NEURO FINAL EXAM URDEN NEURO FINAL EXAM URDEN

NEURO FINAL EXAM URDEN NEURO FINAL EXAM URDEN NEURO FINAL EXAM URDEN 1. Which of the following arterial blood gas values would indicate a need for oxygen therapy? a. PaO2 of 80 mm Hg c. HCO3- of 24 mEq b. PaCO2 of 35 mm Hg d. SaO2 of 87% ANS: D The amount of oxygen administered depends on the pathophysiologic mechanisms affecting the patient's oxygenation status. In most cases, the amount required should provide an arterial partial pressure of oxygen (PaO2) of greater than 60 mm Hg or an arterial hemoglobin saturation (SaO2) of greater than 90% during both rest and exercise. 2. Which of the following oxygen administration devices can deliver oxygen concentrations of 90%? a. Nonrebreathing mask c. Partial rebreathing mask b. Nasal cannula d. Simple mask ANS: A With an FiO2 of 55% to 70%, a nonrebreathing mask with a tight seal over the face can deliver 90% to 100% oxygen. It is used in emergencies and short-term therapy requiring moderate to high FiO2. 3. The most accurate and reliable control of FiO2 can be achieved through the use of a(n) a. simple mask. c. air-entrainment mask. b. nonrebreathing circuit (closed). ANS: B The most reliable and accurate means of delivering a prescribed concentration of oxygen is through the use of a nonrebreathing circuit (closed). 4. Use of oxygen therapy in the patient who is hypercapnic may result in a. oxygen toxicity. c. carbon dioxide retention. b. absorption atelectasis. d. pneumothorax. ANS: C Deoxygenated hemoglobin carries more CO2 compared with oxygenated hemoglobin. Administration of oxygen increases the proportion of oxygenated hemoglobin, which causes increased release of CO2 at the lung level. Because of the risk of CO2 accumulation, all patients who are chronically hypercapnic require careful low-flow oxygen administration. 5. The correct procedure for selecting an oropharyngeal airway is to: a. measure from the tip of the nose to the ear lobe. b. measure from the mouth to the ear lobe. c. measure from the tip of the nose to the middle of the trachea. d. measure the airway from the corner of the patient's mouth to the angle of the jaw. ANS: D An oropharyngeal airway's proper size is selected by holding the airway against the side of the patient's face and ensuring that it extends from the corner of the mouth to the angle of the jaw. If the airway is improperly sized, it will occlude the airway. Nasopharyngeal airways are measured by holding the tube against the side of the patient's face and ensuring that it extends from the tip of the nose to the ear lobe. 6. The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly intubated patient is probably caused by a a. right mainstem intubation. c. right hemothorax. b. left pneumothorax. d. gastric intubation. ANS: A The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly intubated patient is probably caused by a right mainstem intubation 7. Long-term ventilator management over 21 days is best handled through use of a(n) a. oropharyngeal airway. c. tracheostomy tube. b. esophageal obturator airway. d. endotracheal intubation. ANS: C Although no ideal time to perform the procedure has been identified, it is commonly accepted that if a patient has been intubated or is anticipated to be intubated for longer than 7 to 10 days, a tracheostomy should be performed. 8. Which of the following statements is correct concerning endotracheal tube cuff management? a. The cuff should be deflated every hour to minimize pressure on the trachea. b. A small leak should be heard on inspiration if the cuff has been inflated using the minimal leak technique. c. Cuff pressures should be kept between 40 to 50 mm Hg to ensure an adequate seal. d. Cuff pressure monitoring should be done once every 24 hours. ANS: B The minimal leak technique consists of injecting air into the cuff until no leak is heard and then withdrawing the air until a small leak is heard on inspiration. Problems with this technique include difficulty maintaining positive end-expiratory pressure and aspiration around the cuff. 9. Nursing interventions to limit the complications of suctioning include a. inserting the suction catheter no more than 5 inches. b. premedicating the patient with atropine. c. hyperoxygenating the patient with 100% oxygen. d. increasing the suction to 150 mm Hg. ANS: C Hypoxemia can be minimized by giving the patient three hyperoxygenation breaths (breaths at 100% FiO2) with the ventilator before the procedure and again after each pass of the suction catheter. 10. Which of the following levels would be classified as a low-flow system of oxygen administration? a. O2 via nasal cannula at 4 L/min b. O2 via nasal catheter at a FiO2 range of 60% to 75% c. O2 via transtracheal catheter at 10 L/min d. O2 via simple mask at 12 L/min. ANS: A A low-flow oxygen delivery system provides supplemental oxygen directly into the patient's airway at a flow of 8 L/min or less. Because this flow is insufficient to meet the patient's inspiratory volume requirements, it results in a variable FiO2 as the supplemental oxygen is mixed with room air. Nasal catheter FiO2 range is 22% to 45%. Oxygen flow through a transtracheal catheter is 0.25 to 4 L/min. A simple mask is a reservoir delivery system. 11. The ventilator variable that causes inspiration is called the a. cycle. c. flow. b. trigger. d. pressure. ANS: B The phase variable that initiates the change from exhalation to inspiration is called the trigger. Breaths may be pressure triggered or flow triggered based on the sensitivity setting of the ventilator and the patient's inspiratory effort or time triggered based on the rate setting of the ventilator. 12. The assist-control mode of ventilation functions in which of the following manners? a. It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts. b. It delivers gas at a preset volume, allowing the patient to breathe spontaneously at his or her own volume. c. It applies positive pressure during both ventilator breaths and spontaneous breaths. d. It delivers gas at preset rate and tidal volume regardless of the patient's inspiratory efforts. ANS: A Whereas a breath that is initiated by the patient is known as a patient-triggered or patient-assisted breath, a breath that is initiated by the ventilator is known as a machine-triggered or machine-controlled breath. A time-triggered breath is a machine-controlled breath that is initiated by the ventilator after a preset length of time has elapsed. It is controlled by the rate setting on the ventilator (e.g., a rate of 10 breaths/min yields 1 breath every 6 seconds). Flow-triggered and pressure-triggered breaths are patient-assisted breaths that are initiated by decreased flow or pressure, respectively, within the breathing circuit. 13. Preset positive pressure used to augment the patient's inspiratory effort is known as a. positive end-expiratory pressure (PEEP). b. continuous positive airway pressure (CPAP). c. pressure control ventilation (PCV). d. pressure support ventilation (PSV). ANS: D Preset positive pressure used to augment the patient's inspiratory efforts is known as pressure support ventilation. With continuous positive airway pressure, positive pressure is applied during spontaneous breaths; the patient controls rate, inspiratory flow, and tidal volume. Positive end-expiratory pressure is positive pressure applied at the end of expiration of ventilator breaths. 14. Which of the following statements best describes the effects of positive-pressure ventilation on cardiac output? a. Positive-pressure ventilation increases intrathoracic pressure, which increases venous return and cardiac output. b. Positive-pressure ventilation decreases venous return, which increases preload and cardiac output. c. Positive-pressure ventilation increases venous return, which decreases preload and cardiac output. d. Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return and cardiac output. ANS: D Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return to the right side of the heart. Impaired venous return decreases preload, which results in a decrease in cardiac output. 15. Nursing management of the patient receiving a neuromuscular blocking agent should include a. withholding all sedation and narcotics. b. protecting the patient from the environment. c. keeping the patient supine. d. speaking to the patient only when necessary. ANS: B Patient safety is a major concern for the patient receiving a neuromuscular blocking agent because these patients are unable to protect themselves from the environment. Special precautions should be taken to protect the patient at all times. 16. A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. When you enter the room, the ventilator inoperative alarm sounds. What is the primary action the nurse would take? a. Troubleshoot the ventilator until the problem is found. b. Take the patient off the ventilator and manually ventilate her. c. Call the respiratory therapist for help. d. Silence the ventilator alarms until the problem is resolved. ANS: B Ensure emergency equipment is at bedside at all times (e.g., manual resuscitation bag connected to oxygen, masks, suction equipment or supplies), including preparations for power failures. If the ventilator malfunctions, the patient should be removed from the ventilator and ventilated manually with a manual resuscitation bag. 17. A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. When you enter the room, the ventilator inoperative alarm sounds. All of the following conditions would set off the high-pressure alarm except a. a leak in the patient's ET tube cuff b. a kink in the ET tubing c. coughing d. increased secretions in the patient's airway ANS: A Low inspiratory pressure alarms will sound because of altered settings, unattached tubing or a leak around the endotracheal tube (ETT), the ETT displaced into the pharynx or esophagus, poor cuff inflation or leak, tracheoesophageal fistula, peak flows that are too low, low tidal volume (Vt), decreased airway resistance resulting from decreased secretions or relief of bronchospasm, increased lung compliance resulting from decreased atelectasis, reduction in pulmonary edema, resolution of ARDS, or a change in position. High-pressure alarms will sound because of improper alarm setting; airway obstruction resulting from patient fighting ventilator (holding breath as ventilator delivers Vt); patient circuit collapse; kinked tubing; the ETT in the right mainstem bronchus or against the carina; cuff herniation; increased airway resistance resulting from bronchospasm, airway secretions, plugs, and coughing; water from the humidifier in the ventilator tubing; and decreased lung compliance resulting from tension pneumothorax, change in patient position, acute respiratory distress syndrome, pulmonary edema, atelectasis, pneumonia, or abdominal distention. 18. A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. When you enter the room, the ventilator inoperative alarm sounds. Which of the following criteria would indicate that the patient is ready to be weaned? a. FiO2 greater than 50% b. Rapid shallow breathing index less than 105 c. Minute ventilation greater than 10 L/min d. Vital capacity/kg greater than or equal to 15 mL ANS: B The rapid shallow breathing index (RSBI) has been shown to be predictive of weaning success. To calculate the RSBI, the patient's respiratory rate and minute ventilation are measured for 1 minute during spontaneous breathing. The measured respiratory rate is then divided by the tidal volume (expressed in liters). An RSBI less than 105 is considered predictive of weaning success. If the patient meets criteria for weaning readiness and has an RSBI less than 105, a spontaneous breathing trial can be performed. 19. A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. When you enter the room, the ventilator inoperative alarm sounds. Which of the following criteria would indicate that the patient is not tolerating weaning? a. A decrease in heart rate from 92 to 80 beats/min b. An SpO2 of 92% c. An increase in respiratory rate from 22 to 38 breaths/min d. Spontaneous tidal volumes of 300 to 350 mL ANS: C Weaning intolerance indicators include (1) a decrease in level of consciousness; (2) a systolic blood pressure increased or decreased by 20 mm Hg; (3) a diastolic blood pressure greater than 100 mm Hg; (4) a heart rate increased by 20 beats/min; (5) premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia; (6) changes in ST segment (usually elevation); (7) a respiratory rate greater than 30 breaths/min or less than 10 breaths/min; (8) a respiratory rate increased by 10 breaths/min; (9) a spontaneous tidal volume less than 250 mL; (10) a PaCO2 increased by 5 to 8 mm Hg or pH less than 7.30; (11) an SpO2 less than 90%; (12) use of accessory muscles of ventilation; (13) complaints of dyspnea, fatigue, or pain; (14) paradoxical chest wall motion or chest abdominal asynchrony; (15) diaphoresis; and (16) severe agitation or anxiety unrelieved with reassurance. 20. Patient safety precautions when working with oxygen involve a. observation for signs of oxygen-introduced hyperventilation. b. restriction of smoking. c. removal of all oxygen devices when eating to prevent aspiration. d. administration of oxygen at the nurse's discretion. ANS: B Patient safety precautions when working with oxygen involve administration of oxygen and monitoring of its effectiveness. Activities include restricting smoking, administering supplemental oxygen as ordered, observing for signs of oxygen-induced hypoventilation, monitoring the patient's ability to tolerate removal of oxygen while eating, and changing the oxygen delivery device from a mask to nasal prongs during meals as tolerated. 21. Which route for ETT placement is used in an emergency? a. Orotracheal c. Nasopharyngeal b. Nasotracheal d. Trachea ANS: A An endotracheal tube (ETT) may be placed through the orotracheal or the nasotracheal route. In most situations involving emergency placement, the orotracheal route is used because it is simpler and allows the use of a larger diameter ETT. Nasotracheal intubation provides greater patient comfort over time and is preferred in patients with a jaw fracture. 22. The Passy-Muir valve is contraindicated in patients a. who are trying to relearn normal breathing patterns. b. who experience low secretions. c. with laryngeal or pharyngeal dysfunction. d. who want to speak while on the ventilator. ANS: C The Passy-Muir valve is contraindicated in patients with laryngeal or pharyngeal dysfunction, excessive secretions, or poor lung compliance. 23. A patient was taken to surgery for a left lung resection earlier today. The patient has been in the postoperative care unit for 30 minutes. When you are completing your assessment, you notice that the chest tube has drained 125 cc of red fluid in the past 30 minutes. The nurse contacts the physician and suspects that the patient has developed a. pulmonary edema. c. acute lung failure. b. hemorrhage. d. bronchopleural fistula. ANS: B Hemorrhage is an early, life-threatening complication that can occur after a lung resection. It can result from bronchial or intercostal artery bleeding or disruption of a suture or clip around a pulmonary vessel. Excessive chest tube drainage can signal excessive bleeding. During the immediate postoperative period, chest tube drainage should be measured every 15 minutes; this frequency should be decreased as the patient stabilizes. If chest tube loss is greater than 100 mL/hr, fresh blood is noted, or a sudden increase in drainage occurs, hemorrhage should be suspected. 24. Which medication may be administered with a bronchodilator because it can cause bronchospasms? a. β2-Agonists c. Anticholinergic agents b. Mucloytics d. Xanthines ANS: B Mucolytics may be administered with a bronchodilator because it can cause bronchospasms and inhibit ciliary function. Treatment is considered effective when bronchorrhea develops and coughing occurs. β2-Agonists are used to relax bronchial smooth muscle and dilate airways to prevent bronchospasms. Anticholinergic agents are used to block the constriction of bronchial smooth muscle and reduce mucus production. Xanthines are used to dilate bronchial smooth muscle and reverse diaphragmatic muscle fatigue. 25. Indications to support a pneumonectomy are a. lesions confined to a single lobe. c. unilateral tuberculosis. b. bronchiectasis. d. lung abscesses or cyst. ANS: C A pneumonectomy is the removal of entire lung with or without resection of the mediastinal lymph nodes. Indications include malignant lesions, unilateral tuberculosis, extensive unilateral bronchiectasis, multiple lung abscesses, massive hemoptysis, and bronchopleural fistula. 26. The therapeutic blood level for theophylline (Xanthines) is a. 5 to 10 mg/dL. c. 20 to 30 mg/dL. b. 10 to 20 mg/dL. d. 35 to 45 mg/dL. ANS: B Therapeutic blood level for theophylline is 10 to 20 mg/dL. 1. Complications of ETT tubes include (Select all that apply.) a. tracheoesophageal fistula. b. cricoid abscess. c. tracheal stenosis. d. tube obstruction. e. tube displacements. ANS: A, B, C, D, E Complications of endotracheal tubes include tube obstruction, tube displacement, sinusitis and nasal injury, tracheoesophageal fistula, mucosal lesions, laryngeal or tracheal stenosis, and cricoid abscess. 2. Which of the following should be used when suctioning a mechanically ventilated patient? (Select all that apply.) a. Three hyperoxygenation breaths (breaths at 100% FiO2) b. Hyperinflation (breaths at 150% tidal volume) c. Limit the number of passes to three. d. Instill 5 to 10 mL of normal saline to facilitate secretion removal. e. Use intermittent suction to avoid damaging tracheal tissue. ANS: A, B, C Hyperoxygenation, hyperinflation, and limiting the number of passes help avoid desaturation. There is no evidence to suggest that intermittent suction reduces damage, and saline instillation can actually increase the risk for infection. 3. Which of the following statements are true regarding rotational therapy? (Select all that apply.) a. Continuous lateral rotation therapy (CLRT) can be effective for improving oxygenation if used for at least 18 hours/day. b. Kinetic therapy can decrease the incidence of ventilator-acquired pneumonia in neurologic and postoperative patients. c. Use of rotational therapy eliminates the need for other pressure ulcer prevention strategies. d. CLRT helps avoid hemodynamic instability secondary to the continuous, gentle turning of the patient. e. CLRT has minimal pulmonary benefits for critically ill patients. ANS: A, B, E Studies have found that to achieve benefits with CLRT or kinetic therapy, rotation must be aggressive, and the patient must be at least 40 degrees per side, with a total arc of at least 80 degrees for at least 18 hours a day. Kinetic therapy has been shown to decrease the incidence of ventilator-acquired pneumonia, particularly in neurologic and postoperative patients. Complications of the procedure include dislodgment or obstruction of tubes, drains, and lines; hemodynamic instability; and pressure ulcers. Lateral rotation does not replace manual repositioning to prevent pressure ulcers. CLRT has been shown to be of minimal pulmonary benefit for the critically ill patients. 4. Identify the clinical manifestations associated with oxygen toxicity. (Select all that apply.) a. Substernal chest pain that increases with deep breathing b. Moist cough and tracheal irritation c. Pleuritic pain occurring on inhalation, followed by dyspnea d. Increasing CO2 e. Sore throat and eye and ear discomfort ANS: A, C, E A number of clinical manifestations are associated with oxygen toxicity. The first symptom is substernal chest pain that is exacerbated by deep breathing. A dry cough and tracheal irritation follow. Eventually, definite pleuritic pain occurs on inhalation followed by dyspnea. Upper airway changes may include a sensation of nasal stuffiness, sore throat, and eye and ear discomforts. 1. Which of the following structures form(s) the blood-brain barrier? a. Postsynaptic terminals c. Vascular endothelial cells b. Pia mater d. Myelin sheath ANS: C The blood-brain barrier operates on the concept of tight junctions between adjacent cells and actually consists of three separate barriers: the endothelial cells of cerebral blood vessels, the epithelial cells of the choroid plexus, and the cells that form the outermost layer of the arachnoid. 2. CNS response to the periphery to produce contraction of the skeletal muscles is the result of a. efferent fibers. c. myelin sheath. b. afferent fibers. d. neurotransmitters. ANS: A Efferent fibers (motor fibers) transmit the central nervous system (CNS) response to the periphery to produce a motor response such as contraction of skeletal muscles, contraction of the smooth muscles of organs, or secretion by endocrine glands. This sensory information is transmitted to the CNS by afferent fibers (sensory fibers). Fibers enclosed in the sheath are called myelinated fibers. Neurotransmitters help with nerve transmission from one neuron to the next. 3. Neuronal function is driven by a. nodes of Ranvier. c. repolarization-depolarization cycles. b. saltatory conduction. d. depolarization-repolarization cycles. ANS: D Neuronal function is driven by depolarization-repolarization cycles, similar to that described for cardiac physiology. Myelinated fibers use a process called saltatory conduction to support rapid axonal transmission of nerve impulses. Structurally, axons participating in this form of impulse transmission are laid out with a noncontinuous myelin cover, interrupted with 2-micrometer bare segments called the nodes of Ranvier. middle meningeal artery? a. Subdural c. Subarachnoid b. Epidural d. Intercerebral ANS: B The main blood supply for the dura mater is the middle meningeal artery. This artery lies on the surface of the dura in the epidural space within grooves formed on the inside of the parietal bone. Traumatic disruption of the parietal bone may result in tearing of the middle meningeal artery and development of an epidural hematoma. 5. Which area of the ventricular system is usually cannulated for intracranial pressure monitoring? a. Frontal horn of the lateral ventricle c. Foramen of Monro b. Aqueduct of Sylvius d. Fourth ventricle ANS: A When cannulation of the ventricular system is required for intracranial pressure monitoring, cerebrospinal fluid (CSF) drainage, or placement of a CSF shunt, the frontal horn of the lateral ventricle on the nondominant side of the brain is most often selected. 6. What percentage of the body's total resting cardiac output is used by the brain? a. 5% c. 20% b. 10% d. 40% ANS: C The brain constitutes 2% of the body's weight but uses 20% of the body's total resting cardiac output. It requires approximately 750 mL of blood flow per minute and can extract as much as 45% of arterial oxygen to meet normal metabolic needs. 7. Which areas of the spinal cord have tenuous blood supply and are especially vulnerable to circulatory embarrassment? a. C2 to C3 c. T8 to T10 b. C5 to C6 d. L4 to L5 ANS: A Arterial supply to the spinal cord is segmented at best, making portions of the spinal cord that receive blood supply from two separate sources vulnerable to low flow states. The most vulnerable of these areas are C2 to C3, T1 to T4, and L1 to L2. 8. Damage to the upper portion of the reticular activating system results in which condition? a. Seizures c. Apnea b. Diabetes insipidus d. Impaired consciousness ANS: D The reticular activating system (RAS) works through activation of the hypothalamus, which results in diffuse cortical stimulation and autonomic stimulation. Damage to the thalamic or hypothalamic RAS pathways results in impaired consciousness. 9. A person with a cerebellar lesion will have difficulty with a. breathing. c. memory. b. equilibrium. d. speech. ANS: B Cerebellar impulses are communicated to descending motor pathways to integrate spatial orientation and equilibrium with posture and muscle tone, ensuring synchronized adjustments in movement that maintain overall balance and motor coordination. Cerebellar monitoring and adjustment of motor activity occurs simultaneously with movement, enabling significant control of fine motor function. 10. The large opening at the base of the cranium is known as the a. cisterna magna. c. foramen magnum. b. median foramen. d. lateral foramen. ANS: C The cranium is a solid, nonexpanding bony vault with only one large opening at the base called the foramen magnum, through which the brainstem projects and connects to the spinal cord. 11. Which statement best describes the role of neuroglial cells? a. They are fewer in number than neurons. b. They provide support to the neuron in nutrients and structural formation. c. They protect the CNS from nonmetabolic primary neoplasms. d. They produce a steady supply of neurotransmitters. ANS: B These cells provide the neuron with structural support, nourishment, and protection (Table 26-1). They also retain their ability to replicate but can replicate abnormally and hence are the primary source of central nervous system neoplasms. 12. Tissue that adheres directly to the brain tissue and is rich in small blood vessels that supply a large amount of arterial blood to the CNS is known as the a. dura mater. c. pia mater. b. arachnoid mater. d. CNS. ANS: C The outermost layer of meninges directly beneath the skull is the dura mater. The arachnoid membrane is a delicate, fragile membrane that loosely surrounds the brain. Cerebrospinal fluid (CSF) circulates freely in the subarachnoid space fragile membrane that loosely surrounds the brain. The pia mater adheres directly to brain tissue. Rich in small blood vessels that supply a large volume of arterial blood to the central nervous system, this membrane closely follows all folds and convolutions of the brain's surface. 13. Obstructive hydrocephalus can occur in the presence of a. blockage in the arachnoid villi. b. malformation of the falx cerebelli. c. blockage of CSF flow in the ventricular system. d. increased production of CSF with poor outlet. ANS: C Blockage of CSF flow occurring within the ventricular system obstructs the normal circulation of CSF, causing dilation of the ventricles, a condition called obstructive hydrocephalus. 14. Substances most likely to pass across the blood-brain barrier have which of the following characteristics? a. Low pH compared with body fluids c. Large particle size b. Lipid solubility d. A close relation to toxic metabolites ANS: B Passage of substances across the blood-brain barrier is a function of particle size, lipid solubility, and protein-binding potential. Most drugs or compounds that are lipid soluble and stable at body pH rapidly cross the blood-brain barrier. The blood-brain barrier is also very permeable to water, oxygen, carbon dioxide, and glucose. 15. Control of the rate of respirations occurs in the a. apneustic center. c. reticular activating system. b. pneumotaxic center. d. midbrain. ANS: B Two respiratory control centers are located in the pons, namely the apneustic and pneumotaxic centers. Whereas the apneustic center controls the length of inspiration and expiration, the pneumotaxic center controls respiratory rate. 16. The sensory, motor, and cognitive functions are the primary functions of the a. diencephalon. c. cerebellum. b. basal ganglia. d. cerebrum. ANS: D The outermost aspect of the cerebrum is called the cerebral cortex. The primary functions of the cerebral cortex include sensory, motor, and intellectual (cognitive) functions, making this area of the brain vital to normal human functioning and providing capabilities that make humans unique as a species. 17. The region of the brain that acts as a relay station for both motor and sensory activity is the a. cerebrum. c. thalamus. b. cerebellum. d. hypothalamus. ANS: C The thalamus consists of two connected ovoid masses of gray matter and forms the lateral walls of the third ventricle. The two thalami serve as a relay station and gatekeeper for motor and sensory stimuli, preventing or enhancing transmission of impulses based on the behavioral needs of the person. 18. When a patient with neurologic damage continues with extremely high core body temperature despite interventions to lower temperature, the area of the brain most likely affected is the a. cerebrum. c. thalamus. b. cerebellum. d. hypothalamus. ANS: D Areas of the internal environment regulated and maintained by the hypothalamus include temperature regulation, autonomic nervous system responses, food and water intake, hormonal secretions, and behavioral responses. 19. A lack or inadequate amount of which two substances can cause disruption in neuronal function and irreversible damage? a. Oxygen and glucose c. Oxygen and protein b. Protein and insulin d. Protein and glucose ANS: A No reserve of either oxygen or glucose is found in the cerebral tissues. A lack or inadequate amount of either one rapidly disrupts cerebral function and produces irreversible damage. 20. Based on the circle of Willis, if the right internal carotid artery is blocked so that inadequate blood flows to the cerebral arteries, oxygen and nutrients to the brain a. can be supported by the circle of Willis. c. are diminished by 50%. b. are diminished by 25%. d. are blocked. ANS: A When complete, the circle of Willis is capable of supporting some degree of collateral blood flow in the case of arterial occlusion, although a sufficient arterial supply in the face of arterial obstruction is not guaranteed. 21. The ability to access CSF by a lumbar puncture is attributable to the flow of CSF in the a. dura mater. c. epidural cavity. b. pia mater. d. subarachnoid space. ANS: D Cerebrospinal fluid fills the ventricular system and surrounds the brain and spinal cord in the subarachnoid space. 22. A patient is admitted to the critical care unit after a stroke. The patient has an altered level of consciousness and garbled speech. A computed tomography scan is performed to determine the cause of the stroke, and a lumbar puncture is performed for analysis of CSF. Because the patient's speech is garbled, the nurse documents the occurrence of which type of aphasia? a. Fluent c. Expressive b. Receptive d. Global ANS: C The area involved in the formulation of verbal speech is the Broca area. Damage to this area results in an expressive or nonfluent aphasia. 23. A patient has coherent speech but the words are illogical. Which part of the brain has been affected? a. The cerebellum c. The Wernicke area b. The Broca area d. The hypothalamus ANS: C The Wernicke area (Brodmann area 22) is partially located within the parietal lobe and partially in the temporal lobe, most commonly on the left side of the cerebral cortex. This area is concerned with reception of written and verbal language and includes many intricate connections to other parts of the brain associated with auditory and visual functions, cognitive appraisal, and expressive language. Injury to this area of the brain may result in disability ranging from minor receptive language dysfunction to receptive or fluent aphasia, in which expressive language function remains but is illogical in content or a "word salad." 24. Which lobe of the brain deals primarily with sensory function? a. Frontal lobe c. Occipital lobe b. Temporal lobe d. Parietal lobe ANS: D The parietal lobe is primarily concerned with sensory functions, including integration of sensory information; awareness of body parts; interpretation of touch, pressure, and pain; and recognition of object size, shape, and texture. Injury to these areas may result in tactile sensory loss on the opposite side of the body. 25. The primary functions of which lobe are hearing, speech, behavior, and memory? a. Frontal lobe c. Occipital lobe b. Temporal lobe d. Parietal lobe ANS: B The temporal lobe lies beneath the temporal bone in the lateral portion of the cranium. Separated from the frontal and parietal lobes by the lateral fissure, this lobe has the primary functions of hearing, speech, behavior, and memory. 26. Cranial nerves IX, X, XI, and XII are located in which section of the brainstem? a. Midbrain c. Medulla oblongata b. Pons d. Reticular formation ANS: C The medulla oblongata forms the last section of the brainstem, situated between the pons and the spinal cord. The cell bodies of cranial nerves IX (glossopharyngeal), X (vagus), XI (spinal accessory), and XII (hypoglossal) are located in the medulla oblongata 27. Stimulation of this nerve will elicit the gag reflex. a. Glossopharyngeal c. Spinal accessory b. Facial d. Hypoglossal ANS: A The glossopharyngeal nerve is a sensory nerve whose functions are taste in the posterior third of the tongue and sensation in the back of the throat; stimulation elicits the gag reflex. 28. An afferent pathway that carries sensory impulses from the body into the spinal cord is the a. subarachnoid. c. ventral root. b. spinal nerves. d. dorsal root. ANS: D The dorsal root is an afferent pathway that carries sensory impulses from the body into the spinal cord. The ventral root is an efferent pathway that carries motor information from the spinal cord to the body. 1. Examples of small-molecule transmitters include (Select all that apply.) a. acetylcholine. b. glucose. c. norepinephrine. d. dopamine. e. epinephrine. f. GABA receptors. ANS: A, C, D, E Examples of small-molecule transmitters include acetylcholine, dopamine, norepinephrine, epinephrine, serotonin, histamine, γ-aminobutyric acid, glycine, and glutamate. 2. Which cranial nerves are responsible for motor functions of the eye? (Select all that apply.) a. Optic nerve b. Oculomotor c. Trochlear d. Trigeminal e. Abducens f. Acoustic ANS: B, C, E The oculomotor nerve is the motor nerve whose function is raising the eyelids and extraocular movement of the eyes. The trochlear nerve is the motor nerve whose function is the extraocular movement of the eyes. The abducens nerve is the motor nerve that functions with extraocular eye movement and rotates the eyeball outward. The optic nerve is the sensory nerve whose function is vision. The trigeminal nerve is the sensory nerve that gives sensation to the cornea, ciliary body, iris, and lacrimal gland. The acoustic nerve is the sensory nerve whose function is hearing. 1. A score of 6 on the Glasgow Coma Scale (GCS) indicates a. a vegetative state. c. coma. b. paraplegia. d. obtundation. ANS: C The best possible score on the Glasgow Coma Scale (GCS) is 15, and the lowest score is 3. Generally, a score of 7 or less on the GCS indicates coma. Originally, the scoring system was developed to assist in general communication concerning the severity of neurologic injury. 2. The GCS is an invalid measure for the patient with a. hemiplegia. c. mental retardation. b. Parkinson disease. d. intoxication. ANS: D Several points should be kept in mind when the Glasgow Coma Scale is used for serial assessment. It provides data about level of consciousness only, and it should never be considered a complete neurologic examination. Additionally, it is not a sensitive tool for evaluation of an altered sensorium, and it does not account for possible aphasia or mechanical intubation. It is also a poor indicator of lateralization of neurologic deterioration 3. Which of the following choices is an acceptable and recommended method of noxious stimulation? a. Nipple pinch c. Supraorbital pressure b. Nail bed pressure d. Sternal rub ANS: B Nail bed pressure and trapezius pinch are acceptable methods of noxious stimulation. Nail bed pressure allows evaluation of individual extremity function. Trapezius pinch is difficult to perform on large or obese adults. Repeated sternal rub can cause the sternum to become excoriated, open, and infected. Supraorbital pressure must be avoided in patients with head injuries, frontal craniotomies, or facial surgery. Nipple and testicle pinching are inappropriate and unnecessary. 4. Which of the following denotes the most serious prognosis? a. Decorticate posturing c. Absence of Babinski reflex b. Decerebrate posturing d. GCS score of 14 ANS: B Outcome studies indicate that abnormal flexion or decorticate posturing has a less serious prognosis than does extension, or decerebrate posturing. Onset of posturing or a change from abnormal flexion to abnormal extension requires immediate physician notification. The Babinski reflex is a pathologic finding; absence of this reflex is a normal neurologic finding in adults. The range of scores for the Glasgow Coma Scale is 3 to 15. A score of 14 denotes a minimal deficit. 5. How much of a size difference between the two pupils is still considered normal? a. 1 mm c. 2 mm b. 1.5 mm d. 2.5 mm ANS: A Pupil size should be documented in millimeters with the use of a pupil gauge to reduce the subjectivity of description. Most people have pupils of equal size, between 2 and 5 mm. A discrepancy up to 1 mm between the two pupils is normal. 6. An oval pupil is indicative of a. cortical dysfunction. c. hydrocephalus. b. intracranial hypertension. d. metabolic coma. ANS: B Pupil shape is also noted in the assessment of pupils. Although the pupil is normally round, an irregularly shaped or oval pupil may be noted in patients with eye surgery. Initial stages of cranial nerve III compression from elevated intracranial pressure can also cause the pupil to have an oval shape. 7. Decerebrate posturing (abnormal extension) indicates dysfunction in which area of the central nervous system? a. Cerebral cortex c. Cerebellum b. Thalamus d. Brainstem ANS: D Abnormal flexion occurs with lesions above the midbrain in the region of the thalamus or cerebral hemispheres. Abnormal extension occurs with lesions in the area of the brainstem. 8. The initial history for the neurologically impaired patient needs to be a. limited to the chief complaint. b. comprehensive, including events preceding hospitalization. c. directed to level of consciousness and pupillary reaction. d. information that only the patient can provide. ANS: B The one factor common to all neurologic assessment is the need to obtain a comprehensive history of events preceding hospitalization. 9. The most important aspect of the neurologic examination is a. medical history. c. level of consciousness. b. physical examination. d. pupillary responses. ANS: C Assessment of the level of consciousness is the most important aspect of the neurologic examination. 10. Which of the following statements best describes assessment of arousal? a. It measures content of consciousness and is a higher level function. b. It is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. c. It becomes a valid parameter when the patient is able to respond to verbal stimuli, such as squeezing the hands on command. d. Noxious stimuli are not to be used as an assessment parameter. ANS: B Assessment of the arousal component of consciousness is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex. Arousal is the lowest level of consciousness, and observation centers on the patient's ability to respond to verbal or noxious stimuli in an appropriate manner. 11. A critically injured patient can be aroused only by vigorous and continuous external stimuli. The patient's level of consciousness is considered a. lethargic. c. stuporous. b. obtunded. d. comatose. ANS: C Stuporous means the patient can be aroused only by vigorous and continuous external stimuli. Motor response is often withdrawal or localizing to stimulus. Obtunded means the patient displays dull indifference to external stimuli, and response is minimally maintained. Questions are answered with a minimal response. Lethargic means the patient displays a state of drowsiness or inaction in which the patient needs an increased stimulus to be awakened. Comatose means vigorous stimulation fails to produce any voluntary neural response in the patient. 12. While starting an intravenous line on the right hand of an unconscious patient, the patient reaches over with his left hand and tries to remove the noxious stimuli. This response is called a. decorticate posturing. c. withdrawal. b. decerebrate posturing. d. localization. ANS: D Localization occurs when the extremity opposite to the extremity receiving pain crosses the midline of the body in an attempt to remove the noxious stimulus from the affected limb. 13. Testing of extraocular eye movements assesses a. pupillary response to light. b. function of the three cranial nerves of the eye. c. the ability of the eyes to accommodate to a closer moving object. d. the oculocephalic reflex. ANS: B Control of eye movements occurs with interaction of three cranial nerves: oculomotor (III), trochlear (IV), and abducens (VI). 14. Before performing the doll's eye or oculocephalic reflex, the nurse must verify a. the absence of cervical injury. b. the depth and rate of respiration. c. a physician's order to perform the maneuver. d. the patient's ability to follow a verbal command. ANS: A In an unconscious patient, assessment of ocular function and innervation of the medial longitudinal fasciculus (MLF) is performed by eliciting the doll's eyes reflex. If the patient is unconscious as a result of trauma, the nurse must ascertain the absence of cervical injury before performing this examination. 15. With an intact oculocephalic reflex, the a. patient's eyes move in the same direction the head is turned. b. patient's eyes move in the opposite direction to the movement of the patient's head. c. patient's eyes remain midline. d. doll's eye reflex is absent. ANS: B To assess the oculocephalic reflex, the nurse holds the patient's eyelids open and briskly turns the head to one side while observing the eye movements and then briskly turns the head to the other side and observes. If the eyes deviate to the opposite direction in which the head is turned, doll's eyes are present, and the oculocephalic reflex arc is intact. If the oculocephalic reflex arc is not intact, the reflex is absent. 16. The oculovestibular reflex, or cold caloric test, a. should not be performed on an unconscious patient because of the risk of aspiration. b. has an abnormal response of rapid nystagmus-like deviation to the side of the body that is tested. c. is a routine test of the nursing neurologic examination. d. is one of the final clinical assessments of brainstem function. ANS: D The oculovestibular reflex is one of the final clinical assessments of brainstem function. After confirmation that the tympanic membrane is intact, the head is raised to a 30-degree angle. Then 20 to 100 mL of ice water is injected into the external auditory canal. In a normal response, eye movement is in the direction of the injection site. An abnormal response is dysconjugate eye movement, which indicates a brainstem lesion, or no response, which indicates little to no brainstem function. 17. The respiratory pattern with rhythmic increase and decrease of rate and depth of respiration, then brief periods of apnea, is known as a. central neurogenic hyperventilation. c. ataxic respirations. b. apneustic breathing. d. Cheyne-Stokes respirations. ANS: D Cheyne-Stokes respirations have a rhythmic crescendo and decrescendo of rate and depth of respiration, including brief periods of apnea. These respirations are usually seen with bilateral deep cerebral lesions or some cerebellar lesions. Central neurogenic hyperventilations are very deep, very rapid respirations with no apneic periods. They are usually seen with lesions of the midbrain and upper pons. Apneustic breathing includes clusters of irregular, gasping respirations separated by long periods of apnea. They are usually seen in lesions of the lower pons or upper medulla. Ataxic respirations are irregular, random patterns of deep and shallow respirations with irregular apneic periods. They are usually seen in lesions of the medulla. 18. Symptoms of late stages of intracranial hypertension include a. decreased perfusion of cerebral tissue. b. widening pulse pressure values. c. increased perfusion pressure across the blood-brain barrier. d. decreased intracranial pressure. ANS: B Attention must also be paid to the pulse pressure because widening of this value may occur in the late stages of intracranial hypertension. With the loss of autoregulation as blood pressure increases, cerebral blood flow (CBF) and cerebral blood volume increase and intracranial pressure (ICP) therefore increases. The mean arterial pressure must be maintained at a level sufficient to produce adequate CBF in the presence of elevated ICP. 19. The clinical manifestations of the Cushing reflex are 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. ANS: A The Cushing reflex is a set of three clinical manifestations (bradycardia, systolic hypertension, and widening pulse pressure) related to pressure on the medullary area of the brainstem. 20. A patient is admitted to the critical care unit with a subdural hematoma. The GCS is used to assess his level of consciousness. Which statement is true concerning the GCS? a. It provides data about level of consciousness only. b. It is considered equivalent to a complete neurologic examination. c. It is a sensitive tool for evaluation of an altered sensorium. d. It is the most critical assessment parameter to account for possible aphasia. ANS: A Several points should be kept in mind when the Glasgow Coma Scale is used for serial assessment. It provides data about level of consciousness only, and it should never be considered a complete neurologic examination. Additionally, it is not a sensitive tool for evaluation of an altered sensorium, and it does not account for possible aphasia or mechanical intubation. It is also a poor indicator of lateralization of neurologic deterioration. 21. A patient is admitted to the critical care unit with a subdural hematoma. The GCS is used to assess his level of consciousness. In assessing the patient's best motor response, the movement that receives the lowest score is a. decerebrate posturing. c. withdrawing from pain. b. localizing pain. d. decorticate posturing. ANS: A Extension, or decerebrate posturing, to noxious stimuli receives a score of 2 on the Glasgow Coma Scale. The only lower score is 1, which is a flaccid response. 22. Presence of the grasp reflex in an adult indicates what type of damage? a. Brainstem c. CN III b. Spinal cord d. Cortical ANS: D The grasp reflex is present when tactile stimulation of the palm of the hand produces a grasp response that is not a conscious voluntary act. The grasp reflex is a primitive reflex that normally disappears with maturational development; thus, the presence of the grasp reflex in the adult indicates cortical damage. 23. Considering anatomic location, which cranial nerve will be affected first by downward pressure onto the infratentorial structures? a. III c. IX b. VI d. X ANS: A With the location of the oculomotor nerve (cranial nerve [CN] III) at the notch of the tentorium, pupil size and reactivity play a key role in the physical assessment of intracranial pressure changes and herniation syndromes. In addition to CN III compression, changes in pupil size occur for other reasons. Large pupils can result from the instillation of cycloplegic agents, such as atropine or scopolamine, or can indicate extreme stress. Extremely small pupils can indicate narcotic overdose, lower brainstem compression, or bilateral damage to the pons. 24. Which of the following is an abnormal finding in the analysis of the cerebrospinal fluid? a. Clear and colorless c. Protein of 20 mg/dL b. Glucose of 60 mg/dL d. 30 red blood cells ANS: D Cerebrospinal fluid is normally a clear, colorless, odorless solution that contains 50 to 75 mg/dL of glucose, 5 to 25 mg/dL of protein, and no red blood cells. 25. Which of the following procedures is the diagnostic study of choice for acute head injury? a. Magnetic resonance imaging c. Transcranial Doppler b. Computed tomography d. Electroencephalography ANS: B Computed tomography offers rapid, convenient, noninvasive visualization of structures and is the diagnostic study of choice for an acute head injury. 26. MRI is superior to CT for which of the following? a. Brain death determination b. Detection of central nervous system infection c. Estimation of intracranial pressure d. Identification of subarachnoid hemorrhage ANS: B Magnetic resonance imaging (MRI) produces images with greater detail than computed tomography (CT) and provides views of several planes (sagittal, coronal, axial, and oblique) that are not possible with CT. MRI with contrast is the preferred study for detection of infectious and inflammatory processes of the central nervous system (CNS). MRI can detect areas of cerebral infarct within a few hours of the incident and can identify small areas of plaque in patients with multiple sclerosis. MRI with contrast is the preferred study for detection of infectious and inflammatory processes of the CNS, malignancy, and metastatic lesions; cervical spine imaging; and postoperative evaluation of tumor recurrence. MRI also is the diagnostic study of choice in the evaluation of spinal cord injury. 27. Successful completion of digital subtraction angiography requires what participation on the part of the patient? a. Responding appropriately to various commands b. Repositioning at appropriate intervals c. Remaining motionless d. Holding inspiration during imaging ANS: C The major disadvantage of digital subtraction angiography involves the patient's ability to remain motionless during the entire procedure. Even swallowing significantly interferes with the imaging process. 28. Cerebral infarction is a serious complication of which procedure? a. Extracranial Doppler c. Myelography b. Evoked potential testing d. Conventional angiography ANS: D Complications associated with cerebral angiography include cerebral embolus caused by the catheter dislodging a segment of atherosclerotic plaque in the vessel, hemorrhage or hematoma formation at the insertion site, vasospasm caused by the irritation of catheter placement, thrombosis of the extremity distal to the injection site, and allergic or adverse reaction to the contrast medium. 29. Results from which two procedures complement each other in the preoperative evaluation of the carotid arteries? a. Ultrasound and magnetic resonance angiography b. Conventional angiography and evoked potential c. CT and magnetic resonance angiography d. Transcranial Doppler and extracranial Doppler ANS: A Magnetic resonance angiography of the carotid arteries has become an established complement to preoperative ultrasound evaluation. It helps determine the area of salvageable tissue (or penumbra) after acute stroke and head injury. 30. Which diagnostic study provides the best evaluation of the functional integrity of cerebral motor pathways? a. Electroencephalography c. Motor-evoked potentials b. Xenon CT d. Emission tomography ANS: C Motor-evoked potentials assess the functional integrity of descending motor pathways. The motor cortex is stimulated via direct high-voltage electrical stimulation through the scalp or use of a magnetic field to induce an electrical current within the brain. 31. Which nuclear medicine studies are used to detect cerebrovascular disease, seizures, and tumors? a. PET c. MRA b. MRI d. SPECT ANS: D The single-photon emission computed tomography (SPECT) test differs from positron emission tomography (PET) in that tracer stays in the bloodstream rather than being absorbed by surrounding tissue, thereby limiting the images to areas where blood flows. SPECT is cheaper and more readily available than higher resolution PET. The major clinical uses of SPECT are to detect cerebrovascular disease, seizures, and tumors. Magnetic resonance imaging and magnetic resonance angiography are radiographic imaging examinations. is a. bacterial meningitis. c. brainstem herniation. b. dural tear. d. spinal cord trauma. ANS: C Two life-threatening risks associated with lumbar puncture include possible brainstem herniation, if intracranial pressure is elevated, and respiratory arrest associated with neurologic deterioration. nurse ask the conscious patient before the procedure? a. Are you allergic to penicillin? c. Are you allergic to latex? b. Are you allergic to iodine-based dye? d. Are you allergic to eggs? ANS: B If the patient is scheduled to receive contrast for computed tomography (CT) scanning, questions about possible sensitivity to iodine-based dye must be asked beforehand, if possible. During infusion of the dye and for 10 to 30 minutes afterward, the patient is observed closely for an anaphylactic reaction. Fewer than 1% of all patients undergoing contrast-enhanced CT have severe anaphylactic reactions, shock, or cardiac arrest. 34. Which of the following patients may need sedation before having an MRI scan? a. Claustrophobic patient c. Elderly patient b. Comatose patient d. Patient with a spinal cord injury ANS: A The magnetic resonance imaging procedure is lengthy and requires the patient to lie motionless in a tight, enclosed space. Mild sedation, a blindfold, or both may be necessary for claustrophobic patients. 35. An important intervention before and after a cerebral angiogram is 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. ANS: A After the cerebral angiogram, adequate hydration is necessary to assist the kidneys in clearing the heavy dye load. Inadequate hydration may lead to renal dysfunction and renal shutdown. 36. The difference between cerebral angiography and digital subtraction angiography is that digital subtraction angiography a. has more complications. b. uses arterial injection of dye. c. uses significantly less dye. d. allows the patient more mobility during the procedure. ANS: C Digital subtraction angiography uses significantly less dye than arterial angiography. Dye is injected in the venous or arterial system. The patient must remain motionless during the procedure. Complications are the same as those for cerebral angiography. 37. Postprocedural care of a patient undergoing a water-based contrast myelogram should include which of the following interventions? a. Maintain the patient flat in bed for 4 to 6 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. ANS: C Postprocedure care includes keeping the patient's head elevated 30 to 45 degrees for 8 hours, monitoring neurologic status, and encouraging oral fluids. 38. Carotid Doppler studies are used to monitor a. blood flow in the anterior, middle, or posterior cerebral arteries. b. blood flow in the common and internal carotid arteries. c. arteriovenous circulation in the intracranial space. d. global cerebral blood flow. ANS: B Ultrasound technology, although not an absolute measure of cerebral blood flow, uses a noninvasive technique to provide information about the flow velocity of blood through carotid vessels. Carotid duplex studies are used as a routine screening procedure for intraluminal narrowing of the common and internal carotid arteries as a result of atherosclerotic plaques. 39. The difference between electroencephalography and evoked potentials is that evoked potentials a. record electrical and muscle activity. b. monitor cerebral blood flow velocity. c. record impulses generated by sensory stimuli. d. cannot be used in the assessment of spinal cord injury. ANS: C Evoked potentials involve the recording of electrical impulses generated by a sensory stimulus as it travels through the brainstem and into the cerebral cortex. 40. Which type of ICP monitoring device has the most accurate ICP measurement and provides access to CSF for sampling? a. Subarachnoid bolt or screw c. Intraventricular catheter b. Subdural or epidural catheter d. Fiberoptic transducer tipped catheter ANS: C An intraventricular catheter allows accurate intracranial pressure (ICP) measurement and provides access to cerebrospinal fluid (CSF) for drainage or sampling. A subarachnoid bolt or screw is less accurate to measure high ICP elevations and provides no access for CSF sampling. A subdural or epidural catheter may have baseline drift over time causing possible loss of reliability or accuracy and provides no access for CSF drainage or sampling. A fiberoptic transducer tipped catheter cannot be recalibrated after placement and provides no access for CSF sampling or drainage. 41. Studies have shown that the intraparenchymal catheter has a better result than the intraventricular catheter. Identify the answer that supports this statement. a. The intraparenchymal catheter allows for CSF drainage. b. The intraparenchymal catheter has increased monitoring time. c. The intraparenchymal catheter has a longer insertion time for monitoring ICP. d. The intraparenchymal catheter has decreased device-related complications. ANS: D The intraventricular space is considered the gold standard for monitoring of intracranial pressure because it is the most accurate of all methods. However, a recent study found that an intraparenchymal catheter was better than an intraventricular catheter unless cerebrospinal fluid drainage was required. The intraparenchymal catheter was associated with decreased monitoring time, decreased length of stay, and decreased device-related complications. 42. The most clinically significant ICP waveform is a. A waves. c. C waves. b. B waves. d. D waves. ANS: A A waves are the most clinically significant of the three types. They usually occur in an already elevated baseline intracranial pressure (ICP) (>20 mm Hg) and are characterized by sharp increases in ICP of 30 to 69 mm Hg, which plateau for 2 to 20 minutes and then return to baseline. B waves appear to reflect fluctuations in cerebral blood. C waves are small, rhythmic waves that occur every 4 to 8 minutes at normal levels of ICP. They are related to normal fluctuations in respiration and systemic arterial pressure. 43. A patient is being prepared for a neurologic work-up. Examinations include a CT scan, cerebral angiography, and lumbar puncture. The best position to place the patient in for a lumbar puncture is a. supine. b. reverse Trendelenburg. c. high Fowler. d. lateral recumbent position with her knees and head slightly tucked. ANS: D Patients undergoing a lumbar puncture are placed either in the lateral recumbent position, with the knees and head tightly tucked, or in the sitting position, leaning over a bedside table or some other support. 44. 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. c. between 15 and 20 mm Hg. b. less than 15 mm Hg. d. between 10 and 20 mm Hg. ANS: A In a patient with head injury, the goal of treatment is to maintain the PbtO2 greater than 20 mm Hg. Factors that decrease PbtO2 include tissue hypoxia, hypocapnia, hypovolemia, decreased blood pressure, low hemoglobin levels, intracranial hypertension, and hyperthermia. Treatment is directed at the underlying cause. 45. The patient's ICP reading has gradually climbed from 15 to 23 mm Hg. The nurse's primary action is to: a. drain off 7 mm of CSF from the catheter. b. notify the physician. c. place the patient in a high Fowler position to decrease the pressure. d. check level of consciousness. ANS: B Under normal physiologic conditions, mean intracranial pressure (ICP) is maintained below 15 mm Hg. An increase in ICP can decrease blood flow to the brain, causing brain damage. Persistent ICP elevation above 20 mm Hg remains the most significant factor associated with a fatal outcome. 46. According to the 2007 Brain Trauma Foundation guidelines, the recommended CPP range is a. 10 to 30 mm Hg. c. 50 to 70 mm Hg. b. 30 to 50 mm Hg. d. 70 to 85 mm Hg. ANS: C The 2007 Brain Trauma Foundation guidelines now recommend a cerebral perfusion pressure (CPP) in the range of 50 to 70 mm Hg and consideration of cerebral autoregulation status when selecting a CPP target in a specific patient. 1. Indications for the use of EEG include (Select all that apply.) a. cerebral infarct. b. metabolic encephalopathy. c. confirmation of brain death. d. altered consciousness. e. all head injuries. ANS: A, B, C, D Indications for the use of electroencephalography include suspected seizure activity, cerebral infarct, metabolic encephalopathies, altered consciousness, infectious disease, some head injuries, and confirmation of brain death. 2. When assessing motor function, which of the following are correct? (Select all that apply.) a. The presence of a Babinski reflex is an abnormal finding in an adult. b. Lower extremity muscle tone is assessed by asking the patient to push or pull his or her foot against resistance. c. When using noxious stimuli to elicit a motor response, each limb is tested separately. d. Abnormal extension, or decerebrate posturing, indicates a less positive outcome than abnormal flexion. e. Evaluation of deep tendon reflexes is an essential part of the nursing assessment. ANS: A, C, D The presence of a Babinski response in an adult is indicative of neurologic dysfunction, pushing or pulling against resistance tests muscle strength, and deep tendon reflexes are not routinely checked by the critical care nurse during assessment. 3. Identify the drawbacks to using continuous electroencephalography (cEEG) in a critical care unit. (Select all that apply.) a. Size of machine b. Expensive c. Labor-intensive program d. Requires expertise for interpretation e. Artifacts from ICU environment ANS: B, C, D, E The drawbacks to the use of cEEG are that it is an expensive, labor-intensive program that requires expertise for interpretation, and is subject to artifacts from the intensive care unit environment. More research on cEEG is needed to determine its cost-saving potential and impact on outcome. 4. Identify the sites for monitoring ICP. (Select all that apply.) a. Intraventricular space b. Epidural space c. Jugular veins d. Subdural space e. Parenchyma ANS: A, B, D, E The five sites for monitoring intracranial pressure are (1) the intraventricular space, (2) the subarachnoid space, (3) the epidural space, (4) the subdural space, and (5) the parenchyma