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Nursing 401 crit care exam with 315Questions and Verified Answers | 100% Correct |2024 Grade A+
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Nursing 401 crit care exam with 315Questions andVerified Answers | 100% Correct |2024 Grade A+
After a 4-year-old child undergoes craniotomy the nurse performs a neurologic
assessment that includes level of consciousness, pupillary activity, and reflex
activity. What else should the nurse include in this assessment - CORRECT
ANSWERS Motor function is part of a neurologic assessment and provides
information about cerebral function. Blood pressure and temperature are not direct
measures of neurologic status. Head circumference provides information as to
skeletal development and brain growth, not neurologic data. A change in head
circumference as a result of increased intracranial pressure is not expected in a 4-
year-old whose cranial bones are fused.
A 12-year-old child is admitted to the hospital for observation after sustaining a
head injury. Twelve hours after the injury the child has none of the signs or
symptoms of a head injury. What is the nurse's priority intervention at this time -
CORRECT ANSWERS Assessing the level of consciousness every hour.
Evidence of a subdural hemorrhage may take hours or days to develop; a
diminishing level of consciousness is an early indication of neurological damage.
What interventions should the nurse implement when caring for a client with
syndrome of inappropriate antidiuretic hormone - CORRECT ANSWERS
Providing frequent oral care
Instituting fall risk precautions
Monitoring for and reporting neurologic changes
The excess production of antidiuretic hormone associated with SIADH leads to
increased water reabsorption by the kidneys. Increased water reabsorption results
in decreased urinary output, increased intravascular fluid volume, serum
hypoosmolality, and dilutional hyponatremia. Because treatment includes restricting
fluids, frequent oral care is provided to increase client comfort. Fall risk precautions
are instituted to protect the client from injury that might occur as a result of
neurologic changes associated with declining serum sodium. The nurse monitors for
and reports changes in neurologic status resulting from cerebral edema and
hyponatremia. Immediate treatment goals are to restore normal fluid balance and
normal serum osmolality. Fluids are restricted to no more than 1000 mL and to no
more than 500 mL for the client with severe hyponatremia. Treatment of SIADH
includes placing the bed flat or elevating the head of the bed no more than 10
degrees. This position promotes venous return to the heart, which increases left
ventricular filling pressure. Increasing left ventricular filling pressure stimulates
osmoreceptors to send a message to the pituitary (via the hypothalamus) that
antidiuretic hormone release should be decreased.
,Nursing 401 crit care exam with 315Questions and
Verified Answers | 100% Correct |2024 Grade A+
A nurse is assessing sudden changes in the neurologic status of different clients
after an earthquake. Which client should require endotracheal intubation and
mechanical ventilation? - CORRECT ANSWERS The Glasgow Coma Scale
(GCS) assigns a numeric score for each of the areas of the client's neurologic status.
The lower the score of the GCS, the lower the client's neurologic function. Client 3 is
opening the eyes on pain, so the score is 2. The client shows abnormal flexion
motor response, which has a score of 3, and the verbal response is
incomprehensible, scoring 2. Therefore, the total score is 2+3+2=7. A score equal
to or below 8 indicates a need for endotracheal intubation and mechanical
ventilation. Client 1 will have a GCS score of 12. Client 2 will have a GCS score of
13. Client 4 will have a GCS score of 9.
A nurse is assessing the level of consciousness of four different clients. Which client
would have the lowest neurologic function? - CORRECT ANSWERS GCS
again
The registered nurse is teaching a coworker about the care to be taken in clients
with neurologic changes associated with aging. Which statement made by the
coworker indicates the nurse needs to intervene? - CORRECT ANSWERS
"Clients with decreased sensory perception of touch should be carefully monitored
for infection."
Decreased sensory perception is a neurological change associated with aging.
Clients with this change should be instructed to reduce the risks associated with
falling. Therefore, the nurse should intervene to correct this misconception. All the
other statements are correct and require no follow up. Clients with an increased risk
for infections due to structural deterioration of microglia should be monitored for
infections. Clients with recent memory loss should be taught by repetition and by
using memory aids that provide recurrent alerts to facilitate retention of
information. This would help the client to learn new information and recall it when
needed. Clients with slower processing time should be provided with sufficient time
to respond to questions or directions. Allowing adequate time for processing helps
differentiate normal findings from neurologic deterioration. Clients with decreased
coordination should be instructed to hold handrails when ambulating to provide
support and prevent falls.
For what clinical manifestations should the nurse assess a client during the first few
hours of the alcohol withdrawal? - CORRECT ANSWERS Irritability
Tachycardia
Increasing anxiety
,Nursing 401 crit care exam with 315Questions and
Verified Answers | 100% Correct |2024 Grade A+
Alcohol is a central nervous system depressant; irritability and increasing anxiety
reflect the body's neurologic adaptation to the withdrawal of alcohol. Tachycardia is
one of the early sign of withdrawal; it results from autonomic overactivity.
Hallucinations are not early signs of alcohol withdrawal; they usually do not occur
before 48 to 72 hours of abstinence. Fever and diaphoresis are later signs of
withdrawal that may be seen during alcohol withdrawal delirium; they result from
autonomic overactivity.
The nurse is conducting a neurologic assessment on a client brought to the
emergency room after a motor vehicle accident. While assessing the client's
response to pain, the client pulls his arms upward and inward. The nurse recognizes
that this response represents an injury to what part of the brain? - CORRECT
ANSWERS Midbrain
Decorticate posturing[1][2][3] is a sign of significant deterioration in a client's
neurologic status and is manifested by rigid flexing of elbows and wrists. This can
represent an injury to the midbrain. Damage to the frontal lobe would affect motor
function, problem solving, spontaneity, memory, language, initiation, judgment,
impulse control, and social and sexual behavior. The pons (which is part of the
brainstem) and brainstem help control breathing and heart rate, vision, hearing,
sweating, blood pressure, digestion, alertness, sleep, and sense of balance. Damage
to this area would manifest itself as abnormal responses in the above listed areas.
A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia
and hemiparesis. The nurse concludes that these neurologic deficits are caused
primarily by which response? - CORRECT ANSWERS Vascular spasms
In an attempt to stop the bleeding, adjacent arteries constrict (vasospasm); this in
turn contributes to the ischemia responsible for the neurologic deficits. The volume
of blood loss is not great enough to significantly alter the oxygen-carrying capability
of the remaining blood supply. Although prolonged ischemia may cause necrosis,
many of the manifestations of cerebral ischemia are reversed as pressure
diminishes, and there may be no permanent damage. Severe electrolyte imbalance
may cause generalized weakness; however, hemiparesis and aphasia are not the
result of electrolyte loss.
To begin the administration of total parenteral nutrition (TPN), a client has a right
subclavian central venous access device inserted. Immediately after insertion of the
, Nursing 401 crit care exam with 315Questions and
Verified Answers | 100% Correct |2024 Grade A+
catheter, what is the priority nursing action? - CORRECT ANSWERS
Auscultate the lungs to evaluate breath sounds.
The most significant and life-threatening complication of insertion of a subclavian
catheter is a pneumothorax because of the proximity of the subclavian vein and the
apex of the upper lobe of the lung; a client's respiratory status always is the priority.
Although a chest x-ray may be done before TPN is begun, it is not the priority
immediately after insertion of the catheter. A baseline blood glucose level should be
obtained before insertion of the catheter. After TPN is started, routine monitoring of
blood glucose levels is important. Although assessing for a neurologic deficit should
be done eventually, it is not the priority at this time.
The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription should
the nurse question? - CORRECT ANSWERS Administer intravenous fluid of
one-half normal saline (NS) at 125 mL/hr.
Because one-half NS is a hypotonic solution, it is contraindicated. It would actually
compound the issue instead of correcting the hyponatremia. Treatment for
hyponatremia can include restricting fluid intake and increasing sodium intake
either via oral intake or, in severe cases, intravenous fluids. The presence of
hyponatremia, as well as correction of hyponatremia if done too quickly, can cause
fluid shifts in the brain, resulting in altered mental status. Therefore it is important
for the nurse to assess for neurologic changes.
A group of clients is admitted with neurologic injury after hiking at high altitude. The
nurse is assessing using the "AVPU" mnemonic. Which type of emergency
assessment is the nurse performing? - CORRECT ANSWERS Disability
assessment is a part of the primary survey that is done to assess the level of
consciousness that may occur due to a neurologic injury. In the mnemonic " AVPU,"
A indicates alert, V indicates response to voice, P stands for response to pain, and U
indicates unresponsive. Exposure assessment is one of the priorities of a primary
survey, which involves removing clothing for a complete assessment and preventing
hypothermia using heat devices. Breathing assessment involves checking breath
sounds and respiratory effort. Circulation assessment is performed in a primary
survey to monitor blood pressure and pulse.
A client has undergone hypophysectomy. Which action would the nurse consider to
be most appropriate during postoperative care to prevent a cerebrospinal fluid (CSF)
leak? - CORRECT ANSWERS Prohibiting coughing or sneezing
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