NR 341 CMS PROCTORED TEST BANK 2023 REAL EXAM QUESTIONS AND CORRECT ANSWERS AND RATIONALES|ALREADY GRADED A+|

NR 341 CMS PROCTORED TEST BANK 2023 REAL EXAM QUESTIONS AND CORRECT ANSWERS AND RATIONALES|ALREADY GRADED A+| What is the max GCS score? - ANSWER- 15 What is the minimum GCS score? - ANSWER- 3 What GCS score should you intubate? - ANSWER- 8 and under What are the limitations of the GCS? - ANSWER- age, drugs, and language What is normal intracranial pressure (ICP)? - ANSWER- 5-15 mmHg What are the signs and symptoms of increased ICP? - ANSWER- change in LOC, change in speech, change in vital signs, seizures, headache, vomiting, eye changes, posture changes What is the first sign of increased ICP? - ANSWER- changes in LOC What is Cushing’s triad? - ANSWER- an effect of increased ICP of increased systolic BP, decreased pulse, and cheyne-stokes respirations What is Cheyne-Stokes respiration? - ANSWER- it is an abnormal rhythm of breathing with alternation periods of hyperventilation and apnea What is Kussmaul respiration? - ANSWER- deep, rapid breathing often induced by acidosis What condition does Kussmaul respirations commonly occur with? - ANSWER- DKA What posture changes occur with increased ICP? - ANSWER- decerebrate, decorticate,or flaccid What is decerebrate posturing? - ANSWER- Extensor response; problem with midbrain or pons What is decorticate posturing? - ANSWER- Flexor response; problem with cervical spinal tract or cerebral hemisphere What are the eye changes that occur with increased ICP? - ANSWER- papilledema, pupillary changes, impaired eye movement What is a common cause of increased brain volume? - ANSWER- cerebral edema; can also be caused by a tumor or meningitis What causes increased blood volume? - ANSWER- loss of auto-regulation, decreased oxygenation, hypercapnia, increased metabolic demands, and obstruction of venous outflow What causes increased cerebrospinal fluid? - ANSWER- hydrocephalus, blockage of normal flow, obstruction of normal re-absorption, and excess production of CSF What is cerebral perfusion pressure (CPP) dependent upon? - ANSWER- intracranial pressure (ICP) and mean arterial pressure (MAP) What is a normal cerebral perfusion pressure (CPP)? - ANSWER- 50-70 What does a low cerebral perfusion pressure (CPP) result in? - ANSWER- loss of auto-regulation and hypoxic insult to brain tissue Nursing Mgmt. ICP: What is the maintenance goal of ICP? - ANSWER- ICP < 20 mmHg Nursing Mgmt. ICP: What is the maintenance goal of CPP? - ANSWER- < 70 mmHg Nursing Mgmt. ICP: Care should be ________ to allow rest. - ANSWER- spaced Nursing Mgmt. ICP: Suctioning should be _______. - ANSWER- minimum/PRN Nursing Mgmt. ICP: What should the HOB be at? - ANSWER- 30-45 degrees (Semi-Fowler's); keep neck in neutral position Nursing Mgmt. ICP: Why should hyperthermia is avoided? - ANSWER- to help reduce metabolic and oxygen demand Nursing Mgmt. ICP: How should the patient is kept? - ANSWER- normovolemic What is normovolemic? - ANSWER- normal blood volume What electrolytes should be monitored with ICP mgmt.? - ANSWER- sodium --> seizures What all should be monitored with ICP mgmt.? - ANSWER- ICP, electrolytes, ABG's vital signs, daily weights, strict I&O, diabetes insipid us (DI), and SIADH What tubes should be placed with increased ICP? - ANSWER- NG tube or gastric tube Which tube is preferred with patients who have facial fractures or skull fractures? - ANSWER- or gastric tube Nursing Mgmt. ICP: What forms of management should be given? - ANSWER- airway, pain and anxiety (sedate) Nursing Mgmt. ICP: How should the transducer is kept? - ANSWER- at level with the drain What is diabetes insipid us? - ANSWER- a disorder caused by inadequate amounts of ADH which causes excessive water loss What are the signs and symptoms of diabetes insipid us? - ANSWER- polyuria, low urine specific gravity, increased diuresis, increased sodium, decreased potassium What is the nursing management of diabetes insipid us? - ANSWER- vasopressin What is SIADH? - ANSWER- abnormal stimulation to the hypothalamic area of the brain, causing excessive secretion of antidiuretic hormone (Vasopressin) What are the signs and symptoms of SIADH? - ANSWER- oliguria, high urine specific gravity, fluid retention, decreased diuresis, decreased sodium, increased potassium What is the nursing management of SIADH? - ANSWER- fluid restrictions Administer potassium Sodium restriction Diuretics Demeclocycline drug use to suppress vasopressin What is the normal urine specific gravity? - ANSWER- 1.000-1.030 Nursing Mgmt. ICP: What should be avoided with increased ICP? - ANSWER- extreme hip flexion, valsalva maneuver, coughing, sneezing, hypoxemia, and sudden arousal from sleep What is the valsalva maneuver? - ANSWER- Exhaling forcibly with the glottis closed What is hypoxemia? - ANSWER- low oxygen in the blood Nursing Mgmt. ICP: Why should extreme hip flexion is avoided? - ANSWER- to protect the patient from injury Medical Mgmt. ICP: Adequate oxygenation - ANSWER- goal PaO2, airway vigilance/watching, mechanical ventilation, adequate hematocrit Medical Mgmt. ICP: What are normal hematocrit levels? - ANSWER- men: 42-54% Women: 38-46% Medical Mgmt. ICP: What is the PaO2 goal? - ANSWER- > 80 mmHg Medical Mgmt. ICP: Carbon Dioxide Management - ANSWER- goal PaCO2 and avoid hyperventilation Medical Mgmt. ICP: What is the goal PaCO2? - ANSWER- 35-45 mmHg What is hyperventilation? - ANSWER- Increased depth and rate of breathing that exceeds the body's need to remove CO2 Medical Mgmt. ICP: Osmotic Diuretics - ANSWER- reduce brain tissue volume and hypertonic saline Medical Mgmt. ICP: What osmotic diuretics are used? - ANSWER- mannitol or 23% NaCl Why is mannitol used? - ANSWER- pulls fluid out of brain cells which decreases the cell size What are side effects of mannitol? - ANSWER- hypotension, polyuria, hyponatremia and hypokalemia, pulmonary edema, and rebound ICP What should be used when administering mannitol? - ANSWER- a filter Why is 23% NaCl given to patients with increased ICP? - ANSWER- can be given to patient faster because it doesn't crystallize Medical Mgmt. ICP: Loop Diuretics - ANSWER- reduce brain tissue volume and decreased CSF formation Medical Mgmt. ICP: Fluid Administration - ANSWER- optimize fluid administration with isotonic solutions, strict I&O, colloids or blood products to restore volume What is the goal of fluid administration? - ANSWER- serum osmolality less than 320 mOsm/L Medical Mgmt. ICP: Blood Pressure - ANSWER- avoids hypertension and avoids hypotension