RNSG 2539 All Quizzes (answered with feedbacks)
Exam (elaborations)
,Cognition quiz
• Question 1
10 out of 10 points
The nurse is caring for a patient admitted with a subdural hematoma
following a motor vehicle accident. Which change in vital signs would
the nurse interpret as a manifestation of increased intracranial
pressure (ICP)?
Selected
Answer:
Bradycar
dia
Correct
Answer:
Bradycar
dia
Response
Feedback Bradycardia could indicate increased ICP. Changes in vital
: signs (known as Cushing's triad) occur with increased ICP.
They consist of increasing systolic pressure with a
widening pulse pressure, bradycardia with a full and
bounding pulse, and irregular respirations.
• Question 2
10 out of 10 points
A male patient suffered a diffuse axonal injury from a traumatic brain
injury (TBI). He has been maintained on IV fluids for 2 days. The nurse
seeks enteral feeding for this patient based on what rationale?
Selected
Answer:
Malnutrition causes continued
, cerebral edema
Correct
Answer:
Malnutrition causes continued
cerebral edema
Response
Feedback A patient with diffuse axonal injury is unconscious and,
: with increased ICP, is in a hypermetabolic, hypercatabolic
state that increases the need for fuel for healing.
Malnutrition promotes continued cerebral edema, and
early feeding may improve outcomes when begun within 3
days after injury. Fluid and electrolytes will be monitored
to maintain balance with the enteral feedings.
• Question 3
10 out of 10 points
The nurse has established a goal of maintaining ICP within the normal
range for a patient with a traumatic brain injury. Which interventions
should the nurse perform? Please select all that apply.
Elevate the head of the bed to 15 to 30 degrees.
Contact the health care provider if the ICP is greater
than 20 mmHg.
Monitor neurologic status using the Glasgow Coma
Scale.
Correct
Answers:
, Elevate the head of the bed to 15 to 30 degrees.
Contact the health care provider if the ICP is greater
than 20 mmHg.
Monitor neurologic status using the Glasgow Coma
Scale.
Response
Feedback The nurse should work to maintain normal ICP by
: elevating the head of the bed to 15 to 30 degrees and
monitoring neurologic status. An ICP greater than 20
indicates a problem, and the HCP should be notifies.
Coughing and range of motion exercises will increase
ICP and should be avoided at this time.
• Question 4
10 out of 10 points
The nurse is providing care for a patient who has been admitted to
the hospital with a head injury and who requires regular neurologic
and vital sign assessment. Which assessments will be components of
the patient's score on the Glasgow Coma Scale (GCS)? (Select all
that apply.)
Eye opening
Best
verbal
response
Exam (elaborations)
,Cognition quiz
• Question 1
10 out of 10 points
The nurse is caring for a patient admitted with a subdural hematoma
following a motor vehicle accident. Which change in vital signs would
the nurse interpret as a manifestation of increased intracranial
pressure (ICP)?
Selected
Answer:
Bradycar
dia
Correct
Answer:
Bradycar
dia
Response
Feedback Bradycardia could indicate increased ICP. Changes in vital
: signs (known as Cushing's triad) occur with increased ICP.
They consist of increasing systolic pressure with a
widening pulse pressure, bradycardia with a full and
bounding pulse, and irregular respirations.
• Question 2
10 out of 10 points
A male patient suffered a diffuse axonal injury from a traumatic brain
injury (TBI). He has been maintained on IV fluids for 2 days. The nurse
seeks enteral feeding for this patient based on what rationale?
Selected
Answer:
Malnutrition causes continued
, cerebral edema
Correct
Answer:
Malnutrition causes continued
cerebral edema
Response
Feedback A patient with diffuse axonal injury is unconscious and,
: with increased ICP, is in a hypermetabolic, hypercatabolic
state that increases the need for fuel for healing.
Malnutrition promotes continued cerebral edema, and
early feeding may improve outcomes when begun within 3
days after injury. Fluid and electrolytes will be monitored
to maintain balance with the enteral feedings.
• Question 3
10 out of 10 points
The nurse has established a goal of maintaining ICP within the normal
range for a patient with a traumatic brain injury. Which interventions
should the nurse perform? Please select all that apply.
Elevate the head of the bed to 15 to 30 degrees.
Contact the health care provider if the ICP is greater
than 20 mmHg.
Monitor neurologic status using the Glasgow Coma
Scale.
Correct
Answers:
, Elevate the head of the bed to 15 to 30 degrees.
Contact the health care provider if the ICP is greater
than 20 mmHg.
Monitor neurologic status using the Glasgow Coma
Scale.
Response
Feedback The nurse should work to maintain normal ICP by
: elevating the head of the bed to 15 to 30 degrees and
monitoring neurologic status. An ICP greater than 20
indicates a problem, and the HCP should be notifies.
Coughing and range of motion exercises will increase
ICP and should be avoided at this time.
• Question 4
10 out of 10 points
The nurse is providing care for a patient who has been admitted to
the hospital with a head injury and who requires regular neurologic
and vital sign assessment. Which assessments will be components of
the patient's score on the Glasgow Coma Scale (GCS)? (Select all
that apply.)
Eye opening
Best
verbal
response
