Elsevier Adaptive Quizzing Quiz performance Intracranial Problems Practice Quiz
pdf
keyboard_arrow_up
School
University of Central Oklahoma *
*We aren’t endorsed by this school
Course
4025
Subject
Communications
Date
Apr 3, 2024
Type
Pages
30
Uploaded by Peculiar2025
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
1/30
Exit
Performance
Intracranial Problems Practice Quiz
Due Mar 10, 2024 by 11:59 pm
Final Score
80%
24 out of 30 questions answered correctly
Completed on Mar 20, 2024 6:15 pm
Incorrect (6)
Report content error
Which priority
outcome would the nurse expect after
administration of IV mannitol prescribed for a patient
experiencing an increased intracranial pressure (ICP)?
Increased urine output
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
2/30
Rationale
Mannitol is an osmotic diuretic that increases osmotic pressure in the
renal tubules to increase the uptake of water and diuresis by the kidneys,
which specifically helps to relieve cerebral edema, thereby decreasing ICP,
which is the priority outcome. Increased urine output, decreased BP, and
increased intracranial perfusion are secondary outcomes of administration
of mannitol. Of these, increased intracranial perfusion is most desirable
because it reduces ICP. The nurse monitors BP closely because an extreme
decrease in BP may occur, resulting in decreased intracranial perfusion.
p. 1491
Report content error
For the patient who sustained a head injury in a motor vehicle
crash, which initial intervention would the nurse include in
the patient’s plan of care? Select all that apply. One, some, or
all responses may be correct.
Some correct answers were not selected
Decreased blood pressure (BP)
Reduced ICP
Increased intracranial perfusion
Control external bleeding.
Administer oxygen.
Assume neck injury.
Maintain normothermia.
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
3/30
Rationale
Controlling external bleeding with sterile pressure dressings,
administering oxygen, assuming a neck injury with the head injury, and
establishing IV access are priority interventions to ensure the health and
safety of the patient. Maintaining normothermia and administering fluids
cautiously are part of ongoing monitoring to help prevent secondary
injury; these interventions can take place after the priority interventions
have been administered.
p. 1500
Report content error
Which clinical manifestation is characteristic of Cushing triad?
Select all that apply. One, some, or all responses may be
correct.
Some correct answers were not selected
Administer fluids cautiously.
Establish/maintain IV access.
Tachycardia
Bradycardia
Systolic hypotension
Systolic hypertension
Widening pulse pressure
Narrowing pulse pressure
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
4/30
Rationale
Cushing triad is a neurologic emergency characterized by bradycardia,
systolic hypertension, and a widening pulse pressure. The heart rate slows,
so Cushing triad does not include tachycardia. Systolic BP increases, so
hypotension is not present. Pulse pressure widens, not narrows, with
Cushing triad.
p. 1487
Report content error
When the nurse is preparing to administer a hypertonic saline
infusion to a patient with an increased intracranial pressure
(ICP), which parameter would the nurse monitor frequently?
Select all that apply. One, some, or all responses may be
correct.
Some correct answers were not selected
Rationale
Hypertonic saline solutions can be used to treat increased ICP. Hypertonic
saline infusions increase the intravascular fluid volume, which may alter
Blood glucose
Serum sodium
BP
Level of sedation
Gastrointestinal disturbances
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
5/30
the serum sodium levels and BP in the body. Monitoring blood glucose
levels would be necessary if administering corticosteroids to a patient.
Monitoring sedation levels would be required if administering barbiturates
to the patient. Monitoring gastrointestinal disturbances would be
necessary if administering corticosteroids to the patient.
Test-Taking Tip:
Be alert for details about what you are asked. In this
question type, you need to select all options that apply to a given situation
or patient. All options likely relate to the situation, but only some of the
options may relate directly to the situation.
p. 1491
Report content error
Which factor would the nurse consider prior to repositioning
a patient with an increased intracranial pressure (ICP)? Select
all that apply. One, some, or all responses may be correct.
Rationale
Maintain the patient's hips in flexed position while lying on the
side.
Take care to prevent extreme neck flexion of patient.
Adjust body position to decrease ICP.
Rotate the patient to a side-lying position to prevent skin
breakdown.
Follow protocol standards to maintain a head-up position for the
patient.
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
6/30
The nurse should take care to prevent extreme neck flexion of the patient
because it can cause venous obstruction and contribute to elevated ICP.
The nurse would position the patient's body to decrease ICP and improve
the cerebral perfusion pressure (CPP). Maintaining a head-up position for
the patient is important because elevation of the head of the bed promotes
drainage and decreases the vascular congestion that can produce cerebral
edema. The patient avoids extreme hip flexion to decrease the risk for
raising the intraabdominal pressure, which increases ICP. Rotating the
patient to a side-lying position may further increase the ICP. Special air
beds can alternate skin pressures to prevent tissue damage.
pp. 1494-1495
Report content error
Which factor would the nurse associate with influencing a
patient’s intracranial pressure (ICP)? Select all that apply. One,
some, or all responses may be correct.
Some correct answers were not selected
Rationale
Posture
Swallowing
Drowsiness
Suctioning
Hypoxemia
Intraabdominal pressure
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
7/30
Posture, suctioning, hypoxemia, and intraabdominal pressure all influence
ICP. Swallowing does not affect ICP. Drowsiness may be a sign of
increased ICP, but it does not influence it.
pp. 1494-1495
Correct (24)
Report content error
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
8/30
Which clinical manifestation would the nurse anticipate
identifying in a patient who is comatose? Select all that apply.
One, some, or all responses may be correct.
Rationale
A coma is the deepest state of unconsciousness in which the corneal and
pupillary reflexes are absent. A comatose patient is also incontinent of
urine and feces and does not respond to painful stimuli. The comatose
patient is not able to cough and swallow and does not have any bowel and
bladder control.
p. 1487
Report content error
Patient can cough and swallow.
Patient has bowel and bladder control.
Patient's corneal and pupillary reflexes are absent.
Patient has incontinence of urine and feces.
Patient does not respond to painful stimuli.
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
9/30
The patient admitted with a closed head injury is awake but
lethargic, and the baseline vital signs include a blood pressure
(BP) of 120/80 mm Hg, pulse of 78 beats/min, and
respirations of 20 breaths/min. Which finding indicates
deterioration of the patient’s condition 2 hours later?
Rationale
Late signs of increased intracranial pressure include an increased systolic
BP and decreasing diastolic BP (widening pulse pressure), bradycardia, and
irregular respirations. The patient may also display a decreased level of
consciousness, seizures, or both. These symptoms represent the Cushing
triad and require immediate intervention. A sleeping patient who awakens
in response to painful stimuli; not remembering what happened; and a BP
of 110/80 mm Hg, pulse of 78 beats/min, and respirations of 20
breaths/min do not necessarily indicate deterioration in the patient's
condition.
p. 1487
Report content error
The patient is sleeping but awakens in response to painful stimuli.
The patient does not remember what happened during the 6
hours prior to the injury.
BP is 110/80 mm Hg, pulse is 78 beats/min, and respirations are
20 breaths/min.
BP is 160/74 mm Hg, pulse is 53 beats/min, and respirations are
irregular.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
10/30
Which interpretation would the nurse associate with a
patient’s Glasgow Coma Scale score of 5 after sustaining a
head injury?
Rationale
The Glasgow Coma Scale ranges from 3 to 15. A score of 8 or less
generally indicates coma. The lower the score, the more serious the
patient's condition. A patient who is alert and oriented, awake but
lethargic, or responding appropriately to commands has a Glasgow Coma
Scale score higher than 8.
p. 1492
Report content error
The patient is alert and oriented.
The patient is unresponsive and comatose.
The patient is awake but lethargic and drowsy.
The patient responds appropriately to commands.
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
11/30
Which response would the nurse document when a patient
with a brain injury experiences the motor function changes
depicted in the image?
Rationale
Decorticate posture
involves internal rotation and adduction of the arms
with extension of the elbows, wrists, and fingers, as illustrated in the
image. This results from interruption of voluntary motor tracts in the
cerebral cortex. The patient may also demonstrate an extension of the legs.
A decerebrate posture may indicate more serious damage and results from
disruption of motor fibers in the midbrain and brainstem. In this position,
the arms are stiffly extended, adducted, and hyperpronated. There is also
hyperextension of the legs with plantar extension of the feet. Sinusoidal
posturing does not exist. Opisthotonic posturing consists of the head,
neck, and spinal column in an arching position.
p. 1487
Decorticate posturing
Decerebrate posturing
Sinusoidal posturing
Opisthotonic posturing
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
12/30
Report content error
When the nurse is assessing a patient’s neurologic status
upon arrival to the emergency room, which indicator would
the nurse utilize as the most
reliable?
Rationale
The level of consciousness is the most sensitive and reliable indicator of
the patient's neurologic status. Dim vision can be due to dysfunction of
the cranial nerves. Papilledema, which is an edematous optic disc seen on
retinal examination, can be noted and is a nonspecific sign associated with
persistent increases in intracranial pressure (ICP). A change in body
temperature may also occur because increased ICP affects the
hypothalamus.
p. 1487
Report content error
Dim vision
Papilledema
Body temperature
Level of consciousness
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
13/30
Which initial intervention would the nurse implement as
emergency management of a patient who fell and presented
with scalp lacerations and a depressed skull? Select all that
apply.One, some, or all responses may be correct.
Rationale
Manage the patient with scalp lacerations and skull depression by
stabilizing the cervical spine, administering oxygen via a non-rebreather
mask, and controlling external bleeding with a sterile pressure dressing.
Wrapping the patient in tight clothing is not appropriate. Instead,
removing the patient's clothes can help. Intubation is required only if the
GCS is less than 8 (comatose).
p. 1500
Report content error
Stabilize the cervical spine.
Wrap the patient in tight clothing.
Administer oxygen via a non-rebreather mask.
Control external bleeding with a sterile pressure dressing.
Intubate if the Glasgow Coma Scale (GCS) score is less than 12.
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
14/30
For the patient presenting with watery sanguineous nasal
drainage after falling from a first-floor roof, which diagnostic
method validates the nurse’s suspicion of a cerebrospinal fluid
(CSF) leak?
Rationale
The patient may be experiencing leakage of CSF from the nose, which is
also sanguineous (bloody). In the presence of blood, the halo test is most
accurate for determining the presence of CSF. Allow the leaking fluid to
drip onto a white gauze pad (4 × 4) or towel, and then observe the
drainage. Within a few minutes, the blood coalesces into the center, and a
yellowish ring encircles the blood if CSF is present. A Gram stain is used to
identify bacterial presence. If blood is present, the Dextrostix will not be
accurate because glucose is present in blood. CSF is sterile in the body and
under normal circumstances does not contain white cells (leukocytes) or
bacteria.
p. 1497
Report content error
Gram stain
The halo test
A Dextrostix
Slide smear for presence of leukocytes
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
15/30
Which patient condition contraindicates testing the doll’s-eye
reflex when performing a neurologic assessment?
Rationale
A doll’s-eye reflex test is performed to determine the oculocephalic reflex.
It is done by turning the patient’s head briskly to the left or right while
holding the eyelids open and then by quickly flexing and extending the
neck. It would be contraindicated in a patient with a cervical spine problem
because of the brisk turning of the patient's head. A doll’s-eye reflex test
can be performed in an unconscious and uncooperative patient. This test
is usually only done as part of the evaluation of brain death.
p. 1493
Report content error
Which intervention would the nurse identify as a priority
when monitoring a patient recovering from a craniotomy?
An unconscious patient
An uncooperative patient
A patient with a cervical spine injury
A patient who is being evaluated for brain death
Monitor the patient for pain.
Monitor the patient for an infection.
Monitor the patient for excessive bleeding or hemorrhage.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
16/30
Rationale
The priority action of the nurse caring for a patient following a craniotomy
is to monitor for increased ICP, which can have serious life-threatening
implications. Managing the patient’s pain is important, but pain is not an
emergency. Monitoring the patient for development of an infection would
be done, but the infection would not be immediately apparent. A
hemorrhage will cause an increase in ICP if it is cerebral.
p. 1507
Report content error
Which Glasgow Coma Scale (GCS) score would the nurse
assign an unconscious patient who opens the eyes in
response to pain but who does not respond to any other
stimulus, moans to any verbal communication, and
demonstrates flexion withdrawal?
Rationale
Monitor the patient for increased intracranial pressure (ICP).
4
6
8
10
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
17/30
The GCS is a quick, practical, and standardized system for assessing loss of
consciousness. According to this scale, the patient’s ability to open his or
her eyes in response to only pain stimulus merits a score of 2. Expressing
incomprehensible words such as moaning merits a score of 2; and for
flexion withdrawal, a score of 4 is given. Therefore 2 + 2 + 4 = 8 indicates
the value for the GCS for this patient.
p. 1492
Report content error
When a plan of care is developed for a patient with an
elevated intracranial pressure (ICP), which factor guides the
nursing interventions? Select all that apply. One, some, or all
responses may be correct.
Rationale
Pain and agitation cause rapid movements, which may increase the ICP.
Extreme hip flexion may raise the intraabdominal pressure, which
increases the ICP. Increased intrathoracic pressure may increase ICP by
impeding venous return. Elevation of the head of the bed promotes
drainage from the head, decreases vascular congestion, and therefore
Pain and agitation may elevate the patient’s ICPs.
Elevating the head of the patient’s bed increases ICPs.
Extreme hip flexion increases intraabdominal pressures.
Increased intrathoracic pressures impede venous return.
Slow and gentle movements exhaust the patient’s energy reserve.
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
18/30
decreases ICP. Slow and gentle movements will provide comfort to the
patient and will not increase the ICP.
Test-Taking Tip:
Be alert for details about what you asked to do. In this
question type, the request was to select all options that apply to a given
situation or patient. All options likely relate to the situation, but only some
of the options may relate directly to the situation.
p. 1495
Report content error
Which method of measurement is the gold standard for
obtaining intracranial pressures (ICPs)?
Rationale
A ventriculostomy is the gold standard for measurement of ICP. A
fiberoptic catheter and air pouch/pneumatic are other measures for
monitoring ICP, but they are not considered the gold standard. A
transcranial Doppler evaluates blood flow in the brain.
p. 1488
Ventriculostomy
Fiberoptic catheter
Air pouch/pneumatic
Transcranial Doppler
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
19/30
Report content error
For the patient admitted with a subdural hematoma following
a motor vehicle accident, which vital sign change would the
nurse interpret as a clinical manifestation of an increasing
intracranial pressure (ICP)?
Rationale
Bradycardia could indicate increased ICP. Changes in vital signs (known as
Cushing triad) occur with increased ICP. The triad consists of increasing
systolic pressure (not hypotension) with a widening pulse pressure (not
narrowing), bradycardia with a full and bounding pulse, and irregular
respirations (not tachypnea).
Test-Taking Tip:
The most reliable way to ensure that you select the correct
response to a multiple-choice question is to recall it. Depend on your
learning and memory to furnish the answer to the question. To do this,
read the stem, and then stop! Do not look at the response options yet. Try
to recall what you know and, based on this, what you would give as the
answer. After you have taken a few seconds to do this, then look at all of
the choices and select the one that most nearly matches the answer you
recalled. Considering all the choices and not just selecting the first option
that seems to fit the answer you recall is important. Remember the
distractors. The second choice may look okay, but wording of the fourth
Hypotension
Bradycardia
Narrowing pulse pressure
Tachypnea
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
20/30
choice may be in a way that makes it a slightly better choice. If you do not
weigh all the choices, you are not maximizing your chances of correctly
answering each question.
p. 1487
Report content error
Assessment findings of a patient include a mean arterial
pressure (MAP) of 64 mm Hg, intracranial pressure (ICP) of 25
mm Hg, and blood pressure (BP) of 180/90 mm Hg. The
nurse calculates what cerebral perfusion pressure (CPP)?
Record answer as a whole number. mm Hg
Rationale
The CPP
is calculated by subtracting the ICP from the MAP; 64 - 25 = 39.
Normal CPP is 60 to 100 mm Hg to ensure blood flow to the brain. As
CPP decreases, autoregulation fails and cerebral blood flow is decreased.
p. 1484
Report content error
39
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
21/30
The nurse would instruct the patient recovering from a head
injury and his or her caregiver to report the development of
which symptom immediately to the health care provider?
Select all that apply. One, some, or all responses may be
correct.
Rationale
Seizures, a stiff neck, and increased drowsiness are the important
symptoms that the patient and caregivers should immediately relay to the
health care provider. Sneezing and constipation are not alarming and can
also be due to other reasons.
p. 1501
Report content error
Which observation would the nurse associate with a
cerebrospinal fluid (CSF) leak when a patient with a suspected
traumatic brain injury (TBI) develops a bloody nasal drainage?
Sneezing
Seizures
Stiff neck
Constipation
Increased drowsiness
A halo sign on the nasal-drip pad
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
22/30
Rationale
When drainage containing both CSF and blood is allowed to drip onto a
white pad, within a few minutes the blood will coalesce into the center,
and a yellowish ring of CSF will encircle the blood, giving a halo effect.
Decreased BP and urinary output would not be indicative of a CSF leak.
The presence of glucose would be unreliable for determining the presence
of CSF because blood also contains glucose. Clear nasal drainage along
with the bloody discharge would need to be assessed with the halo test to
see if there is a yellowish ring of CSF around the blood.
p. 1497
Report content error
Which physiologic effect is associated with a patient’s
calculated mean arterial pressure (MAP) below 70 mm Hg?
Rationale
Decreased BP and urinary output
A positive reading for glucose on a test-tape strip
Clear nasal drainage along with the bloody discharge
Normal intracranial pressure (ICP)
Increased ICP
Decreased cerebral blood flow (CBF)
Increased cerebral perfusion pressure (CPP)
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
23/30
A MAP below 70 mm Hg results in a decreased CBF. The decreased MAP
does not indicate a normal or increased ICP. The CPP decreases as a result
of the diminished MAP. A MAP below 70 mm Hg does not necessarily
guarantee a normal ICP. The normal range of a MAP is between 70 and
100 mm Hg. A MAP of at least 60 mm Hg is vital to provide enough blood
to the coronary arteries, kidneys, and brain.
p. 1484
Report content error
Which intervention would the nurse implement to promote
positive outcomes for a patient experiencing increased
intracranial pressures (ICPs) in the neurologic intensive care
unit? Select all that apply. One, some, or all responses may
be correct.
Rationale
ICP monitoring, elevating the head of the bed 30 degrees, and
maintaining a systolic arterial pressure of 100 to 160 mm Hg are
components of expected management for a patient with increased ICP.
Monitor ICP.
Obtain consent for a cerebral angiography.
Elevate the head of the bed to 30 degrees.
Obtain a patient history and physical examination.
Maintain a PaO
of 90 mm Hg or greater.
2 Maintain systolic arterial pressure of 100 to 160 mm Hg.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
24/30
Cerebral angiography, patient history, and a physical examination are
diagnostic assessment tools rather than interventions to promote a
positive outcome. The PaO
should be maintained at 100 mm Hg or
greater.
p. 1488
Report content error
Which clinical manifestation would the nurse report
immediately to the health care provider when providing care
for a patient with a traumatic brain injury and an increased
intracranial pressure (ICP)?
Rationale
An increased urine output of 500 mL in 1 hour could cause critical fluid
and electrolyte imbalance issues. It could also indicate that the patient is
going into diabetes insipidus, which is caused by a decrease in antidiuretic
hormone (ADH) and results in increased urine output and hypernatremia.
This would need prompt attention. An ICP of 20 mm Hg, respiratory rate
of 24 breaths/min, and pulse of 100 beats/min do not indicate a need for
the nurse to call the health care provider.
p. 1494
2
ICP of 20 mm Hg
Urine output of 500 mL in 1 hour
Respiratory rate of 24 breaths/min
Pulse of 100 beats/min
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
25/30
Report content error
For which potential complication related to cerebral
hemorrhage and edema would the nurse monitor in a patient
admitted with a head injury?
Rationale
Increased intracranial pressure can occur as a potential complication
related to cerebral hemorrhage and edema. Anxiety can result from an
abrupt change in health status, being in a hospital environment, and
having an uncertain future. Hyperthermia can occur because of increased
metabolism, infection, and hypothalamic injury. Impaired physical
mobility is related to a decreased level of consciousness.
Test-Taking Tip:
The most reliable way to ensure that you select the correct
response to a multiple-choice question is to recall it. Depend on your
learning and memory to furnish the answer to the question. To do this,
read the stem, and then stop! Do not look at the response options yet. Try
to recall what you know and, based on this, what you would give as the
answer. After you have taken a few seconds to do this, then look at all of
the choices and select the one that most nearly matches the answer you
recalled. It is important that you consider all the choices and not just
Anxiety
Hyperthermia
Impaired physical mobility
Increased intracranial pressure
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
26/30
choose the first option that seems to fit the answer you recall. Remember
the distractors. The second choice may look okay, but the fourth choice
may be worded in a way that makes it a slightly better choice. If you do not
weigh all the choices, you are not maximizing your chances of correctly
answering each question.
p. 1485
Report content error
Which rationale would the nurse use to explain to family
members why older adult patients who fall have a high risk for
developing a chronic subdural hematoma?
Rationale
Chronic subdural hematomas are more common in older adults because
of the potentially larger subdural space due to brain atrophy. Changes in
vasculature occur in the elderly but do not put the patient at risk for a
subdural hematoma from a fall. With aging, a reduction in pain sensation
may occur, but this is not the physiologic cause for the risk of a chronic
subdural hematoma. The older adult patient does not normally experience
a decreased level of consciousness; this is an alteration in mental status
Older adult patients have larger subdural spaces.
Changes in vasculature occur with older adult patients.
Older adult patients experience a decrease in sensing their pain.
There is a decreased level of consciousness in the older adult
patient.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
27/30
and is a pathologic symptom unrelated to the risk for chronic subdural
hematoma.
p. 1499
Report content error
A patient’s blood pressure (BP) is 120/60 mm Hg and the
intracranial pressure (ICP) is 24 mm Hg. After calculating the
patient’s cerebral perfusion pressure (CPP), which
interpretation would the nurse apply to the results?
Rationale
A normal CPP is 60 to 100 mm Hg. Determine the calculated CPP by
subtracting the ICP from the mean arterial pressure (MAP).
MAP = (systolic blood pressure [SBP] + 2[diastolic blood pressure (DBP)])/3:
(120 mm Hg + 2[60 mm Hg])/3 = (120 mm Hg + 120 mm Hg)/3 = 240/3 =
80 mm Hg.
MAP – ICP: 80 mm Hg (MAP) – 24 mm Hg (ICP) = a CPP of 56 mm Hg.
The decreased CPP (<60 mm Hg) indicates an impaired cerebral blood
flow and impaired autoregulation of the CPP. Because the ICP is 24 mm
Hg, the pressure is elevated, preventing perfusion of the brain, and it
requires treatment.
High blood flow to the brain
Normal ICP
Impaired blood flow to the brain
Adequate autoregulation of blood flow
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
28/30
pp. 1484-1485
Report content error
Which position would the nurse expect a patient to display as
decerebrate posturing when diagnosed with an elevated
intracranial pressure (ICP) causing serious disruption of motor
fibers in the midbrain and brainstem?
Rationale
Decerebrate posture
(Choice 2) is when all four extremities are in rigid
extension with hyperpronation of the forearms and plantar flexion of feet.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
29/30
Decorticate posture (Choice 1) is internal rotation and adduction of the
arms with flexion of the elbows, wrists, and fingers caused by interruption
of voluntary motor tracts in the cerebral cortex. Decorticate response on
one side of the body and decerebrate response on the other side of the
body (Choice 3) may occur depending on the damage to the brain.
Opisthotonic posturing (Choice 4) is decerebrate posture with the neck
and back arched posteriorly and is potentially visualized with traumatic
brain injury.
p. 1487
Report content error
Which medication is an osmotic diuretic that the nurse would
prepare to administer to lower a patient’s intracranial pressure
(ICP)?
Rationale
Mannitol is an osmotic diuretic given via IV to decrease ICP. Cimetidine is
a histamine (H
) receptor blocker given to a patient receiving
corticosteroids to prevent gastrointestinal ulcers and bleeding.
Dexamethasone is a corticosteroid used to treat vasogenic edema.
Hypertonic saline is an IV solution used to help reduce cerebral swelling.
Mannitol
Cimetidine
Dexamethasone
Hypertonic saline
2
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
3/20/24, 7:21 PM
Elsevier Adaptive Quizzing - Quiz performance
https://eaqng.elsevier.com/#/quizPerformance/54956077
30/30
p. 1491
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help