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NUR LEVEL 4 Test 3 ICP/ARDS/Brain tumors Questions With Complete Solutions
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NUR LEVEL 4 Test 3 ICP/ARDS/Brain tumors Questions With Complete Solutions
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NUR LEVEL 4 Test 3 ICP/ARDS/Brain tumors QuestionsWith Complete Solutions
A client is admitted to the emergency department after falling
off a ladder and developing syndrome of inappropriate
(SIADH). Which assessment finding should the nurse
anticipate? Correct Answers confusion
*due to hyponatremia
A collection of air or gas in the pleural cavity, resulting in a
collapsed lung, describes a condition called Correct Answers
Pneumothorax
A double fracture of three or more adjacent ribs resulting in
instability in the chest wall describes a patient with Correct
Answers Flail chest
A nurse from the acute care unit is reassigned for the shift to the
neurologic intermediate care unit. An appropriate assignment
would include which patient?
1. A patient just returning from a craniotomy for evacuation of
subdural hematoma.
2. A patient with traumatic brain injury who is being transferred
to a rehabilitative facility.
3. An alert patient with viral encephalitis who has a scheduled
dose of intravenous (IV) acyclovir.
4. An unconscious patient with bacterial meningitis who is
needing another lumbar puncture for repeat cultures. Correct
Answers 3.
,A nurse is assessing a patient with a T2-level spinal cord injury.
The nurse notices that there is a kink in the catheter, the bladder
is distended, and the blood pressure is 220/100 mm Hg. What
nursing interventions would be appropriate for this patient if the
nurse suspects autonomic dysreflexia? Select all that apply.
a. Lower the head of the bed.
b. Monitor blood pressure regularly.
c. Make the patient lie flat on the bed.
d. Notify the primary health care provider.
e. Check for the presence of bowel impaction.
f. Remove the kink in the catheter and drain the bladder.
Correct Answers b, d, e, f
A sudden rise in blood pressure for a spinal cord injury patient
above the level of T6 is generally indicative of autonomic
dysreflexia. Nursing interventions in a serious emergency like
autonomic dysreflexia include notifying the primary health care
provider and determining the cause. The blood pressure should
be regularly monitored; administration of an alpha-adrenergic
blocker or an arteriolar vasodilator is required. Contractions of
the rectum are also a cause; therefore, the nurse should check for
bowel impaction and treat it accordingly. The most common
cause is bladder distension. If a catheter is present, the presence
of any kinks or folds should be checked. However, the most
important nursing intervention in this case is elevating the head
of the bed 45 degrees or higher to make the patient sit upright;
this would lower the blood pressure.
A nurse is caring for a patient who is orally intubated and
receiving mechanical ventilation. To decrease the risk for
ventilator-associated pneumonia, which action will the nurse
,include in the plan of care? Correct Answers Elevate head of
bed to 30 to 45 degrees.
A nurse is caring for a patient with a closed head injury and
increased intracranial pressure. Which of the following
manifestations does the nurse report to the health care provider
that represents Cushing's triad? Select all that apply.
Bradycardia
Weak pulse
Irregular respirations
Increasing systolic blood pressure
Decreasing systolic blood pressure Correct Answers
Bradycardia
Irregular respirations
Increasing systolic blood pressure
A nurse is caring for a patient with a traumatic brain injury and
increased intracranial pressure (ICP). Which symptom would the
nurse report to the physician immediately?
1. ICP of 20 mm Hg
2. Urine output of 1000 mL in 1 hr
3. Respiratory rate of 24
4. Pulse of 100 beats/minute Correct Answers 1. ICP of 20 mm
Hg
2. Urine output of 1000 mL in 1 hr
A nurse is caring for a patient with acute respiratory distress
syndrome (ARDS) who is receiving mechanical ventilation
using synchronized intermittent mandatory ventilation (SIMV).
The settings include fraction of inspired oxygen (FIO2) of 80%,
tidal volume of 450, rate of 16/minute, and positive end-
, expiratory pressure (PEEP) of 5 cm. Which assessment finding
is most important for the nurse to report to the health care
provider Correct Answers O2 saturation of 99%
**FIO2 of 80%=toxicity= decrease FIO2
A nurse is caring for a patient with ARDS who is being treated
with mechanical ventilation and high levels of positive end-
expiratory pressure (PEEP). Which assessment finding by the
nurse indicates that the PEEP may need to be reduced? Correct
Answers The patient has subcutaneous emphysema on the
upper thorax
A nurse is caring for a patient with right lower lobe pneumonia
who is obese. Which position will provide the best gas
exchange? Correct Answers On the left side
A nurse is monitoring a client diagnosed with SIADH after the
administration of furosemide and Tolvaptan. For which findings
should the nurse immediately notify the provider? Correct
Answers decreased level of consciousness
A patient admitted with acute respiratory failure has ineffective
airway clearance from thick secretions. Which nursing
intervention would specifically address this patient problem
Correct Answers Offer the patient fluids at frequent intervals
A patient develops increasing dyspnea and hypoxemia 2 days
after heart surgery. What procedure should the nurse anticipate
assisting with to determine whether the patient has acute
respiratory distress syndrome (ARDS) or pulmonary edema
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