NUR 413: Nursing Concepts for Complex
Care Exam 3 Questions and Correct Answers,
With Complete Solution.
Management of delirium focuses on:
A. Keeping the patient medicated until transfer.
B. Keeping the patient safe.
C. Maintaining patency of the artificial airway.
D. Maximizing conversations with healthcare providers.
B. Keeping the patient safe.
What is the therapeutic effect of head-of-the-bed elevation and neutral head and
neck alignment on increased intracranial pressure (ICP)?
A. Lowering ICP by allowing for elevations in CO2 to dilate cerebral arteries
B. Lowering ICP by facilitating venous drainage and decreasing venous
obstruction
C. Lowering ICP by maintaining an open airway
D. Lowering ICP by reducing the risk of snoring
B. Lowering ICP by facilitating venous drainage and decreasing venous obstruction
Under normal circumstances the cerebral vasculature exhibits pressure and
chemical autoregulation. What happens when autoregulation is lost?
A. Central venous engorgement occurs.
B. Cerebral blood flow is not affected.
C. Hypertension increases cerebral blood flow.
D. Shunting of cerebrospinal fluid (CSF) is blocked.
C. Hypertension increases cerebral blood flow.
The nurse is monitoring a patient's intracranial pressure (ICP). While the nurse is
providing hygiene measures, she observes that the ICP reading is sustained at 18
mm Hg. What is the priority nursing action?
A. Cease stimulating the patient.
B. Continue with hygiene measures.
C. Lower the head of the bed to 10 degrees.
D. Open the ICP monitor to continuous drainage.
A. Cease stimulating the patient.
Herniation syndromes can be life-threatening situations. Which syndrome causes
the supratentorial contents to shift downward and compress vital centers of the
brainstem?
A. Central herniation
B. Cingulate herniation
C. Tonsillar herniation
D. Uncal herniation
A. Central herniation
In a patient with increased intracranial pressure (ICP), which of the following
cranial nerves would be assessed for consensual light response, elevation of the
,eyelids, and eye movement?
A. I, IX, X
B. II, V, VII
C. II, VI, X
D. III, IV, VI
D. III, IV, VI
The nurse is managing the blood pressure of a patient with a traumatic brain
injury. When planning the care of this patient, which statement best represents
appropriate blood pressure management?
A. Cerebral perfusion pressure (CPP) should be sustained at least 70 mmHg.
B. Hypertension greater than 160 mmHg is necessary to achieve adequate
perfusion.
C. Nimodipine reduces blood pressure through its effect on cerebral vessels.
D. Nitrates are the vasopressors of choice with increased ICP.
A. Cerebral perfusion pressure (CPP) should be sustained at least 70 mmHg.
The nurse is caring for a patient with a ruptured cerebral aneurysm. During initial
assessment, the nurse notes that the cerebrospinal fluid draining into a
ventriculostomy system is blood tinged. What is the best interpretation of this
finding by the nurse?
A. Cerebral aneurysms commonly rupture in the subarachnoid space.
B. This assessment finding is indicative of developing cerebral meningitis.
C. Patient movement has resulted in dislodgement of the catheter.
D. Normal cerebral spinal fluid contains a small amount of visible blood.
A. Cerebral aneurysms commonly rupture in the subarachnoid space.
The nurse is caring for a patient with an assessed Glasgow Coma Scale score of
3. What is the best understanding of this finding?
A. Coma scale score is a direct result of dysfunction of the cerebellum.
B. Damage to the patient's corpus callosum has led to a comatose state.
C. A Glasgow Coma Scale score of less than 3 indicates a semi-comatose state.
D. There is impairment of the reticular activating system (RAS), resulting in coma.
D. There is impairment of the reticular activating system (RAS), resulting in coma.
Autonomic dysreflexia is characterized by an exaggerated response of the
sympathetic nervous system to a variety of stimuli. Common causes of
autonomic dysreflexia include: (Select all that apply.)
A. Bladder distention.
B. Fecal impaction.
C. Sinus bradycardia.
D. Urinary tract infection.
A. Bladder distention.
B. Fecal impaction.
Which statements best represent optimal fluid administration for the management
of increased intracranial pressure? (Select all that apply.)
A. Normal saline (0.9%) is recommended for fluid volume resuscitation.
B. The goal is to keep serum osmolality greater than 320 mOsm/L.
C. 0.45% saline solution is acceptable for fluid volume resuscitation.
D. Hypotonic solutions are avoided to prevent an increase in cerebral edema.
,A. Normal saline (0.9%) is recommended for fluid volume resuscitation.
D. Hypotonic solutions are avoided to prevent an increase in cerebral edema.
A hallmark of DKA is metabolic acidosis. The primary treatment to correct this
form of metabolic acidosis is:
A. Dialysis.
B. Insulin.
C. Normal saline IV.
D. Sodium bicarbonate replacement.
B. Insulin.
A patient with type 1 diabetes is admitted with altered mental status. The
following arterial blood gas readings are obtained: pH 6.88; PaCO2 20 mm Hg;
PaO2 98 mm Hg; HCO3- 4 mEq/L. The carbon dioxide reading is a result of:
A. Dehydration.
B. Respiratory compensation for ketoacidosis.
C. Renal compensation for ketoacidosis.
D. The formation of ketones.
B. Respiratory compensation for ketoacidosis.
Polydipsia, polyuria, abdominal pain, nausea, and "fruity" breath are typical
findings in:
A. Addison's disease.
B. DKA.
C. HHS.
D. Myxedema coma.
B. DKA.
Kussmaul's respiration, the rapid deep breathing seen in DKA, is the body's effort
to compensate for metabolic acidosis caused by:
A. Bicarbonate.
B. Carbonic acid.
C. Ketone bodies.
D. Lactic acid.
C. Ketone bodies.
Cortisol is released in response to:
A. Anterior pituitary release of ACTH.
B. Increased plasma sodium.
C. Increased blood glucose.
D. Reduced renal perfusion.
A. Anterior pituitary release of ACTH.
The hypothyroid state in secondary hypothyroidism is often caused by:
A. Age-related changes.
B. Pregnancy.
C. Destruction of the thyroid by radiation.
D. Pituitary gland dysfunction.
D. Pituitary gland dysfunction.
A test that may be performed to assess for the presence of adrenal insufficiency
is the:
A. Cortisol stimulation test.
, B. Glucose tolerance test.
C. Vasopressin test.
D. Water deprivation test.
A. Cortisol stimulation test.
Signs of SIADH include which of the following?
A. Hypernatremia
B. Hyponatremia
C. Increased serum osmolality
D. Ketonuria
B. Hyponatremia
A potential cause of ectopic ADH secretion, causing SIADH is:
A. Guillain-Barré syndrome.
B. Heredity.
C. Intracranial surgery
D. Small cell carcinoma of the lung.
D. Small cell carcinoma of the lung.
A patient is admitted to the critical care unit with an anion gap of 24 mEq/L. This
laboratory finding is characteristic of which condition?
A. DKA
B. HHS
C. Hypoglycemia
D. SIADH
A. DKA
Clinical findings associated with cerebral salt wasting include:
A. Decreased plasma volume and decreased serum sodium.
B. Decreased plasma volume and increased serum sodium.
C. Increased plasma volume and increased serum sodium.
D. Increased plasma volume and decreased serum sodium.
A. Decreased plasma volume and decreased serum sodium.
Expected aboratory findings in SIADH include which of the following? (Select all
that apply.)
A. Low serum osmolality
B. Low urine sodium
C. High urine osmolality
D. Serum hyponatremia
A. Low serum osmolality
C. High urine osmolality
D. Serum hyponatremia
Fresh frozen plasma (FFP) is administered to replace:
A. Clotting factors.
B. Erythrocytes.
C. Leukocytes.
D. Platelets.
A. Clotting factors.
In distributive shock, the major physiological problem causing the shock is:
A. Blood loss and actual hypovolemia.
Care Exam 3 Questions and Correct Answers,
With Complete Solution.
Management of delirium focuses on:
A. Keeping the patient medicated until transfer.
B. Keeping the patient safe.
C. Maintaining patency of the artificial airway.
D. Maximizing conversations with healthcare providers.
B. Keeping the patient safe.
What is the therapeutic effect of head-of-the-bed elevation and neutral head and
neck alignment on increased intracranial pressure (ICP)?
A. Lowering ICP by allowing for elevations in CO2 to dilate cerebral arteries
B. Lowering ICP by facilitating venous drainage and decreasing venous
obstruction
C. Lowering ICP by maintaining an open airway
D. Lowering ICP by reducing the risk of snoring
B. Lowering ICP by facilitating venous drainage and decreasing venous obstruction
Under normal circumstances the cerebral vasculature exhibits pressure and
chemical autoregulation. What happens when autoregulation is lost?
A. Central venous engorgement occurs.
B. Cerebral blood flow is not affected.
C. Hypertension increases cerebral blood flow.
D. Shunting of cerebrospinal fluid (CSF) is blocked.
C. Hypertension increases cerebral blood flow.
The nurse is monitoring a patient's intracranial pressure (ICP). While the nurse is
providing hygiene measures, she observes that the ICP reading is sustained at 18
mm Hg. What is the priority nursing action?
A. Cease stimulating the patient.
B. Continue with hygiene measures.
C. Lower the head of the bed to 10 degrees.
D. Open the ICP monitor to continuous drainage.
A. Cease stimulating the patient.
Herniation syndromes can be life-threatening situations. Which syndrome causes
the supratentorial contents to shift downward and compress vital centers of the
brainstem?
A. Central herniation
B. Cingulate herniation
C. Tonsillar herniation
D. Uncal herniation
A. Central herniation
In a patient with increased intracranial pressure (ICP), which of the following
cranial nerves would be assessed for consensual light response, elevation of the
,eyelids, and eye movement?
A. I, IX, X
B. II, V, VII
C. II, VI, X
D. III, IV, VI
D. III, IV, VI
The nurse is managing the blood pressure of a patient with a traumatic brain
injury. When planning the care of this patient, which statement best represents
appropriate blood pressure management?
A. Cerebral perfusion pressure (CPP) should be sustained at least 70 mmHg.
B. Hypertension greater than 160 mmHg is necessary to achieve adequate
perfusion.
C. Nimodipine reduces blood pressure through its effect on cerebral vessels.
D. Nitrates are the vasopressors of choice with increased ICP.
A. Cerebral perfusion pressure (CPP) should be sustained at least 70 mmHg.
The nurse is caring for a patient with a ruptured cerebral aneurysm. During initial
assessment, the nurse notes that the cerebrospinal fluid draining into a
ventriculostomy system is blood tinged. What is the best interpretation of this
finding by the nurse?
A. Cerebral aneurysms commonly rupture in the subarachnoid space.
B. This assessment finding is indicative of developing cerebral meningitis.
C. Patient movement has resulted in dislodgement of the catheter.
D. Normal cerebral spinal fluid contains a small amount of visible blood.
A. Cerebral aneurysms commonly rupture in the subarachnoid space.
The nurse is caring for a patient with an assessed Glasgow Coma Scale score of
3. What is the best understanding of this finding?
A. Coma scale score is a direct result of dysfunction of the cerebellum.
B. Damage to the patient's corpus callosum has led to a comatose state.
C. A Glasgow Coma Scale score of less than 3 indicates a semi-comatose state.
D. There is impairment of the reticular activating system (RAS), resulting in coma.
D. There is impairment of the reticular activating system (RAS), resulting in coma.
Autonomic dysreflexia is characterized by an exaggerated response of the
sympathetic nervous system to a variety of stimuli. Common causes of
autonomic dysreflexia include: (Select all that apply.)
A. Bladder distention.
B. Fecal impaction.
C. Sinus bradycardia.
D. Urinary tract infection.
A. Bladder distention.
B. Fecal impaction.
Which statements best represent optimal fluid administration for the management
of increased intracranial pressure? (Select all that apply.)
A. Normal saline (0.9%) is recommended for fluid volume resuscitation.
B. The goal is to keep serum osmolality greater than 320 mOsm/L.
C. 0.45% saline solution is acceptable for fluid volume resuscitation.
D. Hypotonic solutions are avoided to prevent an increase in cerebral edema.
,A. Normal saline (0.9%) is recommended for fluid volume resuscitation.
D. Hypotonic solutions are avoided to prevent an increase in cerebral edema.
A hallmark of DKA is metabolic acidosis. The primary treatment to correct this
form of metabolic acidosis is:
A. Dialysis.
B. Insulin.
C. Normal saline IV.
D. Sodium bicarbonate replacement.
B. Insulin.
A patient with type 1 diabetes is admitted with altered mental status. The
following arterial blood gas readings are obtained: pH 6.88; PaCO2 20 mm Hg;
PaO2 98 mm Hg; HCO3- 4 mEq/L. The carbon dioxide reading is a result of:
A. Dehydration.
B. Respiratory compensation for ketoacidosis.
C. Renal compensation for ketoacidosis.
D. The formation of ketones.
B. Respiratory compensation for ketoacidosis.
Polydipsia, polyuria, abdominal pain, nausea, and "fruity" breath are typical
findings in:
A. Addison's disease.
B. DKA.
C. HHS.
D. Myxedema coma.
B. DKA.
Kussmaul's respiration, the rapid deep breathing seen in DKA, is the body's effort
to compensate for metabolic acidosis caused by:
A. Bicarbonate.
B. Carbonic acid.
C. Ketone bodies.
D. Lactic acid.
C. Ketone bodies.
Cortisol is released in response to:
A. Anterior pituitary release of ACTH.
B. Increased plasma sodium.
C. Increased blood glucose.
D. Reduced renal perfusion.
A. Anterior pituitary release of ACTH.
The hypothyroid state in secondary hypothyroidism is often caused by:
A. Age-related changes.
B. Pregnancy.
C. Destruction of the thyroid by radiation.
D. Pituitary gland dysfunction.
D. Pituitary gland dysfunction.
A test that may be performed to assess for the presence of adrenal insufficiency
is the:
A. Cortisol stimulation test.
, B. Glucose tolerance test.
C. Vasopressin test.
D. Water deprivation test.
A. Cortisol stimulation test.
Signs of SIADH include which of the following?
A. Hypernatremia
B. Hyponatremia
C. Increased serum osmolality
D. Ketonuria
B. Hyponatremia
A potential cause of ectopic ADH secretion, causing SIADH is:
A. Guillain-Barré syndrome.
B. Heredity.
C. Intracranial surgery
D. Small cell carcinoma of the lung.
D. Small cell carcinoma of the lung.
A patient is admitted to the critical care unit with an anion gap of 24 mEq/L. This
laboratory finding is characteristic of which condition?
A. DKA
B. HHS
C. Hypoglycemia
D. SIADH
A. DKA
Clinical findings associated with cerebral salt wasting include:
A. Decreased plasma volume and decreased serum sodium.
B. Decreased plasma volume and increased serum sodium.
C. Increased plasma volume and increased serum sodium.
D. Increased plasma volume and decreased serum sodium.
A. Decreased plasma volume and decreased serum sodium.
Expected aboratory findings in SIADH include which of the following? (Select all
that apply.)
A. Low serum osmolality
B. Low urine sodium
C. High urine osmolality
D. Serum hyponatremia
A. Low serum osmolality
C. High urine osmolality
D. Serum hyponatremia
Fresh frozen plasma (FFP) is administered to replace:
A. Clotting factors.
B. Erythrocytes.
C. Leukocytes.
D. Platelets.
A. Clotting factors.
In distributive shock, the major physiological problem causing the shock is:
A. Blood loss and actual hypovolemia.
