MSN 377 Exam 4 Questions And Answers Verified 100% Correct

MSN 377 Exam 4 Questions And Answers Verified 100% Correct A patient has a systemic blood pressure of 120/60 mm Hg and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? A. high blood flow to the brain B. normal intracranial pressure C. impaired bloodflow to the brain D. adequate autoregulation of bloodflow - ANSWER C. impaired bloodflow to the brain Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP - ICP: 80 mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24 mm Hg, treatment is required. The patient with a brain tumor is being monitored for increased intracranial pressure (ICP) with a ventriculostomy. What nursing intervention is priority? A. administer IV mannitol B. ventilator use to hyperoxygenate the patient C. use strict aseptic technique with dressing changes D. be aware of changes in ICP related to leaking cerebrospinal fluid - ANSWER C. use strict aseptic technique with dressing changes The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. The nurse is caring for a patient admitted to the hospital with a head injury who requires frequent neurologic assessment. Which components are assessed using the Glasgow Coma Scale (GCS) (select all that apply.)? A. judgement B. eye opening C. abstract reasoning D. best verbal response E. best motor response F. cranial nerve function - ANSWER B. eye opening D. best verbal response E. best motor response In planning long-term care for a patient after craniotomy, what must the nurse include in family and caregiver education? A. seizure disorders may occur in weeks or months B. the family will be unable to cope with role reversals C. there are often residual changes in personality and cognition D. referrals will be made to eliminate residual deficits from the damage - ANSWER C. there are often residual changes in personality and cognition In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. The patient's magnetic resonance imaging revealed the presence of a brain tumor. The nurse anticipates which treatment modality? A. surgery B. chemotherapy C. radiation therapy D. biologic drug therapy - ANSWER A. surgery The nurse assesses a patient for signs of meningeal irritation. Which finding indicates nuchal rigidity is present? A. tonic spasms of the legs B. curling in a fetal position C. arching of the neck and back D. resistance to flexion of the neck - ANSWER D. resistance to flexion of the neck Nuchal rigidity is a clinical manifestation of meningitis. A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is most appropriate? A. test the drainage for the presence of glucose B. apply a loose gauze pad under the patient's nose C. place the patient in a modified trendelenburg position D. ask the patient to gently blow the nose to clear the drainage - ANSWER B. apply a loose gauze pad under the patient's nose Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may occur with a frontal skull fracture. A loose collection pad may be placed under the nose, and if thin bloody fluid is present, the blood will coalesce and a yellow halo will form if CSF is present. The nurse is caring for a patient admitted with a subdural hematoma after a motor vehicle accident. What change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? A. tachypnea B. bradycardia C. hypotension D. narrowing pulse pressure - ANSWER B. bradycardia What nursing intervention should be implemented for a patient experiencing increased intracranial pressure (ICP)? A. monitor fluid and electrolyte status carefully B. position the patient in a high Fowler's position C. administer vasoconstrictors to maintain cerebral perfusion D. maintain physical restraints to prevent episodes of agitation - ANSWER A. monitor fluid and electrolyte status carefully The nurse prepares to administer temozolomide (Temodar) to a 59-yr-old white male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication? A. serum potassium and serum sodium levels B. urine osmolality and urine specific gravity C. absolute neutrophil count and platelet count D. cerebrospinal fluid pressure and cell count - ANSWER C. absolute neutrophil count and platelet count The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? A. document the ICP reading in the chart B. determine if the patient has a headache C. assess the patient's level of consciousness D. position the patient with the head elevated to 60 degrees - ANSWER C. assess the patient's level of consciousness The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most sensitive and reliable indicator of neurologic status is level of consciousness. The Glasgow Coma Scale may be used to determine the degree of impaired consciousness. The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old woman with an ischemic stroke. Which action by the student will require the nurse to intervene? A. giving the patient 1 oz of water to swallow B. telling the patient to perform a chin tuck before swallowing C. assisting the patient to sit in a chair before feeding the patient D. assessing cranial nerves III, IV, VI before attempting the feeding - ANSWER D. Assessing cranial nerves III, IV, and VI before attempting feeding