Exam 3 - Unit 13

While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first? a. Deliver rescue breaths. b. Wrap the client in dry blankets. c. Assess for signs of bleeding. d. Check for a carotid pulse.

ANS: A In this emergency situation, the nurse should immediately initiate airway clearance and ventilator support measures, including delivering rescue breaths.

A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. "I can go swimming all by myself because I am a certified lifeguard." b. "I cannot leave my toddler alone in the bathtub for even a minute." c. "I will appoint one adult to supervise the pool at all times during a party." d. "I will make sure that there is a phone near my pool in case of an emergency."

ANS: A People should never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching.

An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head

ANS: A Clients who survive an immediate lightning strike can have serious myocardial injury, which can be manifested by ECG and myocardial perfusion abnormalities. The nurse should prioritize the ECG. Other assessments should be completed but are not the priority.

A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment? a. Administer intravenous morphine. b. Wrap the limb with a compression dressing. c. Massage the frostbitten areas. d. Assess the limb for compartment syndrome.

ANS: A Rapid rewarming in a water bath is recommended for all instances of partial-thickness and full-thickness frostbite. Clients experience severe pain during the rewarming process and nurses should administer intravenous analgesics.

An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement? a. Administer dexamethasone (Decadron). b. Complete a mini-mental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.

ANS: A The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE). Dexamethasone (Decadron) reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not treat mountain sickness or HACE.

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

ANS: A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.

An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications e. Isolation precautions

ANS: A, B, E Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client's situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions.

An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at higher risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. Illicit drug users c. White people d. Hockey players e. Older adults

ANS: A, B, E Some of the most vulnerable, at-risk populations for heat-related illness include older adults; blacks (more than whites); people who work outside, such as construction and agricultural workers (more men than women); homeless people; illicit drug users (especially cocaine users); outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan).

A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Consult an exterminator to control bugs in and around your home." b. "Do not swat at insects or wasps." c. "Wear sandals whenever you go outside." d. "Keep your prescribed epinephrine auto-injector in a bedside drawer." e. "Use screens in your windows and doors to prevent flying insects from entering."

ANS: A, B, E To prevent arthropod bites and stings, clients should wear protective clothing, cover garbage cans, use screens in windows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine auto-injector at all times if they are known to be allergic to bee or wasp stings.

A nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) a. Seek shelter inside a building or vehicle. b. Hide under a tall tree. c. Do not take a bath or shower. d. Turn off the television. e. Remove all body piercings. f. Put down golf clubs or gardening tools.

ANS: A, C, D, F When thunder is heard, shelter should be sought in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing, water, and metal objects. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a person's chances of being struck by lightning.

An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101° F. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes.

ANS: A, D, E Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids should be provided, and baseline laboratory tests should be performed as quickly as possible. The client should be cooled until core body temperature is reduced to 102° F. Antipyretics should not be administered.

A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) a. "Wear synthetic clothing instead of cotton to keep your skin dry." b. "Drink plenty of fluids. Brandy can be used to keep your body warm." c. "Remove your hat when exercising to prevent the loss of heat." d. "Wear sunglasses to protect skin and eyes from harmful rays." e. "Know your physical limits. Come in out of the cold when limits are reached."

ANS: A, D, E To prevent hypothermia and frostbite, the nurse should teach clients to wear synthetic clothing (which moves moisture away from the body and dries quickly), layer clothing, and wear a hat, facemask, sunscreen, and sunglasses. The client should also be taught to drink plenty of fluids, but to avoid alcohol when participating in winter activities. Clients should know their physical limits and come in out of the cold when these limits have been reached.

The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse - Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner - Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse - Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs d. Emergency medical technician - Obtains client histories, collects evidence, and offers counseling and follow-up care for victims of rape, child abuse, and domestic violence e. Paramedic - Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

ANS: A, E The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client's behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? a. A 22-year-old with a painful and swollen right wrist b. A 45-year-old reporting chest pain and diaphoresis c. A 60-year-old reporting difficulty swallowing and nausea d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F

ANS: B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

A provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, "What is this medication for?" How should the nurse respond? a. "This medication is an antivenom for this type of bite." b. "It will relieve your muscle rigidity and spasms." c. "It prevents respiratory difficulty from excessive secretions." d. "This medication will prevent respiratory failure."

ANS: B Black widow spider venom produces a syndrome known as latrodectism, which manifests as severe abdominal pain, muscle rigidity and spasm, hypertension, and nausea and vomiting. Diazepam is a muscle relaxant that can relieve pain related to muscle rigidity and spasms. It does not prevent respiratory difficulty or failure.

A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? a. The facility's neurologist b. The poison control center c. The physical therapy department d. A herpetologist (snake specialist)

ANS: B For the client with a snakebite, the nurse should contact the regional poison control center immediately for specific advice on anti-venom administration and client management.

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. Which action should the nurse take first? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospital's crisis team.

ANS: B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I - Located within remote areas and provides advanced life support within resource capabilities b. Level II - Located within community hospitals and provides care to most injured clients c. Level III - Located in rural communities and provides only basic care to clients d. Level IV - Located in large teaching hospitals and provides a full continuum of trauma care for all clients

ANS: B Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma centers are made.

A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the client's extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.

ANS: B Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia should be treated by core rewarming methods, which include administration of warm IV fluids, heated oxygen, and heated peritoneal, pleural, gastric, or bladder lavage, and by positioning the client in a supine position to prevent orthostatic changes. The client's trunk should be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.

A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication? a. Assess temperature and for signs of fever. b. Check the client's creatinine kinase level. c. Ask about allergies to pineapple or papaya. d. Inspect the skin for signs of urticaria (hives).

ANS: C CroFab is an antivenom for pit viper snakebites. Clients should be assessed for hypersensitivity to bromelain (a pineapple derivative), papaya, and sheep protein prior to administration. During and after administration, the nurse should assess for urticaria, fever, and joint pain, which are signs of serum sickness.

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes.

ANS: B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this client's temperature or improve the client's symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate.

A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.

ANS: B, C, D To ensure client and staff safety, nurses should use two identifiers per The Joint Commission's National Patient Safety Goals; follow the hospital's security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.

An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair

ANS: B, C, E, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

A nurse is triaging clients in the emergency department. Which client should the nurse classify as "non-urgent?" a. A 44-year-old with chest pain and diaphoresis b. A 50-year-old with chest trauma and absent breath sounds c. A 62-year-old with a simple fracture of the left arm d. A 79-year-old with a temperature of 104° F

ANS: C A client in a non-urgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered non-urgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

A nurse is triaging clients in the emergency department. Which client should be considered "urgent"? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102° F d. A 50-year-old male with new-onset confusion and slurred speech

ANS: C A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.

ANS: C A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department.

An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client's care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

ANS: C All other members of the health care team listed may be used in the management of this client's care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

ANS: C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm

ANS: C Manifestations of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.

After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching? a. "If my climbing partner can't think straight, we should descend to a lower altitude." b. "I will ask my provider about medications to help prevent acute mountain sickness." c. "My partner and I will plan to sleep at a higher elevation to acclimate more quickly." d. "I will drink plenty of fluids to stay hydrated while on the mountain."

ANS: C Teaching to prevent altitude-related illness should include descending when symptoms start, staying hydrated, and taking acetazolamide (Diamox), which is commonly used to prevent and treat acute mountain sickness. The client should be taught to sleep at a lower elevation.

An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48-year-old with a simple fracture of the lower leg

ANS: C The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the client's trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the client. c. Listen to the client's concerns and needs. d. Ask security to store the client's belongings.

ANS: C To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the client's belongings and personal space.

A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment should the nurse perform to identify complications of this bite? a. Ask the client about pruritus at the bite site. b. Inspect the bite site for a bluish purple vesicle. c. Assess the extremity for redness and swelling. d. Monitor the client's temperature every 4 hours.

ANS: D Fever and chills indicate systemic toxicity, which can lead to hemolytic reactions, kidney failure, pulmonary edema, cardiovascular collapse, and death. Assessing for a fever should be the nurse's priority. All other symptoms are normal for a brown recluse bite and should be assessed, but they do not provide information about complications from the bite, and therefore are not the priority.

While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. Which action should the nurse take first? a. Elevate the site and notify the person's next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.

ANS: D The client's swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.

ANS: D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.

A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (Select all that apply.) a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. d. Screen for depression and suicide. e. Complete a functional assessment.

ANS: D, E Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.

A patient in the neurologic intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating would this patient have for verbal response? 1. 1 2. 4 3. 2 4. 3

Correct Answer: 1 Rationale 1: The Glasgow Coma Scale assesses both level of consciousness and motor response to a stimulus. The scale has three sections: eye opening, motor response, and verbal response. If the patient is unable to talk because of intubation, the score is a 1. Rationale 2: The patient is unable to talk and would not be scored as a 4. Rationale 3: The patient is unable to talk and would not be scored as a 2. Rationale 4: The patient is unable to talk and would not be scored as a 3.

A patient is demonstrating neurologic changes consistent with increasing intracranial pressure. For which primary causes of this pressure increase will the nurse assess at this time? Standard Text: Select all that apply. 1. Cerebral hemorrhage 2. Ischemic stroke 3. Airway obstruction 4. Drop in blood pressure 5. Electrolyte imbalance

Correct Answer: 1,2 Rationale 1: Cerebral hemorrhage is a primary cause of increased intracranial pressure. Rationale 2: Ischemic stroke is a primary cause of increased intracranial pressure. Rationale 3: Airway obstruction is a secondary cause of increased intracranial pressure. Rationale 4: Hypotension is a secondary cause of increased intracranial pressure. Rationale 5: Electrolyte imbalances indicate metabolic disorders, which are secondary causes of increased intracranial pressure.

The nurse is caring for a patient who sustained head and abdominal injuries from a motor vehicle crash. While the nurse is inserting a nasogastric tube to decompress the stomach, the patient begins to cough and gag. What cranial nerves did the nurse inadvertently assess when inserting the nasogastric tube into the patient? Standard Text: Select all that apply. 1. IX (glossopharyngeal) 2. X (vagus) 3. V (trigeminal) 4. VII (facial) 5. III (oculomotor)

Correct Answer: 1,2 Rationale 1: This nerve is intact when the patient exhibits the cough and gag reflex. Rationale 2: This nerve is intact when the patient exhibits the cough and gag reflex. Rationale 3: This nerve is used to assess for the corneal reflex. Rationale 4: This nerve is used to assess for the corneal reflex. Rationale 5: This nerve is used to assess pupillary response.

A patient, diagnosed with a subdural hematoma, has an intracranial pressure of 14 mm Hg. The nurse realizes that if this pressure increases, the body may respond by: Standard Text: Select all that apply. 1. Displacing cerebrospinal fluid into the lumbar cistern 2. Reabsorbing more cerebrospinal fluid 3. Shunting blood out of venous sinuses 4. Raising the body temperature 5. Increasing the carbon dioxide level

Correct Answer: 1,2,3 Rationale 1: According to the Munro Kelly hypothesis, intracranial pressure is kept within a range between 5 to 15 mm Hg by a mechanism known as compliance. When the volume of one of the components increases, the body may respond by displacing cerebrospinal fluid into the lumbar cistern. Rationale 2: According to the Munro Kelly hypothesis, intracranial pressure is kept within a range between 5 to 15 mm Hg by a mechanism known as compliance. When the volume of one of the components increases, the body may respond by reabsorbing more cerebrospinal fluid. Rationale 3: According to the Munro Kelly hypothesis, intracranial pressure is kept within a range between 5 to 15 mm Hg by a mechanism known as compliance. When the volume of one of the components increases, the body may respond by compressing veins and shunting blood out of the venous sinuses. Rationale 4: Elevating the body temperature is not controlled by the compliance mechanism. Rationale 5: Increasing the carbon dioxide level is not controlled by the compliance mechanism.

A patient with a traumatic brain injury is diagnosed with an acute subdural hematoma. What would the nurse be more likely to assess in this patient than in one who had experienced a chronic subdural hematoma? Standard Text: Select all that apply. 1. Loss of consciousness 2. Hemiparesis 3. Dysphagia 4. Confusion 5. Headache

Correct Answer: 1,2,3 Rationale 1: Loss of consciousness is a manifestation of acute subdural hematoma. Rationale 2: Hemiparesis is a manifestation of acute subdural hematoma. Rationale 3: Dysphagia is a manifestation of acute subdural hematoma. Rationale 4: Confusion is a manifestation of chronic subdural hematoma. Rationale 5: Headache is a manifestation of chronic subdural hematoma.

A patient is diagnosed with meningitis that developed after experiencing otitis media. What will the nurse most likely assess in this patient? Standard Text: Select all that apply. 1. Fever 2. Stiff neck 3. Confusion 4. Photophobia 5. Palpitations

Correct Answer: 1,2,3,4 Rationale 1: Fever is a manifestation of meningitis. Rationale 2: A stiff neck or nuchal rigidity is a manifestation of meningitis. Rationale 3: A change in mental status is a manifestation of meningitis. Rationale 4: Photophobia is a manifestation of meningitis. Rationale 5: Palpitations are not manifestations of meningitis.

A patient has been receiving treatment for status epilepticus for the last 20 minutes. What will the nurse prepare to implement to help the patient at this time? Standard Text: Select all that apply. 1. Prepare for emergency intubation. 2. Insert an indwelling urinary catheter. 3. Monitor body temperature. 4. Obtain an order for a bedside electroencephalogram. 5. Insert an intravenous access line.

Correct Answer: 1,2,3,4 Rationale 1: If the seizure continues beyond 20 to 30 minutes, the patient should be intubated. Rationale 2: If the seizure continues beyond 20 to 30 minutes, the patient should have an indwelling urinary catheter inserted. Rationale 3: If the seizure continues beyond 20 to 30 minutes, the nurse should monitor the patient's body temperature. Rationale 4: If the seizure continues beyond 20 to 30 minutes, an electroencephalogram should be obtained. Rationale 5: An intravenous access line would have been placed earlier for the administration of intravenous medication.

The nurse is concerned that a patient's intracranial pressure monitor readings are incorrect. What can the nurse do to ensure that the monitor is measuring accurately? Standard Text: Select all that apply. 1. Check the location of the stopcocks. 2. Check the position of the transducer. 3. Check the monitoring line for air. 4. Ensure the catheter is not obstructed. 5. Check to make sure the dressing is dry.

Correct Answer: 1,2,3,4 Rationale 1: One reason for inaccurate intracranial pressure readings would be an incorrect position of the stopcocks. Rationale 2: One reason for inaccurate intracranial pressure readings would be an incorrect position of the transducer. Rationale 3: One reason for inaccurate intracranial pressure readings would be air in the monitoring line. Rationale 4: One reason for inaccurate intracranial pressure readings would be the catheter being obstructed. Rationale 5: The condition of the dressing will not impact the accuracy of intracranial pressure readings.

The nurse is teaching a patient, recovering from a mild brain injury, about manifestations to expect during the recovery process. What will the nurse instruct this patient to expect while recuperating from this injury? Standard Text: Select all that apply. 1. Headache 2. Dizziness 3. Fatigue 4. Memory loss 5. Nausea

Correct Answer: 1,2,3,4 Rationale 1: Problems experienced by patients with mild brain injuries include headache. Rationale 2: Problems experienced by patients with mild brain injuries include dizziness. Rationale 3: Problems experienced by patients with mild brain injuries include fatigue. Rationale 4: Problems experienced by patients with mild brain injuries include memory loss. Rationale 5: Nausea is not a problem experienced by patients with mild brain injuries.

When administering hypertonic saline to the patient with increased intracranial pressure (ICP), the nurse would: Standard Text: Select all that apply. 1. Monitor the patient for renal failure and pulmonary edema. 2. Administer any concentrations greater than 2% through a central line. 3. Monitor serum sodium levels frequently during administration. 4. Expect the patient's neurologic status and ICP will begin to improve within 15 minutes following administration. 5. Monitor the patient's serum osmolarity every 24 hours.

Correct Answer: 1,2,3,4 Rationale 1: Renal failure and pulmonary edema can occur from this fluid. Rationale 2: A solution greater than 2% should be administered through a central line. Rationale 3: Serum sodium levels should be frequently monitored during the administration of this fluid. Rationale 4: The patient's neurologic status and intracranial pressure level will improve within 15 minutes following the administration of this fluid. Rationale 5: Serum osmolarity should be measured at least every 12 hours and maintained at less than 320 mOsm/L.

A patient's mean arterial pressure (MAP) decreases to 50 while his ICP is 20. The nurse realizes that this drop in MAP is likely to lead to: 1. Increased intracranial pressure 2. Hypoxic cerebral tissue 3. Increased urine output 4. Bradycardia

Correct Answer: 2 Rationale 1: A decline in mean arterial pressure is not going to cause an increase in intracranial pressure. Rationale 2: Cerebral perfusion is dependent on the blood pressure and the intracranial pressure. It is the difference between the pressure of the incoming blood or MAP and the force opposing perfusion of the brain, or the intracranial pressure. Normal values for cerebral perfusion pressure should be greater than 50 to 60. A pressure less than 40 to 50 usually results in the loss of autoregulation and leads to hypoxia of cerebral tissue. Rationale 3: A decline in mean arterial pressure is not going to cause an increase in urine output. Rationale 4: A decline in mean arterial pressure is not going to cause bradycardia.

What might a patient develop if intravenous phenytoin (Dilantin) was administered faster than 50 mg/minute? 1. A severe rash 2. Hypotension 3. Hematologic abnormalities such as agranulocytosis 4. A pronounced increase in heart rate

Correct Answer: 2 Rationale 1: A severe rash would not immediately occur. Rationale 2: Phenytoin is administered no faster than 25 to 50 mg/min, because faster administration may result in bradycardia, hypotension, heart block, and ventricular fibrillation. Rationale 3: Hematologic abnormalities would not occur immediately. Rationale 4: Bradycardia, heart block, and ventricular fibrillation can occur.

A patient with acute meningitis is receiving antibiotic therapy. The nurse realizes that another medication is used as adjuvant therapy. This medication is: 1. An anticonvulsant 2. A steroid 3. A barbiturate 4. A pain medication

Correct Answer: 2 Rationale 1: Anticonvulsants are not used as adjuvant therapy for meningitis. Rationale 2: Steroids are currently recommended as adjunctive treatment of bacterial meningitis. Dexamethasone is believed to interrupt the neurotoxic effects resulting from the lysis of bacteria during the first days of antibiotic use. When steroids are given, they should be administered prior to or during the administration of antibiotics on the first 2 days of therapy. Rationale 3: Barbiturates are not used as adjuvant therapy for meningitis. Rationale 4: Pain medication is not used as adjuvant therapy for meningitis.

The nurse is planning care for a patient with increased intracranial pressure. Which intervention would be appropriate for this patient? 1. Encourage family and physician to discuss patient's care and prognosis in the patient's room. 2. Assess for daily bowel movement and provide intervention as appropriate. 3. Maintain head of bed at a 15-degree angle with knee elevation. 4. Cluster care activities.

Correct Answer: 2 Rationale 1: Keeping external stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes discussion around the patient by both the family and the health care team. Rationale 2: When a patient engages in a Valsalva maneuver when straining with a bowel movement or pushing up in bed, the ICP usually rises. Many neurosurgeons will provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is necessary to ensure that the patient has a daily soft bowel movement without straining. Rationale 3: The head of the bed should be elevated at 30 degrees to allow for adequate cerebral perfusion while promoting venous return from the head. The body and neck should be in alignment without knee elevation. Rationale 4: The patient's ICP may rise when nursing activities are delivered in a traditional "cluster" fashion, with one activity following another. The ICP may rise with the first activity and continue to rise with each additional activity. The patient's ICP should be permitted to return to baseline before continuing with other activities.

A patient who has suffered a traumatic brain injury has his blood pressure increase from 130/60 to 170/65 mm Hg. The nurse should respond to this increase in blood pressure by: 1. Weighing the patient to determine if the patient is fluid overloaded 2. Documenting the blood pressure and completing a neurologic assessment 3. Alerting the physician and preparing to administer an antihypertensive agent 4. Providing the patient with immediate pain and/or antianxiety medication

Correct Answer: 2 Rationale 1: This change in blood pressure is not due fluid volume overload. Rationale 2: Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. The nurse needs to assess the impact of the increased blood pressure on the patient's neurologic status by completing a neurologic assessment. Rationale 3: The nurse would need to assess the patient's neurologic status before contacting the physician for treatment. Rationale 4: The nurse needs to first assess the patient's neurologic status before medicating for pain or anxiety since these types of medications will dampen neurologic responses.

A patient with a head injury has a pO2 of 88 and a pCO2 of 58. The nurse realizes that which physiologic process will occur in this patient? 1. Cerebral blood vessels will constrict. 2. Cerebral blood vessels will dilate. 3. Blood flow to the cerebral cortex will slow. 4. Blood will be shunted from the cerebral cortex.

Correct Answer: 2 Rationale 1: This is not an expected physiologic response to the patient's oxygen and carbon dioxide levels. Rationale 2: Autoregulation ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such as when there is a drop in cerebral oxygen levels or an increase in cerebral carbon dioxide levels. Rationale 3: This is not an expected physiologic response to the patient's oxygen and carbon dioxide levels. Rationale 4: This is not an expected physiologic response to the patient's oxygen and carbon dioxide levels.

A patient with a severe head injury has a pO2 of 88 and a pCO2 of 48. What should be done to support this patient? 1. Assess oxygen saturation and plan for intubation if saturation is below 86%. 2. Provide 100% oxygen via face mask. 3. Plan for a rapid sequence intubation. 4. Plan for a routine intubation.

Correct Answer: 3 Rationale 1: An oxygen saturation less than 90% is associated with increased morbidity and mortality in these patients. Rationale 2: Oxygen would be provided with a bag-valve mask. Rationale 3: Many organizations utilize rapid sequence intubation, which might include supporting the patient's respirations with a 100% O2 via bag-valve mask; administration of lidocaine to inhibit central responses that can increase ICP; administration of a sedative hypnotic agent; administration of a rapid-acting neuroblocking agent; checking for jaw relaxation after 30 seconds, if it is present; intubation; confirmation of tube placement; and sedation. Rationale 4: Intubation can be a noxious procedure and may increase intracranial pressure. Because of this, routine intubation would not be done.

What would be appropriate for the nurse to do when assessing a patient's motor function? 1. Assess all four extremities together. 2. Assess the right leg and the right arm together. 3. Assess the arms together and then assess the legs separately. 4. Assess the left leg and the left arm together.

Correct Answer: 3 Rationale 1: Assessing all extremities together would not enable the nurse to compare strength and movement of both sides of the body. Rationale 2: The legs are usually assessed separately. Rationale 3: Although the nurse can assess the arms simultaneously, the legs are usually assessed separately. It is important that the nurse assesses the movement in all four of the extremities and compare the strength of movement on both sides of the body. Rationale 4: The legs are usually assessed separately.

The nurse, evaluating the tracing made from a patient's intracranial pressure monitor, notes the presence of many C waves. This finding would be indicative of: 1. Decreased cerebral compliance 2. Pending brain herniation 3. No evidence of pathology 4. Impaired cerebral spinal fluid flow

Correct Answer: 3 Rationale 1: Decreased cerebral compliance would be indicated by the presence of A waves. Rationale 2: Pending brain herniation would be indicated by the presence of A waves. Rationale 3: "C" waves are smaller rhythmic oscillations that occur 4 to 8 times/minute and are not indicative of pathology. Rationale 4: Impaired cerebral spinal fluid flow would be indicated by the presence of A waves.

A patient with a traumatic brain injury is showing signs of having pain. What would be the medication of choice for this patient? 1. Propofol 2. Meperidine 3. Morphine sulfate 4. Fentanyl

Correct Answer: 3 Rationale 1: Propofol is a sedative-hypnotic anesthetic and not used for this patient. Rationale 2: There is no evidence to support the use of meperidine for treating the pain associated with a traumatic brain injury. Rationale 3: The patient with a head injury may experience significant pain either from the head injury or from other injuries incurred in the traumatic event. Morphine is most widely used because it has a high level of efficacy and safety yet is minimally sedating. If necessary for a neurologic assessment, it can be reversed with Narcan. Rationale 4: Fentanyl is used cautiously because it results in a mild but definite increase in intracranial pressure.

The nurse is assessing a patient's corneal reflex. The cranial nerve that is being assessed with this reflex is: 1. Oculomotor 2. Optic 3. Trigeminal 4. Vagus

Correct Answer: 3 Rationale 1: The oculomotor nerve is assessed when the pupils are checked. Rationale 2: The optic nerve is assessed when the pupils are checked. Rationale 3: Portions of the trigeminal and facial cranial nerves can be assessed by checking for a corneal reflex. Rationale 4: The vagus nerve is assessed by checking for a cough and gag reflex.

When providing care to a patient with increased intracranial pressure, the nurse would be concerned about which clinical finding because it can result in an additional increase in intracranial pressure? 1. Temperature of 99°F (37.2°C) 2. Respiratory rate of 24 3. Serum sodium of 110 mEq/L 4. Blood pressure of 150/65

Correct Answer: 3 Rationale 1: This is a minor temperature elevation and would not contribute to the patient's increased intracranial pressure. Rationale 2: This is a minor respiratory rate increase and would not contribute to the patient's increased intracranial pressure. Rationale 3: Hyponatremia is considered a secondary cause that contributes to increases in intracranial pressure. This laboratory value should be reported and treatment started to avoid additional pressure increases. Rationale 4: This blood pressure is within parameters that would not affect the patient's cerebral perfusion and is unlikely to contribute to the patient's increased intracranial pressure.

A patient with a skull fracture was admitted unconscious, became conscious, and has since moved into unconsciousness again. This patient is demonstrating findings indicative of: 1. A cerebral spinal fluid leak 2. A subdural hematoma 3. An epidural hematoma 4. A subarachnoid hemorrhage

Correct Answer: 3 Rationale 1: This is not a symptom of a cerebral spinal fluid leak. Rationale 2: Acute subdural hematomas are collections of thick, jelly-like blood that accumulate within the first 24 to 48 hours after blunt trauma. Patients usually present with a loss of consciousness and they may have focal signs such as hemiparesis or dysphagia. Subacute subdural hematomas usually develop over days to weeks following the injury. Chronic subdural hematomas are more common in older adults during the 2 to 3 weeks following the injury. Patients usually develop nonspecific symptoms such as headache, confusion, and speech deficits. Rationale 3: Epidural hematomas usually occur in conjunction with a skull fracture and result from a laceration of the middle meningeal artery, causing bleeding between the dura mater and the skull. Approximately half of the patients who suffer this injury demonstrate the classic presentation of an initial loss of consciousness followed by a lucid interval and then a sudden reloss of consciousness with rapid deterioration in neurologic status. Rationale 4: Subarachnoid hemorrhage, or bleeding between the arachnoid and pia matter, may result from rupture of a preexisting or a traumatic cerebral aneurysm.

The nurse is caring for a patient with status epilepticus. The first goal of care for this patient would be to: 1. Determine the patient's medical history. 2. Obtain an EEG. 3. Maintain an airway. 4. Identify the cause of the seizure.

Correct Answer: 3 Rationale 1: This is not the first priority for this patient. Rationale 2: This is not the first priority for this patient. Rationale 3: The first priority in status epilepticus is airway and oxygenation. For some patients, a nasopharyngeal airway is sufficient with provision of oxygen by nasal cannula. For other patients, endotracheal intubation is necessary. Rationale 4: This is not the first priority for this patient.

The nurse is providing medication to a patient with status epilepticus. The medication of choice for this patient would be: 1. A barbiturate 2. A steroid 3. An opioid 4. A benzodiazepine

Correct Answer: 4 Rationale 1: A barbiturate is not the medication of choice for a patient experiencing status epilepticus. Rationale 2: A steroid is not the medication of choice for a patient experiencing status epilepticus. Rationale 3: An opioid is not the medication of choice for a patient experiencing status epilepticus. Rationale 4: The initial drug of choice is a benzodiazepine, usually lorazepam administered at the rate of 2 to 4 mg IV over 1 minute because it terminates seizures 75% to 80% of the time. The dose may be repeated after 5 to 10 minutes if the seizure has not stopped.

The nurse is preparing to conduct an hourly neurologic assessment on a patient in the intensive care unit. What is included in this assessment? 1. ECG 2. Brainstem functioning 3. Reflexes 4. Level of consciousness

Correct Answer: 4 Rationale 1: An electrocardiogram is not a part of an hourly neurologic assessment. Rationale 2: On occasion, the nurse might be involved with assessing brainstem functioning; however, this is not a part of an hourly neurologic assessment. Rationale 3: Reflexes are not a part of an hourly neurologic assessment. Rationale 4: Components of an hourly neurologic assessment usually include, at least, the Glasgow Coma Scale or another assessment of level of consciousness, pupillary response to light, motor function, and vital signs. Assessment of cranial nerves, reflexes, and sensation may be added if indicated. On occasion, the nurse might be involved with assessing brainstem functioning.

The nurse is going to assist with the assessment of a patient's oculovestibular reflex. What should be done before this reflex is assessed? 1. Ensure that the patient's spinal cord has been found intact. 2. Ensure that the patient has an intact gag reflex. 3. Determine that the patient can tolerate being in the supine position. 4. Determine that the patient has an intact tympanic membrane.

Correct Answer: 4 Rationale 1: It is not necessary to ensure that the patient's spinal cord has been found intact. Rationale 2: It is not necessary to ensure that the patient has an intact gag reflex before assessing this reflex. Rationale 3: The head of the patient's bed is elevated 30 degrees when testing this reflex. Rationale 4: The oculovestibular reflex, or cold calorics, is performed only after determining that the tympanic membrane is intact. The head of the patient's bed is elevated 30 degrees, and then 50 mL of cool saline is injected into an ear.

The nurse is providing care to a patient with an intracranial pressure monitoring device. What is a priority when providing care to this patient? 1. Monitor intracranial pressure every 4 hours. 2. Perform neurologic assessment checks every 2 hours. 3. Use clean technique when working with the system. 4. Use strict aseptic technique when working with the system.

Correct Answer: 4 Rationale 1: Pressure would be monitored every hour. Rationale 2: Neurologic assessment checks would be monitored every hour. Rationale 3: Clean technique could cause the patient to develop an infection. Rationale 4: The most common complication in patients with intracranial monitoring devices is infection. To avoid infection, the nurse should maintain strict aseptic technique when working with the system.

A patient with a penetrating traumatic head injury has a Glasgow Coma Scale of 9. The nurse realizes that what will most likely be implemented for this patient? 1. Prophylactic hypothermia treatment 2. High-dose barbiturate therapy 3. Intubation 4. Prophylactic anticonvulsant therapy

Correct Answer: 4 Rationale 1: Prophylactic hypothermia treatment is not recommended for routine use at this time. Rationale 2: High-dose barbiturate therapy might be considered when the elevated ICP is refractory to other treatments or when the patient has uncontrolled seizures. Rationale 3: Most patients with a traumatic brain injury will be intubated. Rationale 4: Risk factors for an early seizure after a traumatic brain injury include a Glasgow Coma Scale score of less than 10; cortical contusion; depressed skull fracture; subdural, epidural, or intracerebral hematomas; penetrating head wounds; and a seizure within the first 24 hours post injury.

A patient is being admitted after sustaining a head injury from an acceleration/deceleration motor vehicle accident. The type of injury that this patient most likely sustained would be: 1. Skull fracture 2. Penetrating 3. Concussion 4. Coup-countercoup

Correct Answer: 4 Rationale 1: Skull fracture is not typically associated with motor vehicle accidents. Rationale 2: Penetrating head trauma is not typically associated with motor vehicle accidents. Rationale 3: Concussion is not typically associated with motor vehicle accidents. Rationale 4: Contusions and axonal injuries often result from acceleration/deceleration injuries from a motor vehicle collision. Contusions develop as the brain accelerates against the fixed skull, causing disruption of the underlying cerebral parenchyma and blood vessels. This is known as a coup injury. After impacting the skull, the brain may recoil and impact the skull on the opposite side, causing additional damage to the cerebral parenchyma. This is known as a countercoup injury.

A patient comes into the emergency department with a fever, stiff neck, and change in mental status. On assessment it is learned that this patient also has a positive Kernig's sign. These findings suggest the patient: 1. Needs surgery to reduce intracranial pressure 2. Needs to be intubated 3. Should receive 100% oxygen via face mask 4. Has meningeal irritation

Correct Answer: 4 Rationale 1: Surgery is not a treatment for a positive Kernig's sign. Rationale 2: Intubation is not a treatment for a positive Kernig's sign. Rationale 3: Oxygen is not a treatment for a positive Kernig's sign. Rationale 4: Signs of meningeal irritation include the Kernig's sign, which is assessed with the patient in a supine position. The hip is flexed at 90 degrees while the knee is flexed at 90 degrees. Extending the knee produces pain in the hamstrings and resistance to further extension. This sign is an indication of meningitis.

A ventilated patient with a head injury needs to be suctioned. What will the nurse do to limit problems related to suctioning? 1. Limit the duration of each suctioning pass to less than 20 seconds. 2. Medicate with opiates after suctioning. 3. Reduce the flow of oxygen prior to suctioning. 4. Preoxygenate before suctioning.

Correct Answer: 4 Rationale 1: The duration of each suctioning pass should be limited to less than 10 seconds. Rationale 2: The patient may be premedicated with opiates before suctioning. Rationale 3: The flow of oxygen should not be reduced before suctioning. Rationale 4: Suctioning the patient's endotracheal tube may result in transient reductions in oxygenation. Suctioning is a noxious procedure. For both these reasons, suctioning may impact ICP. The nurse should preoxygenate the patient prior to suctioning.

When administering mannitol (Osmitrol) to a patient with increased intracranial pressure (ICP), the nurse would: 1. Expect that any reduction in ICP will begin approximately an hour after the dose is administered. 2. Assess the patient carefully for the development of hypertension. 3. Review lab data to identify the presence of hypernatremia and hyperkalemia. 4. Monitor the osmolality of the blood every 4 to 6 hours if repeated doses are administered.

Correct Answer: 4 Rationale 1: The reduction in intracranial pressure would begin almost immediately. Rationale 2: Mannitol can cause hypotension. Rationale 3: Hyponatremia and hypokalemia can occur with this medication. Rationale 4: Mannitol increases the osmolality of the blood with optimal osmolality between 300 and 320 mOsm. If repeated doses of mannitol are given, the nurse monitors the serum osmolality every 4 to 6 hours and ensures that it remains less than 320 mOsm.

A patient is admitted with a fracture to the base of the skull. What might the nurse assess in this patient? 1. Depressed respiratory rate 2. Ecchymoses of the neck 3. Increased intracranial pressure 4. Cerebral spinal fluid leak from the nose

Correct Answer: 4 Rationale 1: There is no evidence to suggest that the patient will have a depressed respiratory rate with this fracture. Rationale 2: Ecchymoses of the neck is not associated with a basilar skull fracture. Rationale 3: There is no evidence to suggest that the patient will have increased intracranial pressure with this fracture. Rationale 4: Basilar fractures occur at the base of the skull. Patients may develop a dural tear and have cerebral spinal fluid draining from their nose and/or ears.