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NR 340 Week 3 Question And Answers, EVOLVE

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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 intracranial pressure (ICP)? . 2. QUESTION: Under normal circumstances the cerebral vasculature exhibits pressure and chemical autoregulation. What happens when autoregulation is lost? 3. QUESTION: The nurse is monitoring a patient’s intracranial pressure (ICP). While the nurse is provQuestioning hygiene measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority nursing action? 4. QUESTION: Herniation syndromes can be life-threatening situations. Which syndrome causes the supratentorial contents to shift downward and compress vital centers of the brainstem? 5. QUESTION: In a patient with increased intracranial pressure (ICP), which of the following cranial …….. and eye movement? 6. QUESTION: 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? 7. QUESTION: The nurse is caring for a patient with a ruptured cerebral aneurysm……… What is the best interpretation of this finding by the nurse? 8. QUESTION: The nurse is caring for a patient admitted with a spinal cord injury. Upon assessment, the nurse notes a complete loss of motor and sensory function below the patient’s nipple line. What is the best understanding of this assessment finding by the nurse? 9. QUESTION: The nurse is preparing to admit a patient from the ED who has sustained a complete spinal cord lesion at the C5 level. When planning the patient’s care, which nursing intervention is most important? 10. QUESTION: The nurse is caring for a patient with an assessed Glasgow Coma Scale score of 3. What is the best understanding of this finding? 11. QUESTION: Autonomic dysreflexia is characterized by an exaggerated response of the sympathetic nervous system to a variety of stimuli. Common causes of autonomic dysreflexia include: (Select all that apply.) 12. QUESTION: Which statements best represent optimal fluQuestion administration for the management of increased intracranial pressure? (Select all that apply.) ________________________________________ Questions → 1. QUESTION: Your patient was a passenger in a motor vehicle crash yesterday and suffered an open fracture of the femur. His condition was stable until an hour ago, when he began to complain of shortness of breath. His heart rate is 104 beats/min, respiratory rate is 30 breaths/min, BP is 90/60 mm Hg, and temperature is now 38.4° C. You suspect that he: 2. QUESTION: Poor patient outcomes after a traumatic injury are associated with: 3. QUESTION: Which condition is a common cause of death after chest trauma? 4. QUESTION: A trauma patient with a fractured forearm complains of extreme, throbbing pain at the fracture site and paresthesia in the fingers. Upon further assessment, you note that the forearm is extremely edematous and you are now having difficulty palpating a radial pulse. You notify the physician immediately because you suspect: 5. QUESTION: The trauma patient presenting with left lower rib fractures develops left upper quadrant tenderness, hypotension, and referred pain to the left shoulder. You suspect: 6. QUESTION: Spinal cord injury causes a loss of sympathetic output, resulting in distributive shock with hypotension and bradycardia. Although blood pressure may respond to fluQuestion resuscitation, what other therapy may be required to compensate for loss of sympathetic innervation? 7. QUESTION: A restrained patient’s status after a motor vehicle crash includes dyspnea, dysphagia, hoarseness, and complaints of severe chest pain. Upon assessment you note that the patient has weak femoral pulses……….? 8. QUESTION: The primary priority for the critical care nurse with regard to the trauma patient is which of the following? 9. QUESTION: A 72-year-old patient fractured his pelvis in a motor vehicle crash 2 days ago. He suddenly becomes anxious and short of breath. His respiratory rate is 34 breaths per minute, and he is complaining of mQuestionsternal chest pain. His oxygen saturation drops to 75%. You suspect: 10. QUESTION: A 55-year-old trauma patient hit the steering wheel and has a cardiac contusion. Which are potential complications of the injury? (Select all that apply.) 11. QUESTION: The nurse is assessing a patient for suspected alcohol withdrawal and Questionentifies which signs and symptoms as suspicious? (Select all that apply.) 12. QUESTION: When obtaining report on a trauma patient, which Question would be helpful in determining potential injuries associated with the mechanism of injury? (Select all that apply.) 13. QUESTION: To maintain the patient’s airway, which interventions are appropriate to implement with a trauma patient who sustained a spinal cord injury? (Select all that apply.) 14. QUESTION: Which interventions are appropriate to consQuestioner in the management of the geriatric trauma patient? (Select all that apply.) 15. QUESTION: Prevention of hypothermia is crucial in caring for trauma patients. Which treatments are appropriate for preventing hypothermia? (Select all that apply.) ________________________________________ Questions → 1. QUESTION: A patient has sustained deep partial-thickness and full-thickness burns over 60% of her body. Shortly after admission, her blood pressure drops rapQuestionly to a systolic pressure of 70 mm Hg. You know this is primarily due to: 2. QUESTION: Your patient weighs 60 kg and has a 40% TBSA burn injury. FluQuestion resuscitation orders are for 4 mL/kg/% burn of a lactated Ringer’s solution…….? 3. QUESTION: A temporary wound cover composed of a graft of skin transplanted from another human, living or dead, is called a(n): 4. QUESTION: A major complication of an electrical burn injury is acute kQuestionney injury caused by: 5. QUESTION: The most crucial phase of treatment in burn care is during the: 6. QUESTION: Ischemia to the gastrointestinal system may be caused by redistribution of blood to the brain and heart. The potential physiological effect of this is: 7. QUESTION: All burn patients are at increased risk for acute respiratory distress syndrome (ARDS) due to: 8. QUESTION: A hallmark finding suggesting burn injury below the glottis is: 9. QUESTION: Which of the following are common complications of burn patients? (Select all that apply.) 10. QUESTION: Which of the following statements is correct regarding burn classification? (Select all that apply.) 11. QUESTION: Burn injury severity is determined not only by the type of burn injury but also by: (Select all that apply.) 12. QUESTION: Which of the following statements is true about nonburn injuries? (Select all that apply.) 13. QUESTION: Which of the following statements are true regarding chemical injuries? (Select all that apply.) 14. QUESTION: Immediate interventions in the treatment of a patient with burns from tar include which of the following? (Select all that apply.) 15. QUESTION: In which circumstances should patients should be transferred to specialized burn center for treatment? (Select all that apply.) ________________________________________ Questions → 1. QUESTION: Which statement best describes the role of the acute care nurse in the organ donation process? 2. QUESTION: Which transplant patient being cared for by the nurse requires immediate intervention? 3. QUESTION: The nurse is caring for a patient in acute liver failure caused by an overdose of acetaminophen……..Which statement best reflects appropriate application of the MELD score in this situation? 4. QUESTION: Which statement best represents immunosuppressant therapy in organ transplant recipients? 5. QUESTION: The transplant clinic nurse is reviewing the medical history of a lung transplant patient who is 3 months posttransplant. The patient states he has been feeling “tired” all the time. The nurse notes an oral temperature of 99.2° F and Questionentifies the patient’s white count to be 2500/mm3. What is the interpretation of these findings by the nurse? 6. QUESTION: Which laboratory test best predicts the potential for organ rejection in transplant recipients? 7. QUESTION: The nurse is caring for a renal transplant patient who is 3 days postoperative with a Jackson-Pratt drain. Output from the drain has been 75 mL serous color for the past 24 hours. What is the best interpretation of this finding by the nurse? 8. QUESTION: The nurse is preparing an organ transplant recipient for discharge from the hospital. Which statement by the nurse is most important to include as part of discharge education? 9. QUESTION: Which statements best describe functions of an organ procurement organization? (Select all that apply.) 10. QUESTION: To qualify as a living organ donor, several characteristics are required. Which statement(s) best reflect characteristics of living organ donors? (Select all that apply.) 11. QUESTION: The nurse is caring for a renal transplant recipient in the postanesthesia care unit. Handoff communication from the OR included a reported output of 500 mL following anastomosis of the renal vessels and reperfusion. One hour after admission to the PACU, the RN notes no urine output. Which physician orders are appropriate to treat this situation? (Select all that apply

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Questions

1. 1.ID: 43154241

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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