NURS424 Chapter 16 Determinants and Assessment of
Cerebral Function Questions With Complete Solutions
A client becomes hypercapnic after being oversedated. The
nurse acts quickly to reverse this situation to prevent which
physiologic changes? Correct Answers Increase in cerebral
blood flow - hypercapnia can cause increase in cerebral blood
flow, which can
result in decreased intracranial adaptive capacity
increase in cerebral blood volume - hypercapnia can cause an
increase in cerebral blood volume, which can result in decreased
intracranial adaptive capacity
A client has developed cerebral edema from a metabolic
disorder. Which nursing intervention would help this client
maintain normal ICP? Correct Answers Keep the client's neck
in a neutral alignment. This allows optimal venous return to help
the body reduce cerebral spinal fluid amounts as is outlined in
the Monro-Kellie hypothesis
A client is diagnosed with a benign tumor in the medulla
oblongata. The nurse would plan to assess this client for changes
in which functions? Correct Answers heart rate, blood pressure,
respiratory rate and swallowing
A client presented to the ED with a GCS score of 12. The nurse
reassessed this client 15 minutes after arrival and assigned a
score of 10. What action should the nurse take? Correct Answers
Collaborate with the ED physician immediately.
Deterioration in the GCS score is significant and should be
relayed to the physician immediately.
, A CT scan has been ordered for a patient who sustained a head
injury playing football. A nurse who is new to the ED asks why
an MRI was not ordered instead. Which responses, made by a
seasoned ED nurse, are correct? Correct Answers "A CT is
quicker" - A CT scan is quicker than an MRI and time is
important in trauma
"MRIs don't show bones as well" - MRI scans do not image
bone structure as well as CT scans. In initial treatment, looking
for bone injury is very important.
A nurse is assessing the client for presence of "doll's eyes."
When the nurse turns the client's head side to side, the client's
eyes move in the directions opposite of the movement. How
would the nurse interpret this response? Correct Answers This
is a normal response. The normal response to the head being
moved from side to side is that the eyes move in the opposite
direction.
A nurse is conducting initial assessment on a client who reports
that he fell out of a tree while hunting. During the assessment,
the clients becomes unconscious, with arms pronating and
extending straight out, wrists and fingers flexing, and feet
plantar flexing. The nurse calls for help because this client is
exhibiting which posturing? Correct Answers decerebrate
decerebrate posturing is abnormal extension and is an omnious
sign indicating brainstem dysfunction
A&O Correct Answers PERRLA, eyes move as head turns,
purposeful movements; responds to stimuli, regular rate/pattern
of breathing
Cerebral Function Questions With Complete Solutions
A client becomes hypercapnic after being oversedated. The
nurse acts quickly to reverse this situation to prevent which
physiologic changes? Correct Answers Increase in cerebral
blood flow - hypercapnia can cause increase in cerebral blood
flow, which can
result in decreased intracranial adaptive capacity
increase in cerebral blood volume - hypercapnia can cause an
increase in cerebral blood volume, which can result in decreased
intracranial adaptive capacity
A client has developed cerebral edema from a metabolic
disorder. Which nursing intervention would help this client
maintain normal ICP? Correct Answers Keep the client's neck
in a neutral alignment. This allows optimal venous return to help
the body reduce cerebral spinal fluid amounts as is outlined in
the Monro-Kellie hypothesis
A client is diagnosed with a benign tumor in the medulla
oblongata. The nurse would plan to assess this client for changes
in which functions? Correct Answers heart rate, blood pressure,
respiratory rate and swallowing
A client presented to the ED with a GCS score of 12. The nurse
reassessed this client 15 minutes after arrival and assigned a
score of 10. What action should the nurse take? Correct Answers
Collaborate with the ED physician immediately.
Deterioration in the GCS score is significant and should be
relayed to the physician immediately.
, A CT scan has been ordered for a patient who sustained a head
injury playing football. A nurse who is new to the ED asks why
an MRI was not ordered instead. Which responses, made by a
seasoned ED nurse, are correct? Correct Answers "A CT is
quicker" - A CT scan is quicker than an MRI and time is
important in trauma
"MRIs don't show bones as well" - MRI scans do not image
bone structure as well as CT scans. In initial treatment, looking
for bone injury is very important.
A nurse is assessing the client for presence of "doll's eyes."
When the nurse turns the client's head side to side, the client's
eyes move in the directions opposite of the movement. How
would the nurse interpret this response? Correct Answers This
is a normal response. The normal response to the head being
moved from side to side is that the eyes move in the opposite
direction.
A nurse is conducting initial assessment on a client who reports
that he fell out of a tree while hunting. During the assessment,
the clients becomes unconscious, with arms pronating and
extending straight out, wrists and fingers flexing, and feet
plantar flexing. The nurse calls for help because this client is
exhibiting which posturing? Correct Answers decerebrate
decerebrate posturing is abnormal extension and is an omnious
sign indicating brainstem dysfunction
A&O Correct Answers PERRLA, eyes move as head turns,
purposeful movements; responds to stimuli, regular rate/pattern
of breathing
