Nur 2243 Final exam With complete solu on| RATED A+ |
NEW 2026
The nurse is caring for a pa ent with increased intracranial pressure. Which ac on is considered
unsafe?
a.
Aligning the neck with the body
b.
Clustering many nursing ac vi es
c.
Eleva ng the head of the bed 30 degrees
d.
Providing stool so#eners or laxa ves as ordered
ANS: B
It is important to minimize stress and ac vi es that could increase intracranial pressure.
Combining many nursing ac vi es could increase oxygen demand and intracranial pressure. This
would not be safe. Interven ons which can promote venous ou+low can help decrease
intracranial pressure. The stress of cons pa on or bowel movements can increase intracranial
pressure; stool so#eners or laxa ves can minimize this.
The earliest and most sensi ve assessment finding that would indicate an altera on in
intracranial regula on would be
a.
change in level of consciousness.
b.
,inability to focus visually.
c.
loss of primi ve reflexes.
d.
unequal pupil size.
ANS: A
A change in level of consciousness is the earliest and most sensi ve indica on of a change in
intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye
opening and verbal and motor response. The inability to focus may indicate a change, but it is
not one of the earliest indicators or a component of the GCS. Primi ve reflexes refers to those
reflexes found in a normal infant that disappear with matura on. These reflexes may reappear
with frontal lobe dysfunc on and may be tested for with a suspected brain injury, so it would be
the reappearance of primi ve reflexes. A change in pupil size or unequal pupils may indicate a
change, but they are not one of the earliest indicators or a component of the GCS.
When caring for the pa ent a#er a head injury, the nurse would be most concerned with
assessment findings which included respiratory changes,
a.
hypertension, and bradycardia.
b.
hypertension, and tachycardia.
c.
hypotension, and bradycardia.
d.
,hypotension, and tachycardia.
ANS: A
Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the
ominous late signs of increased intracranial pressure and indica ons of impending hernia on
(Cushings triad). It is bradycardia, not tachycardia, which is the component of this ominous
triad. It is hypertension, not hypotension, which is the component of this ominous triad.
Components of the GCS the nurse would use to assess a pa ent a#er a head injury include
a.
blood pressure.
b.
cranial nerve func on.
c.
head circumference.
d.
verbal responsiveness.
ANS: D
Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness.
The nurse would want to assess the blood pressure, but this is not a component of the coma
scale. Assessment of cranial nerve func on is appropriate as altera ons such as cranial nerve VI
palsies may occur, but this is not part of the coma scale. Increases in head circumference are
associated with altera ons in intracranial pressure in infants, but this is not part of the coma
scale.
Primary preven on strategies to reduce the occurrence of head injuries would include
a.
, blood pressure control.
b.
smoking cessa on.
c.
maintaining a healthy weight.
d.
violence preven on.
ANS: D
Injury preven on measures such as wearing a seat belt, helmet use, firearm safety, and violence
preven on programs reduce the risk of trauma c brain injuries. Blood pressure control and
exercising can decrease the risk of vascular disease, impac ng the cerebral arteries, rather than
head injuries. Smoking cessa on is one primary preven on strategy which can decrease the risk
of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.
The nurse preparing to care for a pa ent a#er a suspected stroke would ques on an order for
a(n)
a.
an hypertensive.
b.
an pyre c.
c.
osmo c diure c.
d.
NEW 2026
The nurse is caring for a pa ent with increased intracranial pressure. Which ac on is considered
unsafe?
a.
Aligning the neck with the body
b.
Clustering many nursing ac vi es
c.
Eleva ng the head of the bed 30 degrees
d.
Providing stool so#eners or laxa ves as ordered
ANS: B
It is important to minimize stress and ac vi es that could increase intracranial pressure.
Combining many nursing ac vi es could increase oxygen demand and intracranial pressure. This
would not be safe. Interven ons which can promote venous ou+low can help decrease
intracranial pressure. The stress of cons pa on or bowel movements can increase intracranial
pressure; stool so#eners or laxa ves can minimize this.
The earliest and most sensi ve assessment finding that would indicate an altera on in
intracranial regula on would be
a.
change in level of consciousness.
b.
,inability to focus visually.
c.
loss of primi ve reflexes.
d.
unequal pupil size.
ANS: A
A change in level of consciousness is the earliest and most sensi ve indica on of a change in
intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye
opening and verbal and motor response. The inability to focus may indicate a change, but it is
not one of the earliest indicators or a component of the GCS. Primi ve reflexes refers to those
reflexes found in a normal infant that disappear with matura on. These reflexes may reappear
with frontal lobe dysfunc on and may be tested for with a suspected brain injury, so it would be
the reappearance of primi ve reflexes. A change in pupil size or unequal pupils may indicate a
change, but they are not one of the earliest indicators or a component of the GCS.
When caring for the pa ent a#er a head injury, the nurse would be most concerned with
assessment findings which included respiratory changes,
a.
hypertension, and bradycardia.
b.
hypertension, and tachycardia.
c.
hypotension, and bradycardia.
d.
,hypotension, and tachycardia.
ANS: A
Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the
ominous late signs of increased intracranial pressure and indica ons of impending hernia on
(Cushings triad). It is bradycardia, not tachycardia, which is the component of this ominous
triad. It is hypertension, not hypotension, which is the component of this ominous triad.
Components of the GCS the nurse would use to assess a pa ent a#er a head injury include
a.
blood pressure.
b.
cranial nerve func on.
c.
head circumference.
d.
verbal responsiveness.
ANS: D
Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness.
The nurse would want to assess the blood pressure, but this is not a component of the coma
scale. Assessment of cranial nerve func on is appropriate as altera ons such as cranial nerve VI
palsies may occur, but this is not part of the coma scale. Increases in head circumference are
associated with altera ons in intracranial pressure in infants, but this is not part of the coma
scale.
Primary preven on strategies to reduce the occurrence of head injuries would include
a.
, blood pressure control.
b.
smoking cessa on.
c.
maintaining a healthy weight.
d.
violence preven on.
ANS: D
Injury preven on measures such as wearing a seat belt, helmet use, firearm safety, and violence
preven on programs reduce the risk of trauma c brain injuries. Blood pressure control and
exercising can decrease the risk of vascular disease, impac ng the cerebral arteries, rather than
head injuries. Smoking cessa on is one primary preven on strategy which can decrease the risk
of vascular disease. Maintaining a healthy weight can decrease the risk of vascular disease.
The nurse preparing to care for a pa ent a#er a suspected stroke would ques on an order for
a(n)
a.
an hypertensive.
b.
an pyre c.
c.
osmo c diure c.
d.
