Nursing 401 Crit Care Questions With
Complete Solutions
What interventions should the nurse implement when caring for a client with syndrome of
inappropriate antidiuretic hormone 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 Questions With
Complete Solutions
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?
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? 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? "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
, Nursing 401 Crit Care Questions With
Complete Solutions
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? 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.
, Nursing 401 Crit Care Questions With
Complete Solutions
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? 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? 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
Complete Solutions
What interventions should the nurse implement when caring for a client with syndrome of
inappropriate antidiuretic hormone 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 Questions With
Complete Solutions
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?
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? 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? "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
, Nursing 401 Crit Care Questions With
Complete Solutions
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? 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.
, Nursing 401 Crit Care Questions With
Complete Solutions
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? 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? 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
