the patients oxygen and carbon dioxide levels.

Rationale 2: Autoregulation ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such as when there is a drop in cerebral oxygen levels or an increase in cerebral carbon dioxide levels.

Rationale 3: This is not an expected physiologic response to the patients oxygen and carbon dioxide levels.

Rationale 4: This is not an expected physiologic response to the patients oxygen and carbon dioxide levels.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-2: List primary and secondary causes of increased intracranial pressure.

Question 2

Type: MCSA

A patient who has suffered a traumatic brain injury has his blood pressure increase from 130/60 to 170/65 mm Hg. The nurse should respond to this increase in blood pressure by:

1. Weighing the patient to determine if the patient is fluid overloaded

2. Documenting the blood pressure and completing a neurologic assessment

3. Alerting the physician and preparing to administer an antihypertensive agent

4. Providing the patient with immediate pain and/or antianxiety medication

Correct Answer: 2

Rationale 1: This change in blood pressure is not due fluid volume overload.

Rationale 2: Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. The nurse needs to assess the impact of the increased blood pressure on the patients neurologic status by completing a neurologic assessment.

Rationale 3: The nurse would need to assess the patients neurologic status before contacting the physician for treatment.

Rationale 4: The nurse needs to first assess the patients neurologic status before medicating for pain or anxiety since these types of medications will dampen neurologic responses.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-1: Explain the importance of cerebral perfusion pressure to brain function.

Question 3

Type: MCSA

When providing care to a patient with increased intracranial pressure, the nurse would be concerned about which clinical finding because it can result in an additional increase in intracranial pressure?

1. Temperature of 99F (37.2C)

2. Respiratory rate of 24

3. Serum sodium of 110 mEq/L

4. Blood pressure of 150/65

Correct Answer: 3

Rationale 1: This is a minor temperature elevation and would not contribute to the patients increased intracranial pressure.

Rationale 2: This is a minor respiratory rate increase and would not contribute to the patients increased intracranial pressure.

Rationale 3: Hyponatremia is considered a secondary cause that contributes to increases in intracranial pressure. This laboratory value should be reported and treatment started to avoid additional pressure increases.

Rationale 4: This blood pressure is within parameters that would not affect the patients cerebral perfusion and is unlikely to contribute to the patients increased intracranial pressure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-2: List primary and secondary causes of increased intracranial pressure.

Question 4

Type: MCSA

A patients mean arterial pressure (MAP) decreases to 50 while his ICP is 20. The nurse realizes that this drop in MAP is likely to lead to:

1. Increased intracranial pressure

2. Hypoxic cerebral tissue

3. Increased urine output

4. Bradycardia

Correct Answer: 2

Rationale 1: A decline in mean arterial pressure is not going to cause an increase in intracranial pressure.

Rationale 2: Cerebral perfusion is dependent on the blood pressure and the intracranial pressure. It is the difference between the pressure of the incoming blood or MAP and the force opposing perfusion of the brain, or the intracranial pressure. Normal values for cerebral perfusion pressure should be greater than 50 to 60. A pressure less than 40 to 50 usually results in the loss of autoregulation and leads to hypoxia of cerebral tissue.

Rationale 3: A decline in mean arterial pressure is not going to cause an increase in urine output.

Rationale 4: A decline in mean arterial pressure is not going to cause bradycardia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-2: List primary and secondary causes of increased intracranial pressure.

Question 5

Type: MCSA

The nurse is preparing to conduct an hourly neurologic assessment on a patient in the intensive care unit. What is included in this assessment?

1. ECG

2. Brainstem functioning

3. Reflexes

4. Level of consciousness

Correct Answer: 4

Rationale 1: An electrocardiogram is not a part of an hourly neurologic assessment.

Rationale 2: On occasion, the nurse might be involved with assessing brainstem functioning; however, this is not a part of an hourly neurologic assessment.

Rationale 3: Reflexes are not a part of an hourly neurologic assessment.

Rationale 4: Components of an hourly neurologic assessment usually include, at least, the Glasgow Coma Scale or another assessment of level of consciousness, pupillary response to light, motor function, and vital signs. Assessment of cranial nerves, reflexes, and sensation may be added if indicated. On occasion, the nurse might be involved with assessing brainstem functioning.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10-3: Describe the elements of a focused assessment of a patient with an intracranial dysfunction.

Question 6

Type: MCSA

A patient in the neurologic intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating would this patient have for verbal response?

1. 1

2. 4

3. 2

4. 3

Correct Answer: 1

Rationale 1: The Glasgow Coma Scale assesses both level of consciousness and motor response to a stimulus. The scale has three sections: eye opening, motor response, and verbal response. If the patient is unable to talk because of intubation, the score is a 1.

Rationale 2: The patient is unable to talk and would not be scored as a 4.

Rationale 3: The patient is unable to talk and would not be scored as a 2.

Rationale 4: The patient is unable to talk and would not be scored as a 3.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-3: Describe the elements of a focused assessment of a patient with an intracranial dysfunction.

Question 7

Type: MCSA

What would be appropriate for the nurse to do when assessing a patients motor function?

1. Assess all four extremities together.

2. Assess the right leg and the right arm together.

3. Assess the arms together and then assess the legs separately.

4. Assess the left leg and the left arm together.

Correct Answer: 3

Rationale 1: Assessing all extremities together would not enable the nurse to compare strength and movement of both sides of the body.

Rationale 2: The legs are usually assessed separately.

Rationale 3: Although the nurse can assess the arms simultaneously, the legs are usually assessed separately. It is important that the nurse assesses the movement in all four of the extremities and compare the strength of movement on both sides of the body.

Rationale 4: The legs are usually assessed separately.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-3: Describe the elements of a focused assessment of a patient with an intracranial dysfunction.

Question 8

Type: MCSA

The nurse is assessing a patients corneal reflex. The cranial nerve that is being assessed with this reflex is:

1. Oculomotor

2. Optic

3. Trigeminal

4. Vagus

Correct Answer: 3

Rationale 1: The oculomotor nerve is assessed when the pupils are checked.

Rationale 2: The optic nerve is assessed when the pupils are checked.

Rationale 3: Portions of the trigeminal and facial cranial nerves can be assessed by checking for a corneal reflex.

Rationale 4: The vagus nerve is assessed by checking for a cough and gag reflex.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-3: Describe the elements of a focused assessment of a patient with an intracranial dysfunction.

Question 9

Type: MCSA

The nurse is going to assist with the assessment of a patients oculovestibular reflex. What should be done before this reflex is assessed?

1. Ensure that the patients spinal cord has been found intact.

2. Ensure that the patient has an intact gag reflex.

3. Determine that the patient can tolerate being in the supine position.

4. Determine that the patient has an intact tympanic membrane.

Correct Answer: 4

Rationale 1: It is not necessary to ensure that the patients spinal cord has been found intact.

Rationale 2: It is not necessary to ensure that the patient has an intact gag reflex before assessing this reflex.

Rationale 3: The head of the patients bed is elevated 30 degrees when testing this reflex.

Rationale 4: The oculovestibular reflex, or cold calorics, is performed only after determining that the tympanic membrane is intact. The head of the patients bed is elevated 30 degrees, and then 50 mL of cool saline is injected into an ear.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10-3: Describe the elements of a focused assessment of a patient with an intracranial dysfunction.

Question 10

Type: MCSA

The nurse, evaluating the tracing made from a patients intracranial pressure monitor, notes the presence of many C waves. This finding would be indicative of:

1. Decreased cerebral compliance

2. Pending brain herniation

3. No evidence of pathology

4. Impaired cerebral spinal fluid flow

Correct Answer: 3

Rationale 1: Decreased cerebral compliance would be indicated by the presence of A waves.

Rationale 2: Pending brain herniation would be indicated by the presence of A waves.

Rationale 3: C waves are smaller rhythmic oscillations that occur 4 to 8 times/minute and are not indicative of pathology.

Rationale 4: Impaired cerebral spinal fluid flow would be indicated by the presence of A waves.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-4: Discuss nursing responsibilities in the care of a patient with intracranial pressure monitoring.

Question 11

Type: MCSA

The nurse is providing care to a patient with an intracranial pressure monitoring device. What is a priority when providing care to this patient?

1. Monitor intracranial pressure every 4 hours.

2. Perform neurologic assessment checks every 2 hours.

3. Use clean technique when working with the system.

4. Use strict aseptic technique when working with the system.

Correct Answer: 4

Rationale 1: Pressure would be monitored every hour.

Rationale 2: Neurologic assessment checks would be monitored every hour.

Rationale 3: Clean technique could cause the patient to develop an infection.

Rationale 4: The most common complication in patients with intracranial monitoring devices is infection. To avoid infection, the nurse should maintain strict aseptic technique when working with the system.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-4: Discuss nursing responsibilities in the care of a patient with intracranial pressure monitoring.

Question 12

Type: MCSA

A patient is being admitted after sustaining a head injury from an acceleration/deceleration motor vehicle accident. The type of injury that this patient most likely sustained would be:

1. Skull fracture

2. Penetrating

3. Concussion

4. Coupcountercoup

Correct Answer: 4

Rationale 1: Skull fracture is not typically associated with motor vehicle accidents.

Rationale 2: Penetrating head trauma is not typically associated with motor vehicle accidents.

Rationale 3: Concussion is not typically associated with motor vehicle accidents.

Rationale 4: Contusions and axonal injuries often result from acceleration/deceleration injuries from a motor vehicle collision. Contusions develop as the brain accelerates against the fixed skull, causing disruption of the underlying cerebral parenchyma and blood vessels. This is known as a coup injury. After impacting the skull, the brain may recoil and impact the skull on the opposite side, causing additional damage to the cerebral parenchyma. This is known as a countercoup injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10-5: Explain the significance of traumatic brain injury.

Question 13

Type: MCSA

A patient is admitted with a fracture to the base of the skull. What might the nurse assess in this patient?

1. Depressed respiratory rate

2. Ecchymoses of the neck

3. Increased intracranial pressure

4. Cerebral spinal fluid leak from the nose

Correct Answer: 4

Rationale 1: There is no evidence to suggest that the patient will have a depressed respiratory rate with this fracture.

Rationale 2: Ecchymoses of the neck is not associated with a basilar skull fracture.

Rationale 3: There is no evidence to suggest that the patient will have increased intracranial pressure with this fracture.

Rationale 4: Basilar fractures occur at the base of the skull. Patients may develop a dural tear and have cerebral spinal fluid draining from their nose and/or ears.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-5: Explain the significance of traumatic brain injury.

Question 14

Type: MCSA

A patient with a skull fracture was admitted unconscious, became conscious, and has since moved into unconsciousness again. This patient is demonstrating findings indicative of:

1. A cerebral spinal fluid leak

2. A subdural hematoma

3. An epidural hematoma

4. A subarachnoid hemorrhage

Correct Answer: 3

Rationale 1: This is not a symptom of a cerebral spinal fluid leak.

Rationale 2: Acute subdural hematomas are collections of thick, jelly-like blood that accumulate within the first 24 to 48 hours after blunt trauma. Patients usually present with a loss of consciousness and they may have focal signs such as hemiparesis or dysphagia. Subacute subdural hematomas usually develop over days to weeks following the injury. Chronic subdural hematomas are more common in older adults during the 2 to 3 weeks following the injury. Patients usually develop nonspecific symptoms such as headache, confusion, and speech deficits.

Rationale 3: Epidural hematomas usually occur in conjunction with a skull fracture and result from a laceration of the middle meningeal artery, causing bleeding between the dura mater and the skull. Approximately half of the patients who suffer this injury demonstrate the classic presentation of an initial loss of consciousness followed by a lucid interval and then a sudden reloss of consciousness with rapid deterioration in neurologic status.

Rationale 4: Subarachnoid hemorrhage, or bleeding between the arachnoid and pia matter, may result from rupture of a preexisting or a traumatic cerebral aneurysm.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-6: Compare and contrast epidural, subdural, and subarachnoid hemorrhages.

Question 15

Type: MCSA

A patient with a severe head injury has a pO2 of 88 and a pCO2 of 48. What should be done to support this patient?

1. Assess oxygen saturation and plan for intubation if saturation is below 86%.

2. Provide 100% oxygen via face mask.

3. Plan for a rapid sequence intubation.

4. Plan for a routine intubation.

Correct Answer: 3

Rationale 1: An oxygen saturation less than 90% is associated with increased morbidity and mortality in these patients.

Rationale 2: Oxygen would be provided with a bag-valve mask.

Rationale 3: Many organizations utilize rapid sequence intubation, which might include supporting the patients respirations with a 100% O2 via bag-valve mask; administration of lidocaine to inhibit central responses that can increase ICP; administration of a sedative hypnotic agent; administration of a rapid-acting neuroblocking agent; checking for jaw relaxation after 30 seconds, if it is present; intubation; confirmation of tube placement; and sedation.

Rationale 4: Intubation can be a noxious procedure and may increase intracranial pressure. Because of this, routine intubation would not be done.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10-7: Discuss the collaborative management of the patient with a severe traumatic brain injury.

Question 16

Type: MCSA

A ventilated patient with a head injury needs to be suctioned. What will the nurse do to limit problems related to suctioning?

1. Limit the duration of each suctioning pass to less than 20 seconds.

2. Medicate with opiates after suctioning.

3. Reduce the flow of oxygen prior to suctioning.

4. Preoxygenate before suctioning.

Correct Answer: 4

Rationale 1: The duration of each suctioning pass should be limited to less than 10 seconds.

Rationale 2: The patient may be premedicated with opiates before suctioning.

Rationale 3: The flow of oxygen should not be reduced before suctioning.

Rationale 4: Suctioning the patients endotracheal tube may result in transient reductions in oxygenation. Suctioning is a noxious procedure. For both these reasons, suctioning may impact ICP. The nurse should preoxygenate the patient prior to suctioning.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-7: Discuss the collaborative management of the patient with a severe traumatic brain injury.

Question 17

Type: MCSA

A patient with a traumatic brain injury is showing signs of having pain. What would be the medication of choice for this patient?

1. Propofol

2. Meperidine

3. Morphine sulfate

4. Fentanyl

Correct Answer: 3

Rationale 1: Propofol is a sedativehypnotic anesthetic and not used for this patient.

Rationale 2: There is no evidence to support the use of meperidine for treating the pain associated with a traumatic brain injury.

Rationale 3: The patient with a head injury may experience significant pain either from the head injury or from other injuries incurred in the traumatic event. Morphine is most widely used because it has a high level of efficacy and safety yet is minimally sedating. If necessary for a neurologic assessment, it can be reversed with Narcan.

Rationale 4: Fentanyl is used cautiously because it results in a mild but definite increase in intracranial pressure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-7: Discuss the collaborative management of the patient with a severe traumatic brain injury.

Question 18

Type: MCSA

A patient with a penetrating traumatic head injury has a Glasgow Coma Scale of 9. The nurse realizes that what will most likely be implemented for this patient?

1. Prophylactic hypothermia treatment

2. High-dose barbiturate therapy

3. Intubation

4. Prophylactic anticonvulsant therapy

Correct Answer: 4

Rationale 1: Prophylactic hypothermia treatment is not recommended for routine use at this time.

Rationale 2: High-dose barbiturate therapy might be considered when the elevated ICP is refractory to other treatments or when the patient has uncontrolled seizures.

Rationale 3: Most patients with a traumatic brain injury will be intubated.

Rationale 4: Risk factors for an early seizure after a traumatic brain injury include a Glasgow Coma Scale score of less than 10; cortical contusion; depressed skull fracture; subdural, epidural, or intracerebral hematomas; penetrating head wounds; and a seizure within the first 24 hours post injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-7: Discuss the collaborative management of the patient with a severe traumatic brain injury.

Question 19

Type: MCSA

The nurse is planning care for a patient with increased intracranial pressure. Which intervention would be appropriate for this patient?

1. Encourage family and physician to discuss patients care and prognosis in the patients room.

2. Assess for daily bowel movement and provide intervention as appropriate.

3. Maintain head of bed at a 15-degree angle with knee elevation.

4. Cluster care activities.

Correct Answer: 2

Rationale 1: Keeping external stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes discussion around the patient by both the family and the health care team.

Rationale 2: When a patient engages in a Valsalva maneuver when straining with a bowel movement or pushing up in bed, the ICP usually rises. Many neurosurgeons will provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is necessary to ensure that the patient has a daily soft bowel movement without straining.

Rationale 3: The head of the bed should be elevated at 30 degrees to allow for adequate cerebral perfusion while promoting venous return from the head. The body and neck should be in alignment without knee elevation.

Rationale 4: The patients ICP may rise when nursing activities are delivered in a traditional cluster fashion, with one activity following another. The ICP may rise with the first activity and continue to rise with each additional activity. The patients ICP should be permitted to return to baseline before continuing with other activities.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-7: Discuss the collaborative management of the patient with a severe traumatic brain injury.

Question 20

Type: MCSA

A patient comes into the emergency department with a fever, stiff neck, and change in mental status. On assessment it is learned that this patient also has a positive Kernigs sign. These findings suggest the patient:

1. Needs surgery to reduce intracranial pressure

2. Needs to be intubated

3. Should receive 100% oxygen via face mask

4. Has meningeal irritation

Correct Answer: 4

Rationale 1: Surgery is not a treatment for a positive Kernigs sign.

Rationale 2: Intubation is not a treatment for a positive Kernigs sign.

Rationale 3: Oxygen is not a treatment for a positive Kernigs sign.

Rationale 4: Signs of meningeal irritation include the Kernigs sign, which is assessed with the patient in a supine position. The hip is flexed at 90 degrees while the knee is flexed at 90 degrees. Extending the knee produces pain in the hamstrings and resistance to further extension. This sign is an indication of meningitis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-8: Describe the manifestations of meningitis.

Question 21

Type: MCSA

A patient with acute meningitis is receiving antibiotic therapy. The nurse realizes that another medication is used as adjuvant therapy. This medication is:

1. An anticonvulsant

2. A steroid

3. A barbiturate

4. A pain medication

Correct Answer: 2

Rationale 1: Anticonvulsants are not used as adjuvant therapy for meningitis.

Rationale 2: Steroids are currently recommended as adjunctive treatment of bacterial meningitis. Dexamethasone is believed to interrupt the neurotoxic effects resulting from the lysis of bacteria during the first days of antibiotic use. When steroids are given, they should be administered prior to or during the administration of antibiotics on the first 2 days of therapy.

Rationale 3: Barbiturates are not used as adjuvant therapy for meningitis.

Rationale 4: Pain medication is not used as adjuvant therapy for meningitis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-8: Describe the manifestations of meningitis.

Question 22

Type: MCSA

The nurse is caring for a patient with status epilepticus. The first goal of care for this patient would be to:

1. Determine the patients medical history.

2. Obtain an EEG.

3. Maintain an airway.

4. Identify the cause of the seizure.

Correct Answer: 3

Rationale 1: This is not the first priority for this patient.

Rationale 2: This is not the first priority for this patient.

Rationale 3: The first priority in status epilepticus is airway and oxygenation. For some patients, a nasopharyngeal airway is sufficient with provision of oxygen by nasal cannula. For other patients, endotracheal intubation is necessary.

Rationale 4: This is not the first priority for this patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10-9: Explain collaborative management of status epilepticus.

Question 23

Type: MCSA

The nurse is providing medication to a patient with status epilepticus. The medication of choice for this patient would be:

1. A barbiturate

2. A steroid

3. An opioid

4. A benzodiazepine

Correct Answer: 4

Rationale 1: A barbiturate is not the medication of choice for a patient experiencing status epilepticus.

Rationale 2: A steroid is not the medication of choice for a patient experiencing status epilepticus.

Rationale 3: An opioid is not the medication of choice for a patient experiencing status epilepticus.

Rationale 4: The initial drug of choice is a benzodiazepine, usually lorazepam administered at the rate of 2 to 4 mg IV over 1 minute because it terminates seizures 75% to 80% of the time. The dose may be repeated after 5 to 10 minutes if the seizure has not stopped.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-9: Explain collaborative management of status epilepticus.

Question 24

Type: MCSA

When administering mannitol (Osmitrol) to a patient with increased intracranial pressure (ICP), the nurse would:

1. Expect that any reduction in ICP will begin approximately an hour after the dose is administered.

2. Assess the patient carefully for the development of hypertension.

3. Review lab data to identify the presence of hypernatremia and hyperkalemia.

4. Monitor the osmolality of the blood every 4 to 6 hours if repeated doses are administered.

Correct Answer: 4

Rationale 1: The reduction in intracranial pressure would begin almost immediately.

Rationale 2: Mannitol can cause hypotension.

Rationale 3: Hyponatremia and hypokalemia can occur with this medication.

Rationale 4: Mannitol increases the osmolality of the blood with optimal osmolality between 300 and 320 mOsm. If repeated doses of mannitol are given, the nurse monitors the serum osmolality every 4 to 6 hours and ensures that it remains less than 320 mOsm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-7: Discuss the collaborative management of the patient with a severe traumatic brain injury.

Question 25

Type: MCMA

When administering hypertonic saline to the patient with increased intracranial pressure (ICP), the nurse would:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Monitor the patient for renal failure and pulmonary edema.

2. Administer any concentrations greater than 2% through a central line.

3. Monitor serum sodium levels frequently during administration.

4. Expect the patients neurologic status and ICP will begin to improve within 15 minutes following administration.

5. Monitor the patients serum osmolarity every 24 hours.

Correct Answer: 1,2,3,4

Rationale 1: Renal failure and pulmonary edema can occur from this fluid.

Rationale 2: A solution greater than 2% should be administered through a central line.

Rationale 3: Serum sodium levels should be frequently monitored during the administration of this fluid.

Rationale 4: The patients neurologic status and intracranial pressure level will improve within 15 minutes following the administration of this fluid.

Rationale 5: Serum osmolarity should be measured at least every 12 hours and maintained at less than 320 mOsm/L.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-7: Discuss the collaborative management of the patient with a severe traumatic brain injury.

Question 26

Type: MCSA

What might a patient develop if intravenous phenytoin (Dilantin) was administered faster than 50 mg/minute?

1. A severe rash

2. Hypotension

3. Hematologic abnormalities such as agranulocytosis

4. A pronounced increase in heart rate

Correct Answer: 2

Rationale 1: A severe rash would not immediately occur.

Rationale 2: Phenytoin is administered no faster than 25 to 50 mg/min, because faster administration may result in bradycardia, hypotension, heart block, and ventricular fibrillation.

Rationale 3: Hematologic abnormalities would not occur immediately.

Rationale 4: Bradycardia, heart block, and ventricular fibrillation can occur.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-9: Explain collaborative management of status epilepticus.

Question 27

Type: MCMA

A patient, diagnosed with a subdural hematoma, has an intracranial pressure of 14 mm Hg. The nurse realizes that if this pressure increases, the body may respond by:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Displacing cerebrospinal fluid into the lumbar cistern

2. Reabsorbing more cerebrospinal fluid

3. Shunting blood out of venous sinuses

4. Raising the body temperature

5. Increasing the carbon dioxide level

Correct Answer: 1,2,3

Rationale 1: According to the Munro Kelly hypothesis, intracranial pressure is kept within a range between 5 to 15 mm Hg by a mechanism known as compliance. When the volume of one of the components increases, the body may respond by displacing cerebrospinal fluid into the lumbar cistern.

Rationale 2: According to the Munro Kelly hypothesis, intracranial pressure is kept within a range between 5 to 15 mm Hg by a mechanism known as compliance. When the volume of one of the components increases, the body may respond by reabsorbing more cerebrospinal fluid.

Rationale 3: According to the Munro Kelly hypothesis, intracranial pressure is kept within a range between 5 to 15 mm Hg by a mechanism known as compliance. When the volume of one of the components increases, the body may respond by compressing veins and shunting blood out of the venous sinuses.

Rationale 4: Elevating the body temperature is not controlled by the compliance mechanism.

Rationale 5: Increasing the carbon dioxide level is not controlled by the compliance mechanism.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-1: Explain the importance of cerebral perfusion pressure to brain function.

Question 28

Type: MCMA

A patient is demonstrating neurologic changes consistent with increasing intracranial pressure. For which primary causes of this pressure increase will the nurse assess at this time?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Cerebral hemorrhage

2. Ischemic stroke

3. Airway obstruction

4. Drop in blood pressure

5. Electrolyte imbalance

Correct Answer: 1,2

Rationale 1: Cerebral hemorrhage is a primary cause of increased intracranial pressure.

Rationale 2: Ischemic stroke is a primary cause of increased intracranial pressure.

Rationale 3: Airway obstruction is a secondary cause of increased intracranial pressure.

Rationale 4: Hypotension is a secondary cause of increased intracranial pressure.

Rationale 5: Electrolyte imbalances indicate metabolic disorders, which are secondary causes of increased intracranial pressure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-2: List primary and secondary causes of increased intracranial pressure.

Question 29

Type: MCMA

The nurse is caring for a patient who sustained head and abdominal injuries from a motor vehicle crash. While the nurse is inserting a nasogastric tube to decompress the stomach, the patient begins to cough and gag. What cranial nerves did the nurse inadvertently assess when inserting the nasogastric tube into the patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. IX (glossopharyngeal)

2. X (vagus)

3. V (trigeminal)

4. VII (facial)

5. III (oculomotor)

Correct Answer: 1,2

Rationale 1: This nerve is intact when the patient exhibits the cough and gag reflex.

Rationale 2: This nerve is intact when the patient exhibits the cough and gag reflex.

Rationale 3: This nerve is used to assess for the corneal reflex.

Rationale 4: This nerve is used to assess for the corneal reflex.

Rationale 5: This nerve is used to assess pupillary response.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-3: Describe the elements of a focused assessment of a patient with an intracranial dysfunction.

Question 30

Type: MCMA

The nurse is concerned that a patients intracranial pressure monitor readings are incorrect. What can the nurse do to ensure that the monitor is measuring accurately?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Check the location of the stopcocks.

2. Check the position of the transducer.

3. Check the monitoring line for air.

4. Ensure the catheter is not obstructed.

5. Check to make sure the dressing is dry.

Correct Answer: 1,2,3,4

Rationale 1: One reason for inaccurate intracranial pressure readings would be an incorrect position of the stopcocks.

Rationale 2: One reason for inaccurate intracranial pressure readings would be an incorrect position of the transducer.

Rationale 3: One reason for inaccurate intracranial pressure readings would be air in the monitoring line.

Rationale 4: One reason for inaccurate intracranial pressure readings would be the catheter being obstructed.

Rationale 5: The condition of the dressing will not impact the accuracy of intracranial pressure readings.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-4: Discuss nursing responsibilities in the care of a patient with intracranial pressure monitoring.

Question 31

Type: MCMA

The nurse is teaching a patient, recovering from a mild brain injury, about manifestations to expect during the recovery process. What will the nurse instruct this patient to expect while recuperating from this injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Headache

2. Dizziness

3. Fatigue

4. Memory loss

5. Nausea

Correct Answer: 1,2,3,4

Rationale 1: Problems experienced by patients with mild brain injuries include headache.

Rationale 2: Problems experienced by patients with mild brain injuries include dizziness.

Rationale 3: Problems experienced by patients with mild brain injuries include fatigue.

Rationale 4: Problems experienced by patients with mild brain injuries include memory loss.

Rationale 5: Nausea is not a problem experienced by patients with mild brain injuries.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 10-5: Explain the significance of traumatic brain injury.

Question 32

Type: MCMA

A patient with a traumatic brain injury is diagnosed with an acute subdural hematoma. What would the nurse be more likely to assess in this patient than in one who had experienced a chronic subdural hematoma?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Loss of consciousness

2. Hemiparesis

3. Dysphagia

4. Confusion

5. Headache

Correct Answer: 1,2,3

Rationale 1: Loss of consciousness is a manifestation of acute subdural hematoma.

Rationale 2: Hemiparesis is a manifestation of acute subdural hematoma.

Rationale 3: Dysphagia is a manifestation of acute subdural hematoma.

Rationale 4: Confusion is a manifestation of chronic subdural hematoma.

Rationale 5: Headache is a manifestation of chronic subdural hematoma.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-6: Compare and contrast epidural, subdural, and subarachnoid hemorrhages.

Question 33

Type: MCMA

A patient is diagnosed with meningitis that developed after experiencing otitis media. What will the nurse most likely assess in this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Fever

2. Stiff neck

3. Confusion

4. Photophobia

5. Palpitations

Correct Answer: 1,2,3,4

Rationale 1: Fever is a manifestation of meningitis.

Rationale 2: A stiff neck or nuchal rigidity is a manifestation of meningitis.

Rationale 3: A change in mental status is a manifestation of meningitis.

Rationale 4: Photophobia is a manifestation of meningitis.

Rationale 5: Palpitations are not manifestations of meningitis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-8: Describe the manifestations of meningitis.

Question 34

Type: MCMA

A patient has been receiving treatment for status epilepticus for the last 20 minutes. What will the nurse prepare to implement to help the patient at this time?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Prepare for emergency intubation.

2. Insert an indwelling urinary catheter.

3. Monitor body temperature.

4. Obtain an order for a bedside electroencephalogram.

5. Insert an intravenous access line.

Correct Answer: 1,2,3,4

Rationale 1: If the seizure continues beyond 20 to 30 minutes, the patient should be intubated.

Rationale 2: If the seizure continues beyond 20 to 30 minutes, the patient should have an indwelling urinary catheter inserted.

Rationale 3: If the seizure continues beyond 20 to 30 minutes, the nurse should monitor the patients body temperature.

Rationale 4: If the seizure continues beyond 20 to 30 minutes, an electroencephalogram should be obtained.

Rationale 5: An intravenous access line would have been placed earlier for the administration of intravenous medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-9: Explain collaborative management of status epilepticus.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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