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NRSG 357 Exam 1 (QBank) – Questions With Expert Verified Solutions
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NRSG 357 Exam 1 (QBank) – Questions With Expert Verified Solutions
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NRSG 357 Exam 1 (QBank) – Questions With ExpertVerified Solutions
Which components are able to change to adapt to small increases in
intracranial pressure (ICP) (select all that apply)?
A. blood
B. Skull bone
C. brain tissue
D. Scalp tissue
E. Cerebrospinal fluid (CSF) Right Ans - A C E
Calculate CPP of a patient whose blood pressure is 106/52 mm Hg and ICP is
14 mm Hg. Right Ans - 56 mm Hg
Calculate CPP of a patient with an ICP of 34 mm Hg and a systemic blood
pressure of 108/64 Right Ans - 44.6 mm Hg
Which factors decrease cerebral blood flow (select all that apply)?
A. increased ICP
B. PaO2 of 45 mm Hg
C. PaCO2 of 30 mm Hg
D. Arterial blood pH of 7.3
E. Decreased mean arterial pressure (map Right Ans - C E
What are the causes of vasogenic cerebral edema (select all that apply)?
A. Hydrocephalus
B. Ingested toxins
C. Destructive lesions or trauma
D. Local distribution of cell membranes
E. Fluid flowing from intravascular to extravascular space Right Ans - B E
Which events cause increased ICP (select all that apply)?
A. Vasodilation
B. Necrotic tissue edema
,C. Blood vessel compression
D. Edema from initial brain insult
E. Brainstem compression and herniation Right Ans - A B D
An early sign of increased ICP that the nurse should assess for is
A. Cushing's triad
B. unexpected vomiting
C. decreased LOC
D. dilated pupil with sluggish response to light Right Ans - C
The nurse recognizes the presence of Cushing's triad in the patient with which
vital sign changes?
A. increased pulse, irregular respiration, increased BP
B. Decreased pulse, increased respiration, decreased systolic BP
C. Decreased pulse, irregular respiration, widened pulse pressure
D. Increased pulse, decreased respiration, widened pulse pressure Right
Ans - C
A patient has ICP monitoring with an intraventricular catheter. What is a
priority using intervention for the patient?
A. Aseptic technique to prevent infection
B. Constant monitoring of ICP waveforms
C. Removal of CSF to maintain normal ICP
D. Sampling CSF to determine abnormalities Right Ans - A
Which drug treatment helps to decrease ICP by expanding plasma and the
osmotic effect to move fluid?
A. Oxygen administration
B. Pentobarbital (Nembutal)
C. Mannitol (Osmitrol) (25%)
D. Dexamethasone (Decadron) Right Ans - C
How are the metabolic and nutritional needs of the patient with increased ICP
best met?
,A. Enteral feedings that are low in sodium
B. Simple glucose available in D5W IV solutions
C. Fluid restriction that promoted a moderate dehydration
D. Balanced, essential nutrition in a form that the patient can tolerate Right
Ans - D
Why is the Glasgow Coma Scale used?
A. To quickly assess the LOC
B. To assess the patient's ability to communicate
C. To assess the patient's ability to respond to commands
D. To assess the patient's coordination with motor responses Right Ans - A
When assessing the body functions of a patient with increased ICP, what
should the nurse assess first?
A. Corneal reflex testing
B. Pupillary reaction to light
C. Extremity strength testing
D. Circulatory and respiratory status Right Ans - D
How is cranial nerve III, originating in the midbrain, assessed by the nurse for
an early indication of pressure on the brainstem?
A. Assess for nystagmus
B. Test the corneal reflex
C. Test pupillary reaction to light
D. Test for oculocephalic (doll's eyes) reflex Right Ans - C
A patient has a nursing diagnosis of risk for ineffective cerebral tissue
perfusion related to cerebral edema. What is an appropriate nursing
intervention for the patient?
A. Avoid positioning the patient with neck or hip flexion
B. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg
C. Cluster nursing activities to provide periods of uninterrupted rest
D. Routinely suction to prevent accumulation of respiratory secretions
Right Ans - A
, An unconscious patient with increased ICP is on ventilatory support. The
nurse notifies the health care provider when the arterial blood gas (ABG)
measurement results reveal what?
A. pH of 7.43
B. SaO2 of 94%
C. PaO2 of 70 mm Hg
D. PaCO2 of 35 mm Hg Right Ans - C (PaO2 should be 100)
The nurse is monitoring a patient for increased ICP following a head injury.
What are manifestations of increased ICP (select all that apply)?
A. Fever
B. Oriented to name only
C. Narrowing pulse pressure
D. Right pupil dilated greater than left pupil
E. Decorticate posturing to painful stimulus Right Ans - A B D E
The patient has been diagnosed with a cerebral concussion. What should the
nurse expect to see in this patient?
A. Deafness, loss of taste, and CSF otorrhea
B. CSF otorrhea, vertigo, the Battle's sign with dura tear
C. Boggy temporal muscle because of the extravasation of blood
D. Headache, retrograde amnesia, and transient reduction in LOC Right Ans
-D
The patient has depressed skull fracture and scalp lacerations with
communication to the intracranial cavity. Which type of injury should the
nurse record?
A. linear skull fracture
B. depressed skull fracture
C. compound skull fracture
D. comminuted skull fracture Right Ans - C.
A patient with a head injury has bloody drainage from the ear. What should
the nurse do to determine if CSF is present in the drainage?
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