ICU Exam 2 (class questions)

What are the main goals of a patient that presents with increased ICP? a. Maintenance of airway b. Adequate cerebral tissue perfusion c. Resonation of fluid balance d. Absence of infections and complications e. All of the above

Answer: A Rationale: "The goals for the patient include maintenance of a patent airway, normalization of respiration, adequate cerebral tissue perfusion through reduction in ICP, restoration of fluid balance, absence of infection, and absence of complications."

The patient reports to the nurse of being afraid to speak up regarding a desire to end care for fear of upsetting spouse and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause? A) Advocacy B) Responsibility C) Confidentiality D) Accountability

Answer: A Rationale: Nurses advocate for patients when they support the patient's cause. A nurse's ability to adequately advocate for a patient is based on the unique relationship that develops and the opportunity to better understand the patient's point of view. Responsibility refers to respecting one's professional obligations and following through on promises. Confidentiality deals with privacy issues, and accountability refers to answering for one's actions.

What is the most common organ donated? A) Kidney B) Heart C) Liver D) Eyes

Answer: A Rationale: The kidneys are the most commonly donated organs with the liver coming in second. Since we have 2 kidneys people can do living donations if they qualify.

Which of the following is NOT part of the Modified Finnegan's Neonatal Abstinence Scoring System? a) Urine color b) Moro Reflex c) Respiratory Rate d) Sneezing

Answer: A Rationale: Although stools may be assessed and are a part of the Finnegan's Neonatal Abstinence Scoring System, urine color is not an area of scoring. Moro Reflexes, Respiratory Rate and sneezing are all scoring areas.

The nurse is assessing a newborn and suspects that the newborn was exposed to drugs in utero because the newborn is exhibiting signs of neonatal abstinence syndrome. Which of the following would the nurse expect to assess? (Select all that apply.) A) Tremors B) Diminished sucking C) Regurgitation D) Shrill, high-pitched cry E) Hypothermia F) Frequent sneezing

Answer: A, C, D, F Rationale: Signs and symptoms of neonatal abstinence syndrome include tremors, frantic sucking, regurgitation or projectile vomiting, shrill high-pitched cry, fever, and frequent sneezing.

According to Petty (2016), which of the following is part of the initial treatment for AMR? Select all that apply. a) detection of DSA b) intravenous medications c) transaminase levels d) past surgical history e) creatine levels

Answer: A,C,E Rationale: Refer to Petty (2016) "Treat for AMR. Medications and Therapies." IV Ig reduces antibody levels. Detection of DSA, physiologic symptoms and specific lab values are combined to determine criteria to initate AMR. Past surgical history is not indicative of a transplant. IV Immunoglobulins can reduce antibody levels and decrease immune function.

When caring for an unconscious patient, what nursing intervention takes highest priority? A) Inserting an indwelling catheter B) Maintaining a patent airway C) Putting in a NG tube in place D) Administering an enema daily

Answer: B Rationale: B is the correct answer. Airway, breathing and circulation (ABC's) are the top priority and everything else comes after. Enemas should be avoided because the danger of increasing intracranial pressure.

The nurse would take which action as part of nursing care of the infant experiencing neonatal abstinence syndrome? a) Place stuffed animals and mobiles in the crib to provide visual stimulation. b) Position the baby's crib in a quiet corner of the nursery. c) Avoid the use of pacifiers. d) Spend extra time holding and rocking the baby.

Answer: B Rationale: Neonatal abstinence syndrome, or drug withdrawal, causes hyperstimulation of the neonate's nervous system. Nursing interventions should focus on decreasing environmental and sensory stimulation during the withdrawal period. Pacifiers allow for nonnutritive sucking by the infant. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Recall that neonatal abstinence syndrome is accompanied by hyperstimulation of the central nervous system. The correct answer would be the option that contains a strategy to reduce stimulation

When planning the care of a newborn addicted to cocaine who is experiencing withdrawal, which of the following would be least appropriate to include? A) Wrapping the newborn snugly in a blanket B) Waking the newborn every hour C) Checking the newborn's fontanels D) Offering a pacifier

Answer: B Rationale: Stimuli need to be decreased. Waking the newborn every hour would most likely be too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive sucking. Checking the fontanels provides evidence of hydration.

A nurse is caring for a newborn whom has suspected neonatal abstinence syndrome. Which of the following findings supports this diagnosis? a) decreased muscle tone b) continuous high-pitched cry c) sleeps for 2 hours after feeding d) mild tremors when disturbed

Answer: B Rationale: -Option A is incorrect- Increased muscle tone is seen in a newborn who has neonatal abstinence syndrome. -Option B is correct- A continuous high-pitched cry is often an indication of CNS disturbances in a newborn who has neonatal abstinence syndrome. -Option C is not correct- A newborn who has neonatal abstinence syndrome can have sleep pattern disturbances and would have difficulty sleeping for 2 hour after feeding. -Option D is incorrect- A newborn who has neonatal abstinence syndrome often has moderate to severe tremors when undisturbed. Many normal newborns have mild tremors when disturbed.

What situation may cause a patient with ESLD on the transplant list to be put in status 7? a. A MELD score of 8 b. An active infection requiring ICU care c. HIV diagnosis d. Family decision to transition to hospice care

Answer: B Rationale: A patient is not appropriate for a transplant with an active infection due to the need for immunosuppressants. A MELD score of 8 is relatively low on the scale of 6 to 40, and would not require a status 7. An HIV diagnosis does not disqualify a pt for transplant, and many patients on the list do have HIV. A transition to hospice care would remove the patient from the list, not put them in status 7. Source: ESLD case study

Which of the following is not indicative of Transplant Rejection, according to Petty (2016)? a) Decreased cardiac output b) Increased Pulmonary Function c) Increase amylase and lipase d) Increased creatinine

Answer: B Rationale: Decreased pulmonary function, not increased forced volume in 1 second is not a organ-specific indication of rejection. See Table 4 in Petty (2016)

Which of the following is NOT a sign or symptom of neonatal abstinence syndrome (NAS)? a. Excessive high-pitched cry b. Tremors c. Hypotonia d. Tremors e. Tachypnea

Answer: C Rationale: All of the options are possible common signs and symptoms of NAS except for hypotonia. Neonates presenting with NAS typically exhibit increased muscle tone.

When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which finding is most important to communicate to the health care provider? a. Dry lips and oral mucous b. Crackles at both lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days

Answer: C Rationale: Infection risk is high in the first few months after liver transplant and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions, but do not indicate a need for urgent action.

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is a) vomiting. b) headache. c) change in level of consciousness d) sluggish pupil response to light.

Answer: C Rationale: LOC is the most sensitive indicator of the patient's neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a) Blood pressure 130/72, pulse 90, respirations 32 b) Blood pressure 148/78, pulse 112, respirations 28 c) Blood pressure 156/60, pulse 60, respirations 14 d) Blood pressure 110/70, pulse 120, respirations 30

Answer: C Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

A 21-year-old is dying after an automobile accident. The family members want to donate the patient's organs and ask the nurse how the decision about brain death is made. The nurse explains that the patient will be considered brain dead when: a. The patient is flaccid and unresponsive b. CPR is ineffective in restoring heartbeat c. The patient is apneic and without brainstem reflexes d. Respiratory efforts cease and no apical pulse is audible

Answer: C Rationale: The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead.

When the nurse is admitting a patient who has acute rejection of an organ transplant, which of these already admitted patients will be the most appropriate roommate? a. A patient who has viral pneumonia b. A patient with second degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus host disease after a recent bone marrow transplant

Answer: C Rationale: Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient with anaphylaxis.

According to Varnmakhasti and Thomas, which is an accurate statement on primary and secondary Traumatic Brain Injuries? a) Both primary and secondary TBI's occur at the time of impact. b) Primary TBIs can lead to brain herniations. c) Primary TBIs are only classified by the Marshall CT score d) Cortical contusions are a common injury of primary TBIs.

Answer: D Rationale: -Option A is false. Primary TBIs occur at the time of impact and secondary injuries can occur gradually. -Option B is false. Secondary TBIs typically lead to brain herniations. Primary TBIs can lead to brain hemorrhages. -Option C is falseBoth primary and secondary TBIs can be classified by the Glasgow Coma Scale and/or the Marshall CT Score. -Option D is correct.

The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. B) Registers normal body temperature. C) Pays attention to grooming. D) Obeys commands with appropriate motor responses.

Answer: D Rationale: An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of "disturbed sensory perception." The outcome of "registers normal body temperature" relates to the diagnosis of "potential for ineffective thermoregulation." Body image disturbance would have a potential outcome of "pays attention to grooming."

The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? a) Has severely high cholesterol b) Has very low urine output c) Has well-controlled type 1 diabetes mellitus d) The chest x-ray showed another lung cancer lesion.

Answer: D Rationale: Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course. The other health factors are serious, but not contraindicative to transplant.

Which of the following instructions would the nurse include in the teaching plan for a mother of a substance-exposed newborn? A) "Avoid using a pacifier because it can damage his teeth in the future." B) "Place your newborn on his side when you feed him." C) "Let your newborn sleep in his stomach for naps but not at night." D) "Wrap him snugly in a blanket and gently rock him if he's fussy."

Answer: D Rationale: The newborn should be positioned upright with the chin down to facilitate sucking and swallowing while feeding. All newborns should sleep on their backs at all times. A pacifier can be helpful in satisfying the newborn's need to nonnutritive sucking.

You're maintaining an external ventricular drain. What should the ICP (intracranial pressure) readings be? a) 5 to 15 mmHg b) 20 to 35 mmHg c) 60 to 100 mmHg d) 5 to 25 mmHg

Answer: a Explanation: Normal ICP should be 5 to 15 mmHg. The other options have too broad of a range of pressures or the pressures are too high.

Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. a. True b. False

Answer: a Rationale: (yes...I accidently did a True/False question. Forgot they weren't allowed on the test.) Definition found on Hinkle, page 1935.

The nurse has created a plan of care for a patient who is at risk for increased ICP. The patient's care plan should specify monitoring for what early sign of increased ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex

Answer: a Rationale: Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.

Which medication would be included in the plan of care for a newborn with acute neonatal abstinence syndrome who is not responding to conservative nursing approaches? a) morphine sulfate b) diazepam c) naloxone d) fentanyl

Answer: a Rationale: Pharmacologic treatment is warranted for NAS if conservative measures are not adequate. It is recommended that for newborns with confirmed drug exposure drug therapy is indicated if the newborn has acute NAS. Common medications used in the management of newborn withdrawal include an opioid (morphine or methadone), and phenobarbital is the second drug if the opiate does not adequately control symptoms

A patient with a head injury has admission vital signs of blood pressure 130/71, pulse 100, and respirations 24. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 156/60, pulse 55, respirations 12 b. Blood pressure 130/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

Answer: a Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.(Hinkle, page 1943)

Illicit substance use (illegal drug use) by a pregnant woman may expose the fetus to the following possibilities: (select all that apply) a. Fetal growth restriction b. Birth defects c. Infection d. Foster care placement

Answer: a, b, c Substance use during pregnancy exposes the fetus to the possibility of fetal growth restriction, prematurity, neurobehavioral and neurophysiologic dysfunction, birth defects, infections, and long-term developmental sequelae (Ricci, page 924)

What are the three classic signs of Cushing's triad? Select all that apply. a. Bradycardia b. Tachycardia c. Hypertension d. Bradypnea e. Hypotension

Answer: a, c, d Rationale: Bradycardia, hypertension and bradypnea are the classic signs of Cushing's triad; these signs are seen with pressure on the medulla as a result of brain stem herniation (Hinkle, page 1935)

Following transplantation, which of the following drugs are given to the recipient to prevent rejection? a) Antihistamines b) Immunosuppressants c) Analgesics d) Antibiotics

Answer: b Explanation: Following transplantation, drugs that suppress immunity are given to prevent rejection of the transplant by the host. The other drugs are given for reasons other than transplant rejection.

The nurse is caring for a client who just learned of his terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle? a) Nonmaleficence b) Autonomy c) Fidelity d) Justice

Answer: b Rationale: By promoting open discussion and informed decision making, the nurse is empowering the client to make his own decisions leading to autonomy. The principle of justice requires fairness and justice to all clients. The principle of nonmaleficence requires that nurse does not intentionally or unintentionally inflict harm on others. The principle of fidelity maintains that nurses are faithful to the care of the clients .

What term is defined as the process of learning the individual comfort measures needed to provide care and comfort for the infant? a. Care for the baby b. Learn the baby c. Providing the infant d. Comfort the infant

Answer: b Rationale: NICU Culture of Care for Infants with Neonatal Abstinence Syndrome: A Focused Ethnography - Nelson. "Nurses repeated the phrase "learn the baby" during participant observation and interviews. This phrase is defined as the process of learning the individual comfort measures needed to provide care and comfort for the infant."

What are 3 questions the patient is asked when assessing LOC? (Select all that apply) a. What color is my shirt? b. What day of the week is it? c. What is the name of your doctor? d. What is your name? e. Where are you?

Answer: b, d, e Rationale: "assessment of the patient with an altered LOC often starts with assessing the verbal response through determining the patient's orientation to time, person, and place"

The patient's blood pressure is 130/88. What is the patient's mean arterial pressure (MAP)? a) 42 b) 74 c) 102 d) 88

Answer: c Explanation: MAP is calculated by taking the DBP (88) and multiplying it by 2. This equals 176. Then take this number and add the SBP (130). This equals 306. Then take this number and divide by 3, which equal 102.

What statement is true about AMR? a. AMR is always highly symptomatic b. Donor-specific antibodies cannot ever be detected in the subclinical state c. Biopsies are the current standard for identifying AMR d. Once AMR has begun it cannot be stopped or slowed

Answer: c Rationale: Biopsies are the current standard, however other tests may be done in conjunction with biopsies, such as DSA detection, and monitoring of graft specific lab values (depending on which organ was transplanted). AMR often is asymptomatic at first, or could have vague or nonspecific symptoms. DSAs can often be detected in the subclinical state, and should be monitored. Many options are available for treating and slowing AMR. Source: Antibody-mediated Rejection in Solid Organ Transplant.

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as: a. Flexion withdrawal. b. Localization of pain. c. Decorticate posturing. d. Decerebrate posturing.

Answer: c Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal. (Hinkle, page 1935)

A newborn is suspected of drug exposure. Which of the following is the most appropriate action by the nurse? a) collect a hair sample to be analyzed for drug exposure. b) regulate the infant's diet to meet changing phenylalanine needs. c) collect a urine or meconium specimen from infant for analysis. d) give oral calcium with feedings.

Answer: c Rationale: When drug exposure is suspected, a urine specimen or meconium sample is collected from the infant for analysis. Drugs or their metabolites are present in the newborn's urine and meconium for various lengths of time after the mother has used them. Regulating a diet to meet changing phenylalanine needs is necessary in infants diagnosis with PKU. Oral calcium is given with feedings in cases of hypocalcemia to prevent gastric irritation

Elevated levels of anti-HLA antibodies make finding a donor match difficult due to the quicker and more aggressive immune response that the body will have to the new organ. Which of the options is not a probable reason for increased levels of anti-HLA antibodies? a. Previous blood transfusions b. Previous organ transplant c. Previous chemotherapy d. Exposure to HLA antigens

Answer: c Rationale: previous chemotherapy itself does not cause an increase in anti-HLA antibodies, all other answers can cause an increase in anti-HLA antibodies. Source: Antibody-mediated Rejection in Solid Organ Transplant.

During an interaction with a patient diagnosed with end stage liver disease, a nurse notes that the patient is silent after she communicates the plan of care. What would be appropriate nurse responses in this situation? Select all that apply. a) Fill the silence with lighter conversation directed at the patient. b) Use the time to perform the care that is needed uninterrupted. c) Discuss the silence with the patient to ascertain its meaning. d) Allow the patient time to think and explore inner thoughts. e) Determine if the patient's culture requires pauses between conversation. f) Arrange for a counselor to help the patient cope with emotional issues.

Answer: c, d, e. Rationale: The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speaking. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor.

While positioning a patient in bed with increased ICP, it is important to avoid? a) Midline positioning of the head b) Placing the HOB at 30-35 degrees c) Preventing flexion of the neck d) Flexion of the hips

Answer: d Explanation: Avoid flexing the hips, this can increase intra-abdominal/thoracic pressure, which will increase ICP.

What nursing intervention should the nurse implement to prevent transient increases in ICP? a) Cluster nursing activities to prevent fatigue. b) Encourage coughing and deep breathing exercises. c) Position the patient with the hips flexed at 90 degrees. d) Provide a stool softener daily.

Answer: d Rationale: A stool softener, along with a high-fiber diet (if possible), prevents straining during defecation, which can lead to increased ICP. Coughing can increase ICP because it increases intra-abdominal and intrathoracic pressure. Coughing should be avoided when possible. Clustering of activities is contraindicated. Nursing interventions should be spaced through the day to prevent rises in ICP. Extreme hip flexion should be avoided because it could cause an increase in intrathoracic and intra-abdominal pressure.

Which is NOT one of the most commonly transplanted organs in the US? a. Heart b. Pancreas c. Lungs d. Eyes e. Intestines

Answer: d Rationale: Transplant Safety - CDC. "In the United States, the most commonly transplanted organs are the kidney, liver, heart, lungs, pancreas and intestines"

Which of the following is NOT an affect that a pregnant mother will have on the fetus? a) Decreased uteroplacental exchange b) Fetal hypoxia, meconium aspiration syndrome c) Placental abruption d) Low birthweight, prematurity e) Decreased oxygen demand

Answer: e Explanation: A pregnant mother going through withdrawal will affect the fetus by causing decreased uteroplacental exchange, fetal hypoxia, meconium aspiration syndrome, fetal demise, placental abruption, and preeclampsia. Low birthweight and prematurity will also happen. The fetus will have an increased oxygen demand to try to counter the withdrawal effects that take place. The fetus will NOT have decreased oxygen demand.

What is NOT a purpose of a craniotomy? a. Remove a tumor b. Relieve elevated ICP c. Remove blood clot d. Control hemorrhage e. Prevent seizures

Answer: e Rationale: "A craniotomy involves opening the skull surgically to gain access to intracranial structures. This procedure is performed to remove a tumor, relieve elevated ICP, evacuate a blood clot, or control hemorrhage."

A nurse in the emergency department is providing care for a client who has increased intracranial pressure (IICP) from a traumatic brain injury from a motor vehicle crash. The nurse anticipates orders for which diagnostic tests in the care of this client? (Select all that apply) a. Intracranial pressure monitor b. Electromyogram c. ABGs d. Cardiac monitoring e. CT of the head

Answers: A, C, D, E Rationale: An intracranial pressure monitor will give information about intracranial pressure. This information can be used to manage the medications and fluids for this client. A CT of the head will give information about possible hemorrhage and diffuse axonal injuries. Cardiac monitoring would be essential to monitor cardiac rate and rhythm. Arterial blood gases give information about oxygen and carbon dioxide levels in the blood. This information is used to manage artificial airways and mechanical ventilation. Electromyography is used to measure skeletal muscle activity. It would not be used in the diagnosis of a client with traumatic brain injury.

A woman who has a history of cocaine abuse gives birth to a newborn. Which of the following would the nurse expect to assess in the newborn? (Select all that apply) A) Prolonged periods of sleep B) Poor sucking C) Inconsolable crying D) Piercing cry E) Flaccid positioning

Answers: B, C, D Rationale: A newborn going through withdrawal will have a poor sucking reflex, inconsolable crying and a high pitched, piercing cry. The Finnegan NAS score sheet will commonly be used with these neonates.

A nurse in the intensive care unit is providing care for a client with increased intracranial pressure (IICP). The nurse monitors the client for which manifestations of IICP? (Select all that apply) a. Increased heart rate b. Decreased blood pressure c. Dilated pupils d. Decreased level of consciousness e. Projectile vomiting

Answers: C, D, E Rationale: Projectile vomiting is a manifestation of increased intracranial pressure. This is caused by pressure on the brainstem from swollen brain tissue. Dilated pupils are a manifestation of increased intracranial pressure. This is caused by pressure on the cranial nerves and vision pathways within the brain. A decreased level of consciousness is a manifestation of increased intracranial pressure. This is caused by pressure on the cerebral cortex and decreased oxygenation of the brain tissues. Increased intracranial pressure causes increased blood pressure, especially the systolic blood pressure. This worsens until there is a wide difference between the systolic blood pressure and the diastolic blood pressure. Increased intracranial pressure causes lowered heart rate. This is caused by the body's attempt to compensate for increased blood pressure.

A nurse is doing a pre-natal assessment on a patient who has a hx of heroin abuse, and is currently on methadone to treat the addiction. She asks the nurse if her baby will act any differently than her babies born before she took any drugs. The nurse lists which symptoms of withdrawal as ones the baby may display a. somnalance b. High pitched crying c. poor feeding d. constipation e. tremors f. excessive hair growth

Answers: a, b, c, e Rationale: Constipation and excessive hair growth are not symptoms, diarrhea or watery stools are. Source: Modified Finnegan Neonatal Abstinence Score Sheet

What symptoms are included in Cushing's triad? (Select all that apply) A) Hypotension B) Hypertension C) Bradycardia D) Bradypnea E) Tachycardia

Asnwer: B, C, D Rationale: Cushing's triad is seen when there is increased intracranial pressure. Hypertension occurs because the body is trying to provide adequate cerebral blood flow to the brain. These symptoms are the direct opposite of shock.

A nurse notes a score of 18 on the Finnegans NAS chart for an infant. While he is in the room giving the appropriate methadone dose, the baby's mother asks if the baby will be able to go home with her tomorrow. What is the nurses appropriate response? a. It will depend on the baby's score tomorrow b. No, the baby will not be allowed to return home with you, social services will be taking the baby. c. No, the baby must score less than 8 without medication for at least 24 hours before we can discharge the baby. d. No, the baby must score less than 8 without medication for at least 3 days before the doctor can consider discharging the baby.

d is the correct answer. After 3 days of scores under 8 without pharmaceuticals the monitoring may cease. This does not mean the baby will automatically be discharged. Source: Modified Finnegan Neonatal Abstinence Score Sheet