Med Surg II Quiz 3 (ch. 16-17)

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 which 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

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

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

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

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

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

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

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 and maximize CPP d. Elevate the patient's head and knees while flexing the hips.

c. Individualize the patient's head position to minimize ICP and maximize CPP

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 verify before performing the test? a. Absence of cervical injury b. Depth and rate of respiration c. Patient's ability to swallow d. Patient's ability to follow a verbal command

a. Absence of cervical injury

What sites can be used for monitoring 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

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.

A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner performed a lumbar puncture. Which result is an abnormal finding? (Select all that apply.) a. Fluid is clear and colorless b. Glucose of 20 mg/dL c. Protein of 20 mg/dL d. Bloody fluid in first sample only e. Pressure of 250 mm H2O

b. Glucose of 20 mg/dL e. Pressure of 250 mm H2O

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.

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

b. Phenytoin

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. ntracerebral hemorrhage

c. Drug overdose

The nurse is caring for a patient with an intracranial pressure monitoring device that provides access to CSF for sampling. Which type of device does the patient have? a. Subarachnoid bolt b. Epidural catheter c. Intraventricular catheter d. Fiberoptic catheter

c. Intraventricular catheter

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

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

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

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 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 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

The nurse is caring for a patient having 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 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.

a. Maintain the patient flat in bed for 4 to 8 hours.

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

The patient is ordered a 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?"

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 indicates the most serious prognosis? a. Abnormal flexion b. Abnormal extension c. Localization d. Withdrawal

b. Abnormal extension

The nurse is 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.

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

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. Patient's eyes move in the same direction as the patient's head when turned. b. Patient's eyes move in the opposite direction as the patient's head when turned. c. Patient's eyes move in opposite directions from each other when the patient's head is turned. d. Patient's eyes move up and down and then back and forth when the patient's head is turned.

b. Patient's eyes move in the opposite direction as the patient's head when turned.

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

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

A patient is admitted immediately after a craniotomy. The patient has no history of eye surgery. When assessing the size and shape of the patient's pupils, the nurse observes the patient's left pupil is oval. What does this finding indicate? a. Cortical dysfunction b. Intracranial hypertension c. Oculomotor nerve damage d. Opioid overdose

c. Oculomotor nerve damage

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 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 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

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."

d. "In most situations, the LOC deteriorates before any other neurologic changes are observed."

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 performed by the practitioner and one of the final clinical assessments of brainstem function."

d. "This test is performed by the practitioner and one of the final clinical assessments of 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

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

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

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

A patient has been admitted after the placement of a ventriculoperitoneal (VP) 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

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

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

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.

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

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 nurse is caring for a patient who 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