NUR 417 FINAL EXAM (Lewis Evolve)
QUESTIONS WITH CORRECT ANSWERS
The patient with a brain tumor is being monitored for increased intracranial
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pressure (ICP) with a ventriculostomy. What nursing intervention is priority?
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A. Administer IV mannitol as ordered.
| | | | |
B. Ventilator use to hyperoxygenate the patient.
| | | | | |
C. Use strict aseptic technique with dressing changes.
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D. Be aware of changes in ICP related to cerebrospinal fluid leaks.
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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.
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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.
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C. Place the patient in a modified Trendelenburg position.
| | | | | | | |
D. Ask the patient to gently blow the nose to clear the drainage.
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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
| | | | | | | | | | | | | | | | | | | | | |
QUESTIONS WITH CORRECT ANSWERS
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
| | | | | | | | | | | | | | | | | | | | | |
