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NUR 417 FINAL EXAM (Lewis Evolve) Questions and Answers
with 100% Complete Solutions UPDATED!!!
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 as ordered.
B. Ventilator use to hyperoxygenate the patient.
C. Use strict aseptic technique with dressing changes.
D. Be aware of changes in ICP related to cerebrospinal fluid
leaks.
C
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.
IV mannitol or hypertonic saline will be administered as ordered
for increased ICP. Ventilators may be used to maintain
oxygenation. CSF leaks may cause inaccurate ICP readings, or
CSF may be drained to decrease ICP, but strict aseptic technique
to prevent infection is the nurse's priority of care.
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A patient 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. Place packing in the patient's nares.
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.
B
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. If clear drainage is present, testing for
glucose would indicate the presence of CSF. Mixed blood and
CSF will test positive for glucose because blood contains
glucose. If CSF rhinorrhea occurs, the nurse should inform the
provider immediately. The head of the bed may be raised to
decrease the CSF pressure so that a tear can seal. The nurse
should not place packing in the nasal cavity, and the patient
should not sneeze or blow the nose.
We have an expert-written solution to this problem!
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A patient is diagnosed with diabetes insipidus after
transsphenoidal resection of a pituitary adenoma. What
should the nurse consider as a sign of improvement?
A. Serum sodium of 120 mEq/L
B. Urine specific gravity of 1.001
C. Fasting blood glucose of 80 mg/dL
D. Serum osmolality of 290 mOsm/kg
D
Laboratory findings in diabetes insipidus include elevated serum
osmolality and serum sodium and decreased urine specific
gravity. Normal serum osmolality is 285 to 295 mOsm/kg,
normal serum sodium is 136 to 145 mEq/L, and normal specific
gravity is 1.005 to 1.030. High blood glucose levels occur with
diabetes.
The provider orders intracranial pressure (ICP) readings every
hour for a 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 LOC.
D. Position the patient with head elevated 60 degrees.
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C
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.
A patient has a systemic BP 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 blood flow to the brain
D. Adequate autoregulation of blood flow
C
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.
We have an expert-written solution to this problem!
4|Page
NUR 417 FINAL EXAM (Lewis Evolve) Questions and Answers
with 100% Complete Solutions UPDATED!!!
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 as ordered.
B. Ventilator use to hyperoxygenate the patient.
C. Use strict aseptic technique with dressing changes.
D. Be aware of changes in ICP related to cerebrospinal fluid
leaks.
C
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.
IV mannitol or hypertonic saline will be administered as ordered
for increased ICP. Ventilators may be used to maintain
oxygenation. CSF leaks may cause inaccurate ICP readings, or
CSF may be drained to decrease ICP, but strict aseptic technique
to prevent infection is the nurse's priority of care.
1|Page
,2|Page
A patient 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. Place packing in the patient's nares.
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.
B
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. If clear drainage is present, testing for
glucose would indicate the presence of CSF. Mixed blood and
CSF will test positive for glucose because blood contains
glucose. If CSF rhinorrhea occurs, the nurse should inform the
provider immediately. The head of the bed may be raised to
decrease the CSF pressure so that a tear can seal. The nurse
should not place packing in the nasal cavity, and the patient
should not sneeze or blow the nose.
We have an expert-written solution to this problem!
2|Page
,3|Page
A patient is diagnosed with diabetes insipidus after
transsphenoidal resection of a pituitary adenoma. What
should the nurse consider as a sign of improvement?
A. Serum sodium of 120 mEq/L
B. Urine specific gravity of 1.001
C. Fasting blood glucose of 80 mg/dL
D. Serum osmolality of 290 mOsm/kg
D
Laboratory findings in diabetes insipidus include elevated serum
osmolality and serum sodium and decreased urine specific
gravity. Normal serum osmolality is 285 to 295 mOsm/kg,
normal serum sodium is 136 to 145 mEq/L, and normal specific
gravity is 1.005 to 1.030. High blood glucose levels occur with
diabetes.
The provider orders intracranial pressure (ICP) readings every
hour for a 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 LOC.
D. Position the patient with head elevated 60 degrees.
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C
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.
A patient has a systemic BP 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 blood flow to the brain
D. Adequate autoregulation of blood flow
C
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.
We have an expert-written solution to this problem!
4|Page
