NUR 417 Final Exam
*1. An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg, and an
intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as
____ mm Hg. *** ANS: 74
Calculate the CPP: (CPP = mean arterial pressure [MAP] ICP). MAP = DBP + 1/3 (systolic blood pressure
[SBP] diastolic blood pressure [DBP]). The MAP is 94. The CPP is 74.
*33. When admitting a 42-year-old patient with a possible brain injury after a car accident to the
emergency department (ED), the nurse obtains the following information. Which finding is most
important to report to the health care provider?
a. The patient takes warfarin (Coumadin) daily.
b. The patients blood pressure is 162/94 mm Hg.
c. The patient is unable to remember the accident.
d. The patient complains of a severe dull headache. *** ANS: A
The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately
reported. The other information would not be unusual in a patient with a head injury who had just
arrived in the ED.
26. After evacuation of an epidural hematoma, a patients intracranial pressure (ICP) is being monitored
with an intraventricular catheter. Which information obtained by the nurse is most important to
communicate to the health care provider?
a. Pulse 102 beats/min
b. Temperature 101.6 F
c. Intracranial pressure 15 mm Hg
d. Mean arterial pressure 90 mm Hg *** ANS: B
Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The
temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and
apical pulse are all borderline high but require only ongoing monitoring at this time.
,25. The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after
a motor vehicle crash. Which assessment finding is most important to report to the health care
provider?
a. Complaint of severe headache
b. Large contusion behind left ear
c. Bilateral periorbital ecchymosis
d. Temperature of 101.4 F (38.6 C) *** ANS: D
Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should
be reported to the health care provider. The other findings are typical of a patient with a basilar skull
fracture.
The nurse obtains these assessment findings for a patient who has a head injury. Which finding should
be reported rapidly to the health care provider?
a. Urine output of 800 mL in the last hour
b. Intracranial pressure of 16 mm Hg when patient is turned
c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour
d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg *** ANS: A
The high urine output indicates that diabetes insipidus may be developing and interventions to prevent
dehydration need to be rapidly implemented. The other data do not indicate a need for any change in
therapy.
24. After the emergency department nurse has received a status report on the following patients who
have been admitted with head injuries, which patient should the nurse assess first?
a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture
b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13
c. A 40-year-old patient who lost consciousness for a few seconds after a fall
d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light *** ANS: D
The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased
intracranial pressure. The other patients are not at immediate risk for complications such as herniation.
,21. After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a
traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?
a. Document the increase in intracranial pressure.
b. Ensure that the patients neck is in neutral position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprivan) infusion. *** ANS: B
Because suctioning will cause a transient increase in intracranial pressure, the nurse should initially
check for other factors that might be contributing to the increase and observe the patient for a few
minutes. Documentation is needed, but this is not the first action. There is no need to notify the health
care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or
agitation. There is no indication that anxiety has contributed to the increase in intracranial pressure.
The earliest signs of increased ICP the nurse should assess for include
a. Cushing's triad
b. unexpected vomiting
c. decreasing level of consciousness (LOC)
d. dilated pupil with sluggish response to light *** C.
One of the most sensitive signs of increased intracranial pressure (ICP) is a decreasing LOC. A decrease in
LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur
The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident.
Which change in vital signs would the nurse interpret as a manifestation of increased intracranial
pressure (ICP)?
A. Tachypnea
B. Bradycardia
C. Hypotension
D. Narrowing pulse pressure *** B
, Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with
increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia
with a full and bounding pulse, and irregular respirations.
19. When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data.
Which finding should be reported immediately to the health care provider?
a. The patient exhibits nuchal rigidity.
b. The patient has a positive Kernigs sign.
c. The patients temperature is 101 F (38.3 C).
d. The patients blood pressure is 88/42 mm Hg. *** d. The patients blood pressure is 88/42 mm Hg.
7. A 41-year-old patient who is unconscious 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. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods. *** ANS: C
The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to
help reduce ICP. Extreme 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.
A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response
except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The
nurse records the patients GCS score as
a. 6
b. 7
c. 9
*1. An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg, and an
intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as
____ mm Hg. *** ANS: 74
Calculate the CPP: (CPP = mean arterial pressure [MAP] ICP). MAP = DBP + 1/3 (systolic blood pressure
[SBP] diastolic blood pressure [DBP]). The MAP is 94. The CPP is 74.
*33. When admitting a 42-year-old patient with a possible brain injury after a car accident to the
emergency department (ED), the nurse obtains the following information. Which finding is most
important to report to the health care provider?
a. The patient takes warfarin (Coumadin) daily.
b. The patients blood pressure is 162/94 mm Hg.
c. The patient is unable to remember the accident.
d. The patient complains of a severe dull headache. *** ANS: A
The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately
reported. The other information would not be unusual in a patient with a head injury who had just
arrived in the ED.
26. After evacuation of an epidural hematoma, a patients intracranial pressure (ICP) is being monitored
with an intraventricular catheter. Which information obtained by the nurse is most important to
communicate to the health care provider?
a. Pulse 102 beats/min
b. Temperature 101.6 F
c. Intracranial pressure 15 mm Hg
d. Mean arterial pressure 90 mm Hg *** ANS: B
Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The
temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and
apical pulse are all borderline high but require only ongoing monitoring at this time.
,25. The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after
a motor vehicle crash. Which assessment finding is most important to report to the health care
provider?
a. Complaint of severe headache
b. Large contusion behind left ear
c. Bilateral periorbital ecchymosis
d. Temperature of 101.4 F (38.6 C) *** ANS: D
Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should
be reported to the health care provider. The other findings are typical of a patient with a basilar skull
fracture.
The nurse obtains these assessment findings for a patient who has a head injury. Which finding should
be reported rapidly to the health care provider?
a. Urine output of 800 mL in the last hour
b. Intracranial pressure of 16 mm Hg when patient is turned
c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour
d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg *** ANS: A
The high urine output indicates that diabetes insipidus may be developing and interventions to prevent
dehydration need to be rapidly implemented. The other data do not indicate a need for any change in
therapy.
24. After the emergency department nurse has received a status report on the following patients who
have been admitted with head injuries, which patient should the nurse assess first?
a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture
b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13
c. A 40-year-old patient who lost consciousness for a few seconds after a fall
d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light *** ANS: D
The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased
intracranial pressure. The other patients are not at immediate risk for complications such as herniation.
,21. After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a
traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?
a. Document the increase in intracranial pressure.
b. Ensure that the patients neck is in neutral position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprivan) infusion. *** ANS: B
Because suctioning will cause a transient increase in intracranial pressure, the nurse should initially
check for other factors that might be contributing to the increase and observe the patient for a few
minutes. Documentation is needed, but this is not the first action. There is no need to notify the health
care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or
agitation. There is no indication that anxiety has contributed to the increase in intracranial pressure.
The earliest signs of increased ICP the nurse should assess for include
a. Cushing's triad
b. unexpected vomiting
c. decreasing level of consciousness (LOC)
d. dilated pupil with sluggish response to light *** C.
One of the most sensitive signs of increased intracranial pressure (ICP) is a decreasing LOC. A decrease in
LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur
The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident.
Which change in vital signs would the nurse interpret as a manifestation of increased intracranial
pressure (ICP)?
A. Tachypnea
B. Bradycardia
C. Hypotension
D. Narrowing pulse pressure *** B
, Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with
increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia
with a full and bounding pulse, and irregular respirations.
19. When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data.
Which finding should be reported immediately to the health care provider?
a. The patient exhibits nuchal rigidity.
b. The patient has a positive Kernigs sign.
c. The patients temperature is 101 F (38.3 C).
d. The patients blood pressure is 88/42 mm Hg. *** d. The patients blood pressure is 88/42 mm Hg.
7. A 41-year-old patient who is unconscious 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. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods. *** ANS: C
The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to
help reduce ICP. Extreme 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.
A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response
except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The
nurse records the patients GCS score as
a. 6
b. 7
c. 9
