NR340 Week 3 Evolve Practice Questions & Complete Study Guide

NR340 Week 3 Evolve Practice
Questions & Complete Study
Guide
(Complete solutions and resources for the course exam)




Questions

1. 1.ID: 43154241

What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on
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increased intracranial pressure (ICP)?
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o Lowering ICPby allowing for elevations in CO2 to dilate cerebral arteries
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o Lowering ICPby facilitating venous drainage and decreasing venous
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obstruction Correct j




o Lowering ICPby maintaining an open airway
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o Lowering ICPby reducing the risk of snoring
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Head-of-the-bed elevation and a neutral head position that avoids hyperextension or
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hyperflexion facilitate jugular venous drainage, helping to minimize increases in ICP.
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Elevated CO2 contributes to cerebral vessel vasodilation, which can increase cerebral blood
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volume and further elevate ICP. Maintaining an open airway alone does not minimize
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increases in ICP. Reducing the risk of snoring by maintaining an open airway alone does not
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minimize increases in ICP. j j j




Awarded 0.0 points out of 1.0 possible points.
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2. 2.ID: 43154255
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Under normal circumstances the cerebral vasculature exhibits pressure and chemical
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,autoregulation. What happens when autoregulation is lost?
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, o Central venous engorgement occurs. j j j




o Cerebral blood flow is not affected. j j j j j




o Hypertension increases cerebralblood flow. Correct j j j j j




o Shunting of cerebrospinal fluid (CSF) is blocked. j j j j j j




Autoregulation is the ability of the cerebral vessels to adjust their diameter in response to
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arterial pressure changes within the brain. If mean arterial blood pressure rises, cerebral
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vessels will constrict to prevent excessive distention of the cerebral arteries. When
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autoregulation is lost, cerebral vessels are no longer able to regulate diameter and as a result
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hypertension increases cerebral perfusion pressure. Cerebral vessels may become engorged
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as a result of the loss of autoregulation. Cerebral blood flow is affected with the loss of
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autoregulation. Loss of autoregulation does not block CSF flow. j j j j j j j j




Awarded 0.0 points out of 1.0 possible points.
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3. 3.ID: 43154263 j




The nurse is monitoring a patient’s intracranial pressure (ICP). While the nurse is providing
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hygiene measures, she observes that the ICPreading is sustained at 18 mm Hg. What is the
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priority nursing action? j j




o Cease stimulating the patient. Correct j j j j




o Continue with hygiene measures. j j j




o Lower the head of the bed to 10 degrees. j j j j j j j j




o Open the ICPmonitor to continuous drainage. j j j j j j




Sustained increases in ICPshould be avoided. Nursing care activities should be spaced to
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prevent an increase in ICP. Actions that cause a sustained elevation in ICP should be avoided
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until ICP returns to baseline resting values. Elevating the head of the bed to 30 degrees or
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more can help reduce ICP. Continuous drainage of CSF fluid will result in herniation.
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Awarded 0.0 points out of 1.0 possible points.
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4. 4.ID: 43154273 j

, Herniation syndromes can be life-threatening situations. Which syndrome causes the
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supratentorial contents to shift downward and compress vital centers of the brainstem? j j j j j j j j j j j




o Central herniation Correct j j




o Cingulate herniation j




o Tonsillar herniation j




o Uncal herniation j




A downward shift of the cerebral hemispheres, basal ganglia, and diencephalon through the
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tentorial notch causes central herniation, which compresses the vital centers of the brainstem.
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This results in a shift of one cerebral hemisphere under the falx cerebri to the other cerebral
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hemisphere. Cerebellar tonsils are displaced through the foramen magnum, causing fatal
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damage to the respiratory and cardiac centers. Uncal herniation compresses the midbrain,
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causing dysfunction of the ipsilateral third nerve, resulting in unilateral pupil dilation.
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Awarded 0.0 points out of 1.0 possible points. j j j j j j j




5. 5.ID: 43154282 j




In a patient with increased intracranial pressure (ICP), which of the following cranial nerves
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would be assessed for consensual light response, elevation of the eyelids, and eye movement?
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o I, IX, X j j




o II,V,VII j j




o II, VI, X j j




o III,IV,VICorrect j j j




Cranial nerve III is responsible for the consensual light response, elevation of the eyelids, and
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eye movements. In addition, cranial nerves III, IV, and VI affect extraocular eye movements.
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Awarded 0.0 points out of 1.0 possible points. j j j j j j j