NR 340 Week 7 Exam Three 2020 With All The Correct Answers
NR 340 Week 7 Exam Three 2020 with all the correct answers
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NR 340 Week 7 Exam Three 2020 with all the correct answers
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NR 340 Week 7 Exam Three 2020 with all the correct answers
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NR 340 Week 7 Exam Three 2020 With All The Correct Answers
NR 340 Week 7 Exam Three 2020 with all the correct answers(Real Exam Graded A)
1) A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this cl...
nr 340 week 7 exam three 2020 with all the correct answersreal exam graded a 1 a client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache
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NR 340 Week 7 Exam Three 2020 with all the
correct answers(Real Exam Graded A)
1) A client admitted to the hospital with a subarachnoid hemorrhage has complaints of
severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar
puncture (LP) would be contraindicated in this client in which of the following
circumstances?
1. Vomiting continues
2. Intracranial pressure (ICP) is increased
3. The client needs mechanical ventilation
4. Blood is anticipated in the cerebralspinal fluid (CSF)
2. Sudden removal of CSF results in pressures lower in the lumbar area than the brain
and favors herniation of the brain; therefore, LP is contraindicated with increased ICP.
Vomiting may be caused by reasons other than increased ICP; therefore, LP isn’t strictly
contraindicated. An LP may be preformed on clients needing mechanical ventilation.
Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before
signs and symptoms of ICP.
2) A client with a subdural hematoma becomes restless and confused, with dilation of
the ipsilateral pupil. The physician orders mannitol for which of the following reasons?
1. To reduce intraocular pressure
2. To prevent acute tubular necrosis
3. To promote osmotic diuresis to decrease ICP
4. To draw water into the vascular system to increase blood pressure
3. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid
from intracellular to intravascular spaces. Although mannitol is used for all the reasons
described, the reduction of ICP in this client is a concern.
3) A client with subdural hematoma was given mannitol to decrease intracranial
pressure (ICP). Which of the following results would best show the mannitol was effective?
1. Urine output increases
2. Pupils are 8 mm and nonreactive
3. Systolic blood pressure remains at 150 mm Hg
4. ICP level of 12
4. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the
,renal tubes, so urine output would increase; however, the reason mannitol was given
was to decrease ICP. An ICP level of 12 is within normal limits. Fixed and dilated
pupils are symptoms of increased ICP or cranial nerve damage. No information is
given that mannitol is being given for renal dysfunction or blood pressure
maintenance.
,4) Which of the following values is considered normal for ICP?
1. 0 to 15 mm Hg
2. 25 mm Hg
3. 35 to 45 mm Hg
4. 120/80 mm Hg
1. Normal ICP is 0-15 mm Hg.
5) Which of the following signs and symptoms of increased ICP after head trauma
would appear first?
1. Bradycardia
2. Large amounts of very dilute urine
3. Restlessness and confusion
4. Widened pulse pressure
3. The earliest symptom of elevated ICP is a change in mental status. Bradycardia,
widened pulse pressure, and bradypnea occur later. The client may void large amounts of
very dilute urine if there’s damage to the posterior pituitary.
6) The nurse is assessing the motor function of an unconscious client. The nurse
would plan to use which of the following to test the client’s peripheral response to pain?
1. Sternal rub
2. Pressure on the orbital rim
3. Squeezing the sternocleidomastoid muscle
4. Nail bed pressure
4. Motor testing on the unconscious client can be done only by testing response to painful
stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain
are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing
the clavicle or sternocleidomastoid muscle.
7) The client is having a lumbar puncture performed. The nurse would plan to place
the client in which position for the procedure?
1. Side-lying, with legs pulled up and head bent down onto the chest
2. Side-lying, with a pillow under the hip
, 3. Prone, in a slight Trendelenburg’s position
4. Prone, with a pillow under the abdomen.
1. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled
up to the abdomen, and with the head bent down onto the chest. This position helps to open
the spaces between the vertebrae.
8) A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious
client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate
movements toward the left followed by a rapid nystagmus toward the right. The nurse
understands that this indicates the client has:
1. A cerebral lesion
2. A temporal lesion
3. An intact brainstem
4. Brain death
3. Caloric testing provides information about differentiating between cerebellar and
brainstem lesions. After determining patency of the ear canal, cold or warm water is injected
in the auditory canal. A normal response that indicates intact function of cranial nerves III,
IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid
nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem
damage.
9) The nurse is caring for the client with increased intracranial pressure. The nurse
would note which of the following trends in vital signs if the ICP is rising?
2. A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and systolic blood pressure, and decreasing pulse and
respirations. Respiratory irregularities also may arise. (Cushing’s Triad)
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