NUR 417 FINAL EXAM
1. Family members ask the nurse about the purpose of the ventriculostomy
system being used
for intracranial pressure monitoring for a patient. Which of the following
responses by the
nurse is best?
a. "This type of monitoring system is complex and highly skilled staff are
needed."
b. "The monitoring system helps show whether blood flow to the brain is
adequate."
c. "The ventriculostomy monitoring system helps check for alterations in
cerebral
perfusion pressure."
d. "This monitoring system has multiple benefits including facilitation of
cerebrospinal fluid drainage.":
,*ANSWER* B Short and simple explanations should be given to patients and family members. The other
explanations are either too complicated to be easily understood or may increase the family member's anxiety.
2. The nurse is caring for a patient with a head injury and has admission vital
signs of blood pressure 128/68 mm Hg, pulse 110 beats/minute, and respira-
tions 26/minute. Which of these vital signs, if taken 1 hour after admission,
will be of most concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30:
*ANSWER* A Systolic hypertension with widening pulse pressure, bradycardia, and
respiratory changes represent Cushing's triad and indicate that the intracranial pressure
(ICP) has increased, and brain herniation may be imminent unless immediate action is taken
to reduce ICP. The other vital signs may indicate the need for changes in treatment, but
they are not indicative of an immediately life-threatening process.
,3. The nurse is assessing a patient who is unconscious and applies a painful
stimulus to the nail beds. The patient responds with internal rotation, adduc-
tion, and flexion of the arms. Which of
, the following terms should the nurse use when documenting the findings?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing:
*ANSWER* C
Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented
as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the
flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
4. A nurse is providing care for an unconscious patient with a head injury
prescribed IV
mannitol. Which of the following parameters is best for the nurse to monitor
to determine if
the mannitol has been effective?
a. Hematocrit
1. Family members ask the nurse about the purpose of the ventriculostomy
system being used
for intracranial pressure monitoring for a patient. Which of the following
responses by the
nurse is best?
a. "This type of monitoring system is complex and highly skilled staff are
needed."
b. "The monitoring system helps show whether blood flow to the brain is
adequate."
c. "The ventriculostomy monitoring system helps check for alterations in
cerebral
perfusion pressure."
d. "This monitoring system has multiple benefits including facilitation of
cerebrospinal fluid drainage.":
,*ANSWER* B Short and simple explanations should be given to patients and family members. The other
explanations are either too complicated to be easily understood or may increase the family member's anxiety.
2. The nurse is caring for a patient with a head injury and has admission vital
signs of blood pressure 128/68 mm Hg, pulse 110 beats/minute, and respira-
tions 26/minute. Which of these vital signs, if taken 1 hour after admission,
will be of most concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30:
*ANSWER* A Systolic hypertension with widening pulse pressure, bradycardia, and
respiratory changes represent Cushing's triad and indicate that the intracranial pressure
(ICP) has increased, and brain herniation may be imminent unless immediate action is taken
to reduce ICP. The other vital signs may indicate the need for changes in treatment, but
they are not indicative of an immediately life-threatening process.
,3. The nurse is assessing a patient who is unconscious and applies a painful
stimulus to the nail beds. The patient responds with internal rotation, adduc-
tion, and flexion of the arms. Which of
, the following terms should the nurse use when documenting the findings?
a. Flexion withdrawal
b. Localization of pain
c. Decorticate posturing
d. Decerebrate posturing:
*ANSWER* C
Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented
as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the
flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
4. A nurse is providing care for an unconscious patient with a head injury
prescribed IV
mannitol. Which of the following parameters is best for the nurse to monitor
to determine if
the mannitol has been effective?
a. Hematocrit
