NR340 Week 3 Evolve Practice
Questions & Complete Study
Guide
(Complete solutions and resources for the course exam)
Questions
1. 1.ID: 43154241
What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on
j j j j j j j j j j j j j j j
increased intracranial pressure (ICP)?
j j j
o Lowering ICPby allowing for elevations in CO2 to dilate cerebral arteries
j j j j j j j j j j j
o Lowering ICPby facilitating venous drainage and decreasing venous
j j j j j j j j j
obstruction Correct j
o Lowering ICPby maintaining an open airway
j j j j j j
o Lowering ICPby reducing the risk of snoring
j j j j j j j
Head-of-the-bed elevation and a neutral head position that avoids hyperextension or
j j j j j j j j j j j
hyperflexion facilitate jugular venous drainage, helping to minimize increases in ICP.
j j j j j j j j j j j
Elevated CO2 contributes to cerebral vessel vasodilation, which can increase cerebral blood
j j j j j j j j j j j j
volume and further elevate ICP. Maintaining an open airway alone does not minimize
j j j j j j j j j j j j j
increases in ICP. Reducing the risk of snoring by maintaining an open airway alone does not
j j j j j j j j j j j j j j j j
minimize increases in ICP. j j j
Awarded 0.0 points out of 1.0 possible points.
j j j j j j j
2. 2.ID: 43154255
j
Under normal circumstances the cerebral vasculature exhibits pressure and chemical
j j j j j j j j j j
,autoregulation. What happens when autoregulation is lost?
j j j j j j
, o Central venous engorgement occurs. j j j
o Cerebral blood flow is not affected. j j j j j
o Hypertension increases cerebralblood flow. Correct j j j j j
o Shunting of cerebrospinal fluid (CSF) is blocked. j j j j j j
Autoregulation is the ability of the cerebral vessels to adjust their diameter in response to
j j j j j j j j j j j j j j j
arterial pressure changes within the brain. If mean arterial blood pressure rises, cerebral
j j j j j j j j j j j j j
vessels will constrict to prevent excessive distention of the cerebral arteries. When
j j j j j j j j j j j j
autoregulation is lost, cerebral vessels are no longer able to regulate diameter and as a result
j j j j j j j j j j j j j j j j
hypertension increases cerebral perfusion pressure. Cerebral vessels may become engorged
j j j j j j j j j j
as a result of the loss of autoregulation. Cerebral blood flow is affected with the loss of
j j j j j j j j j j j j j j j j j
autoregulation. Loss of autoregulation does not block CSF flow. j j j j j j j j
Awarded 0.0 points out of 1.0 possible points.
j j j j j j j
3. 3.ID: 43154263 j
The nurse is monitoring a patient’s intracranial pressure (ICP). While the nurse is providing
j j j j j j j j j j j j j j
hygiene measures, she observes that the ICPreading is sustained at 18 mm Hg. What is the
j j j j j j j j j j j j j j j j j
priority nursing action? j j
o Cease stimulating the patient. Correct j j j j
o Continue with hygiene measures. j j j
o Lower the head of the bed to 10 degrees. j j j j j j j j
o Open the ICPmonitor to continuous drainage. j j j j j j
Sustained increases in ICPshould be avoided. Nursing care activities should be spaced to
j j j j j j j j j j j j j j
prevent an increase in ICP. Actions that cause a sustained elevation in ICP should be avoided
j j j j j j j j j j j j j j j j
until ICP returns to baseline resting values. Elevating the head of the bed to 30 degrees or
j j j j j j j j j j j j j j j j j
more can help reduce ICP. Continuous drainage of CSF fluid will result in herniation.
j j j j j j j j j j j j j
Awarded 0.0 points out of 1.0 possible points.
j j j j j j j
4. 4.ID: 43154273 j
, Herniation syndromes can be life-threatening situations. Which syndrome causes the
j j j j j j j j j j
supratentorial contents to shift downward and compress vital centers of the brainstem? j j j j j j j j j j j
o Central herniation Correct j j
o Cingulate herniation j
o Tonsillar herniation j
o Uncal herniation j
A downward shift of the cerebral hemispheres, basal ganglia, and diencephalon through the
j j j j j j j j j j j j j
tentorial notch causes central herniation, which compresses the vital centers of the brainstem.
j j j j j j j j j j j j
This results in a shift of one cerebral hemisphere under the falx cerebri to the other cerebral
j j j j j j j j j j j j j j j j j j
hemisphere. Cerebellar tonsils are displaced through the foramen magnum, causing fatal
j j j j j j j j j j j
damage to the respiratory and cardiac centers. Uncal herniation compresses the midbrain,
j j j j j j j j j j j j
causing dysfunction of the ipsilateral third nerve, resulting in unilateral pupil dilation.
j j j j j j j j j j j
Awarded 0.0 points out of 1.0 possible points. j j j j j j j
5. 5.ID: 43154282 j
In a patient with increased intracranial pressure (ICP), which of the following cranial nerves
j j j j j j j j j j j j j j
would be assessed for consensual light response, elevation of the eyelids, and eye movement?
j j j j j j j j j j j j j
o I, IX, X j j
o II,V,VII j j
o II, VI, X j j
o III,IV,VICorrect j j j
Cranial nerve III is responsible for the consensual light response, elevation of the eyelids, and
j j j j j j j j j j j j j j j
eye movements. In addition, cranial nerves III, IV, and VI affect extraocular eye movements.
j j j j j j j j j j j j j
Awarded 0.0 points out of 1.0 possible points. j j j j j j j
Questions & Complete Study
Guide
(Complete solutions and resources for the course exam)
Questions
1. 1.ID: 43154241
What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on
j j j j j j j j j j j j j j j
increased intracranial pressure (ICP)?
j j j
o Lowering ICPby allowing for elevations in CO2 to dilate cerebral arteries
j j j j j j j j j j j
o Lowering ICPby facilitating venous drainage and decreasing venous
j j j j j j j j j
obstruction Correct j
o Lowering ICPby maintaining an open airway
j j j j j j
o Lowering ICPby reducing the risk of snoring
j j j j j j j
Head-of-the-bed elevation and a neutral head position that avoids hyperextension or
j j j j j j j j j j j
hyperflexion facilitate jugular venous drainage, helping to minimize increases in ICP.
j j j j j j j j j j j
Elevated CO2 contributes to cerebral vessel vasodilation, which can increase cerebral blood
j j j j j j j j j j j j
volume and further elevate ICP. Maintaining an open airway alone does not minimize
j j j j j j j j j j j j j
increases in ICP. Reducing the risk of snoring by maintaining an open airway alone does not
j j j j j j j j j j j j j j j j
minimize increases in ICP. j j j
Awarded 0.0 points out of 1.0 possible points.
j j j j j j j
2. 2.ID: 43154255
j
Under normal circumstances the cerebral vasculature exhibits pressure and chemical
j j j j j j j j j j
,autoregulation. What happens when autoregulation is lost?
j j j j j j
, o Central venous engorgement occurs. j j j
o Cerebral blood flow is not affected. j j j j j
o Hypertension increases cerebralblood flow. Correct j j j j j
o Shunting of cerebrospinal fluid (CSF) is blocked. j j j j j j
Autoregulation is the ability of the cerebral vessels to adjust their diameter in response to
j j j j j j j j j j j j j j j
arterial pressure changes within the brain. If mean arterial blood pressure rises, cerebral
j j j j j j j j j j j j j
vessels will constrict to prevent excessive distention of the cerebral arteries. When
j j j j j j j j j j j j
autoregulation is lost, cerebral vessels are no longer able to regulate diameter and as a result
j j j j j j j j j j j j j j j j
hypertension increases cerebral perfusion pressure. Cerebral vessels may become engorged
j j j j j j j j j j
as a result of the loss of autoregulation. Cerebral blood flow is affected with the loss of
j j j j j j j j j j j j j j j j j
autoregulation. Loss of autoregulation does not block CSF flow. j j j j j j j j
Awarded 0.0 points out of 1.0 possible points.
j j j j j j j
3. 3.ID: 43154263 j
The nurse is monitoring a patient’s intracranial pressure (ICP). While the nurse is providing
j j j j j j j j j j j j j j
hygiene measures, she observes that the ICPreading is sustained at 18 mm Hg. What is the
j j j j j j j j j j j j j j j j j
priority nursing action? j j
o Cease stimulating the patient. Correct j j j j
o Continue with hygiene measures. j j j
o Lower the head of the bed to 10 degrees. j j j j j j j j
o Open the ICPmonitor to continuous drainage. j j j j j j
Sustained increases in ICPshould be avoided. Nursing care activities should be spaced to
j j j j j j j j j j j j j j
prevent an increase in ICP. Actions that cause a sustained elevation in ICP should be avoided
j j j j j j j j j j j j j j j j
until ICP returns to baseline resting values. Elevating the head of the bed to 30 degrees or
j j j j j j j j j j j j j j j j j
more can help reduce ICP. Continuous drainage of CSF fluid will result in herniation.
j j j j j j j j j j j j j
Awarded 0.0 points out of 1.0 possible points.
j j j j j j j
4. 4.ID: 43154273 j
, Herniation syndromes can be life-threatening situations. Which syndrome causes the
j j j j j j j j j j
supratentorial contents to shift downward and compress vital centers of the brainstem? j j j j j j j j j j j
o Central herniation Correct j j
o Cingulate herniation j
o Tonsillar herniation j
o Uncal herniation j
A downward shift of the cerebral hemispheres, basal ganglia, and diencephalon through the
j j j j j j j j j j j j j
tentorial notch causes central herniation, which compresses the vital centers of the brainstem.
j j j j j j j j j j j j
This results in a shift of one cerebral hemisphere under the falx cerebri to the other cerebral
j j j j j j j j j j j j j j j j j j
hemisphere. Cerebellar tonsils are displaced through the foramen magnum, causing fatal
j j j j j j j j j j j
damage to the respiratory and cardiac centers. Uncal herniation compresses the midbrain,
j j j j j j j j j j j j
causing dysfunction of the ipsilateral third nerve, resulting in unilateral pupil dilation.
j j j j j j j j j j j
Awarded 0.0 points out of 1.0 possible points. j j j j j j j
5. 5.ID: 43154282 j
In a patient with increased intracranial pressure (ICP), which of the following cranial nerves
j j j j j j j j j j j j j j
would be assessed for consensual light response, elevation of the eyelids, and eye movement?
j j j j j j j j j j j j j
o I, IX, X j j
o II,V,VII j j
o II, VI, X j j
o III,IV,VICorrect j j j
Cranial nerve III is responsible for the consensual light response, elevation of the eyelids, and
j j j j j j j j j j j j j j j
eye movements. In addition, cranial nerves III, IV, and VI affect extraocular eye movements.
j j j j j j j j j j j j j
Awarded 0.0 points out of 1.0 possible points. j j j j j j j
