NUR417 / NUR 417
FINAL EXAM
Care of Adult II, Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
100% Guarantee Pass.
Expert Verified Explanation
Multiple choice (single best answer)
Select All That Apply (SATA)
Fill-in-the-blank
Case Studies/Scenario-Based Questions
,The nurse is providing care for a patient who has been admitted to the hospital with a head
injury and who requires regular neurologic and vital sign assessment. Which assessments
will be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that
apply)?
A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best verbal response
E. Best motor response
F. Cranial nerve function
ANSWERS
B,D,E
The three dimensions of the GCS are eye opening, best verbal response, and best motor
response. Judgment, abstract reasoning, and cranial nerve function are not components of the
GCS.
A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated,
and does not respond to a verbal command to move but attempts to remove a painful
stimulus. The nurse records the patient's Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15.
ANSWER
B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor
,response.
DIF: Cognitive Level: Application REF: 1434
A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110,
and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of
most concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANSWER
A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes
represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and
brain herniation may be imminent unless immediate action is taken to reduce ICP. The other
vital signs may indicate the need for changes in treatment, but they are not indicative of an
immediately life-threatening process.
DIF: Cognitive Level: Application REF: 1429-1430
An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion
related to cerebral tissue swelling. Which nursing intervention will be included in the plan
of care?
a. Keep the head of the bed elevated to 30 degrees.
b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.
ANSWER
A
The patient with increased intracranial pressure (ICP) should be maintained in the head-up
, position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure,
which increases ICP. Because the stimulation associated with nursing interventions increases
ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic
pressure and ICP.
DIF: Cognitive Level: Application REF: 1436-1437
A patient who is suspected of having an epidural hematoma is admitted to the emergency
department. Which action will the nurse plan to take?
a. Administer IV furosemide (Lasix).
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.
ANSWER
D
The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and
prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or
high-dose barbiturate therapy may be needed, but these will not be of benefit unless the
hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is
usually not necessary.
A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm
Hg. Which action should the nurse take first?
a. Elevate the head of the patient's bed to 60 degrees.
b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP.
ANSWER
C
The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg
FINAL EXAM
Care of Adult II, Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
100% Guarantee Pass.
Expert Verified Explanation
Multiple choice (single best answer)
Select All That Apply (SATA)
Fill-in-the-blank
Case Studies/Scenario-Based Questions
,The nurse is providing care for a patient who has been admitted to the hospital with a head
injury and who requires regular neurologic and vital sign assessment. Which assessments
will be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that
apply)?
A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best verbal response
E. Best motor response
F. Cranial nerve function
ANSWERS
B,D,E
The three dimensions of the GCS are eye opening, best verbal response, and best motor
response. Judgment, abstract reasoning, and cranial nerve function are not components of the
GCS.
A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated,
and does not respond to a verbal command to move but attempts to remove a painful
stimulus. The nurse records the patient's Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15.
ANSWER
B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor
,response.
DIF: Cognitive Level: Application REF: 1434
A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110,
and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of
most concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANSWER
A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes
represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and
brain herniation may be imminent unless immediate action is taken to reduce ICP. The other
vital signs may indicate the need for changes in treatment, but they are not indicative of an
immediately life-threatening process.
DIF: Cognitive Level: Application REF: 1429-1430
An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion
related to cerebral tissue swelling. Which nursing intervention will be included in the plan
of care?
a. Keep the head of the bed elevated to 30 degrees.
b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.
ANSWER
A
The patient with increased intracranial pressure (ICP) should be maintained in the head-up
, position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure,
which increases ICP. Because the stimulation associated with nursing interventions increases
ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic
pressure and ICP.
DIF: Cognitive Level: Application REF: 1436-1437
A patient who is suspected of having an epidural hematoma is admitted to the emergency
department. Which action will the nurse plan to take?
a. Administer IV furosemide (Lasix).
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.
ANSWER
D
The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and
prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or
high-dose barbiturate therapy may be needed, but these will not be of benefit unless the
hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is
usually not necessary.
A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm
Hg. Which action should the nurse take first?
a. Elevate the head of the patient's bed to 60 degrees.
b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP.
ANSWER
C
The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg
