EXAM 3 - NURC 424 QUESTIONS WITH COMPLETE
SOLUTIONS
The nurse is caring for a patient who sustained major head
trauma after a motor vehicle collision. The patient's lab values
reveal a BUN of 47, creatinine of 3.1, hemoglobin of 6.8 and
potassium level of 6.1. Which provider order would the nurse
question?
mannitol
Mannitol (Osmitrol)
class: osmotic diuretic
Indication increased ICP, oliguric renal failure, edema,
intraocular pressure
Action: inhibits reabsorption of water and electrolytes by
increasing osmotic pressure, excreted by kidneys
Nursing Considerations:
- may cause phlebitis at IV site
- may cause dehydration, fluid and electrolyte imbalances
- monitor neuro status
- administer via a filter
During the assessment of a patient with a head injury from a fall,
the patient reports a sudden severe headache, nausea and
vomiting. The nurse notes right sided weakness, slurred speech
and a right facial droop. For which collaborative care procedure
would the nurse expect to prepare the patient?
Burr holes
,A nurse is monitoring a patient with increased intracranial
pressure using a ventriculostomy. The patient's ICP monitor
indicates that the P2 wave is higher than the other waves. Which
provider order would the nurse anticipate?
SURGERY
A nurse is caring for a patient after resection of a temporal lobe
tumor. The patient begins to complain of headache and nausea.
Which action should the nurse take?
elevate HOB
A nurse is assisting the provider during a neurological
assessment on an unconscious adult patient with increased
intracranial pressure. When holding the eyelids open and
moving the patient's head to the right side, the eyes move to the
right side. How would the nurse report this finding?
normal oculocephalic reflex
cranial nerve 1
Olfactory (smell)
cranial Nerve 2
Optic - vision
cranial never III controls what?
oculomotor - eye movement
cranial nerve IV
Trochlear - motor: eye movement
cranial Nerve V
, trigeminal nerve function
BOTH S and M
sensory: face, teeth, tongue
motor: muscles of mastication
Cranial Nerve VI
the abducens nerve which innervates the lateral rectus muscle
(abducts the eye)
Cranial Nerve VII
Facial - controls most facial expressions & secretion of tears &
saliva & taste
Cranial VIII
vestibulocochlear - hearing, balance, equilibrium
Cranial nerve IX
Glossopharyngeal - taste & senses carotid blood pressure
Cranial X
vagus
=gag reflex
=movement of uvula and soft palate
Cranial XI
accessory nerve
Cranial nerve XII
Hypoglossal nerve - motor
innervates muscles of the tongue
SOLUTIONS
The nurse is caring for a patient who sustained major head
trauma after a motor vehicle collision. The patient's lab values
reveal a BUN of 47, creatinine of 3.1, hemoglobin of 6.8 and
potassium level of 6.1. Which provider order would the nurse
question?
mannitol
Mannitol (Osmitrol)
class: osmotic diuretic
Indication increased ICP, oliguric renal failure, edema,
intraocular pressure
Action: inhibits reabsorption of water and electrolytes by
increasing osmotic pressure, excreted by kidneys
Nursing Considerations:
- may cause phlebitis at IV site
- may cause dehydration, fluid and electrolyte imbalances
- monitor neuro status
- administer via a filter
During the assessment of a patient with a head injury from a fall,
the patient reports a sudden severe headache, nausea and
vomiting. The nurse notes right sided weakness, slurred speech
and a right facial droop. For which collaborative care procedure
would the nurse expect to prepare the patient?
Burr holes
,A nurse is monitoring a patient with increased intracranial
pressure using a ventriculostomy. The patient's ICP monitor
indicates that the P2 wave is higher than the other waves. Which
provider order would the nurse anticipate?
SURGERY
A nurse is caring for a patient after resection of a temporal lobe
tumor. The patient begins to complain of headache and nausea.
Which action should the nurse take?
elevate HOB
A nurse is assisting the provider during a neurological
assessment on an unconscious adult patient with increased
intracranial pressure. When holding the eyelids open and
moving the patient's head to the right side, the eyes move to the
right side. How would the nurse report this finding?
normal oculocephalic reflex
cranial nerve 1
Olfactory (smell)
cranial Nerve 2
Optic - vision
cranial never III controls what?
oculomotor - eye movement
cranial nerve IV
Trochlear - motor: eye movement
cranial Nerve V
, trigeminal nerve function
BOTH S and M
sensory: face, teeth, tongue
motor: muscles of mastication
Cranial Nerve VI
the abducens nerve which innervates the lateral rectus muscle
(abducts the eye)
Cranial Nerve VII
Facial - controls most facial expressions & secretion of tears &
saliva & taste
Cranial VIII
vestibulocochlear - hearing, balance, equilibrium
Cranial nerve IX
Glossopharyngeal - taste & senses carotid blood pressure
Cranial X
vagus
=gag reflex
=movement of uvula and soft palate
Cranial XI
accessory nerve
Cranial nerve XII
Hypoglossal nerve - motor
innervates muscles of the tongue
