NUR 417 FINAL EXAM (Lewis Evolve)
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1. The patient with a brain tu- C
mor is being monitored for in- The priority nursing intervention is to use strict aseptic tech-
creased intracranial pressure nique with dressing changes and any handling of the insertion
(ICP) with a ventriculostomy. site to prevent the serious complication of infection. IV man-
What nursing intervention is nitol or hypertonic saline will be administered as ordered for
priority? increased ICP. Ventilators may be used to maintain oxygenation.
A. Administer IV mannitol as CSF leaks may cause inaccurate ICP readings, or CSF may be
ordered. drained to decrease ICP, but strict aseptic technique to prevent
B. Ventilator use to hyperoxy- infection is the nurse's priority of care.
genate the patient.
C. Use strict aseptic technique
with dressing changes.
D. Be aware of changes in ICP
related to cerebrospinal fluid
leaks.
2. A patient is hospitalized for a B
frontal skull fracture from a Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage
blunt force head injury. Thin from the nose) may occur with a frontal skull fracture. A loose
bloody fluid is draining from collection pad may be placed under the nose, and if thin bloody
the patient's nose. What ac- fluid is present, the blood will coalesce, and a yellow halo will
tion by the nurse is most ap- form if CSF is present. If clear drainage is present, testing
propriate? for glucose would indicate the presence of CSF. Mixed blood
A. Place packing in the pa- and CSF will test positive for glucose because blood contains
tient's nares. glucose. If CSF rhinorrhea occurs, the nurse should inform the
B. Apply a loose gauze pad un- provider immediately. The head of the bed may be raised to
der the patient's nose. decrease the CSF pressure so that a tear can seal. The nurse
C. Place the patient in a modi- should not place packing in the nasal cavity, and the patient
fied Trendelenburg position. should not sneeze or blow the nose.
D. Ask the patient to gently
blow the nose to clear the
drainage.
, NUR 417 FINAL EXAM (Lewis Evolve)
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3. A patient is diagnosed D
with diabetes insipidus after Laboratory findings in diabetes insipidus include elevated
transsphenoidal resection of serum osmolality and serum sodium and decreased urine spe-
a pituitary adenoma. What cific gravity. Normal serum osmolality is 285 to 295 mOsm/kg,
should the nurse consider as normal serum sodium is 136 to 145 mEq/L, and normal specific
a sign of improvement? gravity is 1.005 to 1.030. High blood glucose levels occur with
A. Serum sodium of 120 diabetes.
mEq/L
B. Urine specific gravity of
1.001
C. Fasting blood glucose of 80
mg/dL
D. Serum osmolality of 290
mOsm/kg
4. The provider orders intracra- C
nial pressure (ICP) readings The patient has an increased ICP (normal ICP ranges from 5
every hour for a patient with to 15 mm Hg). The most sensitive and reliable indicator of
a traumatic brain injury from neurologic status is level of consciousness. The Glasgow Coma
a motor vehicle crash. The pa- Scale may be used to determine the degree of impaired con-
tient's ICP reading is 21 mm sciousness.
Hg. It is most important for
the nurse to take which ac-
tion?
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.
, NUR 417 FINAL EXAM (Lewis Evolve)
Study online at https://quizlet.com/_ixqvn9
5. A patient has a systemic BP C
of 120/60 mm Hg and an ICP Normal CPP is 60 to 100 mm Hg. The CPP is calculated with
of 24 mm Hg. After calcu- mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/
lating the patient's cerebral 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP − ICP:
perfusion pressure (CPP), how 80 mm Hg − 24 mm Hg = 56 mm Hg CPP. The decreased
does the nurse interpret the CPP indicates that there is impaired cerebral blood flow and
results? that autoregulation is impaired. Because the ICP is 24 mm Hg,
A. High blood flow to the treatment is required.
brain
B. Normal intracranial pres-
sure
C. Impaired blood flow to the
brain
D. Adequate autoregulation of
blood flow
6. A patient with suspected bac- C
terial meningitis just had a Bacterial meningitis is a medical emergency. When meningitis
lumbar puncture in which is suspected, antibiotic therapy (e.g., ceftriaxone) is started
cerebrospinal fluid was ob- immediately after the collection of specimens for cultures and
tained for culture. Which med- even before the diagnosis is confirmed. Dexamethasone may
ication should the nurse give be given before or with the first dose of antibiotics. The nurse
first? should collaborate with the health care provider to manage
A. Codeine the headache (with codeine), fever (with acetaminophen), and
B. Phenytoin seizures (with phenytoin).
C. Ceftriaxone
D. Acetaminophen
7. The nurse is caring for a pa- B D E
tient admitted to the hospi- The three dimensions of the GCS are eye opening, best verbal
tal with a head injury who re- response, and best motor response. Judgment, abstract rea-
quires frequent neurologic as-
, NUR 417 FINAL EXAM (Lewis Evolve)
Study online at https://quizlet.com/_ixqvn9
sessment. Which components soning, and cranial nerve function are not components of the
are assessed using the Glas- GCS.
gow 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
8. What nursing intervention A
should be implemented for Fluid and electrolyte changes can have an adverse effect on
a patient with increased in- ICP and must be monitored vigilantly. The head of the patient's
tracranial pressure (ICP)? bed should be kept at 30 degrees in most circumstances, and
A. Monitor fluid and elec- physical restraints are not applied unless absolutely necessary.
trolyte status carefully. Vasoconstrictors are not typically used in the treatment of ICP.
B. Position the patient in a
high Fowler's position.
C. Administer vasoconstric-
tors to maintain cerebral per-
fusion.
D. Maintain physical restraints
to prevent episodes of agita-
tion.
9. The nurse is caring for a pa- B
tient admitted with a subdural Bradycardia could indicate increased ICP. Changes in vital signs
hematoma after a motor ve- (known as Cushing's triad) occur with increased ICP. They con-
hicle accident. What change sist of increasing systolic pressure with a widening pulse pres-
in vital signs would the nurse sure, bradycardia with a full and bounding pulse, and irregular
interpret as a manifestation respirations.
Study online at https://quizlet.com/_ixqvn9
1. The patient with a brain tu- C
mor is being monitored for in- The priority nursing intervention is to use strict aseptic tech-
creased intracranial pressure nique with dressing changes and any handling of the insertion
(ICP) with a ventriculostomy. site to prevent the serious complication of infection. IV man-
What nursing intervention is nitol or hypertonic saline will be administered as ordered for
priority? increased ICP. Ventilators may be used to maintain oxygenation.
A. Administer IV mannitol as CSF leaks may cause inaccurate ICP readings, or CSF may be
ordered. drained to decrease ICP, but strict aseptic technique to prevent
B. Ventilator use to hyperoxy- infection is the nurse's priority of care.
genate the patient.
C. Use strict aseptic technique
with dressing changes.
D. Be aware of changes in ICP
related to cerebrospinal fluid
leaks.
2. A patient is hospitalized for a B
frontal skull fracture from a Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage
blunt force head injury. Thin from the nose) may occur with a frontal skull fracture. A loose
bloody fluid is draining from collection pad may be placed under the nose, and if thin bloody
the patient's nose. What ac- fluid is present, the blood will coalesce, and a yellow halo will
tion by the nurse is most ap- form if CSF is present. If clear drainage is present, testing
propriate? for glucose would indicate the presence of CSF. Mixed blood
A. Place packing in the pa- and CSF will test positive for glucose because blood contains
tient's nares. glucose. If CSF rhinorrhea occurs, the nurse should inform the
B. Apply a loose gauze pad un- provider immediately. The head of the bed may be raised to
der the patient's nose. decrease the CSF pressure so that a tear can seal. The nurse
C. Place the patient in a modi- should not place packing in the nasal cavity, and the patient
fied Trendelenburg position. should not sneeze or blow the nose.
D. Ask the patient to gently
blow the nose to clear the
drainage.
, NUR 417 FINAL EXAM (Lewis Evolve)
Study online at https://quizlet.com/_ixqvn9
3. A patient is diagnosed D
with diabetes insipidus after Laboratory findings in diabetes insipidus include elevated
transsphenoidal resection of serum osmolality and serum sodium and decreased urine spe-
a pituitary adenoma. What cific gravity. Normal serum osmolality is 285 to 295 mOsm/kg,
should the nurse consider as normal serum sodium is 136 to 145 mEq/L, and normal specific
a sign of improvement? gravity is 1.005 to 1.030. High blood glucose levels occur with
A. Serum sodium of 120 diabetes.
mEq/L
B. Urine specific gravity of
1.001
C. Fasting blood glucose of 80
mg/dL
D. Serum osmolality of 290
mOsm/kg
4. The provider orders intracra- C
nial pressure (ICP) readings The patient has an increased ICP (normal ICP ranges from 5
every hour for a patient with to 15 mm Hg). The most sensitive and reliable indicator of
a traumatic brain injury from neurologic status is level of consciousness. The Glasgow Coma
a motor vehicle crash. The pa- Scale may be used to determine the degree of impaired con-
tient's ICP reading is 21 mm sciousness.
Hg. It is most important for
the nurse to take which ac-
tion?
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.
, NUR 417 FINAL EXAM (Lewis Evolve)
Study online at https://quizlet.com/_ixqvn9
5. A patient has a systemic BP C
of 120/60 mm Hg and an ICP Normal CPP is 60 to 100 mm Hg. The CPP is calculated with
of 24 mm Hg. After calcu- mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/
lating the patient's cerebral 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP − ICP:
perfusion pressure (CPP), how 80 mm Hg − 24 mm Hg = 56 mm Hg CPP. The decreased
does the nurse interpret the CPP indicates that there is impaired cerebral blood flow and
results? that autoregulation is impaired. Because the ICP is 24 mm Hg,
A. High blood flow to the treatment is required.
brain
B. Normal intracranial pres-
sure
C. Impaired blood flow to the
brain
D. Adequate autoregulation of
blood flow
6. A patient with suspected bac- C
terial meningitis just had a Bacterial meningitis is a medical emergency. When meningitis
lumbar puncture in which is suspected, antibiotic therapy (e.g., ceftriaxone) is started
cerebrospinal fluid was ob- immediately after the collection of specimens for cultures and
tained for culture. Which med- even before the diagnosis is confirmed. Dexamethasone may
ication should the nurse give be given before or with the first dose of antibiotics. The nurse
first? should collaborate with the health care provider to manage
A. Codeine the headache (with codeine), fever (with acetaminophen), and
B. Phenytoin seizures (with phenytoin).
C. Ceftriaxone
D. Acetaminophen
7. The nurse is caring for a pa- B D E
tient admitted to the hospi- The three dimensions of the GCS are eye opening, best verbal
tal with a head injury who re- response, and best motor response. Judgment, abstract rea-
quires frequent neurologic as-
, NUR 417 FINAL EXAM (Lewis Evolve)
Study online at https://quizlet.com/_ixqvn9
sessment. Which components soning, and cranial nerve function are not components of the
are assessed using the Glas- GCS.
gow 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
8. What nursing intervention A
should be implemented for Fluid and electrolyte changes can have an adverse effect on
a patient with increased in- ICP and must be monitored vigilantly. The head of the patient's
tracranial pressure (ICP)? bed should be kept at 30 degrees in most circumstances, and
A. Monitor fluid and elec- physical restraints are not applied unless absolutely necessary.
trolyte status carefully. Vasoconstrictors are not typically used in the treatment of ICP.
B. Position the patient in a
high Fowler's position.
C. Administer vasoconstric-
tors to maintain cerebral per-
fusion.
D. Maintain physical restraints
to prevent episodes of agita-
tion.
9. The nurse is caring for a pa- B
tient admitted with a subdural Bradycardia could indicate increased ICP. Changes in vital signs
hematoma after a motor ve- (known as Cushing's triad) occur with increased ICP. They con-
hicle accident. What change sist of increasing systolic pressure with a widening pulse pres-
in vital signs would the nurse sure, bradycardia with a full and bounding pulse, and irregular
interpret as a manifestation respirations.
