NR 340 Week 3 EVOLVE Question And Answers
NR 340 Week 3 Evolve Questions and Answers: Chamberlain College of nursing
NR 340 Week 3 Evolve Questions and Answers 1. QUESTION: What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on increased intracrani...
What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck
alignment on increased intracranial pressure (ICP)?
o Lowering ICP by allowing for elevations in CO2 to dilate cerebral arteries
o Lowering ICP by facilitating venous drainage and decreasing venous
obstruction Correct
o Lowering ICP by maintaining an open airway
o Lowering ICP by reducing the risk of snoring
Head-of-the-bed elevation and a neutral head position that avoids hyperextension or
hyperflexion facilitate jugular venous drainage, helping to minimize increases in ICP.
Elevated CO2 contributes to cerebral vessel vasodilation, which can increase cerebral
blood volume and further elevate ICP. Maintaining an open airway alone does not
minimize increases in ICP. Reducing the risk of snoring by maintaining an open airway
alone does not minimize increases in ICP.
Awarded 0.0 points out of 1.0 possible points.
2. 2.ID: 43154255
Under normal circumstances the cerebral vasculature exhibits pressure and chemical
autoregulation. What happens when autoregulation is lost?
o Central venous engorgement occurs.
o Cerebral blood flow is not affected.
o Hypertension increases cerebral blood flow. Correct
o Shunting of cerebrospinal fluid (CSF) is blocked.
Autoregulation is the ability of the cerebral vessels to adjust their diameter in response to
arterial pressure changes within the brain. If mean arterial blood pressure rises, cerebral
vessels will constrict to prevent excessive distention of the cerebral arteries. When
, autoregulation is lost, cerebral vessels are no longer able to regulate diameter and as a
result hypertension increases cerebral perfusion pressure. Cerebral vessels may become
engorged as a result of the loss of autoregulation. Cerebral blood flow is affected with the
loss of autoregulation. Loss of autoregulation does not block CSF flow.
Awarded 0.0 points out of 1.0 possible points.
3. 3.ID: 43154263
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?
o Cease stimulating the patient. Correct
o Continue with hygiene measures.
o Lower the head of the bed to 10 degrees.
o Open the ICP monitor to continuous drainage.
Sustained increases in ICP should be avoided. Nursing care activities should be spaced to
prevent an increase in ICP. Actions that cause a sustained elevation in ICP should be
avoided until ICP returns to baseline resting values. Elevating the head of the bed to 30
degrees or more can help reduce ICP. Continuous drainage of CSF fluid will result in
herniation.
Awarded 0.0 points out of 1.0 possible points.
4. 4.ID: 43154273
Herniation syndromes can be life-threatening situations. Which syndrome causes the
supratentorial contents to shift downward and compress vital centers of the brainstem?
o Central herniation Correct
o Cingulate herniation
o Tonsillar herniation
o Uncal herniation
, A downward shift of the cerebral hemispheres, basal ganglia, and diencephalon through
the tentorial notch causes central herniation, which compresses the vital centers of the
brainstem. This results in a shift of one cerebral hemisphere under the falx cerebri to the
other cerebral hemisphere. Cerebellar tonsils are displaced through the foramen magnum,
causing fatal damage to the respiratory and cardiac centers. Uncal herniation compresses
the midbrain, causing dysfunction of the ipsilateral third nerve, resulting in unilateral
pupil dilation.
Awarded 0.0 points out of 1.0 possible points.
5. 5.ID: 43154282
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?
o I, IX, X
o II, V, VII
o II, VI, X
o III, IV, VI Correct
Cranial nerve III is responsible for the consensual light response, elevation of the eyelids,
and eye movements. In addition, cranial nerves III, IV, and VI affect extraocular eye
movements.
Awarded 0.0 points out of 1.0 possible points.
6. 6.ID: 43154291
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?
o Cerebral perfusion pressure (CPP) should be sustained at least 70 mm Hg.
Correct
o Hypertension greater than 160 mm Hg is necessary to achieve adequate
perfusion.
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