Gero Exam #3
The nursing management plan for a patient undergoing an oil-based contrast myelogram should include intervention? a. Maintain the patient flat in bed for 4 to 8 hours. b. Observe the puncture sight every 15 minutes for 2 hours for signs of bleeding. c. Keep the patient's head elevated 30 to 45 degrees for 8 hours. d. Administer a sedative to keep the patient from moving around.
ANS: A Postprocedure care of the patient undergoing an oil-based iophendylate myelogram includes keeping the patient's flat in bed for 4 to 8 hours.
A patient has been experiencing drowsiness, confusion, and slight focal deficits for several days. The initial noncontract CT findings are negative. The patient is being prepared for a lumbar puncture. Which CSF appearance finding should the nurse expect? a. Cloudy b. Bloody c. Xanthochromic d. Clear
ANS: B If the initial computed tomography findings are negative, a lumbar puncture is performed to obtain cerebrospinal fluid (CSF) for analysis. CSF after subarachnoid hemorrhage (SAH) appears bloody and has a red blood cell count greater than 1000 cells/mm3. If the lumbar puncture is performed more than 5 days after the SAH, the CSF fluid is xanthochromic (dark amber) because the blood products have broken down. Cloudy CSF usually indicates some type of infectious process such as bacterial meningitis, not SAH.
A patient with a serious head injury has been admitted. The nurse knows that certain neurologic findings can indicate the prognosis for the patient. Which finding denotes the most serious prognosis? a. Abnormal flexion b. Abnormal extension c. Localization d. Withdrawal
ANS: B Outcome studies indicate that abnormal extension or decerebrate posturing has a more serious prognosis than does abnormal extension or decorticate posturing. Onset of posturing or a change from abnormal flexion to abnormal extension requires immediate physician notification. Localization and withdrawal are abnormal neurologic findings; however, these findings are less serious than abnormal extension.
The nurse is teaching a nursing student about the importance of assessing the patient's level of conscious (LOC). Which statement indicates the nursing student understood the information? a. "The LOC is the most prognostic indicator of the patient's neurologic outcome." b. "The LOC limited to the Glasgow Coma Scale making it the quickest part of the assessment." c. "The LOC is the easiest part of the neurologic exam and thus is generally performed first." d. "In most situations, the LOC deteriorates before any other neurologic changes are observed."
ANS: D Assessment of the level of consciousness is the most important aspect of the neurologic examination.
The nurse and a new graduate nurse are caring for a comatose patient on continuous electroencephalography (cEEG) monitor. The new graduate says "This monitor is great. How come we don't use it on all the neuro patients?" What are the drawbacks to using this type of monitor? (Select all that apply.) A. Size of machine B. Expensive C. Labor-intensive program D. Requires expertise for interpretation E. Artifacts from ICU environment
B. Expensive C. Labor-intensive program D. Requires expertise for interpretation E. Artifacts from ICU environment The drawbacks to the use of continuous electroencephalography (cEEG) are that it is an expensive, labor-intensive program that requires expertise for interpretation, and is subject to artifacts from the intensive care unit environment. More research on cEEG is needed to determine its cost-saving potential and impact on outcome.
The nurse knows that change in pupil size is a significant neurologic finding particularly in the patient with a head injury. How much of a size difference between the two pupils is still considered normal? a. 1 mm b. 1.5 mm c. 2 mm d. 2.5 mm
a. 1 mm Pupil size should be documented in millimeters with the use of a pupil gauge to reduce the subjectivity of description. Most people have pupils of equal size, between 2 and 5 mm. A discrepancy up to 1 mm between the two pupils is normal.
The patient was admitted with a head injury and an intracranial pressure (ICP) monitoring device was placed. The nurse knows to notify the practitioner if what type of wave start to appear on the monitor? a. A waves b. B wave c. C waves d. D waves
a. A waves A waves are the most clinically significant of the three types. They usually occur in an already elevated baseline intracranial pressure (ICP) (>20 mm Hg) and are characterized by sharp increases in ICP of 30 to 69 mm Hg, which plateau for 2 to 20 minutes and then return to baseline. B waves appear to reflect fluctuations in cerebral blood. C waves are small, rhythmic waves that occur every 4 to 8 minutes at normal levels of ICP. They are related to normal fluctuations in respiration and systemic arterial pressure.
A patient is admitted to the critical care unit with a subdural hematoma. The nurse is assessing the patient's Glasgow Coma Scale (GCS) score. When assessing the patient's best motor response, which movement would receive the lowest score? a. Abnormal extension b. Localizing pain c. Withdrawing from pain d. Decorticate posturing
a. Abnormal extension Abnormal extension (decerebrate posturing) receives a score of 2 on the Glasgow Coma Scale (GCS). The only lower score is 1, which is for a flaccid response.
The nurse is caring for a severely head injured comatose patient who is dying. The practitioner asks to be notified when the patient starts to exhibit signs of Cushing reflex. The nurse would call the practitioner when the patient starts to show what signs? a. Bradycardia, systolic hypertension, and widening pulse pressure b. Tachycardia, systolic hypotension, and tachypnea c. Headache, nuchal rigidity, and hyperthermia d. Bradycardia, aphasia, and visual field disturbances
a. Bradycardia, systolic hypertension, and widening pulse pressure The Cushing reflex is a set of three clinical manifestations (bradycardia, systolic hypertension, and widening pulse pressure) related to pressure on the medullary area of the brainstem.
Which patient may need sedation before having a magnetic resonance imaging (MRI) scan? a. Claustrophobic patient b. Comatose patient c. Elderly patient d. Patient with a spinal cord injury
a. Claustrophobic patient The magnetic resonance imaging procedure is lengthy and requires the patient to lie motionless in a tight, enclosed space. Mild sedation, a blindfold, or both may be necessary for claustrophobic patients.
The nurse is caring for a patient who has just had a cerebral angiogram. Which intervention should be part of the nursing management plan? a. Ensuring that the patient is adequately hydrated b. Maintaining the patient on an NPO status c. Administering antibiotics to the patient d. Keeping the patient flat in bed for 24 hours
a. Ensuring that the patient is adequately hydrated After the cerebral angiogram, adequate hydration is necessary to assist the kidneys in clearing the heavy dye load. Inadequate hydration may lead to renal dysfunction and renal shutdown.
Considering anatomic location, which cranial nerve will be affected first by downward pressure onto the infratentorial structures? a. III b. VI c. IX d. X
a. III With the location of the oculomotor nerve (cranial nerve [CN] III) at the notch of the tentorium, pupil size and reactivity play a key role in the physical assessment of intracranial pressure changes and herniation syndromes. In addition to CN III compression, changes in pupil size occur for other reasons. Large pupils can result from the instillation of cycloplegic agents, such as atropine or scopolamine, or can indicate extreme stress. Extremely small pupils can indicate narcotic overdose, lower brainstem compression, or bilateral damage to the pons.
What sites can be used for monitoring intracranial pressure (ICP)? (Select all that apply.) a. Intraventricular space b. Epidural space c. Jugular veins d. Subdural space e. Parenchyma
a. Intraventricular space b. Epidural space d. Subdural space e. Parenchyma The five sites for monitoring intracranial pressure are (1) the intraventricular space, (2) the subarachnoid space, (3) the epidural space, (4) the subdural space, and (5) the parenchyma.
A patient is admitted to the critical care unit with a subdural hematoma. The nurse is assessing the patient's Glasgow Coma Scale (GCS) score. Which statement is true concerning the GCS? a. It provides data about level of consciousness only. b. It is considered equivalent to a complete neurologic examination. c. It is a sensitive tool for evaluation of an altered sensorium. d. It is the most critical assessment parameter to account for possible aphasia.
a. It provides data about level of consciousness only. Several points should be kept in mind when the Glasgow Coma Scale is used for serial assessment. It provides data about level of consciousness only, and it should never be considered a complete neurologic examination. Additionally, it is not a sensitive tool for evaluation of an altered sensorium, and it does not account for possible aphasia or mechanical intubation. It is also a poor indicator of lateralization of neurologic deterioration.
The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. What must the nurse verity prior to performing the test? a. The absence of cervical injury b. The depth and rate of respiration c. The patient's ability to swallow d. The patient's ability to follow a verbal command
a. The absence of cervical injury In an unconscious patient, assessment of ocular function and innervation of the medial longitudinal fasciculus (MLF) is performed by eliciting the doll's eyes reflex. If the patient is unconscious as a result of trauma, the nurse must ascertain the absence of cervical injury before performing this examination.
Which statements are correct regarding the assessment of motor function in the neurologically impaired patient? (Select all that apply.) a. The presence of a Babinski reflex is an abnormal finding in an adult. b. Lower extremity muscle tone is assessed by asking the patient to push or pull his or her foot against resistance. c. When using noxious stimuli to elicit a motor response, each limb is tested separately. d. The presence of abnormal extension indicates a less positive outcome for the patient than abnormal flexion. e. The evaluation of deep tendon reflexes is an essential part of the nursing neurologic assessment.
a. The presence of a Babinski reflex is an abnormal finding in an adult. c. When using noxious stimuli to elicit a motor response, each limb is tested separately. d. The presence of abnormal extension indicates a less positive outcome for the patient than abnormal flexion. The presence of a Babinski response in an adult is indicative of neurologic dysfunction, pushing or pulling against resistance tests muscle strength not tone, and deep tendon reflexes are not routinely checked by the critical care nurse during assessment.
A patient is undergoing a preoperative evaluation for carotid arteries. What two test should the nurse expect to see ordered for the patient? a. Ultrasound and magnetic resonance angiography b. Conventional angiography and evoked potential c. Computed tomography (CT) and magnetic resonance angiography d. Transcranial Doppler and extracranial Doppler
a. Ultrasound and magnetic resonance angiography Magnetic resonance angiography of the carotid arteries has become an established complement to preoperative ultrasound evaluation. It helps determine the area of salvageable tissue (or penumbra) after acute stroke and head injury.
Indications for the use of electroencephalography (EEG) include (Select all that apply.) a. cerebral infarct. b. metabolic encephalopathy. c. confirmation of brain death. d. altered consciousness. e. all head injuries.
a. cerebral infarct. b. metabolic encephalopathy. c. confirmation of brain death. d. altered consciousness. Indications for the use of electroencephalography include suspected seizure activity, cerebral infarct, metabolic encephalopathies, altered consciousness, infectious disease, some head injuries, and confirmation of brain death.
A critical care patient is diagnosed with massive head trauma. The patient is receiving brain tissue oxygen pressure (PbtO2) monitoring. The nurse recognized that the goal of this treatment is to maintain PbtO2: a. greater than 20 mm Hg. b. less than 15 mm Hg. c. between 15 and 20 mm Hg. d. between 10 and 20 mm Hg.
a. greater than 20 mm Hg. In a patient with head injury, the goal of treatment is to maintain the PbtO2 greater than 20 mm Hg. Factors that decrease PbtO2 include tissue hypoxia, hypocapnia, hypovolemia, decreased blood pressure, low hemoglobin levels, intracranial hypertension, and hyperthermia. Treatment is directed at the underlying cause.
How often should lubricating eye drops be administered to a patient in a coma to prevent corneal epithelial breakdown? a.2 hours b.4 hours c.8 hours d.12 hours
a.2 hours Instillation of saline or methylcellulose drops every 2 hours prevents corneal breakdown in the coma patient. In addition, taping a polyethylene film over the eyes, extending from beyond the orbit to over the eyebrow, creates a moisture chamber and has been effective in keeping the eyes moist.
Which patient has the best prognosis based on the cause of coma? a.A 36-year-old man with closed head injury b.A 50-year-old woman with hepatic encephalopathy c.A 46-year-old woman with subarachnoid hemorrhage d.A 72-year-old man with hypertensive intracerebral hemorrhage
a.A 36-year-old man with closed head injury Prognosis depends on the cause of coma and the length of time unconsciousness persists. Only 15% of patients in nontraumatic coma make a satisfactory recovery. Metabolic coma usually has a better prognosis compared with coma caused by a structural lesion, and traumatic coma usually has a better outcome compared with nontraumatic coma.
A patient has been admitted with an ischemic stroke. The patient received recombinant tissue plasminogen activator (rtPA) in the emergency department. The nurse reviews the medication administration record to make sure the patient does not have which medications for the next 24 hours? (Select all that apply.) a.Aspirin b.Sodium nitroprusside c.Warfarin d.Labetalol e.Any antiplatelet drugs
a.Aspirin c.Warfarin e.Any antiplatelet drugs The major risk and complication of rtPA therapy is bleeding, especially intracranial hemorrhage. Unlike fibrinolytic protocols for acute myocardial infarction, subsequent therapy with anticoagulant or antiplatelet agents is not recommended after rtPA administration in ischemic stroke. Patients receiving fibrinolytic therapy for stroke should not receive aspirin, heparin, warfarin, ticlopidine, or any other antithrombotic or antiplatelet drugs for at least 24 hours after treatment. Sodium nitroprusside and labetalol are used to manage blood pressure after a stroke.
A patient is admitted with acute kidney injury. The nurse would expect to see elevated values in which laboratory results? (Select all that apply.) a.Blood urea nitrogen (BUN) b.Creatinine c.Glucose d.Hemoglobin and hematocrit e.Protein
a.Blood urea nitrogen (BUN) b.Creatinine d. Hgb & Hct With kidney dysfunction, the blood urea nitrogen (BUN) is elevated because of a decrease in the glomerular filtration rate and resulting decrease in urea excretion. Elevations in the BUN can be correlated with the clinical manifestations of uremia; as the BUN rises, symptoms of uremia become more pronounced. Creatinine levels are fairly constant and are affected by fewer factors than BUN. As a result, the serum creatinine level is a more sensitive and specific indicator of kidney function than BUN. Creatinine excess occurs most often in persons with acute kidney injury resulting from impaired excretion. Decreased hematocrit value can indicate fluid volume excess because of the dilutional effect of the extra fluid load. Decreases also can result from anemias, blood loss, liver damage, or hemolytic reactions. In individuals with acute kidney injury, anemia may occur early in the disease.
A patient has just been admitted with head trauma. While awaiting the results of the CT scan, the patient becomes comatose, develops fixed and dilated pupils, and flaccid to noxious stimuli. The nurse knows that these signs are indicative of which type of herniation? a.Central b.Uncal c.Cingulate d.Infratentorial
a.Central Clinical manifestations of central herniation include loss of consciousness; small, reactive pupils progressing to fixed, dilated pupils; respiratory changes leading to respiratory arrest; and abnormal flexion (decorticate) posturing progressing to flaccidity. Clinical manifestations of uncal herniation include ipsilateral pupil dilation, decreased LOC, respiratory pattern changes leading to respiratory arrest, and contralateral hemiplegia leading to abnormal flexion (decorticate) or abnormal extension (decerebrate) posturing
A patient has been admitted with acute kidney injury. The nurse knows the most important consideration for evaluating the patient's fluid status is what parameter? select two a.Daily weights b.Urine and serum osmolality c.Intake and output d.Hemoglobin and hematocrit levels
a.Daily weights One of the most important assessments of kidney and fluid status is the patient's weight. In the critical care unit, weight is monitored for each patient every day and is an important vital signs measurement.
A patient with a ruptured cerebral aneurysm has been admitted for monitoring. The nurse knows that incidence of rebleeding is highest during which time periods? a.First 24 hours b.4 to 12 days c.3 to 4 weeks d.3 to 6 months
a.First 24 hours Rebleeding is the occurrence of a second subarachnoid hemorrhage in an unsecured aneurysm or, less commonly, an arteriovenous malformation. The incidence of rebleeding during the first 24 hours after the first bleed is 4%, with a 1% to 2% chance per day for the following month. Mortality with aneurysmal rebleeding is approximately 70%.
The nurse is caring for a patient who has had a head injury and is now having seizures. Which medication should the nurse anticipate being ordered for this patient? a.Lorazepam b.Phenytoin c.Phenobarbital d.Midazolam
a.Lorazepam Lorazepam is a fast-acting, short-duration agent that may be indicated for breakthrough seizures until therapeutic drug levels can be reached. Phenytoin is the recommended medication for seizure prophylaxis. Phenobarbital is a barbiturate whose action produces central nervous system depression and reduces the spread of an epileptic focus.
The nurse is caring for a patient head trauma with increased intracranial pressure who is being mechanically ventilated. The patient management plan should include which intervention? a.Maintain the PaCO2 between 33 and 37 mm Hg. b.Maintain the PaCO2 between 25 and 35 mm Hg. c.Maintain the FiO2 at 80%. d.Maintain the respiratory rate at 20 breaths/min.
a.Maintain the PaCO2 between 33 and 37 mm Hg. The current trend is to maintain PaCO2 levels on the lower side of normal (35 ± 2 mm Hg) by carefully monitoring arterial blood gas measurements and by adjusting ventilator settings. Although hypoxemia must be avoided, excessively high levels of oxygen offer no benefits, and increasing inspired oxygen concentrations to greater than 60% may lead to toxic changes in lung tissue. The patient's respiratory rate should not be preset at a certain level but should be titrated to maintain the PaCO2 between 33 and 37 mm Hg.
Patient has been admitted who is severely malnourished. The patient's serum albumin is very low. Which finding would the nurse expect to see in this patient? a.Peripheral edema b.Extra heart sounds c.Hypertension d.Hyponatremia
a.Peripheral edema Decreased albumin levels in the vascular space result in a plasma-to-interstitium fluid shift, creating peripheral edema. A decreased albumin level can occur as a result of protein-calorie malnutrition, which occurs in many critically ill patients in whom available stores of albumin are depleted. A decrease in the plasma oncotic pressure results, and fluid shifts from the vascular space to the interstitial space.
A right-handed patient has been admitted with an intracerebral hemorrhage. A CT of the patient's head reveals a large left parietal area bleed. Based on the type of stroke, which signs and signs might the patient exhibit? a.Right-sided hemiplegia and receptive aphasia b.Left-sided hemiplegia and tactile agnosia c.Decorticate posturing and unequal pupils d.Unilateral neglect and dressing apraxia
a.Right-sided hemiplegia and receptive aphasia Damage to the dominant hemisphere produces problems with speech and language and abstract and analytical skills.
What causes the presence of myoglobin in urine? (Select all that apply.) a.Injection b.Crush injury c.Acidosis d.Rhabdomyolysis e.Intrarenal acute kidney injury
b.Crush injury d.Rhabdomyolysis Myoglobin in the urine may result from a crush injury or rhabdomyolysis. Intrarenal acute kidney injury can result from rhabdomyolysis. Infection and acidosis do not cause myoglobin to appear in the urine.
A patient has been admitted in acute kidney failure with a 10-lb weight gain over 5 days. Which findings may be present in the patient? (Select all that apply.) a.S3 or S4 b.Distended neck veins c.Crackles d.Tachycardia with hypotension e.Edema that disappears with elevation of extremity
a.S3 or S4 b.Distended neck veins c.Crackles The patient is in fluid overload. An S3 or S4, distended neck veins, and crackles may be present in the patient. Tachycardia with hypotension is indicative of hypovolemia. Dependent edema that disappears with elevation of the extremity is indicative of poor circulation.
When calculating the anion gap, what is the predominant cation? a.Sodium b.Potassium c.Chloride d.Bicarbonate
a.Sodium The anion gap is a calculation of the difference between the measurable extracellular plasma cations (sodium and potassium) and the measurable anions (chloride and bicarbonate). In plasma, sodium is the predominant cation, and chloride is the predominant anion.
The patient is ordered a computed tomography (CT) scan with contrast. Which question should the nurse ask the conscious patient before the procedure? a. "Are you allergic to penicillin?" b. "Are you allergic to iodine-based dye?" c. "Are you allergic to latex?" d. "Are you allergic to eggs?"
b. "Are you allergic to iodine-based dye?" If the patient is scheduled to receive contrast for computed tomography (CT) scanning, questions about possible sensitivity to iodine-based dye must be asked beforehand, if possible. During infusion of the dye and for 10 to 30 minutes afterward, the patient is observed closely for an anaphylactic reaction. Fewer than 1% of all patients undergoing contrast-enhanced CT have severe anaphylactic reactions, shock, or cardiac arrest.
Which procedure is the diagnostic study of choice for acute head injury? a. Magnetic resonance imaging b. Computed tomography c. Transcranial Doppler d. Electroencephalography
b. Computed tomography Computed tomography offers rapid, convenient, noninvasive visualization of structures and is the diagnostic study of choice for an acute head injury.
A patient with a serious head injury has been admitted. The nurse knows that certain neurologic findings can indicate the prognosis for the patient. Which finding denotes the most serious prognosis? a. Decorticate posturing b. Decerebrate posturing c. Absence of Babinski reflex d. Glasgow Coma Scale (GCS) score of 14
b. Decerebrate posturing Outcome studies indicate that abnormal flexion or decorticate posturing has a less serious prognosis than does extension, or decerebrate posturing. Onset of posturing or a change from abnormal flexion to abnormal extension requires immediate physician notification. The Babinski reflex is a pathologic finding; absence of this reflex is a normal neurologic finding in adults. The range of scores for the Glasgow Coma Scale is 3 to 15. A score of 14 denotes a minimal deficit.
A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner orders magnetic resonance imaging (MRI). The nurse knows in certain situations an MRI is superior to computed tomography (CT). What is one those situations? a. Brain death determination b. Detection of central nervous system infection c. Estimation of intracranial pressure d. Identification of subarachnoid hemorrhage
b. Detection of central nervous system infection Magnetic resonance imaging (MRI) produces images with greater detail than computed tomography (CT) and provides views of several planes (sagittal, coronal, axial, and oblique) that are not possible with CT. MRI with contrast is the preferred study for detection of infectious and inflammatory processes of the central nervous system (CNS). MRI can detect areas of cerebral infarct within a few hours of the incident and can identify small areas of plaque in patients with multiple sclerosis. MRI with contrast is the preferred study for detection of infectious and inflammatory processes of the CNS, malignancy, and metastatic lesions; cervical spine imaging; and postoperative evaluation of tumor recurrence. MRI also is the diagnostic study of choice in the evaluation of spinal cord injury.
The nurse is caring for a patient immediately after a craniotomy. When assessing the size and shape of the patient's pupils the nurse notes the patient's left pupil is oval. What does this finding indicate? a. Cortical dysfunction b. Intracranial hypertension c. Hydrocephalus d. Metabolic coma
b. Intracranial hypertension Pupil shape is also noted in the assessment of pupils. Although the pupil is normally round, an irregularly shaped or oval pupil may be noted in patients with eye surgery. Initial stages of cranial nerve III compression from elevated intracranial pressure can also cause the pupil to have an oval shape.
Which of the following statements best describes assessment of arousal? a. It measures content of consciousness and is a higher-level function. b. It is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. c. It becomes a valid parameter when the patient is able to respond to verbal stimuli, such as squeezing the hands on command. d. Noxious stimuli are not to be used as an assessment parameter.
b. It is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. Assessment of the arousal component of consciousness is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. Arousal is the lowest level of consciousness, and observation centers on the patient's ability to respond to verbal or noxious stimuli in an appropriate manner.
The nurses are admitting a neurologically impaired patient. The patient's family is present. How comprehensive should the initial history be? a. It should be limited to the chief complaint and personal habits. b. It should be all-inclusive, including events preceding hospitalization. c. It should be confined to current medications and family history. d. It should be restricted to only information that the patient can provide.
b. It should be all-inclusive, including events preceding hospitalization. The one factor common to all neurologic assessment is the need to obtain a comprehensive history of events preceding hospitalization.
The nurse is precepting a nursing student. The student asks about testing of extraocular eye movements. What should the nurse tell the student? a. It tests the pupillary response to light. b. It tests function of the three cranial nerves. c. It tests the ability of the eyes to accommodate to a closer moving object. d. It tests the oculocephalic reflex.
b. It tests function of the three cranial nerves. Control of eye movements occurs with interaction of three cranial nerves: oculomotor (III), trochlear (IV), and abducens (VI).
The nurse is caring for a patient with a head injury who is obtunded. The nurse is going to use noxious stimuli to elicit a response. What is an acceptable method? a. Nipple pinch b. Nail bed pressure c. Supraorbital pressure d. Sternal rub
b. Nail bed pressure Nail bed pressure and trapezius pinch are acceptable methods of noxious stimulation. Nail bed pressure allows evaluation of individual extremity function. Trapezius pinch is difficult to perform on large or obese adults. Repeated sternal rub can cause the sternum to become excoriated, open, and infected. Supraorbital pressure must be avoided in patients with head injuries, frontal craniotomies, or facial surgery. Nipple and testicle pinching are inappropriate and unnecessary.
A patient has developed acute kidney injury (AKI) secondary to cardiogenic shock. Which laboratory value would the nurse find helpful in evaluating patient's renal status? a. Serum sodium b. Serum creatinine c. Serum potassium d. Urine potassium
b. Serum creatinine In the acutely ill patient, small changes in the serum creatinine level and urine output may signal important declines in the glomerular filtration rate and kidney function
The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. Which findings indicate that the patient has an intact oculocephalic reflex? a. The patient's eyes move in the same direction the head is turned. b. The patient's eyes move in the opposite direction to the movement of the patient's head. c. The patient's eyes rove and move in opposite directions from each other. d. The patient's eyes move up and down and then back and forth.
b. The patient's eyes move in the opposite direction to the movement of the patient's head. To assess the oculocephalic reflex, the nurse holds the patient's eyelids open and briskly turns the head to one side while observing the eye movements and then briskly turns the head to the other side and observes. If the eyes deviate to the opposite direction in which the head is turned, doll's eyes are present, and the oculocephalic reflex arc is intact. If the oculocephalic reflex arc is not intact, the reflex is absent.
The practitioner has ordered a carotid Doppler study for a patient. The patient asks the nurse what the test is for. How should the nurse respond? a. The test evaluates blood flow in the anterior, middle, or posterior cerebral arteries. b. The test estimates blood flow velocity thought the carotid arteries. c. The test assesses arteriovenous circulation in the intracranial space. d. The test gauges global cerebral blood flow.
b. The test estimates blood flow velocity thought the carotid arteries. Ultrasound technology, although not an absolute measure of cerebral blood flow, uses a noninvasive technique to provide information about the flow velocity of blood through carotid vessels. Carotid duplex studies are used as a routine screening procedure for intraluminal narrowing of the common and internal carotid arteries as a result of atherosclerotic plaques.
The nurse is caring for a severely head injured comatose patient who is dying. The nurse knows the patient has entered the late stages of intracranial hypertension when the nurse observes which signs? a. Pupils are equal and reactive b. Widening pulse pressure c. Eupnea d. Decreased intracranial pressure
b. Widening pulse pressure Attention must also be paid to the pulse pressure because widening of this value may occur in the late stages of intracranial hypertension. With the loss of autoregulation as blood pressure increases, cerebral blood flow (CBF) and cerebral blood volume increase and intracranial pressure (ICP) therefore increases. The mean arterial pressure must be maintained at a level sufficient to produce adequate CBF in the presence of elevated ICP.
The patient's intracranial pressure (ICP) reading has gradually climbed from 15 to 23 mm Hg. The nurse's primary action is to: a. drain off 7 mm of cerebrospinal fluid (CSF) from the catheter. b. notify the physician. c. place the patient in a high Fowler position to decrease the pressure. d. check level of consciousness.
b. notify the physician. Under normal physiologic conditions, mean intracranial pressure (ICP) is maintained below 15 mm Hg. An increase in ICP can decrease blood flow to the brain, causing brain damage. Persistent ICP elevation above 20 mm Hg remains the most significant factor associated with a fatal outcome.
Which assessment finding in a patient in coma 10 to 12 hours after cardiopulmonary arrest is indicative of unlikely survival? a.Decorticate posturing b.Absent pupillary light reflexes c.Decerebrate posturing d.Central hyperventilation
b.Absent pupillary light reflexes Much research has been directed toward identifying the prognostic indicators for the patient in coma after a cardiopulmonary arrest. In a meta-analysis, the best predictors of poor outcome after cardiac arrest were lack of corneal or papillary response at 24 hours and lack of motor movement at 72 hours. However, regardless of the cause or duration of coma, the outcome for an individual cannot be predicted with 100% accuracy.
While caring for a comatose patient with intracranial hypertension, the nurse observes the patient's ICP fall from 65 to 12 mm Hg. After troubleshooting the monitoring system and finding no issues, the nurse suspects the cause of this change is which situation? a.A seizure b.Brain herniation c.Resolving cerebral d.Excessive dehydration
b.Brain herniation Herniation of intracerebral contents results in the shifting of tissue from one compartment of the brain to another and places pressure on cerebral vessels and vital function centers of the brain. If unchecked, herniation rapidly causes death as a result of the cessation of cerebral blood flow and respirations. Signs of brain herniation include fixed and dilated pupils, flaccidity, and respiratory arrest. The intracranial pressure drops as the pressure is relieved by shifting the intracranial components downward.
A patient has been admitted post craniotomy for a brain tumor. The patient management plan should include monitoring the patient for which complications? (Select all that apply.) a.Diabetes mellitus b.Fluid retention c.Intracranial hypotension d.Surgical hemorrhage e.Corneal abrasions
b.Fluid retention d.Surgical hemorrhage e.Corneal abrasions Complications associated with a craniotomy include intracranial hypertension, surgical hemorrhage, fluid imbalance, cerebrospinal fluid leak, deep venous thrombosis, infection, corneal abrasions, and injury from fall or seizures.
A patient is admitted in acute heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. Which diagnostic tests would provide the best information about the internal kidney structures, such as the parenchyma, calyces, pelvis, ureters, and bladder? a.Kidney-ureter-bladder (KUB) b.Intravenous pyelography (IVP) c.Renal ultrasonography (ECHO) d.Renal angiography
b.Intravenous pyelography (IVP) Intravenous pyelography allows visualization of the internal kidney parenchyma, calyces, pelvis, ureters, and bladder. Kidney-ureter-bladder flat-plate radiography of the abdomen determines the position, size, and structure of the kidneys, urinary tract, and pelvis. It is useful for evaluating the presence of calculi and masses and is usually followed by additional tests. In ultrasonography, high-frequency sound waves are transmitted to the kidneys and urinary tract, and the image is viewed on an oscilloscope. This noninvasive procedure identifies fluid accumulation or obstruction, cysts, stones or calculi, and masses. It is useful for evaluating the kidneys before biopsy. Angiography is injection of contrast into arterial blood perfusing the kidneys. It allows for visualization of renal blood flow and may also visualize stenosis, cysts, clots, trauma, and infarctions.
A patient has been admitted with a stroke. The nurse anticipates a practitioner's order for which diagnostic study before initiating therapy? a.Magnetic resonance imaging b.Noncontrast computed tomography c.Contrast computed tomography d.Lumbar puncture
b.Noncontrast computed tomography Confirmation of the diagnosis of ischemic stroke is the first step in the emergent evaluation of these patients. Differentiation from intracranial hemorrhage is vital. Noncontrast computed tomography (CT) scanning is the method of choice for this purpose, and it is considered the most important initial diagnostic study. Magnetic resonance imaging (MRI) can demonstrate infarction of cerebral tissue earlier than can CT but is less useful in the emergent differential diagnosis. Lumbar puncture is performed only if subarachnoid hemorrhage is suspected and the CT scan findings are normal.
A patient has been on complete bed rest for 3 days. The practitioner has left orders to get the patient out of bed for meals. The patient complains of feeling dizzy and faint while sitting at the bedside. The nurse suspects that the patient is experiencing what problem? a.Orthostatic hypertension b.Orthostatic hypotension c.Hypervolemia d.Electrolyte imbalance
b.Orthostatic hypotension Orthostatic hypotension produces subjective feelings of weakness, dizziness, or faintness. Orthostatic hypotension occurs with hypovolemia or prolonged bed rest or as a side effect of medications that affect blood volume or blood pressure.
Percussion of kidneys is usually done to assess what parameter? a.Size and shape of the kidneys b.Presence of pain in the renal area c.Presence of a fluid wave d.Patient's overall fluid status
b.Presence of pain in the renal area Percussion is performed to detect pain in the area of a kidney or to determine excess accumulation of air, fluid, or solids around the kidneys. Percussion of the kidneys also provides information about kidney location, size, and possible problems
A patient has been admitted in acute heart failure. Which parameter would indicate to the nurse that the patient is fluid overloaded? a.Central venous pressure of 4 mm Hg b.Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg c.Cardiac index of 2.5 L/min/m2 d.Mean arterial pressure of 40 mm Hg
b.Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg The pulmonary artery occlusion pressure (PAOP) represents the left atrial pressure required to fill the left ventricle. When the left ventricle is full at the end of diastole, this represents the volume of blood available for ejection. It is also known as left ventricular preload and is measured by the PAOP. The normal PAOP is 5 to 12 mm Hg. In fluid volume excess, PAOP rises. In fluid volume deficit, PAOP is low.
A patient was admitted with acute kidney injury. Which urinalysis value reflects a decreased ability of the kidneys to concentrate urine? a.pH of 5.0 b.Specific gravity of 1.000 c.No casts d.Urine sodium of 140 mEq/24 hr
b.Specific gravity of 1.000 Specific gravity measures the density or weight of urine compared with that of distilled water. The normal urinary specific gravity is 1.005 to 1.025. For comparison, the specific gravity of distilled water is 1.000. Because urine is composed of many solutes and substances suspended in water, the specific gravity should always be higher than that of water.
A patient was admitted with acute heart failure a few days ago. Today the patient's urine has a specific gravity of 1.040. What could be the potential cause for this value? a.Volume overload b.Volume deficit c.Acidosis d.Urine ketones
b.Volume deficit Specific gravity ranges from 1.003 to 1.030. Possible causes for increased values include volume deficit, glycosuria, proteinuria, and prerenal acute kidney injury (AKI). Possible causes for decreased values include volume overload and intrarenal AKI.
According to the 2007 Brain Trauma Foundation guidelines, the recommended CPP range is: a. 10 to 30 mm Hg. b. 30 to 50 mm Hg. c. 50 to 70 mm Hg. d. 70 to 85 mm Hg.
c. 50 to 70 mm Hg. The 2007 Brain Trauma Foundation guidelines now recommend a cerebral perfusion pressure (CPP) in the range of 50 to 70 mm Hg and consideration of cerebral autoregulation status when selecting a CPP target in a specific patient.
A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner is going to perform a lumbar puncture. What is the most serious complication of lumbar puncture? a. Meningitis b. Dural tear c. Brainstem herniation d. Spinal cord trauma
c. Brainstem herniation Two life-threatening risks associated with lumbar puncture include possible brainstem herniation, if intracranial pressure is elevated, and respiratory arrest associated with neurologic deterioration.
The nurse is caring for a patient who is going to have digital subtraction angiography. The patient asks what is the difference between conventional and digital subtraction angiography. What should the nurse tell the patient? a. Digital subtraction angiography has fewer complications. b. Digital subtraction angiography is noninvasive. c. Digital subtraction angiography uses significantly less dye. d. Digital subtraction angiography is done through the femoral vein.
c. Digital subtraction angiography uses significantly less dye. Digital subtraction angiography uses significantly less dye than arterial angiography. Dye is injected in the venous or arterial system. The patient must remain motionless during the procedure. Complications are the same as those for cerebral angiography.
The nurse is precepting a new graduate nurse. The new graduate asks about the difference between electroencephalography and evoked potentials. What should the nurse tell the new graduate? a. Evoked potentials measure and record electric and muscle activity in response to noxious stimuli. b. Electroencephalography measures cerebral blood flow and oxygen extraction. c. Evoked potentials measure cerebral electrical impulses generated in response to sensory stimuli. d. Electroencephalography measures the biochemical changes in the brain to assess metabolic activity.
c. Evoked potentials measure cerebral electrical impulses generated in response to sensory stimuli. Evoked potentials involve the recording of electrical impulses generated by a sensory stimulus as it travels through the brainstem and into the cerebral cortex. Electroencephalography (EEG) records electric impulses, commonly called brain waves, generated by the brain.
Why is assessment of level of conscious (LOC) the most important aspect of the neurologic examination? a. The LOC is the most prognostic indicator of the patient's outcome. b. The LOC is generally limited to the Glasgow Coma Scale making it the quickest part of the assessment. c. In most situations the LOC deteriorates before any other neurologic changes are noted. d. The LOC is the easiest part of the neurologic exam and thus is generally performed first.
c. In most situations the LOC deteriorates before any other neurologic changes are noted. Assessment of the level of consciousness is the most important aspect of the neurologic examination.
A patient is going for digital subtraction angiography. The patient education plan to prepare the patient for the procedure should include which instruction? a. Inform the patient that the procedure is very noisy and earplugs will be provided b. Tell the patient that repositioning will be required at appropriate intervals c. Instruct the patient to remaining motionless during the entire procedure d. Let the patient know he will be expected to swallow frequently during the procedure
c. Instruct the patient to remaining motionless during the entire procedure The major disadvantage of digital subtraction angiography involves the patient's ability to remain motionless during the entire procedure. Even swallowing significantly interferes with the imaging process.
The nurse is caring for a patient with an intracranial pressure-monitoring device that provides access to cerebrospinal fluid (CSF) for sampling. What type of device does the patient have? a. Subarachnoid bolt b. Epidural catheter c. Intraventricular catheter d. Fiber-optic catheter
c. Intraventricular catheter An intraventricular catheter allows accurate intracranial pressure (ICP) measurement and provides access to cerebrospinal fluid (CSF) for drainage or sampling. A subarachnoid bolt, epidural catheter, and fiber-optic catheter provide no access for CSF sampling.
The nursing management plan for a patient undergoing a water-based contrast myelogram should include intervention? a. Maintain the patient flat in bed for 4 to 6 hours b. Observe the puncture sight every 15 minutes for 2 hours for signs of bleeding c. Keep the patient's head elevated 30 to 45 degrees for 8 hours d. Administer a sedative to keep the patient from moving around
c. Keep the patient's head elevated 30 to 45 degrees for 8 hours Postprocedure care includes keeping the patient's head elevated 30 to 45 degrees for 8 hours, monitoring neurologic status, and encouraging oral fluids.
The practitioner wishes to evaluate the functional integrity of cerebral motor pathways in a brain-injured patient. Which test should the nurse anticipate the practitioner will order? a. Electroencephalography b. Xenon computed tomography (CT) c. Motor-evoked potentials d. Emission tomography
c. Motor-evoked potentials Motor-evoked potentials assess the functional integrity of descending motor pathways. The motor cortex is stimulated via direct high-voltage electric stimulation through the scalp or use of a magnetic field to induce an electrical current within the brain.
The nurse is caring for a patient with a closed head injury with a Glasgow Coma Scale (GCS) score of 6. What does this score indicate about the patient's neurologic status? a. Patient is in a vegetative state. b. Patient is a paraplegic. c. Patient is in a coma. d. Patient is able to obey commands.
c. Patient is in a coma. The best possible score on the Glasgow Coma Scale (GCS) is 15, and the lowest score is 3. Generally, a score of 7 or less on the GCS indicates coma. Originally, the scoring system was developed to assist in general communication concerning the severity of neurologic injury.
An elderly patient is in a motor vehicle accident and sustains a significant internal hemorrhage. The nurse knows the patient is at risk for developing what type of acute kidney injury (AKI)? a. Intrinsic b. Postrenal c. Prerenal d. Intrarenal
c. Prerenal Any condition that decreases blood flow, blood pressure, or kidney perfusion before arterial blood reaches the renal artery that supplies the kidney may be anatomically described as prerenal acute kidney injury (AKI). When arterial hypoperfusion caused by low cardiac output, hemorrhage, vasodilation, thrombosis, or other cause reduces the blood flow to the kidney, glomerular filtration decreases, and consequently urine output decreases.
A patient is admitted with an anoxic brain injury. The nurse notes abnormal extension of both extremities to noxious stimuli. This finding indicates dysfunction in which area of the central nervous system? a. Cerebral cortex b. Thalamus c. Cerebellum d. Brainstem
d. Brainstem Abnormal extension occurs with lesions in the area of the brainstem. Abnormal flexion occurs with lesions above the midbrain in the region of the thalamus or cerebral hemispheres.
The nurse is caring for a critically injured patient who can only be aroused by vigorous external stimuli. Which category should the nurse use to document the patient's level of consciousness? a. Lethargic b. Obtunded c. Stuporous d. Comatose
c. Stuporous Stuporous means the patient can be aroused only by vigorous and continuous external stimuli. Motor response is often withdrawal or localizing to stimulus. Obtunded means the patient displays dull indifference to external stimuli, and response is minimally maintained. Questions are answered with a minimal response. Lethargic means the patient displays a state of drowsiness or inaction in which the patient needs an increased stimulus to be awakened. Comatose means vigorous stimulation fails to produce any voluntary neural response in the patient.
A patient was admitted with acute heart failure. The nurse is assessing the patient for peripheral edema. The nurse presses two fingers over the tibial area, and it takes 1 minute before the indention disappears. What would the nurse in the medical record? a.+1 pitting edema b.+2 pitting edema c.+3 pitting edema d.+4 pitting edema
c.+3 pitting edema The pitting edema scale includes +1 = 2-mm depth; +2 = 4-mm depth (lasting up to 15 seconds); +3 = 6-mm depth (lasting up to 60 seconds); and +4 = 8-mm depth (lasting longer than 60 seconds).
A patient is admitted with acute kidney injury. The patient's weight upon admission was 176 lb and the next day it is 184 lb. What is the approximate amount of fluid retained with this weight gain? a.800 mL b.2200 mL c.3600 mL d.8000 mL
c.3600 mL One liter of fluid equals 1 kg, which is 2.2 lb; 8 lb equals 3.6 kg, which is 3.6 liters; 3.6 liters is equal to 3600 mL.
As serum osmolality rises, intravascular fluid equilibrium will be maintained by the release of what substance? a.Ketones b.Glucagon c.Antidiuretic hormone d.Potassium
c.Antidiuretic hormone When the serum osmolality level increases, antidiuretic hormone is released from the posterior pituitary gland and stimulates increased water resorption in the kidney tubules. This expands the vascular space, returns the serum osmolality level back to normal, and results in more concentrated urine and an elevated urine osmolality level.
A patient has been admitted for observation after a head injury. The practitioner is concerned that the patient may develop intracranial hypertension. Which sign should the nurse be observing the patient for? a.Bradycardia b.Abnormal extension c.Decrease in level of consciousness d.Increase in pupillary size
c.Decrease in level of consciousness One of the earliest and most important signs of increased intracranial pressure is a decrease in the level of consciousness. The other signs are later signs.
A patient has been admitted in a coma of unknown cause. Structural causes have been ruled out. The nurse suspects the patient may be experiencing which cause of coma? a.Trauma b.Ischemic stroke c.Drug overdose d.Intracerebral hemorrhage
c.Drug overdose Causes of metabolic coma include drug overdose, infectious diseases, endocrine disorders, and poisonings. Structural causes of coma include ischemic stroke, intracerebral hemorrhage, trauma, and brain tumors.
Nursing actions for the patient with increased intracranial pressure (ICP) should include which activity? a.Elevate the head of the bed 30 to 40 degrees. b.Place the patient supine with the neck in a neutral alignment. c.Individualize the patient's head position to minimize ICP. d.Elevate the patient's head and knees while flexing the hips.
c.Individualize the patient's head position to minimize ICP. The recent trend is to individualize the head position to maximize cerebral perfusion pressure and minimize intracranial pressure measurements. Head elevation has long been advocated as a conventional nursing intervention to control ICP, presumably by increasing venous return; however, this may decrease CPP.
The management plan for a patient with a clipped cerebral aneurysm receiving hemodynamic augmentation includes which intervention? a.Administering osmotic diuretics and vasodilator agents b.Providing the patient with a quiet environment c.Maintaining the patient's systolic blood pressure at 150 to 160 mm Hg d.Keeping the patient's central venous pressure at 5 to 8 mm Hg
c.Maintaining the patient's systolic blood pressure at 150 to 160 mm Hg Hemodynamic augmentation therapy involves increasing the patient's blood pressure and cardiac output with vasoactive medications. Systolic blood pressure is maintained between 150 and 160 mm Hg. The increase in pressure forces blood through the vasospastic area at higher pressures.
A patient was admitted with acute heart failure who has been receiving diuretic therapy. The nurse suspects the patient is hypovolemic. What auscultatory parameter would confirm the nurse's suspicion? a.Hypertension b.Third or fourth heart sound c.Orthostatic hypotension d.Vascular bruit
c.Orthostatic hypotension A drop in systolic blood pressure of 20 mm Hg or more, a drop in diastolic blood pressure of 10 mm Hg or more, or a rise in pulse rate of more than 15 beats/min from lying to sitting or from sitting to standing indicates orthostatic hypotension. The drop in blood pressure occurs because a sufficient preload is not immediately available when the patient changes position. The heart rate increases in an attempt to maintain cardiac output and circulation.
A patient is admitted in acute kidney injury. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. The nurse suspects the main cause of ascites is what condition? a.Hypervolemia b.Dehydration c.Volume overload d.Liver damage
c.Volume overload Individuals with acute kidney injury may have ascites caused by volume overload, which forces fluid into the abdomen because of increased capillary hydrostatic pressures. However, ascites may or may not represent fluid volume excess.
A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner is going to perform a lumbar puncture. What is an abnormal finding in the cerebrospinal fluid? a. Clear and colorless b. Glucose of 60 mg/dL c. Protein of 20 mg/dL d. 30 red blood cells
d. 30 red blood cells Cerebrospinal fluid is normally a clear, colorless, odorless solution that contains 50 to 75 mg/dL of glucose, 5 to 25 mg/dL of protein, and no red blood cells.
Cerebral infarction is a serious complication of which procedure? a. Extracranial Doppler b. Evoked potential testing c. Myelography d. Cerebral angiography
d. Cerebral angiography Complications associated with cerebral angiography include cerebral embolus caused by the catheter dislodging a segment of atherosclerotic plaque in the vessel, hemorrhage or hematoma formation at the insertion site, vasospasm caused by the irritation of catheter placement, thrombosis of the extremity distal to the injection site, and allergic or adverse reaction to the contrast medium.
The nurse is caring for a patient with a head injury and observes a rhythmic increase and decrease in the rate and depth of respiration followed by brief periods of apnea. What should the nurse document under breathing pattern? a. Central neurogenic hyperventilation b. Apneustic breathing c. Ataxic respirations d. Cheyne-Stokes respirations
d. Cheyne-Stokes respirations Cheyne-Stokes respirations have a rhythmic crescendo and decrescendo of rate and depth of respiration, including brief periods of apnea. These respirations are usually seen with bilateral deep cerebral lesions or some cerebellar lesions. Central neurogenic hyperventilations are very deep, very rapid respirations with no apneic periods. They are usually seen with lesions of the midbrain and upper pons. Apneustic breathing includes clusters of irregular, gasping respirations separated by long periods of apnea. They are usually seen in lesions of the lower pons or upper medulla. Ataxic respirations are irregular, random patterns of deep and shallow respirations with irregular apneic periods. They are usually seen in lesions of the medulla.
The nurse is caring for a comatose patient with a brain tumor. When the nurse touches the palm of the patient's hand, the patient grasps the nurse's hand. What is this sign indicative of? a. There is damage to the brainstem. b. It's a normal finding. c. The patient is getting better. d. Cortical damage is present.
d. Cortical damage is present. The grasp reflex is present when tactile stimulation of the palm of the hand produces a grasp response that is not a conscious voluntary act. The grasp reflex is a primitive reflex that normally disappears with maturational development; thus, the presence of the grasp reflex in the adult indicates cortical damage.
One therapeutic measure for treating hyperkalemia is the administration of dextrose and regular insulin. Which description regarding how this treatment works is accurate? a. Forces potassium out of the serum into the lymphatic space. b. Promotes higher excretion of potassium in the urine. c. Binds with potassium lowering available amounts. d. Forces potassium out of the serum into the cells.
d. Forces potassium out of the serum into the cells. Acute hyperkalemia can be treated temporarily by intravenous administration of insulin and glucose. An infusion of 50 mL of 50% dextrose accompanied by 10 units of regular insulin forces potassium out of the serum and into the cells.
A patient is being prepared for a neurologic work-up. The practitioner is getting ready to perform a lumbar puncture. What is the best position for the nurse to place the patient in for the procedure? a. Prone b. Reverse Trendelenburg c. High Fowler d. Lateral recumbent position with knees and head slightly tucked.
d. Lateral recumbent position with knees and head slightly tucked. Patients undergoing a lumbar puncture are placed either in the lateral recumbent position, with the knees and head tightly tucked, or in the sitting position, leaning over a bedside table or some other support.
The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious patient. During the procedure the patient reaches over with his left hand and tries to remove the noxious stimuli. How would the nurse document this response? a. Decorticate posturing b. Decerebrate posturing c. Withdrawal d. Localization
d. Localization Localization occurs when the extremity opposite to the extremity receiving pain crosses the midline of the body in an attempt to remove the noxious stimulus from the affected limb.
While the Glasgow Coma Scale (GCS) is part of the routine neurologic assessment, the nurse knows that it is not a valid measure for certain types of patients. In which patient is the GCS not valid? a. Patient with hemiplegia b. Patient with Parkinson disease c. Patient with dyslexia d. Patient who is intoxicated
d. Patient who is intoxicated Several points should be kept in mind when the Glasgow Coma Scale is used for serial assessment. It provides data about level of consciousness only, and it should never be considered a complete neurologic examination. Additionally, it is not a sensitive tool for evaluation of an altered sensorium, and it does not account for possible aphasia or mechanical intubation. It is also a poor indicator of lateralization of neurologic deterioration
Which nuclear medicine study should the nurse anticipate a practitioner's order for in a patient who is being evaluated for a brain tumor? a. PET b. MRI c. MRA d. SPECT
d. SPECT The single-photon emission computed tomography (SPECT) test differs from positron emission tomography (PET) in that tracer stays in the bloodstream rather than being absorbed by surrounding tissue, thereby limiting the images to areas where blood flows. SPECT is cheaper and more readily available than higher resolution PET. The major clinical uses of SPECT are to detect cerebrovascular disease, seizures, and tumors. Magnetic resonance imaging and magnetic resonance angiography are radiographic imaging examinations.
The nurse is precepting a new graduate nurse. The new graduate asks about testing the oculovestibular reflex. What should the nurse tell the new graduate? a. The test should not be performed on an unconscious patient because of the risk of aspiration. b. An abnormal response is manifested by conjugate, slow, tonic nystagmus deviating toward the irrigated ear. c. This test should be included in the nursing neurologic examination of a patient with a head injury. d. This test is one of the final clinical assessments of brainstem function.
d. This test is one of the final clinical assessments of brainstem function. The oculovestibular reflex is one of the final clinical assessments of brainstem function and is only performed by a practitioner. After confirmation that the tympanic membrane is intact, the head is raised to a 30-degree angle. Then 20 to 100 mL of ice water is injected into the external auditory canal. In a normal response, eye movement is in the direction of the injection site. An abnormal response is disconjugate eye movement, which indicates a brainstem lesion, or no response, which indicates little to no brainstem function.
Which patient problem has the highest priority in the patient management plan for a patient with Guillain-Barré syndrome? a.Nutritional deficient due to lack of exogenous nutrients or increased metabolic demand b.Acute pain due to transmission and perception of cutaneous, visceral, muscular, or ischemic impulses c.Increased probability of aspiration due to impaired swallowing d.Abnormal breathing pattern due to musculoskeletal fatigue or neuromuscular impairment
d.Abnormal breathing pattern due to musculoskeletal fatigue or neuromuscular impairment The most common cause of death of patients with GBS is respiratory arrest; thus, the highest nursing priority for a patient with Guillain-Barré syndrome is directed toward providing ventilatory support and maintaining surveillance for complications. Facilitating nutritional support, providing comfort and emotional support, and educating the patient and family are important but rank lower than issues with the respiratory system.
A patient is admitted with an acute head injury after a motor vehicle accident. The patient is intubated and ventilated, and a ventriculostomy is placed. In addition to monitoring of intracranial pressure, what treatment can be provided with the ventriculostomy? a.Instillation of mannitol b.Drainage of subdural hematoma c.Brain tissue sampling d.Cerebrospinal fluid drainage
d.Cerebrospinal fluid drainage Advantages of a ventriculostomy include access for cerebrospinal fluid drainage and sampling, access for determination of volume-pressure curves, direct measurement of pressure, and access for medication instillation.
In a patient with a distended abdomen differentiating ascites from solid bowel contents is accomplished by performing what assessment? a.Auscultation of bowel sounds b.Palpation of the liver margin c.Measuring abdominal girth d.Eliciting a fluid wave
d.Eliciting a fluid wave Differentiating ascites from distortion by solid bowel contents is accomplished by producing what is called a fluid wave. The fluid wave is elicited by exerting pressure to the abdominal midline while one hand is placed on the right or left flank. Tapping the opposite flank produces a wave in the accumulated fluid that can be felt under the hands.
A patient has been admitted after the placement of a ventriculoperitoneal shunt. The nurse should monitor the patient for evidence of which condition? a.Hyponatremia b.Cerebrospinal fluid leak c.Ascending paralysis d.Increased intracranial pressure
d.Increased intracranial pressure The patient should be monitored for signs of increased intracranial hypertension secondary to hydrocephalus. If the shunt is not working correctly, cerebrospinal fluid will accumulate and cause increased intracranial pressure.
A patient has been admitted with an intracerebral hemorrhage. A CT of the patient's head reveals a large left parietal area bleed. Patient assessment includes T—98.7°F, P—98 beats/min and thready, R—8 breaths/min, and BP—168/100 mm Hg. Initial management of the patient includes which intervention? a.Placing the patient in the Trendelenburg position b.Administering an antihypertensive agent c.Initiating hemodynamic augmentation therapy d.Intubating and ventilating the patient
d.Intubating and ventilating the patient Intracerebral hemorrhage is a medical emergency. Initial management requires attention to airway, breathing, and circulation. Intubation is usually necessary. Blood pressure management must be based on individual factors. Reduction in blood pressure is usually necessary to decrease ongoing bleeding, but lowering blood pressure too much or too rapidly may compromise cerebral perfusion pressure, especially in a patient with elevated intracranial pressure. National guidelines recommend keeping the mean arterial blood pressure below 130 mm Hg in patients with a history of hypertension by moderate blood pressure reduction to a mean arterial pressure below 110 mm Hg. Vasopressor therapy after fluid replenishment is recommended if systolic blood pressure falls below 90 mm Hg
A patient presents with aphasia, decreased level of consciousness, and right-sided weakness. The patient has a history of heart disease, hyperlipidemia, and transient ischemic attacks. Based on the history, the nurse suspects that the patient has sustained which type of stroke? a.Hemorrhagic stroke b.Intracerebral hemorrhages c.Subarachnoid hemorrhages d.Ischemic stroke
d.Ischemic stroke Ischemic stroke results from interruption of blood flow to the brain and accounts for 80% to 85% of all strokes. The interruption can be the result of a thrombotic or embolic event. Thrombosis can form in large vessels (large-vessel thrombotic strokes) or small vessels (small-vessel thrombotic strokes). Embolic sources include the heart (cardioembolic strokes) and atherosclerotic plaques in larger vessels (atheroembolic strokes). In 30% of the cases, the underlying cause of the stroke is unknown (cryptogenic strokes). Strokes are classified as ischemic and hemorrhagic. Hemorrhagic strokes can be further categorized as subarachnoid hemorrhages and intracerebral hemorrhages.
A patient with unruptured cerebral aneurysm has been admitted for monitoring. The nurse is aware that this condition poses which risk to the patient? a.It shunts blood away from the surrounding tissues. b.It leaks blood into the subarachnoid space. c.It causes damage the middle layer of the arterial wall. d.It places pressure on the surrounding tissues.
d.It places pressure on the surrounding tissues. An unruptured aneurysm may be problematic because it places pressure on the surrounding tissues. The aneurysm becomes clinically significant when the vessel wall becomes so thin that it ruptures, sending arterial blood at a high pressure into the subarachnoid space.
A patient was admitted with multiple trauma who has been volume resuscitated. The nurse suspects the patient is fluid overloaded. Which assessment findings would confirm the nurse's suspicion? a.Venous filling of the hand veins greater than 5 seconds b.Distended neck veins in the supine position c.Presence of orthostatic hypotension d.Presence of a third heart sound
d.Presence of a third heart sound Auscultation of the heart requires not only assessing rate and rhythm but also listening for extra sounds. Fluid overload is often accompanied by a third or fourth heart sound, which is best heard with the bell of the stethoscope.
A patient has been admitted in a coma of unknown cause. The nurse should anticipate the practitioner ordering the rapid intravenous administration of which three agents? a.Epinephrine, hydrocortisone, and Benadryl b.Dopamine, 10% dextrose in distilled water, and calcium chloride c.Mannitol, dexamethasone, and sodium bicarbonate d.Thiamine, glucose, and opioid antagonist
d.Thiamine, glucose, and opioid antagonist The goal of medical management of the patient in coma is identification and treatment of the underlying cause of the condition. Initial medical management includes emergency measures to support vital functions and prevent further neurologic deterioration. Protection of the airway and ventilatory assistance are often needed. Administration of thiamine (at least 100 milligrams [mg]), glucose, and an opioid antagonist is suggested when the cause of coma is not immediately known.
The nurse is caring for a patient who is had transsphenoidal surgery for removal of a pituitary tumor. The nurse observes a large amount of clear drainage from the nose. The practitioner requests the drainage be tested for the presence of glucose. What is the purpose of this intervention? a.To assess for an infection b.To check for a shift in osmolality c.To check for occult blood d.To assess for a cerebrospinal fluid leak
d.To assess for a cerebrospinal fluid leak To differentiate cerebrospinal fluid (CSF) drainage from postoperative serous drainage, a specimen is tested for glucose content. A CSF leak is confirmed by glucose values of 30 mg/dL or greater.
The patient complains of a metallic taste and loss of appetite. The nurse is concerned that the patient has developed what problem? a.Glycosuria b.Proteinuria c.Myoglobin d.Uremia
d.Uremia A history of recent onset of nausea and vomiting or appetite loss caused by taste changes (uremia often causes a metallic taste) may provide clues to the rapid onset of kidney problems. Glycosuria is the presence of glucose in the urine. Proteinuria is the presence of protein in the urine. Myoglobin is the presence of red blood cells in the urine.
