Critical Care Questions- Neuro
Critical Care Questions- Neuro
Study online at https://quizlet.com/_cjfh5l
1. What would be appro- 3. Assess the arms together and then assess the legs separately.
priate for the nurse to
do when assessing a pa- Correct Answer: 3
tient's motor function? Rationale 1: Assessing all extremities together would not enable the
1. Assess all four extremi- nurse to compare strength and movement of both sides of the body.
ties together. Rationale 2: The legs are usually assessed separately.
2. Assess the right leg and *Rationale 3: Although the nurse can assess the arms simultaneously,
the right arm together. the legs are usually assessed separately. It is important that the nurse
3. Assess the arms to- assesses the movement in all four of the extremities and compare the
gether and then assess strength of movement on both sides of the body.*
the legs separately. Rationale 4: The legs are usually assessed separately.
4. Assess the left leg and
the left arm together.
2. The nurse is assessing 3. Trigeminal
a patient's corneal reflex.
The cranial nerve that is Correct Answer: 3
being assessed with this Rationale 1: The oculomotor nerve is assessed when the pupils are
reflex is: checked.
1. Oculomotor Rationale 2: The optic nerve is assessed when the pupils are checked.
2. Optic *Rationale 3: Portions of the trigeminal and facial cranial nerves can
3. Trigeminal be assessed by checking for a corneal reflex. *
4. Vagus Rationale 4: The vagus nerve is assessed by checking for a cough and
gag reflex.
3. The nurse is going 4. Determine that the patient has an intact tympanic membrane.
to assist with the as-
sessment of a pa- Correct Answer: 4
tient's oculovestibular re- Rationale 1: It is not necessary to ensure that the patient's spinal cord
flex. What should be done has been found intact.
before this reflex is as- Rationale 2: It is not necessary to ensure that the patient has an intact
sessed? gag reflex before assessing this reflex.
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, Critical Care Questions- Neuro
Critical Care Questions- Neuro
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1. Ensure that the pa- Rationale 3: The head of the patient's bed is elevated 30 degrees when
tient's spinal cord has testing this reflex.
been found intact. *Rationale 4: The oculovestibular reflex, or cold calorics, is performed
2. Ensure that the patient only after determining that the tympanic membrane is intact. The head
has an intact gag reflex. of the patient's bed is elevated 30 degrees, and then 50 mL of cool
3. Determine that the pa- saline is injected into an ear.*
tient can tolerate being in
the supine position.
4. Determine that the pa-
tient has an intact tym-
panic membrane.
4. The nurse, evaluating the 3. No evidence of pathology
tracing made from a pa-
tient's intracranial pres- Correct Answer: 3
sure monitor, notes the Rationale 1: Decreased cerebral compliance would be indicated by the
presence of many C presence of A waves.
waves. This finding would Rationale 2: Pending brain herniation would be indicated by the pres-
be indicative of: ence of A waves.
1. Decreased cerebral *Rationale 3: "C" waves are smaller rhythmic oscillations that occur 4
compliance to 8 times/minute and are not indicative of pathology.*
2. Pending brain hernia- Rationale 4: Impaired cerebral spinal fluid flow would be indicated by
tion the presence of A waves.
3. No evidence of pathol-
ogy
4. Impaired cerebral
spinal fluid flow
5. The nurse is providing 4. Use strict aseptic technique when working with the system.
care to a patient with
an intracranial pressure Correct Answer: 4
monitoring device. What Rationale 1: Pressure would be monitored every hour.
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, Critical Care Questions- Neuro
Critical Care Questions- Neuro
Study online at https://quizlet.com/_cjfh5l
is a priority when provid- Rationale 2: Neurologic assessment checks would be monitored every
ing care to this patient? hour.
1. Monitor intracranial Rationale 3: Clean technique could cause the patient to develop an
pressure every 4 hours. infection.
2. Perform neurologic as- *Rationale 4: The most common complication in patients with in-
sessment checks every 2 tracranial monitoring devices is infection. To avoid infection, the nurse
hours. should maintain strict aseptic technique when working with the sys-
3. Use clean technique tem.*
when working with the
system.
4. Use strict aseptic tech-
nique when working with
the system.
6. A patient is being ad- 4. Coup-countercoup
mitted after sustaining a
head injury from an accel- Correct Answer: 4
eration/deceleration mo- Rationale 1: Skull fracture is not typically associated with motor vehicle
tor vehicle accident. The accidents.
type of injury that this Rationale 2: Penetrating head trauma is not typically associated with
patient most likely sus- motor vehicle accidents.
tained would be: Rationale 3: Concussion is not typically associated with motor vehicle
1. Skull fracture accidents.
2. Penetrating *Rationale 4: Contusions and axonal injuries often result from acceler-
3. Concussion ation/deceleration injuries from a motor vehicle collision. Contusions
4. Coup-countercoup develop as the brain accelerates against the fixed skull, causing dis-
ruption of the underlying cerebral parenchyma and blood vessels. This
is known as a coup injury. After impacting the skull, the brain may recoil
and impact the skull on the opposite side, causing additional damage
to the cerebral parenchyma. This is known as a countercoup injury.*
7.
actualstudy Page 3
Critical Care Questions- Neuro
Study online at https://quizlet.com/_cjfh5l
1. What would be appro- 3. Assess the arms together and then assess the legs separately.
priate for the nurse to
do when assessing a pa- Correct Answer: 3
tient's motor function? Rationale 1: Assessing all extremities together would not enable the
1. Assess all four extremi- nurse to compare strength and movement of both sides of the body.
ties together. Rationale 2: The legs are usually assessed separately.
2. Assess the right leg and *Rationale 3: Although the nurse can assess the arms simultaneously,
the right arm together. the legs are usually assessed separately. It is important that the nurse
3. Assess the arms to- assesses the movement in all four of the extremities and compare the
gether and then assess strength of movement on both sides of the body.*
the legs separately. Rationale 4: The legs are usually assessed separately.
4. Assess the left leg and
the left arm together.
2. The nurse is assessing 3. Trigeminal
a patient's corneal reflex.
The cranial nerve that is Correct Answer: 3
being assessed with this Rationale 1: The oculomotor nerve is assessed when the pupils are
reflex is: checked.
1. Oculomotor Rationale 2: The optic nerve is assessed when the pupils are checked.
2. Optic *Rationale 3: Portions of the trigeminal and facial cranial nerves can
3. Trigeminal be assessed by checking for a corneal reflex. *
4. Vagus Rationale 4: The vagus nerve is assessed by checking for a cough and
gag reflex.
3. The nurse is going 4. Determine that the patient has an intact tympanic membrane.
to assist with the as-
sessment of a pa- Correct Answer: 4
tient's oculovestibular re- Rationale 1: It is not necessary to ensure that the patient's spinal cord
flex. What should be done has been found intact.
before this reflex is as- Rationale 2: It is not necessary to ensure that the patient has an intact
sessed? gag reflex before assessing this reflex.
actualstudy Page 1
, Critical Care Questions- Neuro
Critical Care Questions- Neuro
Study online at https://quizlet.com/_cjfh5l
1. Ensure that the pa- Rationale 3: The head of the patient's bed is elevated 30 degrees when
tient's spinal cord has testing this reflex.
been found intact. *Rationale 4: The oculovestibular reflex, or cold calorics, is performed
2. Ensure that the patient only after determining that the tympanic membrane is intact. The head
has an intact gag reflex. of the patient's bed is elevated 30 degrees, and then 50 mL of cool
3. Determine that the pa- saline is injected into an ear.*
tient can tolerate being in
the supine position.
4. Determine that the pa-
tient has an intact tym-
panic membrane.
4. The nurse, evaluating the 3. No evidence of pathology
tracing made from a pa-
tient's intracranial pres- Correct Answer: 3
sure monitor, notes the Rationale 1: Decreased cerebral compliance would be indicated by the
presence of many C presence of A waves.
waves. This finding would Rationale 2: Pending brain herniation would be indicated by the pres-
be indicative of: ence of A waves.
1. Decreased cerebral *Rationale 3: "C" waves are smaller rhythmic oscillations that occur 4
compliance to 8 times/minute and are not indicative of pathology.*
2. Pending brain hernia- Rationale 4: Impaired cerebral spinal fluid flow would be indicated by
tion the presence of A waves.
3. No evidence of pathol-
ogy
4. Impaired cerebral
spinal fluid flow
5. The nurse is providing 4. Use strict aseptic technique when working with the system.
care to a patient with
an intracranial pressure Correct Answer: 4
monitoring device. What Rationale 1: Pressure would be monitored every hour.
actualstudy Page 2
, Critical Care Questions- Neuro
Critical Care Questions- Neuro
Study online at https://quizlet.com/_cjfh5l
is a priority when provid- Rationale 2: Neurologic assessment checks would be monitored every
ing care to this patient? hour.
1. Monitor intracranial Rationale 3: Clean technique could cause the patient to develop an
pressure every 4 hours. infection.
2. Perform neurologic as- *Rationale 4: The most common complication in patients with in-
sessment checks every 2 tracranial monitoring devices is infection. To avoid infection, the nurse
hours. should maintain strict aseptic technique when working with the sys-
3. Use clean technique tem.*
when working with the
system.
4. Use strict aseptic tech-
nique when working with
the system.
6. A patient is being ad- 4. Coup-countercoup
mitted after sustaining a
head injury from an accel- Correct Answer: 4
eration/deceleration mo- Rationale 1: Skull fracture is not typically associated with motor vehicle
tor vehicle accident. The accidents.
type of injury that this Rationale 2: Penetrating head trauma is not typically associated with
patient most likely sus- motor vehicle accidents.
tained would be: Rationale 3: Concussion is not typically associated with motor vehicle
1. Skull fracture accidents.
2. Penetrating *Rationale 4: Contusions and axonal injuries often result from acceler-
3. Concussion ation/deceleration injuries from a motor vehicle collision. Contusions
4. Coup-countercoup develop as the brain accelerates against the fixed skull, causing dis-
ruption of the underlying cerebral parenchyma and blood vessels. This
is known as a coup injury. After impacting the skull, the brain may recoil
and impact the skull on the opposite side, causing additional damage
to the cerebral parenchyma. This is known as a countercoup injury.*
7.
actualstudy Page 3
