NR 340 Week 7 Exam 3 Question And Answers, Chamberlain College of Nursing.
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NR 304
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NR 304
NR 340 Week 7 Exam 3 Question And Answers, Chamberlain College of Nursing.
NR340 Week 7 Exam Three: Critical Care Nursing: Chamberlain College of Nursing
NR 340 Week 7 Exam Three / NR340 Week 7 Exam Three: Critical Care Nursing: Chamberlain College of Nursing 1. Question: A client admitted t...
(below each question Answers an explanation are written)
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)
Answers:
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)
, 10) The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect
the client is developing meningitis as a complication of surgery if the client exhibits:
1. A positive Brudzinski’s sign
2. A negative Kernig’s sign
3. Absence of nuchal rigidity
4. A Glascow Coma Scale score of 15
1. Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski’s
sign, and positive Kernig’s sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is
especially noticeable when the neck is fixed. Kernig’s sign is positive when the client feels pain and spasm of
the hamstring muscles when the knee and thigh are extended from a flexed-right angle position.
Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing
the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is
awake and alert with no neurological deficits.
11) During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following
would be most appropriate to institute?
1. Limiting conversation with the child
2. Keeping extraneous noise to a minimum
3. Allowing the child to play in the bathtub
4. Performing treatments quickly
2. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore,
extraneous noise should be minimized and bright lights avoided as much as possible. There is no need to
limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. The
child needs gentle and calm bathing. Because of the acuteness of the infection, sponge baths would be more
appropriate than tub baths. Although treatments need to be completed as quickly as possible to prevent
overstressing the child, any treatments should be performed carefully and at a pace that avoids sudden
movements to prevent startling the child and subsequently increasing intracranial pressure.
12) Which of the following would lead the nurse to suspect that a child with meningitis has developed
disseminated intravascular coagulation?
1. Hemorrhagic skin rash
2. Edema
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