EXAM 3 QUESTIONS AND ANSWERS
1) 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 clients needing mechanical ventilation.
Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before
signs and symptoms of ICP.
2) A client with a subdural hematoma becomes restless and confused, with dilation of
the ipsilateral pupil. The physician orders mannitol for which of the following reasons?
1. To reduce intraocular pressure
2. To prevent acute tubular necrosis
3. To promote osmotic diuresis to decrease ICP
4. To draw water into the vascular system to increase blood pressure
3. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid
from intracellular to intravascular spaces. Although mannitol is used for all the reasons
described, the reduction of ICP in this client is a concern.
3) A client with subdural hematoma was given mannitol to decrease intracranial
pressure (ICP). Which of the following results would best show the mannitol was effective?
1. Urine output increases
2. Pupils are 8 mm and nonreactive
3. Systolic blood pressure remains at 150 mm Hg
4. ICP level of 12
,EXAM 3 QUESTIONS AND ANSWERS
4. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the
renal tubes, so urine output would increase; however, the reason mannitol was given
was to decrease ICP. An ICP level of 12 is within normal limits. Fixed and dilated
pupils are symptoms of increased ICP or cranial nerve damage. No information is
given that mannitol is being given for renal dysfunction or blood pressure
maintenance.
,EXAM 3 QUESTIONS AND ANSWERS
4) Which of the following values is considered normal for ICP?
1. 0 to 15 mm Hg
2. 25 mm Hg
3. 35 to 45 mm Hg
4. 120/80 mm Hg
1. Normal ICP is 0-15 mm Hg.
5) Which of the following signs and symptoms of increased ICP after head trauma
would appear first?
1. Bradycardia
2. Large amounts of very dilute urine
3. Restlessness and confusion
4. Widened pulse pressure
3. The earliest symptom of elevated ICP is a change in mental status. Bradycardia,
widened pulse pressure, and bradypnea occur later. The client may void large amounts of
very dilute urine if there’s damage to the posterior pituitary.
6) The nurse is assessing the motor function of an unconscious client. The nurse
would plan to use which of the following to test the client’s peripheral response to pain?
1. Sternal rub
2. Pressure on the orbital rim
3. Squeezing the sternocleidomastoid muscle
4. Nail bed pressure
4. Motor testing on the unconscious client can be done only by testing response to painful
stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain
are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing
the clavicle or sternocleidomastoid muscle.
7) The client is having a lumbar puncture performed. The nurse would plan to place
the client in which position for the procedure?
, EXAM 3 QUESTIONS AND ANSWERS
1. Side-lying, with legs pulled up and head bent down onto the chest
2. Side-lying, with a pillow under the hip
1) 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 clients needing mechanical ventilation.
Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before
signs and symptoms of ICP.
2) A client with a subdural hematoma becomes restless and confused, with dilation of
the ipsilateral pupil. The physician orders mannitol for which of the following reasons?
1. To reduce intraocular pressure
2. To prevent acute tubular necrosis
3. To promote osmotic diuresis to decrease ICP
4. To draw water into the vascular system to increase blood pressure
3. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid
from intracellular to intravascular spaces. Although mannitol is used for all the reasons
described, the reduction of ICP in this client is a concern.
3) A client with subdural hematoma was given mannitol to decrease intracranial
pressure (ICP). Which of the following results would best show the mannitol was effective?
1. Urine output increases
2. Pupils are 8 mm and nonreactive
3. Systolic blood pressure remains at 150 mm Hg
4. ICP level of 12
,EXAM 3 QUESTIONS AND ANSWERS
4. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the
renal tubes, so urine output would increase; however, the reason mannitol was given
was to decrease ICP. An ICP level of 12 is within normal limits. Fixed and dilated
pupils are symptoms of increased ICP or cranial nerve damage. No information is
given that mannitol is being given for renal dysfunction or blood pressure
maintenance.
,EXAM 3 QUESTIONS AND ANSWERS
4) Which of the following values is considered normal for ICP?
1. 0 to 15 mm Hg
2. 25 mm Hg
3. 35 to 45 mm Hg
4. 120/80 mm Hg
1. Normal ICP is 0-15 mm Hg.
5) Which of the following signs and symptoms of increased ICP after head trauma
would appear first?
1. Bradycardia
2. Large amounts of very dilute urine
3. Restlessness and confusion
4. Widened pulse pressure
3. The earliest symptom of elevated ICP is a change in mental status. Bradycardia,
widened pulse pressure, and bradypnea occur later. The client may void large amounts of
very dilute urine if there’s damage to the posterior pituitary.
6) The nurse is assessing the motor function of an unconscious client. The nurse
would plan to use which of the following to test the client’s peripheral response to pain?
1. Sternal rub
2. Pressure on the orbital rim
3. Squeezing the sternocleidomastoid muscle
4. Nail bed pressure
4. Motor testing on the unconscious client can be done only by testing response to painful
stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain
are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing
the clavicle or sternocleidomastoid muscle.
7) The client is having a lumbar puncture performed. The nurse would plan to place
the client in which position for the procedure?
, EXAM 3 QUESTIONS AND ANSWERS
1. Side-lying, with legs pulled up and head bent down onto the chest
2. Side-lying, with a pillow under the hip
