Chapter 11 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 11

Question 1

Type: MCSA

A patient is recovering from transphenoidal surgery for partial resection of a pituitary adenoma. The nurse should instruct the patient to avoid doing which action(s)?

1. Blowing the nose or sneezing

2. Deep breathing

3. Drinking more than 2 liters of fluid a day

4. Sitting up in bed higher than 30 degrees

Correct Answer: 1

Rationale 1: These activities may cause the patch to dislodge, which could result in a cerebrospinal fluid leak (CSF) and increase the risk of infection.

Rationale 2: Deep breathing is a post-operative activity that all post-operative patients should perform to prevent atelectasis.

Rationale 3: Drinking 2 liters of fluid per day is a post-op activity that helps the body metabolize anesthesia, maintains hydration, and liquefies pulmonary secretions.

Rationale 4: The head of the beds needs to be elevated at least 30 degrees or higher to reduce post-op edema. This also allows for better lung expansion to prevent atelectasis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors.

Question 2

Type: MCSA

A patient is diagnosed with a grade II astrocytoma. The nurse realizes that this patients prognosis is:

1. Excellent

2. Good as long as the tumor is treated soon

3. Good because the tumor is well defined

4. Poor because the tumor cells are irregularly shaped

Correct Answer: 2

Rationale 1: Grade II tumor cells are less well defined and there is the possibility that a grade II tumor will transform to a higher grade. Excellent prognosis is not associated with this type of brain tumor.

Rationale 2: Astrocytomas are the most common types of primary brain tumor and are graded from I to IV according to tissue histology. Grade I and grade II tumors are considered to be low-grade tumors and they have the most favorable survival rates and respond well to early treatment.

Rationale 3: Grade I tumor cells are well defined and almost normally shaped. They have a low incidence of brain infiltration. Grade II tumor cells are less well defined and there is the possibility that a grade II tumor will transform to a higher grade.

Rationale 4: Higher-grade (III and IV) tumor cells are abnormally shaped and have a pronounced ability to infiltrate normal brain tissue; therefore, the prognosis is poor.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-1: List the common manifestations of brain tumors and explain their causation.

Question 3

Type: MCSA

The nurse is assessing a patient with a meningioma. The nurse realizes that this patient will have:

1. A hearing disorder

2. A life expectancy of about 10 months

3. An excellent prognosis if the tumor is totally removed

4. Metastasis to other body organs

Correct Answer: 3

Rationale 1: Other common benign brain tumors arise from nerve sheaths such as acoustic neuromas, which can lead to a hearing loss.

Rationale 2: Meningiomas are usually benign and do not affect life expectancy.

Rationale 3: The most common benign brain tumors arise from the meninges and are called meningiomas. They are usually well circumscribed, may be attached to the dura, and are associated with an excellent prognosis when gross-total resection is possible.

Rationale 4: Meningiomas are encapsulated and benign so therefore do not metastasize to other organs.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-1: List the common manifestations of brain tumors and explain their causation.

Question 4

Type: MCSA

A patient with increased intracranial pressure is diagnosed with a brain tumor. The nurse realizes that this patient most likely has:

1. An astrocytoma

2. A meningioma

3. A tumor less than 1 mm in size

4. A tumor greater than 1 mm in size

Correct Answer: 4

Rationale 1: Astrocytomas are grade I and II tumors that grow slowly and the first symptom is seizures. A late symptom is increased intracranial pressure.

Rationale 2: Meningiomas are extremely slow growing tumors. There is a low incidence of the development of increased intracranial pressure.

Rationale 3: Tumors of less than 1 mm in size do not result in the development of cerebral edema as there is minimal displacement of cerebral tissue.

Rationale 4: Brain tumors appear to cause symptoms by different mechanisms. One mechanism is the development of cerebral edema. Cerebral edema appears to develop once tumors have increased in size beyond 1 mm. The new blood vessels that feed the tumor lack the normal blood-brain barrier and are more permeable to macromolecules, proteins, and ions, resulting in vasogenic cerebral edema. Simultaneously, macrophages and inflammatory mediators that increase vascular permeability and edema are released.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-1: List the common manifestations of brain tumors and explain their causation.

Question 5

Type: MCSA

An older patient is not concerned about having a brain tumor because the only symptom has been a slight increase in forgetfulness and no headaches. The nurse realizes that this patient most likely:

1. Does not have a brain tumor because brain tumors are rarely present with cognitive changes

2. Does not have a tumor because forgetfulness is seen in children with a brain tumor

3. Could have a brain tumor even though a headache is not present

4. Has the beginnings of Alzheimers disease

Correct Answer: 3

Rationale 1: The presence of a brain tumor in the elderly often manifests with cognitive changes as forgetfulness.

Rationale 2: The manifestation of forgetfulness is a symptom of the presence of a tumor in the elderly, not in the pediatric population.

Rationale 3: Because older adults have age-related brain atrophy, they are less likely to present with generalized symptoms of increased intracranial pressure such as headache and papilledema; instead they are more likely to present with mental changes. Mental and/or personality changes can be caused by the tumor itself, by increased intracranial pressure, or by involvement of the parts of the brain that control personality. These can range from problems with short-term memory, speech, communication, and/or concentration changes to severe intellectual problems and confusion.

Rationale 4: Alzheimers disease has many more symptoms other than forgetfulness, such as language problems. A CT scan would be negative for the presence of a tumor.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-1: List the common manifestations of brain tumors and explain their causation.

Question 6

Type: MCSA

A patient tells the nurse about an area on the arm that has been getting numb and feels funny. This information is important because it will:

1. Possibly pinpoint the location of a brain tumor

2. Determine the type and amount of medication to prescribe

3. Serve as a minor symptom that is nothing for the patient to worry about

4. Determine how long the patient has to stay in the hospital

Correct Answer: 1

Rationale 1: Focal seizures, such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling, may occur. Other more specific symptoms, known as focal symptoms, occur in approximately one third of patients with brain tumors. Focal symptoms include hearing problems such as ringing or buzzing sounds or hearing loss, decreased muscle control, lack of coordination, decreased sensation, weakness or paralysis, difficulty with walking or speech, balance problems, or double vision. Because the symptoms are usually caused by invasion or compression from the tumor, these focal symptoms can help identify the location of the tumor.

Rationale 2: The type and length of treatment of a tumor is based on location, grade, and type. These factors would be relevant to the treatment, whether it be surgical, radiation, or chemotherapy.

Rationale 3: The neurologic changes present with a brain tumor are never taken lightly and should be noted as they are helpful with the diagnosis of an abnormality.

Rationale 4: Treatment would determine length of hospital stay.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-1: List the common manifestations of brain tumors and explain their causation.

Question 7

Type: MCSA

During an assessment, a patient asks the nurse if something is burning. The nurse realizes that this patient could be demonstrating:

1. Engorged nasal passages

2. A focal seizure

3. A way to have the nurse leave to check if something is burning

4. Increased intracranial pressure

Correct Answer: 2

Rationale 1: Engorged nasal passages usually result in the loss of smell, not the presence of unusual smells.

Rationale 2: Focal symptoms can occur in patients with brain tumors. The nurse should question the patient about any experienced symptoms such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling.

Rationale 3: This action is usually taken after the nurse has fully assessed the patient for neurologic changes. Priority care would include providing safety measures to protect the patient.

Rationale 4: The initial changes associated with increased intracranial pressure are subtle changes in level of consciousness such as alertness, changes in orientation, and motor and sensory deficits. Seizure activity is a late sign.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-1: List the common manifestations of brain tumors and explain their causation.

Question 8

Type: MCSA

A patient with a brain tumor is having a diagnostic test to help determine response to therapy. This patient is most likely having a(n):

1. CT scan

2. PET scan

3. Angiogram

4. MRI

Correct Answer: 4

Rationale 1: MRI scans are utilized more often than CT scans because they are more sensitive, and capable of detecting tumors too small to be noted on CT scans.

Rationale 2: Positron emission tomography (PET) scans are not the most accurate method to diagnose or treat brain tumors. This method may have a role in grading a tumor for prognosis, localizing a tumor for biopsy, and mapping brain areas prior to surgery.

Rationale 3: An angiogram is the diagnostic tool used for detecting vascular abnormalities, not tissue masses.

Rationale 4: Functional MRIs may be used to assess the potential clinical outcomes of the tumor.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors.

Question 9

Type: MCSA

The nurse is preparing to administer a medication to a patient to decrease the cerebral edema caused by a brain tumor. This medication is most likely a(n):

1. Antiseizure medication

2. Pain medication

3. Glucocorticoid

4. Antispasmodic

Correct Answer: 3

Rationale 1: Antiseizure medication is used to reduce the excitability threshold of brain cells to the stimuli that result in seizure activity. These medications do not reduce cerebral edema.

Rationale 2: Pain medications do not reduce cerebral edema or lower intracranial pressure. These medications can be dangerous in the neurologic patient as they can alter level of consciousness.

Rationale 3: Glucocorticoids are the mainstay of treatment for vasogenic cerebral edema. These agents decrease the tissue swelling associated with brain tumors and manage some of the signs and symptoms that patients experience. Glucocorticoid therapy with dexamethasone has been the standard treatment for tumor-associated edema.

Rationale 4: Antispasmodic medications do not cross the blood-brain barrier and have no effect on cerebral tissue.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-2: Explain why glucocorticoids are administered to patients with brain tumors.

Question 10

Type: MCSA

A patient is recovering from posterior fossa surgery. What should the nurse include in the patients plan of care?

1. Assess vital signs and level of consciousness every hour.

2. Maintain the patient flat in bed for at least 24 hours.

3. Maintain the patients neck in hyperextension.

4. Observe the patient for the development of diabetes insipidus.

Correct Answer: 1

Rationale 1: The tumor was near the brainstem, which has vasomotor control over the vital signs. There is also potential for cerebral edema and increased intracranial pressure so assessment of level of consciousness is very important.

Rationale 2: The head of the bed needs to be elevated from 10 to 60 degrees to promote venous drainage from the brain. This is to help prevent cerebral edema and control intracranial pressure.

Rationale 3: The neck needs to remain in a neutral position to promote venous drainage and to reduce stress on the surgical site. This is accomplished by the application of a stiff dressing or the use of a soft cervical collar.

Rationale 4: This complication is associated with pressure on the pituitary gland and transphenoidal hypophesectomy.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors.

Question 11

Type: MCSA

A patient with a brain tumor is going to have an ablative procedure to treat the mass. A potential reason for this procedure would be:

1. A way to preserve eloquent areas of the brain.

2. The tumor is in an easy-to-reach area of the brain.

3. The tumor is too large to resect.

4. The tumor is small and is in a hard-to-reach area of the brain.

Correct Answer: 4

Rationale 1: This procedure is not designed to preserve but to destroy blood supply to a tumor.

Rationale 2: If a tumor is too large, it is initially treated with radiation to shrink to a more manageable size for surgical removal. This is then followed with chemotherapy.

Rationale 3: The ablation procedure is used for small, nonaccessible tumors.

Rationale 4: An alternative to surgery would be ablative procedures that cause cell death and necrosis of the tumor over time. They are most appropriate for people with smaller tumors in nonaccessible areas.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors.

Question 12

Type: MCSA

The nurse is planning care for a patient who had a supratentoral craniotomy. What will be included in this plan of care?

1. Apply a soft cervical collar.

2. Keep the head of the bed elevated at a 30-degree angle.

3. Keep the head of the bed flat.

4. Position the patient on the side of the tumor.

Correct Answer: 2

Rationale 1: This patient had surgery involving the supretetorium; therefore, a cervical collar is not necessary.

Rationale 2: Post-operatively, patients are usually positioned with the head of their bed elevated 30 degrees. This facilitates venous drainage from the head and neck, preventing increases in intracranial pressure and increasing patient comfort.

Rationale 3: The head of the bed needs to be elevated at least 10 degrees or greater up to 60 degrees in order to facilitate venous drainage from the operative site. This prevents increased intracranial pressure and herniation.

Rationale 4: This patient had a small tumor resected. If a large tumor was resected, the patient would usually not be permitted to turn the head to the operative side because it may cause a shift in cerebral contents.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors.

Question 13

Type: MCSA

The nurse is applying pneumatic compression boots on a post-operative craniotomy patient. The reason for this device is to reduce the risk of developing:

1. Meningitis

2. A deep vein thromboembolism

3. A cerebrospinal fluid leak

4. Seizures

Correct Answer: 2

Rationale 1: Prophylaxis to prevent meningitis includes good hand washing, maintaining aseptic technique when handling external ventricular drains, tubes, and surgical sites, and administering antibiotic medications.

Rationale 2: Prophylaxis for deep vein thromboembolism is recommended for most patients following surgery for malignant primary brain tumors. Pneumatic compression boots and graduated compression stockings have been shown to decrease the occurrence of venous thromboemboli without increasing intracranial pressure.

Rationale 3: Prophylaxis to prevent a cerebral spinal fluid leak includes keeping the intracranial pressure at a normal level by keeping the head of the bed at 30 degrees and administering glucocorticoid medications.

Rationale 4: Prophylaxis for seizures is the use of medications such as Dilantin (phenytoin) and Phenobarbital.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-4: Summarize strategies used to prevent common complications post craniotomy.

Question 14

Type: MCMA

A patient recovering from a craniotomy is complaining of a headache and has the head of the bed elevated. The nurse also sees a damp mark on the patients pillow. The nurse should:

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 drainage for the presence of glucose.

2. Alert the physician.

3. Elevate the head of the bed to 45 degrees.

4. Plan for insertion of an external ventricular drain.

5. Apply an occlusive dressing to stop the leak.

Correct Answer: 1,2

Rationale 1: A cerebrospinal fluid leak can be identified by clear fluid containing glucose that is leaking from the patients ear or nose and forming a halo as it settles on a pillowcase. The patient will complain of a headache.

Rationale 2: The nurse should notify the health care provider regarding the presence of cerebrospinal fluid leakage in the event surgical intervention is required to close the tear.

Rationale 3: Raising the head of the bed further would create more irritation to the dura and thus worsen the headache. A CSF leak may also be related to increased ICP and raising the head of the bed would increase the risk of herniation.

Rationale 4: The insertion of an external ventricular drain would further deplete cerebrospinal fluid. As this is also an invasive procedure, there would be an increased risk for the development of meningitis.

Rationale 5: An occlusive dressing would be contraindicated because the cerebrospinal fluid should be allowed to flow freely. This is to prevent an increase of intracerebral pressure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-4: Summarize strategies used to prevent common complications post craniotomy.

Question 15

Type: MCSA

A patient with a brain tumor is prescribed an antiseizure medication. The nurse realizes that the purpose of this medication will be to:

1. Eliminate all seizure activity.

2. Reduce focal seizures.

3. Premedicate for status epilepticus.

4. Control the onset of seizure activity.

Correct Answer: 4

Rationale 1: The majority of patients with brain tumors continue with some type of seizure, most commonly a focal seizure.

Rationale 2: The majority of patients with brain tumors continue with some type of seizure, most commonly a focal seizure.

Rationale 3: The use of seizure medication in the patient with a brain tumor is not to premedicate for status epilepticus.

Rationale 4: The risk of seizures after craniotomy is extremely common and the risk of seizure development is partially dependent on the type of brain tumor. Recurrent seizures post craniotomy continues to cause significant clinical problems. The use of antiseizure medication is used to control the onset of seizure activity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-4: Summarize strategies used to prevent common complications post craniotomy.

Question 16

Type: MCSA

A patient recovering from a glioma has concluded radiation therapy. The nurse realizes that the next step of treatment for this patient will most likely be:

1. Chemotherapy

2. An additional 6 weeks of radiation

3. Nothing, unless there is evidence the tumor has returned

4. Antiseizure medication

Correct Answer: 1

Rationale 1: Standard treatment for malignant gliomas has included primary resection, followed by radiation therapy and temozlomide, which has shown improved prognosis. Recent studies have looked at the addition of bevacizumab (Avastin) for single agent use in recurrent glioblastoma.

Rationale 2: Additional treatments of radiation have not been shown to decrease morbidity or mortality in the treatment of gliomas. Adjunct treatment of chemotherapy has been proven to improve outcome.

Rationale 3: Chemotherapy, both systemic and local, is used after the completion of radiation therapy.

Rationale 4: Antiseizure medications are only used if the patient develops seizures.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary tumors.

Question 17

Type: MCSA

A patient is diagnosed with an intracerebral hemorrhage. What is the most common cause of this disorder?

1. Hypertension

2. Atrial fibrillation

3. Atherosclerosis

4. Hyperinsulinemia

Correct Answer: 1

Rationale 1: The most common causes of intracerebral hemorrhage are hypertension, trauma, illicit drug use (particularly amphetamines and cocaine), vascular malformations, and bleeding diathesis. Intracerebral hemorrhage results from hypertension when the arteries in the brain become brittle and susceptible to cracking, and rupture.

Rationale 2: Atrial fibrillation increases the risk of the development of an ischemic cerebrovascular accident.

Rationale 3: Atherosclerosis is the cause of hypertension, which can lead to intracranial hemorrhage.

Rationale 4: Hyperinsulinemia is a risk factor for the development of atherosclerosis and hypertension, which may eventually lead to an intracranial hemorrhage. However, this is not a primary cause.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-5: Compare and contrast the mechanisms of hemorrhagic and ischemic strokes.

Question 18

Type: MCSA

A patient complains of having the worst headache ever. The nurse realizes that this description is often seen in:

1. Intracranial hemorrhage

2. Ischemic stroke

3. Subarachnoid hemorrhage

4. A brain tumor

Correct Answer: 3

Rationale 1: Intracranial hemorrhage is a local hematoma in the brain that is manifested by neurologic symptoms such as a change in level of consciousness, and sensory and motor deficits.

Rationale 2: Ischemic stroke is characterized by confusion, difficulty speaking, visual disturbances, and sensory and motor deficits. Headache does occur.

Rationale 3: Subarachnoid hemorrhage is rupture of an aneurysm that releases blood directly into the cerebrospinal fluid under arterial pressure. The blood spreads rapidly, immediately increasing intracranial pressure. If bleeding continues, deep coma or death may result. Typically the bleeding lasts only a few seconds but there is risk of rebleeding. The classic symptom is a sudden, severe headache that begins abruptly and is described as the worst headache of my life.

Rationale 4: The headache associated with a brain tumor is worse in the morning but improves during the day. It worsens with coughing, exercise, and changes in position. This type of headache does not respond to usual headache treatment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-7: Compare and contrast intracerebral hemorrhage and subarachnoid hemorrhage.

Question 19

Type: MCSA

A patient with an embolic stroke is demonstrating urinary incontinence, contralateral weakness, and altered mental status. This location of the embolism is most likely the:

1. Middle cerebral artery

2. Anterior cerebral artery

3. Posterior cerebral artery

4. Vertebrobasilar artery

Correct Answer: 2

Rationale 1: Middle cerebral artery occlusions commonly produce hemiparesis, hypesthesia on the opposite side of the body, hemianopsia, and gaze preference toward the side of the lesion.

Rationale 2: Anterior cerebral artery occlusions primarily affect frontal lobe function and can result in disinhibition, speech perseveration, altered mental status, impaired judgment, contralateral weakness, and urinary incontinence.

Rationale 3: Posterior cerebral artery occlusions affect vision and thought, producing homonymous hemianopsia, cortical blindness, visual agnosia, altered mental status, and impaired memory.

Rationale 4: Vertebrobasilar artery occlusion is difficult to detect because it results in a wide variety of cranial nerve, cerebellar, and brainstem deficits.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-5: Compare and contrast the mechanisms of hemorrhagic and ischemic strokes.

Question 20

Type: MCSA

A patient is diagnosed with an ischemic stroke with the onset of symptoms within the last 2 hours. The best course of treatment for this patient would be to:

1. Admit the patient to a neurosurgical unit for a surgery consultation.

2. Consider the administration of intravenous recombinant tissue-type plasminogen activator (rt-PA or alteplase).

3. Observe for continuing symptoms.

4. Provide intravenous fluids.

Correct Answer: 2

Rationale 1: If the CT scan is positive for a hemorrhagic stroke, an immediate neurosurgical consult should be ordered. Immediate surgery for an ischemic stroke is not indicated at this time. The priority is to re-establish blood flow to limit neurologic deficits and preserve neurologic function. Once the patient has been stabilized and has recovered, carotid endarterectomy may be considered if indicated.

Rationale 2: In the case of ischemic stroke, intravenous thrombolysis should be administered if the time since the onset of symptoms is less than 3 hours and the patient is eligible based on criteria.

Rationale 3: Merely observing the patient is not sufficient because as the obstruction continues, the neurologic deficits worsen. The priority is to re-establish blood flow as soon as possible.

Rationale 4: The use of IV fluids is a means to administer antihypertensive medications to control blood pressure. Fluid restriction may be indicated to assist in controlling hypertension but not so restricted to cause dehydration, which would increase blood viscosity, raising the risk of the development of more thromboemboli.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-6: Describe emergent management of the patient with an ischemic stroke.

Question 21

Type: MCSA

A patient with an ischemic stroke has an oxygen saturation of 88%. What should be done to help this patient?

1. Position the patient on one side.

2. Elevate the head of the bed.

3. Provide low-dose oxygen.

4. Provide high-dose oxygen.

Correct Answer: 4

Rationale 1: Positioning the patient on one side does not improve O2 saturation.

Rationale 2: Raising the head of the bed assists in keeping the airway open as well as facilitating lung expansion to prevent atelectasis but will not improve oxygen saturation.

Rationale 3: Low-dose oxygen does not provide adequate supplementation to maintain oxygen saturation, especially when it falls below 90%. It is helpful as an adjunct when the saturation is 90%, in order to raise saturation to more appropriate levels.

Rationale 4: High-flow oxygen therapy is indicated when arterial blood gases or O2 saturation is less than 92%. Hypoventilation may cause an elevation in carbon dioxide, which could lead to cerebral vasodilation and further increase ICP.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-6: Describe emergent management of the patient with an ischemic stroke.

Question 22

Type: MCSA

A patient being treated with warfarin (Coumadin) experiences an intracerebral hemorrhage. What should be considered to aid in the care of this patient?

1. Prepare the patient for surgery.

2. Prepare the patient for a ventriculostomy.

3. Prepare to administer vitamin K.

4. Prepare to administer protamine sulfate.

Correct Answer: 3

Rationale 1: Surgery is indicated only after the cause of the bleed has been identified. This management will be based on the location and type of bleed.

Rationale 2: A ventriculostomy is not used as a therapy in the management of the intracerebral hematoma. This therapy is limited and is only indicated if it would be beneficial in reducing intracranial pressure by controlling cerebrospinal fluid.

Rationale 3: Since the patient has been receiving the anticoagulant warfarin (Coumadin), the appropriate drug is the administration of vitamin K to reverse the effects of this medication.

Rationale 4: Protamine sulfate is the medication used to reverse heparin-associated ICH. The dose is dependent on the time since the cessation of heparin.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-6: Describe emergent management of the patient with an ischemic stroke.

Question 23

Type: MCSA

A patient with a ruptured cerebral aneurysm is demonstrating drowsiness and confusion. On the Hunt and Hess scale, this patient would be rated as being a:

1. Grade 1

2. Grade 2

3. Grade 3

4. Grade 4

Correct Answer: 3

Rationale 1: A grade 1 is asymptomatic or is evidenced by minimal headache and slight nuchal rigidity.

Rationale 2: A grade 2 is evidenced by moderate-to-severe headache, nuchal rigidity, and no neurologic deficit other than cranial nerve palsy.

Rationale 3: A grade 3 is evidenced by drowsiness, confusion, or mild focal deficit.

Rationale 4: In grade 4 there is stupor, moderate-to-severe hemiparesis, possible early decerebrate rigidity, and vegetative disturbances.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-7: Compare and contrast intracerebral hemorrhage and subarachnoid hemorrhage.

Question 24

Type: MCSA

A patient develops cerebral vasospasm after a ruptured cerebral aneurysm. Collaborative treatment should be focused on:

1. Reducing blood pressure

2. Dehydrating the patient

3. Concentrating red blood cells

4. Volume expansion

Correct Answer: 4

Rationale 1: Blood pressure needs to be maintained 1060 mm Hg above baseline and/or kept between 150200 mm Hg systolic blood pressure.

Rationale 2: Dehydration is not desirable as it will increase blood viscosity and increase the risk of clot formation.

Rationale 3: Keeping the RBCs concentrated is also not desirable as this can lead to the formation of blood clots.

Rationale 4: Vasospasm management is hypertensive, hypervolemic, and hemodilution (HHH) therapy. Volume expansion raises the blood pressure and decreases blood viscosity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-8: Describe the three most common complications following rupture of an aneurysm and subarachnoid hemorrhage.

Question 25

Type: MCSA

While providing oral medications to a patient recovering from a stroke, the nurse notices that the patient coughs repeatedly and has difficulty clearing the throat. What should the nurse do?

1. Change the diet to full liquid.

2. Change the diet to soft.

3. Request a physical therapy consult.

4. Request a swallowing evaluation by speech therapy.

Correct Answer: 4

Rationale 1: This patient needs to be made NPO immediately. A nutritional consult needs to be done in order to determine an alternative means of providing nutrition for this patient, such enteral or parenteral routes.

Rationale 2: This patient needs to be made NPO immediately. A nutritional consult needs to be done in order to determine an alternative means of providing nutrition for this patient.

Rationale 3: A PT consult would be done but it would be for promoting mobility and preventing muscle atrophy.

Rationale 4: Dysphagia, or difficulty swallowing, is very common post stroke and is a major risk factor for developing aspiration pneumonia. The nurse should keep the patient NPO and ask for a speech therapy order for a swallowing evaluation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-9: Discuss screening for dysphagia in the stroke survivor.

Question 26

Type: MCMA

While conducting a health history the nurse suspects a patient with headaches is demonstrating signs of a brain tumor. How did the patient most likely describe the headaches to the nurse?

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

Standard Text: Select all that apply.

1. Worse in the morning

2. Worsen when coughing

3. Become severe when bending to tie shoes

4. Worse in the evening

5. Relieved by over-the-counter pain medication

Correct Answer: 1,2,3

Rationale 1: The headache associated with a brain tumor is typically worse in the morning.

Rationale 2: The headache associated with a brain tumor will worsen with coughing.

Rationale 3: The headache associated with a brain tumor will worsen with a position change such as bending over.

Rationale 4: The headache associated with a brain tumor is not worse in the evening.

Rationale 5: The headache associated with a brain tumor will not respond to usual headache remedies.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-1: List the common manifestations of brain tumors and explain their causation.

Question 27

Type: MCMA

The nurse provides intravenous dexamethasone (Decadron) 10 mg to a patient with a metastatic brain tumor. What patient outcomes would indicate that the medication is effective?

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

Standard Text: Select all that apply.

1. Neurologic symptoms improve within 12 hours

2. Reduced intracranial pressure

3. Neurologic symptoms improve immediately

4. Reduced respiratory rate

5. Increased heart rate and blood pressure

Correct Answer: 1,2

Rationale 1: Administration of dexamethasone can produce a reduction in cerebral edema and an improvement in neurologic symptoms most commonly in 12 to 24 hours

Rationale 2: The decline in cerebral edema and ICP can persist for as long as 72 hours.

Rationale 3: Administration of dexamethasone improves neurologic symptoms within 12 to 24 hours and not immediately.

Rationale 4: Dexamethasone does not affect the respiratory rate.

Rationale 5: Dexamethasone does not affect the heart rate or blood pressure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 11-2: Explain why glucocorticoids are administered to patients with brain tumors.

Question 28

Type: MCMA

The nurse is concerned that a patient recovering from a craniotomy for a malignant brain tumor is at risk for developing a deep vein thrombosis. What interventions would be appropriate for 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. Apply graduated compression stockings as indicated.

2. Administer subcutaneous low-molecular weight heparin (LMWH) 5,000 units twice a day as prescribed.

3. Administer enoxaparin 40 mg each day.

4. Position with the legs of the bed elevated.

5. Perform bedside passive range of motion exercises every 8 hours.

Correct Answer: 1,2,3

Rationale 1: Graduated compression stockings have been shown to decrease the occurrence of venous thrombosis without increasing intracranial pressure.

Rationale 2: The use of low-molecular weight heparin is an alternative to the use of compression boots to reduce the risk for venous thrombosis.

Rationale 3: The use of enoxaparin 40 mg each day is an alterative to the use of compression boots to reduce the risk for venous thrombosis.

Rationale 4: Elevating the legs of the bed will not reduce the development of venous thrombosis in this patient.

Rationale 5: Passive range of motion exercises every 8 hours will not reduce the development of venous thrombosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-4: Summarize strategies used to prevent common complications post craniotomy.

Question 29

Type: MCMA

A patient being treated for a cardiac dysrhythmia is demonstrating signs of an ischemic stroke. What assessment findings alerted the nurse to the development of this complication?

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

Standard Text: Select all that apply.

1. Garbled speech

2. Inability to see out of the right eye

3. Complaint of a sudden severe headache

4. New onset of left arm and leg weakness

5. Sudden onset of pain and swelling in one lower extremity limb

Correct Answer: 1,2,3,4

Rationale 1: Difficulty understanding speech or speaking is symptom of an ischemic stroke.

Rationale 2: The inability to see out of one eye is a symptom of an ischemic stroke.

Rationale 3: A new onset of a sudden severe headache is a symptom of an ischemic stroke.

Rationale 4: The onset of weakness on one side of the body is a symptom of an ischemic stroke.

Rationale 5: The sudden onset of pain and swelling in one lower extremity limb is not a symptom of ischemic stroke but rather a venous thromboembolism.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-5: Compare and contrast the mechanisms of hemorrhagic and ischemic stroke.

Question 30

Type: MCMA

A patient is admitted with symptoms of an ischemic stroke. After further evaluation, it is determined that the patient is not a candidate for thrombolytic therapy. What interventions would be appropriate to reduce the patients blood pressure?

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

Standard Text: Select all that apply.

1. Assess for pain when measuring blood pressure.

2. Assess for bladder distention.

3. Assess neurologic function with every blood pressure assessment.

4. Administer medication to reduce blood pressure by 15% over 24 hours.

5. Provide antihypertensive medication to reduce pressure to normal levels.

Correct Answer: 1,2,3,4

Rationale 1: When blood pressure is elevated the nurse should assess for factors such as pain that can contribute to the patients hypertension.

Rationale 2: When blood pressure is elevated the nurse should assess for factors such as bladder distention that can contribute to the patients hypertension.

Rationale 3: While treating the elevated blood pressure, continual reassessment of neurologic function is recommended.

Rationale 4: When treatment is needed, blood pressure should be lowered by about 15% over the first 24 hours.

Rationale 5: Blood pressure should be lowered by about 15% over the first 24 hours and not to normal levels since this could cause cerebral hypoperfusion.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-6: Describe emergent management of the patient with an ischemic stroke.

Question 31

Type: MCMA

A patient receiving an infusion of heparin for treatment of a venous thromboembolism is diagnosed with an intracerebral hemorrhage. What interventions should the nurse anticipate for 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. Administering protamine sulfate

2. Administering vitamin K

3. Preparing for ventriculostomy placement

4. Preparing for surgery to clip the aneurysm

5. Preparing for endovascular embolization

Correct Answer: 1,3

Rationale 1: Protamine sulfate is used to revere heparin-associated intracerebral hemorrhage.

Rationale 2: Vitamin K is used to reverse the effects of warfarin (Coumadin).

Rationale 3: A ventriculostomy may need to be performed and an external ventricular drain inserted to drain CSF.

Rationale 4: Aneurysms are associated with subarachnoid hemorrhages.

Rationale 5: This is a treatment for an aneurysm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11-7: Compare and contrast intracerebral hemorrhage and subarachnoid hemorrhage.

Question 32

Type: MCMA

While recovering from surgery to repair an aneurysm the nurse is concerned the patient is experiencing vasospasm. What did the nurse assess in 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. Increased lethargy

2. Elevated body temperature

3. Nuchal rigidity

4. Dysphagia

5. Ventricular dysrhythmia

Correct Answer: 1,2,3,4

Rationale 1: A change in mental status such as lethargy is a symptom associated with vasospasm.

Rationale 2: Elevated body temperature is a symptom associated with vasospasm.

Rationale 3: Neck stiffness is a symptom associated with vasospasm.

Rationale 4: Dysphagia is a symptom associated with vasospasm.

Rationale 5: Ventricular dysrhythmia is not a symptom associated with vasospasm.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11-8: Describe the three most common complications following rupture of an aneurysm and subarachnoid hemorrhage.

Question 33

Type: MCMA

A patient recovering from a stroke is demonstrating signs of dysphagia. The patient is scheduled for a barium swallow because this diagnostic test will:

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

Standard Text: Select all that apply.

1. Identify the presence of an aspiration

2. Identify the presence of abnormalities

3. Visualize the sequence of events of a swallow

4. Analyze muscle activities

5. Correct swallowing abnormalities

Correct Answer: 1,2

Rationale 1: A barium swallow may identify the presence of an aspiration.

Rationale 2: A barium swallow may identify subtle anatomic abnormalities. This test is especially useful if more than one abnormality is discovered.

Rationale 3: Videofluoroscopy visualizes the sequence of events of a swallow.

Rationale 4: Videofluoroscopy analyzes muscle activities.

Rationale 5: The barium swallow does not correct swallowing abnormalities.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11-9: Discuss screening for dysphagia in the stroke survivor.

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

Copyright 2012 by Pearson Education, Inc.

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