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A client admitted to the hospital with a subarachnoid
hemorrhage has complaints of severe headache, nuchal rigidity,
and projectile vomiting. The nurse knows lumbar puncture (LP)
would be contraindicated in this client in which of the following
circumstances?
1. Vomiting continues
2. Intracranial pressure (ICP) is increased
3. The client needs mechanical ventilation
4. Blood is anticipated in the cerebralspinal fluid (CSF)
2. Sudden removal of CSF results in pressures lower in the
lumbar area than the brain and favors herniation of the brain;
therefore, LP is contraindicated with increased ICP. Vomiting
may be caused by reasons other than increased ICP; therefore,
LP isn’t strictly contraindicated. An LP may be preformed on
NR 340 EXAM 3 QUESTIONS & ANSWERS
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,NR 340 EXAM 3 QUESTIONS & ANSWERS
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clients needing mechanical ventilation. Blood in the CSF is
diagnostic for subarachnoid hemorrhage and was obtained
before signs and symptoms of ICP.
A nurse is assisting with caloric testing of the oculovestibular
reflex of an unconscious client. Cold water is injected into the
left auditory canal. The client exhibits eye conjugate
movements toward the left followed by a rapid nystagmus
toward the right. The nurse understands that this indicates the
client has:
1. A cerebral lesion
2. A temporal lesion
3. An intact brainstem
4. Brain death
NR 340 EXAM 3 QUESTIONS & ANSWERS
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,NR 340 EXAM 3 QUESTIONS & ANSWERS
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3. Caloric testing provides information about differentiating
between cerebellar and brainstem lesions. After determining
patency of the ear canal, cold or warm water is injected in the
auditory canal. A normal response that indicates intact function of
cranial nerves III, IV, and VIII is conjugate eye movements toward
the side being irrigated, followed by rapid nystagmus to the
opposite side. Absent or dysconjugate eye movements indicate
brainstem damage.
The nurse is caring for the client with increased intracranial
pressure. The nurse would note which of the following trends in
vital signs if the ICP is rising?
1. Increasing temperature, increasing pulse, increasing
respirations, decreasing systolic blood pressure.
2. Increasing temperature, decreasing pulse, decreasing
NR 340 EXAM 3 QUESTIONS & ANSWERS
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, NR 340 EXAM 3 QUESTIONS & ANSWERS
ALL ANSWERS 100% CORRECT /VERIFIED
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respirations, increasing systolic blood pressure.
3. Decreasing temperature, decreasing pulse, increasing
respirations, decreasing systolic blood pressure.
4. Decreasing temperature, increasing pulse, decreasing
respirations, increasing systolic blood pressure.
2. A change in vital signs may be a late sign of increased
intracranial pressure. Trends include increasing temperature
and systolic blood pressure, and decreasing pulse and
respirations. Respiratory irregularities also may arise.
(Cushing’s Triad)
The nurse is evaluating the status of a client who had a
craniotomy 3 days ago. The nurse would suspect the client is
developing meningitis as a complication of surgery if the client
exhibits:
1. A positive Brudzinski’s sign
NR 340 EXAM 3 QUESTIONS & ANSWERS
ALL ANSWERS 100% CORRECT /VERIFIED
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