NRNP 6566 ADVANCED CARE OF ADULTS IN ACUTE
SETTINGS I WEEK 5 KNOWLEDGE CHECK 2026/2027 |
Questions and Verified Answers | Pass Guaranteed - A+
Graded
Domain 1: Neurologic Acute Care (15 Questions)
Q1: A 68-year-old male is brought to the emergency department after being found
confused at home. His wife reports he was normal this morning but became
increasingly lethargic over 4 hours. On examination, he opens his eyes to pain, localizes
to painful stimuli, and uses inappropriate words. His pupils are equal and reactive, and
he has no focal motor deficits. Vital signs reveal BP 158/92 mmHg, HR 88 bpm, RR 14
breaths/min, temperature 36.8°C, and SpO2 94% on room air. CT head is pending. What
is his Glasgow Coma Scale (GCS) score, and what is the most appropriate immediate
priority?
A. GCS 10; immediate intubation for airway protection
B. GCS 10; supplemental oxygen and prepare for emergent CT imaging
C. GCS 9; immediate hyperventilation to target PaCO2 25-30 mmHg
D. GCS 11; administer mannitol 1 g/kg IV bolus prophylactically
Correct Answer: B
,Rationale: The patient's GCS is calculated as follows: Eye opening to pain = 2, Best
motor response (localizes to pain) = 5, Best verbal response (inappropriate words) = 3.
Total GCS = 10. A GCS of 10 indicates moderate traumatic brain injury severity, but does
not automatically mandate immediate intubation if the airway is protected and
oxygenation is adequate. The immediate priority in altered mental status is to address
reversible causes and prevent secondary brain injury. Supplemental oxygen to maintain
SpO2 >94% addresses potential hypoxia, while emergent CT imaging is essential to
identify intracranial pathology (hemorrhage, mass lesion, stroke) causing the altered
mental status.
Option A is incorrect because while GCS ≤8 typically indicates need for airway
protection, this patient has a GCS of 10 with intact airway reflexes and adequate
oxygenation; prophylactic intubation is not indicated without respiratory compromise or
herniation signs. Option C is incorrect because hyperventilation is reserved for acute
herniation syndromes with impending brainstem compression, not for stable patients
with moderate alterations in consciousness; prophylactic hyperventilation causes
cerebral vasoconstriction and may worsen ischemia. Option D is incorrect because
mannitol is indicated for clinically significant cerebral edema or elevated ICP with signs
of herniation, not prophylactically; unnecessary osmotic therapy risks renal dysfunction
and electrolyte disturbances without therapeutic benefit.
Q2: A 72-year-old female with a history of atrial fibrillation on warfarin presents with
sudden onset right-sided weakness and aphasia. NIH Stroke Scale (NIHSS) score is 18.
CT head shows no hemorrhage. Her last known well time was 90 minutes ago. INR is
2.8. Blood pressure is 185/110 mmHg. What is the most appropriate immediate
management?
,A. Administer IV alteplase 0.9 mg/kg immediately after initiating nicardipine to lower BP
below 180/105 mmHg
B. Withhold thrombolysis due to elevated INR; proceed with mechanical thrombectomy
if large vessel occlusion confirmed
C. Administer IV alteplase 0.9 mg/kg immediately; blood pressure will normalize
spontaneously after reperfusion
D. Administer 4-factor prothrombin complex concentrate (PCC) to reverse warfarin, then
proceed with thrombolysis if INR normalizes within 4.5-hour window
Correct Answer: B
Rationale: The patient has an absolute contraindication to IV thrombolysis with
alteplase due to INR >1.7 (current INR 2.8) while on warfarin anticoagulation. Current
AHA/ASA guidelines specify that therapeutic anticoagulation with vitamin K antagonists
and INR elevation precludes IV alteplase administration due to unacceptable risk of
hemorrhagic transformation. Mechanical thrombectomy remains an option if CT
angiography confirms large vessel occlusion (internal carotid artery or proximal middle
cerebral artery M1 segment), as this intervention does not carry the same hemorrhagic
risk profile and can be performed up to 24 hours from last known well in selected
patients.
Option A is incorrect because administering alteplase with INR 2.8 violates absolute
contraindications and carries approximately 15-20% risk of symptomatic intracranial
hemorrhage. Option C is incorrect because uncontrolled hypertension (≥185/110
, mmHg) is itself a contraindication to thrombolysis, and assuming spontaneous
normalization is dangerous; moreover, the INR contraindication supersedes blood
pressure considerations. Option D is incorrect because while PCC can rapidly reverse
warfarin, the time required for INR normalization (typically 30-60 minutes) combined
with the 4.5-hour therapeutic window makes this approach impractical; the delay risks
exceeding the treatment window, and guidelines do not support this strategy for acute
stroke management.
Q3: A 58-year-old male post-craniotomy for meningioma resection develops acute
confusion and agitation on postoperative day 3. He is attempting to remove his IV lines
and does not recognize his family. CAM-ICU assessment is positive for delirium. Which
intervention represents the most appropriate first-line management strategy?
A. Initiate haloperidol 5 mg IV every 6 hours scheduled to control agitation
B. Implement multicomponent non-pharmacologic interventions including reorientation,
sleep hygiene optimization, early mobilization, and vision/hearing aids
C. Administer lorazepam 2 mg IV for immediate sedation and chemical restraint
D. Obtain emergent CT head to rule out postoperative hemorrhage before any other
interventions
Correct Answer: B
SETTINGS I WEEK 5 KNOWLEDGE CHECK 2026/2027 |
Questions and Verified Answers | Pass Guaranteed - A+
Graded
Domain 1: Neurologic Acute Care (15 Questions)
Q1: A 68-year-old male is brought to the emergency department after being found
confused at home. His wife reports he was normal this morning but became
increasingly lethargic over 4 hours. On examination, he opens his eyes to pain, localizes
to painful stimuli, and uses inappropriate words. His pupils are equal and reactive, and
he has no focal motor deficits. Vital signs reveal BP 158/92 mmHg, HR 88 bpm, RR 14
breaths/min, temperature 36.8°C, and SpO2 94% on room air. CT head is pending. What
is his Glasgow Coma Scale (GCS) score, and what is the most appropriate immediate
priority?
A. GCS 10; immediate intubation for airway protection
B. GCS 10; supplemental oxygen and prepare for emergent CT imaging
C. GCS 9; immediate hyperventilation to target PaCO2 25-30 mmHg
D. GCS 11; administer mannitol 1 g/kg IV bolus prophylactically
Correct Answer: B
,Rationale: The patient's GCS is calculated as follows: Eye opening to pain = 2, Best
motor response (localizes to pain) = 5, Best verbal response (inappropriate words) = 3.
Total GCS = 10. A GCS of 10 indicates moderate traumatic brain injury severity, but does
not automatically mandate immediate intubation if the airway is protected and
oxygenation is adequate. The immediate priority in altered mental status is to address
reversible causes and prevent secondary brain injury. Supplemental oxygen to maintain
SpO2 >94% addresses potential hypoxia, while emergent CT imaging is essential to
identify intracranial pathology (hemorrhage, mass lesion, stroke) causing the altered
mental status.
Option A is incorrect because while GCS ≤8 typically indicates need for airway
protection, this patient has a GCS of 10 with intact airway reflexes and adequate
oxygenation; prophylactic intubation is not indicated without respiratory compromise or
herniation signs. Option C is incorrect because hyperventilation is reserved for acute
herniation syndromes with impending brainstem compression, not for stable patients
with moderate alterations in consciousness; prophylactic hyperventilation causes
cerebral vasoconstriction and may worsen ischemia. Option D is incorrect because
mannitol is indicated for clinically significant cerebral edema or elevated ICP with signs
of herniation, not prophylactically; unnecessary osmotic therapy risks renal dysfunction
and electrolyte disturbances without therapeutic benefit.
Q2: A 72-year-old female with a history of atrial fibrillation on warfarin presents with
sudden onset right-sided weakness and aphasia. NIH Stroke Scale (NIHSS) score is 18.
CT head shows no hemorrhage. Her last known well time was 90 minutes ago. INR is
2.8. Blood pressure is 185/110 mmHg. What is the most appropriate immediate
management?
,A. Administer IV alteplase 0.9 mg/kg immediately after initiating nicardipine to lower BP
below 180/105 mmHg
B. Withhold thrombolysis due to elevated INR; proceed with mechanical thrombectomy
if large vessel occlusion confirmed
C. Administer IV alteplase 0.9 mg/kg immediately; blood pressure will normalize
spontaneously after reperfusion
D. Administer 4-factor prothrombin complex concentrate (PCC) to reverse warfarin, then
proceed with thrombolysis if INR normalizes within 4.5-hour window
Correct Answer: B
Rationale: The patient has an absolute contraindication to IV thrombolysis with
alteplase due to INR >1.7 (current INR 2.8) while on warfarin anticoagulation. Current
AHA/ASA guidelines specify that therapeutic anticoagulation with vitamin K antagonists
and INR elevation precludes IV alteplase administration due to unacceptable risk of
hemorrhagic transformation. Mechanical thrombectomy remains an option if CT
angiography confirms large vessel occlusion (internal carotid artery or proximal middle
cerebral artery M1 segment), as this intervention does not carry the same hemorrhagic
risk profile and can be performed up to 24 hours from last known well in selected
patients.
Option A is incorrect because administering alteplase with INR 2.8 violates absolute
contraindications and carries approximately 15-20% risk of symptomatic intracranial
hemorrhage. Option C is incorrect because uncontrolled hypertension (≥185/110
, mmHg) is itself a contraindication to thrombolysis, and assuming spontaneous
normalization is dangerous; moreover, the INR contraindication supersedes blood
pressure considerations. Option D is incorrect because while PCC can rapidly reverse
warfarin, the time required for INR normalization (typically 30-60 minutes) combined
with the 4.5-hour therapeutic window makes this approach impractical; the delay risks
exceeding the treatment window, and guidelines do not support this strategy for acute
stroke management.
Q3: A 58-year-old male post-craniotomy for meningioma resection develops acute
confusion and agitation on postoperative day 3. He is attempting to remove his IV lines
and does not recognize his family. CAM-ICU assessment is positive for delirium. Which
intervention represents the most appropriate first-line management strategy?
A. Initiate haloperidol 5 mg IV every 6 hours scheduled to control agitation
B. Implement multicomponent non-pharmacologic interventions including reorientation,
sleep hygiene optimization, early mobilization, and vision/hearing aids
C. Administer lorazepam 2 mg IV for immediate sedation and chemical restraint
D. Obtain emergent CT head to rule out postoperative hemorrhage before any other
interventions
Correct Answer: B
