CVA NCLEX real Actual EXAM 2 Complete Verified Questions And Correct Detailed Answers with Rationales Graded A+ Guaranteed Pass

CVA NCLEX real Actual EXAM

CVA NCLEX real Actual EXAM 2 Complete
Verified Questions And Correct Detailed
Answers with Rationales Graded A+
Guaranteed Pass




Which Glasgow Coma Scale score is indicative of a severe head injury?
A. 11
B. 7
C. 9
D. 13
B. 7
Rationale:A score between 3 and 8 is generally accepted as indicating a severe head injury.
The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale
(GCS) score of 7. This score is generally interpreted as
A. most responsive.
B. minimally responsive.


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C. coma.
D. least responsive.
C. coma
Rationale:The GCS is a tool for assessing a client's response to stimuli. A score of 7 or less is
generally interpreted as a coma. The lowest score is 3 (least responsive/deep coma); the highest
is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head
injury. No category is termed "least" responsive.
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a
head injury?
A. Increased respirations
B. Widened pulse pressure
C. Increased pulse
D. Decreased body temperature
B. Widened pulse pressure
Rationale:Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing
systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression
increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse
slows further. This is an ominous development, as is a rapid fluctuation of vital signs.
Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may
indicate that bleeding is occurring elsewhere in the body.
Select the main structures below that play a role with altering intracranial pressure:
A. Brain
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Periosteum
F. Dura mater
The answers are A, C, and D.
Inside the skull are three structures that can alter intracranial pressure. They are the brain,
cerebrospinal fluid (CSF), and blood
The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the
skull that play a role with intracranial pressure. Which of the following are NOT compensatory
mechanisms performed by the body to decrease intracranial pressure naturally? Select all that
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apply:

A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord
B. Vasodilation of cerebral vessels
C. Decreasing cerebrospinal fluid production
D. Leaking proteins into the brain barrier
The answers are B and D.


These are NOT compensatory mechanisms, but actions that will actually increase intracranial
pressure. Vasoconstriction (not dilation) decreases blood flow and helps lower ICP. Leaking of
protein actually leads to more swelling of the brain tissue. Remember water is attracted to
protein (oncotic pressure).
A patient is being treated for increased intracranial pressure. Which activities below should the
patient avoid performing?
A. Coughing
B. Sneezing
C. Talking
D. Valsalva maneuver
E. Vomiting
F. Keeping the head of the bed between 30- 35 degrees
The answers are A, B, D, and E. These activities can increase ICP.
A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of
20 mmHg. As the nurse you know that the PaCO2 level will?
A. cause vasoconstriction and decrease the ICP
B. promote diuresis and decrease the ICP
C. cause vasodilation and increase the ICP
D. cause vasodilation and decrease the ICP
The answer is C.


An elevated carbon dioxide level (52 is high...normal 35-45) in the blood will cause vasodilation
(NOT constriction), which will increase ICP (normal ICP 5 to 15 mmHg). Therefore, many patients
with severe ICP may need to be mechanical ventilated so PaCO2 levels can be lowered (30-35),
which will lead to vasoconstriction and decrease ICP (with constriction there is less blood volume
and flow going to the brain and this helps decrease pressure)....remember Monro-Kellie
hypothesis.
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You're providing education to a group of nursing students about ICP. You explain that when
cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies.
A student asks, "What is a normal cerebral perfusion pressure level?" Your response is:
A. 5-15 mmHg
B. 60-100 mmHg
C. 30-45 mmHg
D. >160 mmHg


The answer is B.
This is a normal CPP. Option A represents a normal intracranial pressure.
Which patient below is at MOST risk for increased intracranial pressure?

A. A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brain injury.
C. A patient who recently experienced a myocardial infarction.
D. A patient post-op from eye surgery.
The answer is B.


Remember head trauma, cerebral hemorrhage, hematoma, hydrocephalus, tumor, encephalitis
etc. can all increase ICP.
A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65,
Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based
on these findings you would?
A. Administered PRN dose of a vasopressor
B. Administer 2 L of oxygen
C. Remove extra blankets and give the patient a cool bath
D. Perform suctioning


The answer is C.


It is important to monitor the patient for hyperthermia (a fever). A fever increases ICP and
cerebral blood volume, and metabolic needs of the patient. The nurse can administer
antipyretics per MD order, remove extra blankets, decrease room temperature, give a cool bath

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