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C56 - ch 57 test bank
Med Surg (Fortis College)
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Chapter 56: Acute Intracranial Problems
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. Family members of a patient who has a traumatic brain injury ask the nurse about the purpose
of the ventriculostomy system being used for intracranial pressure monitoring. Which
response by the nurse is best for this situation?
a. “This type of monitoring system is complex and it is managed by skilled staff.”
b. “The monitoring system helps show whether blood flow to the brain is adequate.”
c. “The ventriculostomy monitoring system helps check for alterations in cerebral
perfusion pressure.”
d. “This monitoring system has multiple benefits including facilitation of
cerebrospinal fluid drainage.”
ANS: B
Short and simple explanations should be given initially to patients and family members. The
other explanations are either too complicated to be easily understood or may increase the
family members’ anxiety.
DIF: Cognitive Level: Analyze (analysis) REF: 1326
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
2. Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse
of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour
later, will be of most concern to the nurse?
a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12
breaths/min
b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32
breaths/min
c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28
breaths/min
d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30
breaths/min
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes
represent Cushing’s triad. These findings indicate that the intracranial pressure (ICP) has
increased, and brain herniation may be imminent unless immediate action is taken to reduce
ICP. The other vital signs may indicate the need for changes in treatment, but they are not
indicative of an immediately life-threatening process.
DIF: Cognitive Level: Apply (application) REF: 1316
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. When a brain-injured patient responds to nail bed pressure with internal rotation, adduction,
and flexion of the arms, the nurse reports the response as
a. flexion withdrawal. c. decorticate posturing.
b. localization of pain. d. decerebrate posturing.
A++
Downloaded by DANIEL NDAMBIRI ()
C56 - ch 57 test bank
Med Surg (Fortis College)
Scan to open on Studocu
A++
Studocu is not sponsored or endorsed by any college or university
Downloaded by DANIEL NDAMBIRI ()
, lOMoARcPSD|16995810
Chapter 56: Acute Intracranial Problems
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. Family members of a patient who has a traumatic brain injury ask the nurse about the purpose
of the ventriculostomy system being used for intracranial pressure monitoring. Which
response by the nurse is best for this situation?
a. “This type of monitoring system is complex and it is managed by skilled staff.”
b. “The monitoring system helps show whether blood flow to the brain is adequate.”
c. “The ventriculostomy monitoring system helps check for alterations in cerebral
perfusion pressure.”
d. “This monitoring system has multiple benefits including facilitation of
cerebrospinal fluid drainage.”
ANS: B
Short and simple explanations should be given initially to patients and family members. The
other explanations are either too complicated to be easily understood or may increase the
family members’ anxiety.
DIF: Cognitive Level: Analyze (analysis) REF: 1326
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
2. Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse
of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour
later, will be of most concern to the nurse?
a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12
breaths/min
b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32
breaths/min
c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28
breaths/min
d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30
breaths/min
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes
represent Cushing’s triad. These findings indicate that the intracranial pressure (ICP) has
increased, and brain herniation may be imminent unless immediate action is taken to reduce
ICP. The other vital signs may indicate the need for changes in treatment, but they are not
indicative of an immediately life-threatening process.
DIF: Cognitive Level: Apply (application) REF: 1316
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. When a brain-injured patient responds to nail bed pressure with internal rotation, adduction,
and flexion of the arms, the nurse reports the response as
a. flexion withdrawal. c. decorticate posturing.
b. localization of pain. d. decerebrate posturing.
A++
Downloaded by DANIEL NDAMBIRI ()
