GNRS 558, Intermediate Medical-Surgical Care of the Adult,
GNRS 558 WEEK 8 Final Exam 2025 LATEST
ACTUAL SUMMER –FALL SESSION GRADED A
(SOLVED) APU
THIS EXAM CONTAINS 200 CORRECTLY ANSWERED QUESTIONS
The nurse provides care for a client dx with IICP. Which is the most important short-term goal?
1. Encourage coughing & deep breathing
2. maintain client in supine position with limited movement
3. Control agitation and restlessness
4. avoid bright lights
3. Control agitation and restlessness
The nurse provides care for a client dx with IICP as the result of a closed head inury. The client is
unconscious with an intracranial pressure monitoring device in place. Which is the most appropriate
position for the nurse to place this client after perfoming nursing care activities?
1. High-fowlers
2. Semi-Fowlers
3. Right lateral recumbent
4. Supine
2. Semi-Fowlers
,GNRS 558, Intermediate Medical-Surgical Care of the Adult,
The nurse provides care for a client dx with severa TBI. The client has been placed on a FR. The client has
an intraventricular monitor in place and the ICP reading is 25 mm Hg. What is the rationale for the FR?
1. to decrease cerebral edema.
2. to decrease peripheral edema
3. to decrease the need for suctioning
4. to decrease the risk for respiratory complications
1. to decrease cerebral edema.
While providing care for a client dx with an intraranial bleed, the nurse notes the pupils are unequal at
2mm and 5mm, the larger pupil is non-reactive to light, and the client only responds to pain. Which
explanation does the nurse determine based on this assessment?
1. the client is blind in one eye.
2. the client has symptoms of IICP
3. These are expected effects from narcotions the client received
4. these findings are abnormal but not significant
2. the client has symptoms of IICP
The nurse cares for a client with IICP. Which activities contribute to IICP? (Select all that apply)
1. A quiet enviorment
2. Hand restraints
3. Having a bowel movement
4. Listening to soft music
,GNRS 558, Intermediate Medical-Surgical Care of the Adult,
5. Watching television
2. Hand restraints
3. Having a bowel movement
The nurse performs an assessment for a client reporting severe headaches and new onset of seizure
activity. At the begining of the shift, the client is talking with family and VS are WNL. 6 hours later, the
nurse finds the client difficult to rouse and unable to speak coherently. The systolic BP is elvated, pulse
pressure is widening, and the client has bradycardia. Which is the most correct interpretation of these
findings?
1. Increasing ICP
2. recent tonic clonic seizure activity
3. phenytoin toxicity
4. severe hypertension
1. Increasing ICP
Which should the nurse include in the plan of care for a cient dx with ICP?
1. Frequently suciton the airway
2. Teach the client to avoid the Valsalva maneuver
3. Position the client supine in a dark room
4. Withold sedatives when the ICP is greater than 20 mm Hg
2. Teach the client to avoid the Valsalva maneuver
, GNRS 558, Intermediate Medical-Surgical Care of the Adult,
A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients
cerebral perfusion pressure, what should the nurse anticipate for this client?
a. Impending brain herniation
b. Poor prognosis and cognitive function
c. Probable complete recovery
d. Unable to tell from this information
ANS: B
The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial
pressure: in this case, 60 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client
has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction
should the client survive. This data does not indicate impending brain herniation or complete recovery.
A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60
beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by
the nurse takes priority?
a. Call the provider or Rapid Response Team.
b. Increase the rate of the IV fluid administration.
c. Notify respiratory therapy for a breathing treatment.
d. Prepare to give IV pain medication.
ANS: A
These manifestations indicate Cushings syndrome, a potentially life-threatening increase in intracranial
pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies
the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not
need a breathing treatment or pain medication
GNRS 558 WEEK 8 Final Exam 2025 LATEST
ACTUAL SUMMER –FALL SESSION GRADED A
(SOLVED) APU
THIS EXAM CONTAINS 200 CORRECTLY ANSWERED QUESTIONS
The nurse provides care for a client dx with IICP. Which is the most important short-term goal?
1. Encourage coughing & deep breathing
2. maintain client in supine position with limited movement
3. Control agitation and restlessness
4. avoid bright lights
3. Control agitation and restlessness
The nurse provides care for a client dx with IICP as the result of a closed head inury. The client is
unconscious with an intracranial pressure monitoring device in place. Which is the most appropriate
position for the nurse to place this client after perfoming nursing care activities?
1. High-fowlers
2. Semi-Fowlers
3. Right lateral recumbent
4. Supine
2. Semi-Fowlers
,GNRS 558, Intermediate Medical-Surgical Care of the Adult,
The nurse provides care for a client dx with severa TBI. The client has been placed on a FR. The client has
an intraventricular monitor in place and the ICP reading is 25 mm Hg. What is the rationale for the FR?
1. to decrease cerebral edema.
2. to decrease peripheral edema
3. to decrease the need for suctioning
4. to decrease the risk for respiratory complications
1. to decrease cerebral edema.
While providing care for a client dx with an intraranial bleed, the nurse notes the pupils are unequal at
2mm and 5mm, the larger pupil is non-reactive to light, and the client only responds to pain. Which
explanation does the nurse determine based on this assessment?
1. the client is blind in one eye.
2. the client has symptoms of IICP
3. These are expected effects from narcotions the client received
4. these findings are abnormal but not significant
2. the client has symptoms of IICP
The nurse cares for a client with IICP. Which activities contribute to IICP? (Select all that apply)
1. A quiet enviorment
2. Hand restraints
3. Having a bowel movement
4. Listening to soft music
,GNRS 558, Intermediate Medical-Surgical Care of the Adult,
5. Watching television
2. Hand restraints
3. Having a bowel movement
The nurse performs an assessment for a client reporting severe headaches and new onset of seizure
activity. At the begining of the shift, the client is talking with family and VS are WNL. 6 hours later, the
nurse finds the client difficult to rouse and unable to speak coherently. The systolic BP is elvated, pulse
pressure is widening, and the client has bradycardia. Which is the most correct interpretation of these
findings?
1. Increasing ICP
2. recent tonic clonic seizure activity
3. phenytoin toxicity
4. severe hypertension
1. Increasing ICP
Which should the nurse include in the plan of care for a cient dx with ICP?
1. Frequently suciton the airway
2. Teach the client to avoid the Valsalva maneuver
3. Position the client supine in a dark room
4. Withold sedatives when the ICP is greater than 20 mm Hg
2. Teach the client to avoid the Valsalva maneuver
, GNRS 558, Intermediate Medical-Surgical Care of the Adult,
A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients
cerebral perfusion pressure, what should the nurse anticipate for this client?
a. Impending brain herniation
b. Poor prognosis and cognitive function
c. Probable complete recovery
d. Unable to tell from this information
ANS: B
The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial
pressure: in this case, 60 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client
has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction
should the client survive. This data does not indicate impending brain herniation or complete recovery.
A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60
beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by
the nurse takes priority?
a. Call the provider or Rapid Response Team.
b. Increase the rate of the IV fluid administration.
c. Notify respiratory therapy for a breathing treatment.
d. Prepare to give IV pain medication.
ANS: A
These manifestations indicate Cushings syndrome, a potentially life-threatening increase in intracranial
pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies
the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not
need a breathing treatment or pain medication
