HCAL III Exam 3
A patient is brought to the ER following a MVA in which he sustained head trauma. Preliminary
assessment reveals a vision deficit in the pt left eye. The nurse should associate this abnormal finding
with trauma to which of the following cerebral lobes?
- Temporal
- Occipital
- Parietal
- Frontal - Answer-- Occipital
RATIONALE: The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The
temporal lobe contains the auditory receptive areas. The parietal lobe contains the primary sensory
cortex, & is essential to an individual's awareness of the body in space, as well as orientation in space &
spatial relations. The frontal lobe functions in concentration, abstract thought, information storage or
memory, & motor function.
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-
related changes. Of what phenomenon should the nurse be aware?
- Hyperactive deep tendon reflexes
- Reduction in cerebral blood flow
- Increased cerebral metabolism
- Hypersensitivity to painful stimuli - Answer-- Reduction in cerebral blood flow
,RATIONALE: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process.
Deep tendon reflexes can be decreased, or in some cases, absent. Cerebral metabolism decreases as the
patient advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an
important warning signal, caution must be used when hot or cold packs are used.
The nurse is conducting a focused neurologic assessment. When assessing the patient's cranial nerve
function, the nurse would include which of the following assessments?
- Assessment of hand grip
- Assessment of orientation to person, time, & place
- Assessment of arm drift
- Assessment of gag reflex - Answer-- Assessment of gag reflex
RATIONALE: The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand
grip & arm drifting are part of motor function assessment. Orientation is an assessment parameter
related to a mental status examination.
A 72-year-old man has been brought to his PCP by his daughter, who claims he has been experiencing
uncharacteristic lapses in memory. What principle should underlie the nurse's assessment &
management of this patient?
- Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic
- Lapses in memory in older adults is considered benign unless they have negative consequences
- Gradual increases in confusion accompany the aging process
- Thorough assessment is necessary because changes in cognition are always considered to be
pathologic - Answer-- Thorough assessment is necessary because changes in cognition are always
considered to be pathologic
RATIONALE: Although mental processing time decreases with age, memory, language, & judgement
capacities remain intact. Change in mental status should never be assumed to be a normal part of aging.
,The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable
to follow verbal commands. How should the nurse proceed with assessing the patient's LOC?
- Assess the patient's VS & correlate these with the patient's baselines
- Assess the patient's eye opening & response to stimuli
- Document that the patient currently lacks a LOC
- Facilitate diagnostic testing in an effort to obtain objective data - Answer-- Assess the patient's eye
opening & response to stimuli
RATIONALE: If the patient is not alert or able to follow commands, the examiner observes for eye
opening; verbal response & motor response to stimuli, if any; & the type of stimuli needed to obtain a
response. VS & diagnostic testing are appropriate, but neither will allow the nurse to gauge the patient's
LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.
A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in
cerebral edema. When planning this patient's care, the nurse would expect to administer what priority
medication?
- Hydrochlorothiazide (HydroDIURIL)
- Furosemide (Lasix)
- Mannitol (Osmitrol)
- Spirolactone (Aldactone_ - Answer-- Mannitol (Osmitrol_
RATIONALE: The osmotic diuretic mannitol is given to dehydrate the brain tissue & reduce cerebral
edema. This drug acts by reducing the volume of brain & extracellular fluid. Spirolactone, furosemide, &
hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting
from cerebral edema.
The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest
priority?
- Maintaining accurate records of I&O
- Maintaining a patent airway
, - Inserting an NG tube as ordered
- Providing appropriate pain control - Answer-- Maintaining a patent airway
RATIONALE: Maintaining a patent airway always takes top priority, even though each of the other listed
actions is necessary & appropriate.
The nurse is caring for a patient in the ICU who has a brain stem herniation & who is exhibiting an
altered LOC. Monitoring reveals that the patients MAP is 60 mmHg with an ICP reading of 5 mmHg.
What is the nurse's most appropriate action?
- Position the patient in the high Fowler's position as tolerated
- Administer osmotic diuretics as ordered
- Participate in interventions to increased cerebral perfusion pressure
- Prepare the patient for craniotomy - Answer-- Participate in interventions to increased cerebral
perfusion pressure
RATIONALE: The cerebral perfusion pressure (CPP) is 55 mmHg, which is considered low. The normal
CPP is 70 to 100 mmHg. Patients with a CPP of less than 50 mmHg experience irreversible neurologic
damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics &
increased height of bed would exacerbate the patient's condition.
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of
care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction & osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?
- Change the patient's position as indicated
- Monitor serum electrolytes
- Maintain NPO status
- Monitor ABG values - Answer-- Monitor serum electrolytes
A patient is brought to the ER following a MVA in which he sustained head trauma. Preliminary
assessment reveals a vision deficit in the pt left eye. The nurse should associate this abnormal finding
with trauma to which of the following cerebral lobes?
- Temporal
- Occipital
- Parietal
- Frontal - Answer-- Occipital
RATIONALE: The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The
temporal lobe contains the auditory receptive areas. The parietal lobe contains the primary sensory
cortex, & is essential to an individual's awareness of the body in space, as well as orientation in space &
spatial relations. The frontal lobe functions in concentration, abstract thought, information storage or
memory, & motor function.
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-
related changes. Of what phenomenon should the nurse be aware?
- Hyperactive deep tendon reflexes
- Reduction in cerebral blood flow
- Increased cerebral metabolism
- Hypersensitivity to painful stimuli - Answer-- Reduction in cerebral blood flow
,RATIONALE: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process.
Deep tendon reflexes can be decreased, or in some cases, absent. Cerebral metabolism decreases as the
patient advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an
important warning signal, caution must be used when hot or cold packs are used.
The nurse is conducting a focused neurologic assessment. When assessing the patient's cranial nerve
function, the nurse would include which of the following assessments?
- Assessment of hand grip
- Assessment of orientation to person, time, & place
- Assessment of arm drift
- Assessment of gag reflex - Answer-- Assessment of gag reflex
RATIONALE: The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand
grip & arm drifting are part of motor function assessment. Orientation is an assessment parameter
related to a mental status examination.
A 72-year-old man has been brought to his PCP by his daughter, who claims he has been experiencing
uncharacteristic lapses in memory. What principle should underlie the nurse's assessment &
management of this patient?
- Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic
- Lapses in memory in older adults is considered benign unless they have negative consequences
- Gradual increases in confusion accompany the aging process
- Thorough assessment is necessary because changes in cognition are always considered to be
pathologic - Answer-- Thorough assessment is necessary because changes in cognition are always
considered to be pathologic
RATIONALE: Although mental processing time decreases with age, memory, language, & judgement
capacities remain intact. Change in mental status should never be assumed to be a normal part of aging.
,The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable
to follow verbal commands. How should the nurse proceed with assessing the patient's LOC?
- Assess the patient's VS & correlate these with the patient's baselines
- Assess the patient's eye opening & response to stimuli
- Document that the patient currently lacks a LOC
- Facilitate diagnostic testing in an effort to obtain objective data - Answer-- Assess the patient's eye
opening & response to stimuli
RATIONALE: If the patient is not alert or able to follow commands, the examiner observes for eye
opening; verbal response & motor response to stimuli, if any; & the type of stimuli needed to obtain a
response. VS & diagnostic testing are appropriate, but neither will allow the nurse to gauge the patient's
LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.
A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in
cerebral edema. When planning this patient's care, the nurse would expect to administer what priority
medication?
- Hydrochlorothiazide (HydroDIURIL)
- Furosemide (Lasix)
- Mannitol (Osmitrol)
- Spirolactone (Aldactone_ - Answer-- Mannitol (Osmitrol_
RATIONALE: The osmotic diuretic mannitol is given to dehydrate the brain tissue & reduce cerebral
edema. This drug acts by reducing the volume of brain & extracellular fluid. Spirolactone, furosemide, &
hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting
from cerebral edema.
The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest
priority?
- Maintaining accurate records of I&O
- Maintaining a patent airway
, - Inserting an NG tube as ordered
- Providing appropriate pain control - Answer-- Maintaining a patent airway
RATIONALE: Maintaining a patent airway always takes top priority, even though each of the other listed
actions is necessary & appropriate.
The nurse is caring for a patient in the ICU who has a brain stem herniation & who is exhibiting an
altered LOC. Monitoring reveals that the patients MAP is 60 mmHg with an ICP reading of 5 mmHg.
What is the nurse's most appropriate action?
- Position the patient in the high Fowler's position as tolerated
- Administer osmotic diuretics as ordered
- Participate in interventions to increased cerebral perfusion pressure
- Prepare the patient for craniotomy - Answer-- Participate in interventions to increased cerebral
perfusion pressure
RATIONALE: The cerebral perfusion pressure (CPP) is 55 mmHg, which is considered low. The normal
CPP is 70 to 100 mmHg. Patients with a CPP of less than 50 mmHg experience irreversible neurologic
damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics &
increased height of bed would exacerbate the patient's condition.
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of
care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction & osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?
- Change the patient's position as indicated
- Monitor serum electrolytes
- Maintain NPO status
- Monitor ABG values - Answer-- Monitor serum electrolytes
