TEST BANK
Chapters 61–69
Complete Test Banks covering all chapters (1 to 69)
are available in the bundled package
,Table of Contents are given below
61. Acute Intracranial Problems
62. Stroke
63. Chronic Neurologic Problems
64. Dementia and Delirium
65. Spinal Cord and Nerve Problems
66. Assessment: Musculoskeletal System
67. Musculoskeletal Trauma and Orthopedic Surgery
68. Musculoskeletal Problems
69. Arthritis and Connective Tissue Diseases
,
, address the tam1ly quest:lon about purpose tor this pat:lent. lerminology
such as ventriculostomy and cerebral perfusion pressure is too complex
for the initial explanation and may increase family members' anxiety.
_J
Question 2 pts
Admission vital signs for a patient who has a brain injury are blood pressure of
128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min.
Which set of vital signs, if taken 1 hour later, would be of most concern to the
nurse?
➔
Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min
Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min
Blood pressure 148/78 mm Hg, pulse 112 beats/min. respirations 28
breaths/min
Blood pressure 110/70 mm Hg, pulse 120 beats/min. respirations 30
breaths/min
Systolic hypertension with widening pulse pressure, bradycardia, and
respiratory changes represent Cushing's triad. These findings 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.
Question 3 pts
When a brain-injured patient responds to nail bed pressure with internal
rotation, adduction, and flexion of the arms, how would the nurse report the
response?
Flexion withdrawal
Localization of pain
➔ Decorticate posturing
Decerebrate posturing
Internal rotation, adduction, and flexion of the arms in an unconscious
patient is documented as decorticate posturing. Extension of the arms
and legs is decerebrate posturing. Because the flexion is generalized, it
does not indicate localization of pain or flexion withdrawal.
Question 4 pts
The nurse has administered prescribed IV mannitol to an unconscious patient.
Which parameter would the nurse monitor to determine the medication's
effectiveness?
Blood pressure
Chapters 61–69
Complete Test Banks covering all chapters (1 to 69)
are available in the bundled package
,Table of Contents are given below
61. Acute Intracranial Problems
62. Stroke
63. Chronic Neurologic Problems
64. Dementia and Delirium
65. Spinal Cord and Nerve Problems
66. Assessment: Musculoskeletal System
67. Musculoskeletal Trauma and Orthopedic Surgery
68. Musculoskeletal Problems
69. Arthritis and Connective Tissue Diseases
,
, address the tam1ly quest:lon about purpose tor this pat:lent. lerminology
such as ventriculostomy and cerebral perfusion pressure is too complex
for the initial explanation and may increase family members' anxiety.
_J
Question 2 pts
Admission vital signs for a patient who has a brain injury are blood pressure of
128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min.
Which set of vital signs, if taken 1 hour later, would be of most concern to the
nurse?
➔
Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min
Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min
Blood pressure 148/78 mm Hg, pulse 112 beats/min. respirations 28
breaths/min
Blood pressure 110/70 mm Hg, pulse 120 beats/min. respirations 30
breaths/min
Systolic hypertension with widening pulse pressure, bradycardia, and
respiratory changes represent Cushing's triad. These findings 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.
Question 3 pts
When a brain-injured patient responds to nail bed pressure with internal
rotation, adduction, and flexion of the arms, how would the nurse report the
response?
Flexion withdrawal
Localization of pain
➔ Decorticate posturing
Decerebrate posturing
Internal rotation, adduction, and flexion of the arms in an unconscious
patient is documented as decorticate posturing. Extension of the arms
and legs is decerebrate posturing. Because the flexion is generalized, it
does not indicate localization of pain or flexion withdrawal.
Question 4 pts
The nurse has administered prescribed IV mannitol to an unconscious patient.
Which parameter would the nurse monitor to determine the medication's
effectiveness?
Blood pressure
