Med surg 2 final exam study guide
The nurse hears snoring sounds in a patient with increase intracranial pressure. What does the nurse
recognize these sounds indicate that require immediate action?
Obstruction
oversedation
normal finding
decreased ICP Correct answerObstruction
When considering the use of hypertonic saline treatment in a patient with increased intracranial
pressure, which factors should the nurse consider? select all
the nurse should closely monitor blood sugar levels in the patient
the nurse should frequently monitor the blood pressure and sodium levels
hypertonic saline treatment works similarly to mannitol in treating increased ICP
hypertonic saline treatment provides massive movement of water out of the swollen brain cells
the nurse should ensure that antacid is given to prevent gastrointestinal complications. Correct
answerThe nurse should frequently monitor the blood pressure and sodium levels
hypertonic saline treatment works similarly to mannitol in treating increased ICP
hypertonic saline tx provides massive movement of water out of swollen brain cells.
a patient with increased ICP is prescribed a high dose of barbiturates. what outcome does the nurse
anticipate the patient will have after administration of the medication
reduce vasogenic edema
decreases cerebral metabolism
causes plasma expansion and osmotic effect
brings massive movement of water out of brain cells. Correct answerdecreases cerebral metabolism
a patient with meningitis has seizures, cranial nerve III palsy, and Bradycardia. what is the most likely
cause for the development of these symptoms
cerebral abscess
subdural effusion
, acute cerebral edema
increased ICP Correct answeracute cerebral edema
The nurse is administering mannitol intravenously to a patient with a head injury. which assessment will
help the nurse determine if the medication is having the desired outcome?
increased BP
decreased body temp
decreased ICP
decreased serum blood glucose Correct answerdecreased ICP
The nurse administers mannitol that has been prescribed for a patient with increased intracranial
pressure. what outcome does the nurse expect after administration?
increased urine output
decreased blood pressure
reduced ICP
increased intracranial perfussion Correct answerreduced ICP
A nurse is examining the pressure ulcer of a patient and observes that subcutaneous fat is visible in the
ulcer, but bones, muscle, and tendon are not visible. slough is present, and there is tunneling of the
ulcer, from this observation what stage of the ulcer should the nurse record in the patients medical
record?
stage 2
stage 3
stage 4
unstageable Correct answerstage 3
the patient is admitted with a pressure ulcer with full thickness skin loss involving damage to the sub q
tissue. how should the nurse document it?
stage 1
stage 2
stage 3
stage 4 Correct answerstage 3
A patient with increased ICP is prescribed a high dose of barbiturates. what outcome does the nurse
anticipate the patient will have after administration of the medication?
reduces vasogenic edema
decreases cerebral metabolism
causes plasma expansion and osmotic effect
brings massive movement of water out of the brain cells Correct answerdecreased cerebral metabolism
The nurse hears snoring sounds in a patient with increase intracranial pressure. What does the nurse
recognize these sounds indicate that require immediate action?
Obstruction
oversedation
normal finding
decreased ICP Correct answerObstruction
When considering the use of hypertonic saline treatment in a patient with increased intracranial
pressure, which factors should the nurse consider? select all
the nurse should closely monitor blood sugar levels in the patient
the nurse should frequently monitor the blood pressure and sodium levels
hypertonic saline treatment works similarly to mannitol in treating increased ICP
hypertonic saline treatment provides massive movement of water out of the swollen brain cells
the nurse should ensure that antacid is given to prevent gastrointestinal complications. Correct
answerThe nurse should frequently monitor the blood pressure and sodium levels
hypertonic saline treatment works similarly to mannitol in treating increased ICP
hypertonic saline tx provides massive movement of water out of swollen brain cells.
a patient with increased ICP is prescribed a high dose of barbiturates. what outcome does the nurse
anticipate the patient will have after administration of the medication
reduce vasogenic edema
decreases cerebral metabolism
causes plasma expansion and osmotic effect
brings massive movement of water out of brain cells. Correct answerdecreases cerebral metabolism
a patient with meningitis has seizures, cranial nerve III palsy, and Bradycardia. what is the most likely
cause for the development of these symptoms
cerebral abscess
subdural effusion
, acute cerebral edema
increased ICP Correct answeracute cerebral edema
The nurse is administering mannitol intravenously to a patient with a head injury. which assessment will
help the nurse determine if the medication is having the desired outcome?
increased BP
decreased body temp
decreased ICP
decreased serum blood glucose Correct answerdecreased ICP
The nurse administers mannitol that has been prescribed for a patient with increased intracranial
pressure. what outcome does the nurse expect after administration?
increased urine output
decreased blood pressure
reduced ICP
increased intracranial perfussion Correct answerreduced ICP
A nurse is examining the pressure ulcer of a patient and observes that subcutaneous fat is visible in the
ulcer, but bones, muscle, and tendon are not visible. slough is present, and there is tunneling of the
ulcer, from this observation what stage of the ulcer should the nurse record in the patients medical
record?
stage 2
stage 3
stage 4
unstageable Correct answerstage 3
the patient is admitted with a pressure ulcer with full thickness skin loss involving damage to the sub q
tissue. how should the nurse document it?
stage 1
stage 2
stage 3
stage 4 Correct answerstage 3
A patient with increased ICP is prescribed a high dose of barbiturates. what outcome does the nurse
anticipate the patient will have after administration of the medication?
reduces vasogenic edema
decreases cerebral metabolism
causes plasma expansion and osmotic effect
brings massive movement of water out of the brain cells Correct answerdecreased cerebral metabolism
