NUR417 / NUR 417
FINAL EXAM
Care of Adult II, Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
100% Guarantee Pass.
Expert Verified Explanation
Multiple choice (single best
answer)
Select All That Apply (SATA)
Fill-in-the-blank
Case Studies/Scenario-Based Questions
,1. The nurse is providing care for a patient who has been admitted to the hospital with a head
injury and who requires regular neurologic and vital sign assessment. Which assessments will
be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)?
A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best verbal response
E. Best motor response
F. Cranial nerve function
ANSWERS:B,D,E
The three dimensions of the GCS are eye opening, best verbal response, and best motor response.
Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.
2. A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and
does not respond to a verbal command to move but attempts to remove a painful stimulus. The
nurse records the patient's Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15.
ANSWER: B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
DIF: Cognitive Level: Application REF: 1434
3. A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and
respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most
concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
, ANSWER: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent
Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be
imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for
changes in treatment, but they are not indicative of an immediately life-threatening process.
DIF: Cognitive Level: Application REF: 1429-1430
4. An unconscious patient 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. Keep the head of the bed elevated to 30 degrees.
b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.
ANSWER: A
The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help
reduce ICP. 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.
DIF: Cognitive Level: Application REF: 1436-1437
5. A patient who is suspected of having an epidural hematoma is admitted to the emergency
department. Which action will the nurse plan to take?
a. Administer IV furosemide (Lasix).
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.
ANSWER:D
The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent
herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate
therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood
loss occurs with head injuries, and transfusion is usually not necessary.
6. A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg.
Which action should the nurse take first?
, a. Elevate the head of the patient's bed to 60 degrees.
b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP.
ANSWER: C
The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and
approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as
fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure.
Adjustments in the head elevation should only be done after consulting with the health care provider.
Continued monitoring and documentation also will be done, but they are not the first actions that the nurse
should take.
7. The nurse on clinical unit is assigned to four patients. Which patient should she assess first?
a. Patient with a skull fracture whose nose is bleeding
b. Older patient with a stroke who is confused and whose daughter is present
c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10
scale
d. Patient who had a craniotomy for a brain tumor who now 3 days postoperative had had
continued vomiting
Answer:C
Rationale: The patient with meningitis should be seen first; patients with meningitis must be observed
closely for manifestations of elevated ICP, which is thought to result from swelling around the dura and
increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in
behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who
has undergone cranial surgery should be seen second; although nausea and vomiting are common after
cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics.
The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nose bleed and
should be seen third. Confusion after a stroke may be expected; the patient should have a family member
present.
8. 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
FINAL EXAM
Care of Adult II, Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
100% Guarantee Pass.
Expert Verified Explanation
Multiple choice (single best
answer)
Select All That Apply (SATA)
Fill-in-the-blank
Case Studies/Scenario-Based Questions
,1. The nurse is providing care for a patient who has been admitted to the hospital with a head
injury and who requires regular neurologic and vital sign assessment. Which assessments will
be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)?
A. Judgment
B. Eye opening
C. Abstract reasoning
D. Best verbal response
E. Best motor response
F. Cranial nerve function
ANSWERS:B,D,E
The three dimensions of the GCS are eye opening, best verbal response, and best motor response.
Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.
2. A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and
does not respond to a verbal command to move but attempts to remove a painful stimulus. The
nurse records the patient's Glasgow Coma Scale score as
a. 9.
b. 11.
c. 13.
d. 15.
ANSWER: B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
DIF: Cognitive Level: Application REF: 1434
3. A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and
respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most
concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
, ANSWER: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent
Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be
imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for
changes in treatment, but they are not indicative of an immediately life-threatening process.
DIF: Cognitive Level: Application REF: 1429-1430
4. An unconscious patient 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. Keep the head of the bed elevated to 30 degrees.
b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.
ANSWER: A
The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help
reduce ICP. 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.
DIF: Cognitive Level: Application REF: 1436-1437
5. A patient who is suspected of having an epidural hematoma is admitted to the emergency
department. Which action will the nurse plan to take?
a. Administer IV furosemide (Lasix).
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.
ANSWER:D
The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent
herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate
therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood
loss occurs with head injuries, and transfusion is usually not necessary.
6. A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg.
Which action should the nurse take first?
, a. Elevate the head of the patient's bed to 60 degrees.
b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP.
ANSWER: C
The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and
approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as
fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure.
Adjustments in the head elevation should only be done after consulting with the health care provider.
Continued monitoring and documentation also will be done, but they are not the first actions that the nurse
should take.
7. The nurse on clinical unit is assigned to four patients. Which patient should she assess first?
a. Patient with a skull fracture whose nose is bleeding
b. Older patient with a stroke who is confused and whose daughter is present
c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10
scale
d. Patient who had a craniotomy for a brain tumor who now 3 days postoperative had had
continued vomiting
Answer:C
Rationale: The patient with meningitis should be seen first; patients with meningitis must be observed
closely for manifestations of elevated ICP, which is thought to result from swelling around the dura and
increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in
behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who
has undergone cranial surgery should be seen second; although nausea and vomiting are common after
cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics.
The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nose bleed and
should be seen third. Confusion after a stroke may be expected; the patient should have a family member
present.
8. 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
