Chapter 18 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 18

Question 1

Type: MCSA

A patient comes into the emergency department with complaints of headache, lethargy, and vomiting. He reports being hit in the head by a batted baseball during a company picnic about 6 weeks ago. The nurse would ask additional assessment questions regarding which condition?

1. Acute subdural hematoma

2. Subacute subdural hematoma

3. Epidural hematoma

4. Chronic subdural hematoma

Correct Answer: 4

Rationale 1: An acute subdural hematoma occurs less than 48 hours from injury so this is an unlikely injury pattern.

Rationale 2: Subacute subdural hematoma occurs 48 hours to 2 weeks from injury so this is an unlikely injury pattern.

Rationale 3: With an epidural hematoma, there is a brief loss of consciousness immediately following the injury, followed by an episode of being alert and oriented, and then a loss of consciousness again. The patient did not describe a loss of consciousness.

Rationale 4: There are three categories of subdural hematoma, based on time of onset of symptoms. Chronic hematoma develops greater than 2 weeks from injury. Since the patient had a head injury a few weeks prior, the nurse would have highest concern regarding a chronic subdural hematoma.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-3

Question 2

Type: MCSA

The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which assessment finding would warrant immediate collaboration with the surgeon?

1. Urine output has dropped from 100 mL each hour to 60 mL per hour.

2. The patients hand grasps are weak bilaterally.

3. Fine crackles can be auscultated in the lung bases bilaterally.

4. The pupil on the side of the injury has become fixed and dilated.

Correct Answer: 4

Rationale 1: Urine output of 60 mL per hour is considered normal and would not require emergency collaboration. If urine output continues to drop, increasing intravenous fluid administration rate may be considered.

Rationale 2: Weak hand grasps bilaterally may or may not indicate a worsening neurological condition. Bilateral weakness is not as significant for emergent conditions as is unilateral weakness.

Rationale 3: Fine crackles auscultated bilaterally in lung bases can be due several conditions, such as immobility, and is not indicative of an emergent neurological condition.

Rationale 4: Nursing care associated with epidural hematoma focuses on diligent neurological assessment. The nurse must look for sudden changes in level of consciousness and for the presence of a fixed and dilated pupil on the side of injury. These findings suggest bleeding has recurred and represents an emergent medical situation.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-3

Question 3

Type: MCSA

The family of a patient with a concussion is concerned that the patient continues to complain of and demonstrate ongoing neurological deficits even though the injury occurred 6 weeks ago. What information should the nurse provide?

1. Symptoms of the concussion will continue for most of the patients life.

2. The concussion might be healed; however, the patient will not recover from the symptoms.

3. Symptoms of the concussion will come and go depending upon the patients health status.

4. Symptoms of a concussion can last 3 months or more.

Correct Answer: 4

Rationale 1: Symptoms of the concussion will not continue for most of the patients life.

Rationale 2: The patient will recover from the symptoms.

Rationale 3: The symptoms of the concussion will not come and go depending upon the patients health status.

Rationale 4: Since almost half of patients with concussion develop postconcussive syndromes that include symptoms similar to those on presentation to the emergency department; these symptoms may continue for 3 months or more after injury.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-3

Question 4

Type: MCSA

A patient diagnosed with mild diffuse axonal injury is being admitted to the intensive care unit. The nurse would anticipate which assessment findings?

1. The accident causing this injury occurred several weeks ago.

2. There are symptoms that are similar to those demonstrated by a patient who sustained a concussion.

3. There is dilation of the pupils for several hours post injury.

4. There is presence of coma that may last for an extended period of time.

Correct Answer: 2

Rationale 1: Mild diffuse axonal injury generally manifests quickly after the accident. Onset of symptoms weeks after injury is more likely seen in patients with chronic subdural hematoma.

Rationale 2: Mild diffuse axonal injury may contribute to post-concussive syndrome experienced by many patients following a brain concussion.

Rationale 3: Dilated pupils are not necessarily associated with any degree of diffuse axonal injury.

Rationale 4: A long term comatose state is seen in severe diffuse axonal injuries.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-3

Question 5

Type: MCSA

A patient with a moderate diffuse head injury is demonstrating a variety of neurological symptoms. What is the priority when caring for this patient?

1. Electrolyte replacements

2. Maintain adequate fluid volume.

3. Supporting nutritional needs

4. Maintain stable cerebral perfusion pressure.

Correct Answer: 4

Rationale 1: Electrolyte management is important to patients with head injury but is not the intervention of highest priority.

Rationale 2: Fluid volume management is important when caring for patients with brain injury, but is not the highest priority.

Rationale 3: Support of nutritional needs is important for all patients, but is not the intervention of highest priority for patients with brain injury.

Rationale 4: Since diffuse head injuries are not limited to a localized area, this makes them more difficult to detect and treat. Management in the acute care phase includes diligent and frequent neurological assessments and pain management. When moderate-to-severe injury is present, priority management includes interventions to lower intracranial pressure, increase cerebral perfusion pressure, and stabilize vital signs, which all contribute to an improved outcome.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-3

Question 6

Type: MCSA

A patient is admitted with a traumatic brain injury. The nurse would anticipate participating in interventions toward which immediate goal?

1. Reducing cerebral swelling

2. Confining inflammation to one area

3. Supporting absorption of debris from neuronal death

4. Limiting ischemic tissue injury

Correct Answer: 4

Rationale 1: Cerebral swelling can cause secondary injury, but this is not the immediate goal.

Rationale 2: Inflammation can cause secondary injury but this is not the immediate goal when caring for someone with TBI.

Rationale 3: Eventually the body will rid itself for debris from death of any cells, but this is not the immediate goal.

Rationale 4: The first goal in treating traumatic brain injury is to limit the primary ischemic tissue injury by aggressive prevention and treatment of hypoxia and hypotension. If efforts to meet this goal are successful, cerebral swelling neuronal death and cerebral inflammation can be limited as well.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-5

Question 7

Type: MCMA

A patient with traumatic brain injury has had placement of an intraventricular catheter (IVC). The nurse participates in level two interventions to reduce intracranial pressure (ICP) through which uses of this catheter?

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

Standard Text: Select all that apply.

1. Assessing of color of the cerebral spinal fluid

2. Assessing of the amount of cerebral spinal fluid

3. Instillation of hyperosmolar therapy via the catheter

4. Draining CSF

5. Directly monitoring the ICP

Correct Answer: 1,2,4,5

Rationale 1: By assessing the color of the cerebral spinal fluid the nurse can identify variation from normal. These variations may indicate bleeding or infection that would increase ICP.

Rationale 2: By using IVC measurements, the nurse can monitor amount of CSF.

Rationale 3: Hyperosmolar therapy is not instilled via this catheter.

Rationale 4: Therapeutic drainage of CSF via the IVC can reduce ICP.

Rationale 5: Insertion of an IVC allows for direct measurement of the ICP.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-5

Question 8

Type: MCSA

A patient with traumatic brain injury continues to have increased intracranial pressure despite conventional therapeutic interventions. The nurse would anticipate which level four intervention?

1. High-dose barbiturate therapy

2. High-volume intravenous fluids

3. Hyperbaric oxygen therapy

4. Hyperosmolar therapy

Correct Answer: 1

Rationale 1: Medical intervention for the treatment of increased intracranial pressure refractory to all other medical interventions may include the use of high-dose barbiturates. This intervention induces a comatose state and significantly decreases cerebral oxygen requirements.

Rationale 2: High-volume intravenous fluid administration would be more likely to increase intracranial pressure.

Rationale 3: Hyperbaric oxygen therapy is not a treatment identified to help with refractory increased intracranial pressure.

Rationale 4: Hyperosmolar therapy is used as a level two intervention, not to treat refractory increase in intracranial pressure.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-5

Question 9

Type: MCSA

A patient diagnosed with a traumatic brain injury is receiving mannitol. The nurse would evaluate which findings as indicating this therapy is having its desired effects?

1. ICP is increasing

2. Serum sodium is 148 mEq/L

3. Serum osmolality is 300 mOsm

4. Osmotic gap is 12

Correct Answer: 4

Rationale 1: Mannitol is given to decrease ICP.

Rationale 2: The desired response is serum sodium above 160 mEq/L.

Rationale 3: The desired effect is serum osmolality greater than 320 mOsm.

Rationale 4: The desired effect is an osmotic gap greater than 10.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 18-6

Question 10

Type: MCSA

A patient being treated for increased intracranial pressure from a traumatic brain injury demonstrates an increase in pressure with minimal care activity. What instruction should the nurse provide the nursing student assisting with care for this patient?

1. We will let this patient rest between his bath and changing his linens.

2. We are going to bath this patient, get his linens changed, suction him, and do all of our other care early this morning, so he can get a long rest this afternoon.

3. Be certain that we dont raise this patients head above 10 degrees during his bath.

4. You have to learn to suction patients with traumatic brain injury very quickly, taking no more than 30 seconds.

Correct Answer: 1

Rationale 1: When simple activities result in an increase in intracranial pressure it is necessary to space care in such a way to allow the patients ICP to recover between events.

Rationale 2: Stacking care activities will be detrimental to this patient.

Rationale 3: The head of the bed should be elevated to 30 degrees to reduce intracranial pressure without compromising cerebral perfusion pressure.

Rationale 4: The patient should be suctioned for 10 seconds or less to reduce an increase in intracranial pressure caused by the suctioning.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-6

Question 11

Type: MCMA

The admission orders for a patient with traumatic brain injury say to keep the patients head elevated with neutral body positioning. Which patient positioning would the nurse consider as meeting this requirement?

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

Standard Text: Select all that apply.

1. The patients head is supported on two pillows.

2. The head of the patients bed is elevated to 20 degrees.

3. The patients hips are flexed at less than 90 degrees.

4. The neck is in the patients position of comfort, which is rotated to the left.

5. The patient is facing forward.

Correct Answer: 3,5

Rationale 1: Placing the head on two pillows flexes the neck which violates the idea of a neutral position.

Rationale 2: Typically the head of the patients bed should be elevated to 30 degrees.

Rationale 3: Hip flexion of greater than 90 degrees should be avoided.

Rationale 4: The neck should not be rotated.

Rationale 5: Neutral positioning for the head and neck is a forward facing position.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 18-6

Question 12

Type: MCSA

A patient being treated for a traumatic brain injury is febrile with a temperature of 100F. What is the priority nursing intervention?

1. Culture the patients urine.

2. Contact the primary health care provider.

3. Administer the prn antipyretic.

4. Have the patient cough and deep breath more frequently.

Correct Answer: 3

Rationale 1: Urinary tract infection will cause increased temperature and this may be a necessary intervention. It is not, however, the primary intervention.

Rationale 2: It is important to keep the primary health care provider apprised of the patients condition, but this is not the primary intervention.

Rationale 3: Hyperthermia will increase cerebral metabolic rates, which will increase cerebral oxygen demands. The patient with a temperature should be provided with antipyretics or other measures to cool the body and reduce the temperature.

Rationale 4: Implementing pulmonary hygiene activities will not reduce the patients body temperature.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-6

Question 13

Type: MCMA

The patient with traumatic brain injury has been intubated and placed on mechanical ventilation. Which nursing interventions would help optimize oxygenation?

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

Standard Text: Select all that apply.

1. Preoxygenate the patient prior to suctioning.

2. Use very low vacuum pressure when suctioning the patient.

3. Limit suction passes to 10 seconds or less.

4. Suction when PaCO2 levels rise above 40 mm Hg.

5. Suction the patient before and after scheduled turns.

Correct Answer: 1,3

Rationale 1: To maintain adequate oxygenation during suctioning, preoxygenation is indicated.

Rationale 2: Low vacuum pressure will not adequately remove secretions, making suctioning ineffective or necessary more often. This will not increase oxygenation.

Rationale 3: For patients at risk for increased ICP, total suction time should be limited to no more than 10 seconds.

Rationale 4: Increased PaCO2 level may or may not be associated with need to suction. Desired PaCO2 level is 35 to 45 mm Hg.

Rationale 5: The patient should be suctioned as needed, but nursing activities should be spaced as much as possible. Routine suctioning both before and after scheduled turns is not likely to be necessary and would decrease oxygenation.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-6

Question 14

Type: MCSA

A patient being treated for a traumatic brain injury is demonstrating signs of contractures as a complication associated with immobility. Which nursing intervention is indicated?

1. Maintain neutral body position.

2. Turn and reposition every 4 hours.

3. Apply antiembolism stockings.

4. Ensure oxygen saturation level of 92%.

Correct Answer: 1

Rationale 1: A neutral body position will help prevent contractures in that it avoids flexion.

Rationale 2: The patient should be turned and repositioned every 2 hours to help prevent contractures.

Rationale 3: Applying antiembolism stockings will prevent the immobility complication of deep vein thrombosis development and not prevent contractures.

Rationale 4: The patients oxygen saturation should be maintained at 92% or higher however this will not prevent the complication of contracture.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-7

Question 15

Type: MCSA

A patient with a traumatic brain injury is being treated for diabetes insipidus. Which finding would the nurse evaluate as indicating treatment is effective?

1. Potassium level has decreased.

2. Blood pressure has decreased.

3. Serum sodium level is increased.

4. Urine output has decreased.

Correct Answer: 4

Rationale 1: Potassium level assessment is not an essential indicator of success in the treatment of a patient with diabetes insipidus.

Rationale 2: The large amount of fluid lost in diabetes insipidus causes hypotension. Continued decrease in blood pressure does not indicate that treatment is successful.

Rationale 3: Continued elevation of serum sodium level would indicate that treatment is not effective.

Rationale 4: Treatment for diabetes insipidus includes replacing intravascular volume and providing synthetic antidiuretic hormone. Evidence that a patient is improving would include a decrease in urine output with an increase in specific gravity.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 18-7

Question 16

Type: MCMA

A patient is admitted to the emergency department after sustaining injury in a fall. Which assessment findings would the nurse immediately communicate to the emergency department physician?

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

Standard Text: Select all that apply.

1. The patient is taking a sulfa drug for urinary tract infection.

2. The patient has a bluish discoloration behind his ear.

3. The patients nose is running.

4. The patients smile is crooked.

5. The patients tongue is lacerated.

Correct Answer: 2,3,4

Rationale 1: Medication history is not the most important information during emergent assessment.

Rationale 2: Mastoid ecchymosis or Battles sign can indicate basilar skull fracture. This assessment requires immediate attention.

Rationale 3: The fluid in the patients nose may be cerebral spinal fluid, not mucous. This is an important assessment of basilar skull fracture.

Rationale 4: Facial nerve paralysis may indicate basilar skull fracture.

Rationale 5: Tongue laceration is important, but is not an emergent problem.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-1

Question 17

Type: MCSA

A patient diagnosed with a traumatic brain injury is demonstrating signs of cerebral salt wasting. Which interventions would the nurse include in this patients plan of care?

1. Restrict fluids.

2. Restrict sodium.

3. Monitor intravenous normal saline administration.

4. Provide potassium chloride intravenous replacements.

Correct Answer: 3

Rationale 1: The patients fluids should not be restricted since this will exacerbate the hypovolemia characteristic of this disorder.

Rationale 2: The patient should not be on a sodium restriction.

Rationale 3: Cerebral salt wasting is a state of hypovolemia so the patient should be treated with salt replacement via intravenous saline and oral salt tablets.

Rationale 4: Potassium replacements are not indicated in the treatment of this complication.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18-7

Question 18

Type: MCSA

A patient has been diagnosed with a benign brain tumor with resultant increase in intracranial pressure. The patient is confused and occasionally combative. His wife expresses concern about how to tell their two young sons. Which nursing diagnosis will guide initial selection of nursing interventions?

1. Ineffective Breathing Pattern

2. Decreased Intracranial Adaptive Capacity

3. Impaired Physical Mobility

4. Risk for Aspiration

Correct Answer: 2

Rationale 1: There is no assessment information that indicates this patients breathing pattern is altered.

Rationale 2: Increased ICP is a result of decreased ability of the intracranial protective mechanisms to compensate for the increase in brain volume caused by the presence of a mass.

Rationale 3: There is no information given that supports the nursing diagnosis of Impaired Mobility.

Rationale 4: There is no current evidence that this patient is at risk for aspiration.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18-2

Question 19

Type: MCMA

A patient is brought to the hospital after being found in the floor at the bottom of a flight of stairs. The patient has an obvious depressed skull fracture and is bleeding from her right ear. Initially, the nurse assesses the patency of the patients airway, her breathing, and the rate and rhythm of her pulse. What assessments and questions will be part of the nurses secondary survey?

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

Standard Text: Select all that apply.

1. How did the injury occur?

2. What care was provided at the site of the injury?

3. Has anything like this ever happened before?

4. Blood pressure measurement will occur.

5. A general systems assessment will occur.

Correct Answer: 1,2,3,5

Rationale 1: The most obvious answer to this question is that the patient fell down the stairs, but this may be an incorrect assumption. The patient may have been injured in some other manner and it was a coincidence that it occurred at the bottom of a flight of stairs. Determining mechanism of injury is a part of the secondary survey.

Rationale 2: The nurse should determine what care has already been provided.

Rationale 3: Comorbid conditions or previous history is a part of the secondary survey.

Rationale 4: Blood pressure measurement is part of the primary survey.

Rationale 5: The general systems assessment is part of the secondary survey.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18-4

Question 20

Type: MCSA

A patient being treated for a traumatic brain injury for 3 days begins to seize. Which intervention is the nurses priority?

1. Administer fosphenytoin (Cerebyx) 4 mg per kg of patient body weight.

2. Keep the patient safe and maintain the airway.

3. Lower the head of the bed.

4. Initiate a recording of the patients cardiac rhythm.

Correct Answer: 2

Rationale 1: The first medication administered is more likely to be a benzodiazepine. Medication administration is not the highest priority.

Rationale 2: Priorities for the care of a patient with a traumatic brain injury that begins to demonstrate seizure activity include keeping the patient safe and maintain airway, breathing, and circulation.

Rationale 3: Lowering the head of the bed may or may not be indicated and is not the priority intervention.

Rationale 4: Seizure activity will interfere with an accurate recording of the patients cardiac rhythm.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18-7

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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