,NSG3280/NSG 3280 Exam 3 | Pathophysiology |
Galen College | 26/27 Updated (PDF)
1. A nurse is assessing a patient with a suspected increase in intracranial pressure (ICP). Which finding
is the earliest and most sensitive indicator of this condition?
A) Fixed and dilated pupils
B) Cushing's triad
C) A change in the level of consciousness
D) Decerebrate posturing
Correct Answer: A change in the level of consciousness
Rationale: A change in the level of consciousness (LOC), such as confusion or lethargy, is typically the
first sign of rising ICP because it reflects impairment of the reticular activating system in the
brainstem. Late findings such as fixed pupils, Cushing's triad, and posturing indicate worsening brain
compression.
2. According to the Monro-Kellie doctrine, what is the initial compensatory mechanism when an
intracranial mass begins to expand?
A) Rapid increase in brain tissue volume to cushion the mass
B) Displacement of cerebrospinal fluid into the spinal canal and a decrease in cerebral blood volume
C) Immediate dilation of cerebral arteries to enhance perfusion
D) Increased production of cerebrospinal fluid to buffer the pressure
Correct Answer: Displacement of cerebrospinal fluid into the spinal canal and a decrease in cerebral
blood volume
Rationale: The Monro-Kellie doctrine states the skull is a rigid container. Initial compensation for an
expanding mass occurs by shifting CSF into the spinal subarachnoid space and reducing cerebral blood
volume through vasoconstriction. The other options describe responses that would increase
intracranial volume and are not compensatory.
,3. A patient with a traumatic brain injury has a mean arterial pressure (MAP) of 90 mm Hg and an ICP
of 25 mm Hg. What is the patient's cerebral perfusion pressure (CPP)?
A) 45 mm Hg
B) 65 mm Hg
C) 90 mm Hg
D) 115 mm Hg
Correct Answer: 65 mm Hg
Rationale: Cerebral perfusion pressure (CPP) is calculated as MAP minus ICP (90 - 25 = 65 mm Hg).
Normal CPP is 60-100 mm Hg. A CPP below 50 mm Hg indicates inadequate cerebral blood flow.
4. A nurse is assessing a patient with a severe closed head injury. Which set of vital signs is most
consistent with Cushing's triad?
A) Hypotension, tachycardia, and rapid shallow respirations
B) Bradycardia, hypotension, and Cheyne-Stokes respirations
C) Hypertension with narrowed pulse pressure, tachycardia, and hyperventilation
D) Hypertension with widened pulse pressure, bradycardia, and irregular respirations
Correct Answer: Hypertension with widened pulse pressure, bradycardia, and irregular respirations
Rationale: Cushing's triad is a late sign of increased ICP and brainstem compression, characterized by
systolic hypertension with a widening pulse pressure, reflex bradycardia, and irregular or depressed
respirations.
5. A patient who sustained a head injury is alert and oriented immediately after the incident but
subsequently becomes lethargic and confused. This presentation is most characteristic of which type
of intracranial hematoma?
A) Epidural hematoma
B) Subdural hematoma
C) Subarachnoid hemorrhage
, D) Intracerebral hematoma
Correct Answer: Epidural hematoma
Rationale: An epidural hematoma, often caused by a tear in the middle meningeal artery, is classically
associated with a lucid interval followed by a rapid decline in consciousness. Subdural hematomas are
more common in the elderly and have a more gradual onset.
6. A patient is diagnosed with a subarachnoid hemorrhage. Which clinical manifestation is the nurse
most likely to observe?
A) Unilateral weakness and slurred speech
B) Sudden, severe "thunderclap" headache
C) Gradual onset of confusion and memory loss
D) Transient visual disturbances
Correct Answer: Sudden, severe "thunderclap" headache
Rationale: A subarachnoid hemorrhage often presents with a sudden, severe headache described as
the "worst headache of my life." Unilateral weakness is more characteristic of an ischemic stroke, and
gradual confusion is not typical.
7. A patient is admitted with an acute ischemic stroke. The nurse understands that the primary goal of
thrombolytic therapy with tissue plasminogen activator (tPA) is to:
A) Prevent the formation of a new clot
B) Dissolve the existing clot and restore blood flow
C) Reduce inflammation in the brain tissue
D) Decrease intracranial pressure
Correct Answer: Dissolve the existing clot and restore blood flow
Galen College | 26/27 Updated (PDF)
1. A nurse is assessing a patient with a suspected increase in intracranial pressure (ICP). Which finding
is the earliest and most sensitive indicator of this condition?
A) Fixed and dilated pupils
B) Cushing's triad
C) A change in the level of consciousness
D) Decerebrate posturing
Correct Answer: A change in the level of consciousness
Rationale: A change in the level of consciousness (LOC), such as confusion or lethargy, is typically the
first sign of rising ICP because it reflects impairment of the reticular activating system in the
brainstem. Late findings such as fixed pupils, Cushing's triad, and posturing indicate worsening brain
compression.
2. According to the Monro-Kellie doctrine, what is the initial compensatory mechanism when an
intracranial mass begins to expand?
A) Rapid increase in brain tissue volume to cushion the mass
B) Displacement of cerebrospinal fluid into the spinal canal and a decrease in cerebral blood volume
C) Immediate dilation of cerebral arteries to enhance perfusion
D) Increased production of cerebrospinal fluid to buffer the pressure
Correct Answer: Displacement of cerebrospinal fluid into the spinal canal and a decrease in cerebral
blood volume
Rationale: The Monro-Kellie doctrine states the skull is a rigid container. Initial compensation for an
expanding mass occurs by shifting CSF into the spinal subarachnoid space and reducing cerebral blood
volume through vasoconstriction. The other options describe responses that would increase
intracranial volume and are not compensatory.
,3. A patient with a traumatic brain injury has a mean arterial pressure (MAP) of 90 mm Hg and an ICP
of 25 mm Hg. What is the patient's cerebral perfusion pressure (CPP)?
A) 45 mm Hg
B) 65 mm Hg
C) 90 mm Hg
D) 115 mm Hg
Correct Answer: 65 mm Hg
Rationale: Cerebral perfusion pressure (CPP) is calculated as MAP minus ICP (90 - 25 = 65 mm Hg).
Normal CPP is 60-100 mm Hg. A CPP below 50 mm Hg indicates inadequate cerebral blood flow.
4. A nurse is assessing a patient with a severe closed head injury. Which set of vital signs is most
consistent with Cushing's triad?
A) Hypotension, tachycardia, and rapid shallow respirations
B) Bradycardia, hypotension, and Cheyne-Stokes respirations
C) Hypertension with narrowed pulse pressure, tachycardia, and hyperventilation
D) Hypertension with widened pulse pressure, bradycardia, and irregular respirations
Correct Answer: Hypertension with widened pulse pressure, bradycardia, and irregular respirations
Rationale: Cushing's triad is a late sign of increased ICP and brainstem compression, characterized by
systolic hypertension with a widening pulse pressure, reflex bradycardia, and irregular or depressed
respirations.
5. A patient who sustained a head injury is alert and oriented immediately after the incident but
subsequently becomes lethargic and confused. This presentation is most characteristic of which type
of intracranial hematoma?
A) Epidural hematoma
B) Subdural hematoma
C) Subarachnoid hemorrhage
, D) Intracerebral hematoma
Correct Answer: Epidural hematoma
Rationale: An epidural hematoma, often caused by a tear in the middle meningeal artery, is classically
associated with a lucid interval followed by a rapid decline in consciousness. Subdural hematomas are
more common in the elderly and have a more gradual onset.
6. A patient is diagnosed with a subarachnoid hemorrhage. Which clinical manifestation is the nurse
most likely to observe?
A) Unilateral weakness and slurred speech
B) Sudden, severe "thunderclap" headache
C) Gradual onset of confusion and memory loss
D) Transient visual disturbances
Correct Answer: Sudden, severe "thunderclap" headache
Rationale: A subarachnoid hemorrhage often presents with a sudden, severe headache described as
the "worst headache of my life." Unilateral weakness is more characteristic of an ischemic stroke, and
gradual confusion is not typical.
7. A patient is admitted with an acute ischemic stroke. The nurse understands that the primary goal of
thrombolytic therapy with tissue plasminogen activator (tPA) is to:
A) Prevent the formation of a new clot
B) Dissolve the existing clot and restore blood flow
C) Reduce inflammation in the brain tissue
D) Decrease intracranial pressure
Correct Answer: Dissolve the existing clot and restore blood flow
