NUR 417 FINAL EXAM (Lewis Evolve) Questions AND
ANSWERS LATEST AND COMPREHENSIVE VERSION
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The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a
ventriculostomy. What nursing intervention is priority?
A. Administer IV mannitol as ordered.
B. Ventilator use to hyperoxygenate the patient.
C. Use strict aseptic technique with dressing changes.
D. Be aware of changes in ICP related to cerebrospinal fluid leaks.
C
The priority nursing intervention is to use strict aseptic technique with dressing changes and any
handling of the insertion site to prevent the serious complication of infection. IV mannitol or
hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to
maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to
decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.
A patient is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody
fluid is draining from the patient’s nose. What action by the nurse is most appropriate?
A. Place packing in the patient's nares.
B. Apply a loose gauze pad under the patient's nose.
C. Place the patient in a modified Trendelenburg position.
D. Ask the patient to gently blow the nose to clear the drainage.
B
Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a
frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody
,fluid is present, the blood will coalesce, and a yellow halo will form if CSF is present. If clear
drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and
CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the
nurse should inform the provider immediately. The head of the bed may be raised to decrease the
CSF pressure so that a tear can seal. The nurse should not place packing in the nasal cavity, and
the patient should not sneeze or blow the nose.
A patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary
adenoma. What should the nurse consider as a sign of improvement?
A. Serum sodium of 120 mEq/L
B. Urine specific gravity of 1.001
C. Fasting blood glucose of 80 mg/dL
D. Serum osmolality of 290 mOsm/kg
D
Laboratory findings in diabetes insipidus include elevated serum osmolality and serum sodium
and decreased urine specific gravity. Normal serum osmolality is 285 to 295 mOsm/kg, normal
serum sodium is 136 to 145 mEq/L, and normal specific gravity is 1.005 to 1.030. High blood
glucose levels occur with diabetes.
The provider orders intracranial pressure (ICP) readings every hour for a patient with a traumatic
brain injury from a motor vehicle crash. The patient’s ICP reading is 21 mm Hg. It is most
important for the nurse to take which action?
A. Document the ICP reading in the chart.
B. Determine if the patient has a headache.
C. Assess the patient's LOC.
D. Position the patient with head elevated 60 degrees.
C
,The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive
and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale
may be used to determine the degree of impaired consciousness.
A patient has a systemic BP of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the
patient’s cerebral perfusion pressure (CPP), how does the nurse interpret the results?
A. High blood flow to the brain
B. Normal intracranial pressure
C. Impaired blood flow to the brain
D. Adequate autoregulation of blood flow
C
Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP)
minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP − ICP:
80 mm Hg − 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired
cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment
is required.
A patient with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal
fluid was obtained for culture. Which medication should the nurse give first?
A. Codeine
B. Phenytoin
C. Ceftriaxone
D. Acetaminophen
C
Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy
(e.g., ceftriaxone) is started immediately after the collection of specimens for cultures and even
, before the diagnosis is confirmed. Dexamethasone may be given before or with the first dose of
antibiotics. The nurse should collaborate with the health care provider to manage the headache
(with codeine), fever (with acetaminophen), and seizures (with phenytoin).
The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent
neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS)?
(Select all that apply.)
A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best motor response
E. Best verbal response
F. Cranial nerve function
BDE
The three dimensions of the GCS are eye opening, best verbal response, and best motor response.
Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.
What nursing intervention should be implemented for a patient with increased intracranial
pressure (ICP)?
A. Monitor fluid and electrolyte status carefully.
B. Position the patient in a high Fowler's position.
C. Administer vasoconstrictors to maintain cerebral perfusion.
D. Maintain physical restraints to prevent episodes of agitation.
A
Fluid and electrolyte changes can have an adverse effect on ICP and must be monitored
vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and
ANSWERS LATEST AND COMPREHENSIVE VERSION
WITH VERIFIED ANSWERS GUARANTEED PASS
WITH INSTANT PDF DOWNLOAD
The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a
ventriculostomy. What nursing intervention is priority?
A. Administer IV mannitol as ordered.
B. Ventilator use to hyperoxygenate the patient.
C. Use strict aseptic technique with dressing changes.
D. Be aware of changes in ICP related to cerebrospinal fluid leaks.
C
The priority nursing intervention is to use strict aseptic technique with dressing changes and any
handling of the insertion site to prevent the serious complication of infection. IV mannitol or
hypertonic saline will be administered as ordered for increased ICP. Ventilators may be used to
maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to
decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.
A patient is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody
fluid is draining from the patient’s nose. What action by the nurse is most appropriate?
A. Place packing in the patient's nares.
B. Apply a loose gauze pad under the patient's nose.
C. Place the patient in a modified Trendelenburg position.
D. Ask the patient to gently blow the nose to clear the drainage.
B
Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a
frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody
,fluid is present, the blood will coalesce, and a yellow halo will form if CSF is present. If clear
drainage is present, testing for glucose would indicate the presence of CSF. Mixed blood and
CSF will test positive for glucose because blood contains glucose. If CSF rhinorrhea occurs, the
nurse should inform the provider immediately. The head of the bed may be raised to decrease the
CSF pressure so that a tear can seal. The nurse should not place packing in the nasal cavity, and
the patient should not sneeze or blow the nose.
A patient is diagnosed with diabetes insipidus after transsphenoidal resection of a pituitary
adenoma. What should the nurse consider as a sign of improvement?
A. Serum sodium of 120 mEq/L
B. Urine specific gravity of 1.001
C. Fasting blood glucose of 80 mg/dL
D. Serum osmolality of 290 mOsm/kg
D
Laboratory findings in diabetes insipidus include elevated serum osmolality and serum sodium
and decreased urine specific gravity. Normal serum osmolality is 285 to 295 mOsm/kg, normal
serum sodium is 136 to 145 mEq/L, and normal specific gravity is 1.005 to 1.030. High blood
glucose levels occur with diabetes.
The provider orders intracranial pressure (ICP) readings every hour for a patient with a traumatic
brain injury from a motor vehicle crash. The patient’s ICP reading is 21 mm Hg. It is most
important for the nurse to take which action?
A. Document the ICP reading in the chart.
B. Determine if the patient has a headache.
C. Assess the patient's LOC.
D. Position the patient with head elevated 60 degrees.
C
,The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive
and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale
may be used to determine the degree of impaired consciousness.
A patient has a systemic BP of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the
patient’s cerebral perfusion pressure (CPP), how does the nurse interpret the results?
A. High blood flow to the brain
B. Normal intracranial pressure
C. Impaired blood flow to the brain
D. Adequate autoregulation of blood flow
C
Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP)
minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP − ICP:
80 mm Hg − 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired
cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment
is required.
A patient with suspected bacterial meningitis just had a lumbar puncture in which cerebrospinal
fluid was obtained for culture. Which medication should the nurse give first?
A. Codeine
B. Phenytoin
C. Ceftriaxone
D. Acetaminophen
C
Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy
(e.g., ceftriaxone) is started immediately after the collection of specimens for cultures and even
, before the diagnosis is confirmed. Dexamethasone may be given before or with the first dose of
antibiotics. The nurse should collaborate with the health care provider to manage the headache
(with codeine), fever (with acetaminophen), and seizures (with phenytoin).
The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent
neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS)?
(Select all that apply.)
A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best motor response
E. Best verbal response
F. Cranial nerve function
BDE
The three dimensions of the GCS are eye opening, best verbal response, and best motor response.
Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.
What nursing intervention should be implemented for a patient with increased intracranial
pressure (ICP)?
A. Monitor fluid and electrolyte status carefully.
B. Position the patient in a high Fowler's position.
C. Administer vasoconstrictors to maintain cerebral perfusion.
D. Maintain physical restraints to prevent episodes of agitation.
A
Fluid and electrolyte changes can have an adverse effect on ICP and must be monitored
vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and
