| Exam Prep | 100% Accurate Answers
1. What is a key nursing intervention for managing increased intracranial
pressure (ICP)?
Encourage the patient to perform deep breathing exercises.
Increase the patient's intake of sodium-rich foods.
Administer sedatives to promote rest.
Monitor fluid and electrolyte status carefully.
2. Why is immobilizing a femur fracture considered an essential intervention in
preventing fat embolism?
Immobilizing the fracture allows for better blood flow to the area.
Immobilizing the fracture helps stabilize the bone and prevents the
release of fat globules into the bloodstream.
Immobilizing the fracture reduces pain and discomfort.
Immobilizing the fracture is necessary for proper surgical alignment.
3. Describe the physiological changes that occur during autonomic dysreflexia
and how they affect the patient.
Autonomic dysreflexia causes an exaggerated sympathetic
response, leading to hypertension and bradycardia.
Autonomic dysreflexia is characterized by a sudden drop in blood
pressure and increased respiratory rate.
Autonomic dysreflexia leads to increased muscle tone and decreased
reflexes.
, Autonomic dysreflexia results in decreased heart rate and increased
blood flow to the extremities.
4. What is the first nursing intervention for a patient experiencing autonomic
dysreflexia?
Check for bowel impaction
Perform urinary catheterization
Elevate the head of the bed
Administer IV hydralazine
5. The patient's intracranial pressure (ICP) reading has gradually climbed from
15 to 23 mm Hg. The nurse's primary action is to:
place the patient in a high Fowler position to decrease the pressure.
check level of consciousness.
drain off 7 mm of cerebrospinal fluid (CSF) from the catheter.
notify the physician.
6. In a scenario where a patient with a ventriculostomy shows signs of infection
at the insertion site, what should the nurse prioritize in their intervention?
Monitor the patient's blood pressure for changes.
Implement strict aseptic technique during dressing changes and
notify the healthcare provider.
Increase the patient's fluid intake to flush out the infection.
Administer antibiotics without a doctor's order.
7. What is a common symptom of autonomic dysreflexia that nurses should
monitor for?
, Fever
Nausea
Severe headache
Muscle weakness
8. Which of the following clinical manifestations should the nurse interpret as a
sign or symptoms of neurogenic shock in a client with acute spinal cord
injury?
Hypertension
Bounding pedal pulses
Neurogenic spasticity
Bradycardia
9. Describe how bradycardia can indicate increased intracranial pressure in a
patient with a subdural hematoma.
Bradycardia is unrelated to intracranial pressure changes and indicates
a normal heart rate.
Bradycardia occurs due to dehydration and has no connection to ICP.
Bradycardia can indicate increased intracranial pressure as the body
responds to elevated ICP by altering heart rate to maintain cerebral
perfusion.
Bradycardia is a sign of infection rather than increased intracranial
pressure.
10. A 22-year-old woman with paraplegia after a spinal cord injury tells the
home care nurse she experiences bowel incontinence two or three times
each day. Which action by the nurse is most appropriate?