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Nursing 401 Crit Care – Questions & Accurate Answers
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Nursing 401 Crit Care – Questions & Accurate Answers
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Nursing 401 Crit Care – Questions & Accurate AnswersAfter 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
Right Ans - 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 Right Ans - 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 Right Ans - 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.
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? Right Ans - 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? Right Ans - 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? Right Ans -
"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? Right Ans - Irritability
Tachycardia
Increasing anxiety
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?
Right Ans - 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? Right Ans - 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 catheter, what is the priority nursing action? Right Ans -
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? Right Ans - 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? Right Ans - 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
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