NR 341 COMPLEX ADULT HEALTH ACTUAL EXAM LATEST
2024/2025 QUESTIONS AND VERIFIED CORRECT
ANSWERS/ALREADY GRADED A++
What is the max GCS score? - ANSWER 15
What is the minimum GCS score? - ANSWER 3
What GCS score should you intubate? - ANSWER 8 and under
What are the limitations of the GCS? - ANSWER age, drugs, and language
What is normal intracranial pressure (ICP)? - ANSWER 5-15 mmHg
What are the signs and symptoms of increased ICP? - ANSWER change in
LOC, change in speech, change in vital signs, seizures, headache,
vomiting, eye changes, posture changes
What is the first sign of increased ICP? - ANSWER changes in LOC
What is cushing's triad? - ANSWER an effect of increased ICP of increased
systolic BP, decreased pulse, and cheyne-stokes respirations
What is Cheyne-Stokes respiration? - ANSWER it is an abnormal rhythm of
breathing with alternation periods of hyperventilation and apnea
What is Kussmaul respiration? - ANSWER deep, rapid breathing often
induced by acidosis
What condition does Kussmaul respirations commonly occur with? -
ANSWER DKA
What posture changes occurs with increased ICP? - ANSWER
decerebrate, decorticate,or flaccid
What is decerebrate posturing? - ANSWER Extensor response; problem
with midbrain or pons
,What is decorticate posturing? - ANSWER Flexor response; problem with
cervical spinal tract or cerebral hemisphere
What are the eye changes that occur with increased ICP? - ANSWER
papilledema, pupillary changes, impaired eye movement
What is a common cause of increased brain volume? - ANSWER cerebral
edema; can also be caused by a tumor or meningitis
What causes increased blood volume? - ANSWER loss of auto-regulation,
decreased oxygenation, hypercapnia, increased metabolic demands, and
obstruction of venous outflow
What causes increased cerebrospinal fluid? - ANSWER hydrocephalus,
blockage of normal flow, obstruction of normal re-absorption, and excess
production of CSF
What is cerebral perfusion pressure (CPP) dependent upon? - ANSWER
intracranial pressure (ICP) and mean arterial pressure (MAP)
What is a normal cerebral perfusion pressure (CPP)? - ANSWER 50-70
What does a low cerebral perfusion pressure (CPP) result in? - ANSWER
loss of auto-regulation and hypoxic insult to brain tissue
Nursing Mgmt. ICP: What is the maintenance goal of ICP? - ANSWER ICP
< 20 mmHg
Nursing Mgmt. ICP: What is the maintenance goal of CPP? - ANSWER <
70 mmHg
Nursing Mgmt. ICP: Care should be ________ to allow rest. - ANSWER
spaced
Nursing Mgmt. ICP: Suctioning should be _______. - ANSWER
minimum/PRN
Nursing Mgmt. ICP: What should the HOB be at? - ANSWER 30-45
degrees (Semi-Fowler's); keep neck in neutral position
,Nursing Mgmt. ICP: Why should hyperthermia be avoided? - ANSWER to
help reduce metabolic and oxygen demand
Nursing Mgmt. ICP: How should the patient be kept? - ANSWER
normovolemic
What is normovolemic? - ANSWER normal blood volume
What electrolytes should be monitored with ICP mgmt.? - ANSWER sodium
--> seizures
What all should be monitored with ICP mgmt.? - ANSWER ICP,
electrolytes, ABG's vital signs, daily weights, strict I&O, diabetes insipidus
(DI), and SIADH
What tubes should be placed with increased ICP? - ANSWER NG tube or
orogastric tube
Which tube is preferred with patients who have facial fractures or skull
fractures? - ANSWER orogastric tube
Nursing Mgmt. ICP: What forms of management should be given? -
ANSWER airway, pain and anxiety (sedate)
Nursing Mgmt. ICP: How should the transducer be kept? - ANSWER at
level with the drain
What is diabetes insipidus? - ANSWER a disorder caused by inadequate
amounts of ADH which causes excessive water loss
What are the signs and symptoms of diabetes insipidus? - ANSWER
polyuria, low urine specific gravity, increased diuresis, increased sodium,
decreased potassium
What is the nursing management of diabetes insipidus? - ANSWER
vasopressin
What is SIADH? - ANSWER abnormal stimulation to the hypothalamic area
of the brain, causing excessive secretion of antidiuretic hormone
(Vasopressin)
, What are the signs and symptoms of SIADH? - ANSWER oliguria, high
urine specific gravity, fluid retention, decreased diuresis, decreased
sodium, increased potassium
What is the nursing management of SIADH? - ANSWER fluid restrictions
administer potassium
sodium restriction
diuretics
Demeclocycline drug use to suppress vasopressin
What is the normal urine specific gravity? - ANSWER 1.000-1.030
Nursing Mgmt. ICP: What should be avoided with increased ICP? -
ANSWER extreme hip flexion, valsalva maneuver, coughing, sneezing,
hypoxemia, and sudden arousal from sleep
What is the valsalva maneuver? - ANSWER Exhaling forcibly with the
glottis closed
What is hypoxemia? - ANSWER low oxygen in the blood
Nursing Mgmt. ICP: Why should extreme hip flexion be avoided? -
ANSWER to protect the patient from injury
Medical Mgmt. ICP: Adequate oxygenation - ANSWER goal PaO2, airway
vigilance/watching, mechanical ventilation, adequate hematocrit
Medical Mgmt. ICP: What is normal hematocrit levels? - ANSWER men:
42-54%
women: 38-46%
Medical Mgmt. ICP: What is the PaO2 goal? - ANSWER > 80 mmHg
Medical Mgmt. ICP: Carbon Dioxide Management - ANSWER goal PaCO2
and avoid hyperventilation
Medical Mgmt. ICP: What is the goal PaCO2? - ANSWER 35-45 mmHg
2024/2025 QUESTIONS AND VERIFIED CORRECT
ANSWERS/ALREADY GRADED A++
What is the max GCS score? - ANSWER 15
What is the minimum GCS score? - ANSWER 3
What GCS score should you intubate? - ANSWER 8 and under
What are the limitations of the GCS? - ANSWER age, drugs, and language
What is normal intracranial pressure (ICP)? - ANSWER 5-15 mmHg
What are the signs and symptoms of increased ICP? - ANSWER change in
LOC, change in speech, change in vital signs, seizures, headache,
vomiting, eye changes, posture changes
What is the first sign of increased ICP? - ANSWER changes in LOC
What is cushing's triad? - ANSWER an effect of increased ICP of increased
systolic BP, decreased pulse, and cheyne-stokes respirations
What is Cheyne-Stokes respiration? - ANSWER it is an abnormal rhythm of
breathing with alternation periods of hyperventilation and apnea
What is Kussmaul respiration? - ANSWER deep, rapid breathing often
induced by acidosis
What condition does Kussmaul respirations commonly occur with? -
ANSWER DKA
What posture changes occurs with increased ICP? - ANSWER
decerebrate, decorticate,or flaccid
What is decerebrate posturing? - ANSWER Extensor response; problem
with midbrain or pons
,What is decorticate posturing? - ANSWER Flexor response; problem with
cervical spinal tract or cerebral hemisphere
What are the eye changes that occur with increased ICP? - ANSWER
papilledema, pupillary changes, impaired eye movement
What is a common cause of increased brain volume? - ANSWER cerebral
edema; can also be caused by a tumor or meningitis
What causes increased blood volume? - ANSWER loss of auto-regulation,
decreased oxygenation, hypercapnia, increased metabolic demands, and
obstruction of venous outflow
What causes increased cerebrospinal fluid? - ANSWER hydrocephalus,
blockage of normal flow, obstruction of normal re-absorption, and excess
production of CSF
What is cerebral perfusion pressure (CPP) dependent upon? - ANSWER
intracranial pressure (ICP) and mean arterial pressure (MAP)
What is a normal cerebral perfusion pressure (CPP)? - ANSWER 50-70
What does a low cerebral perfusion pressure (CPP) result in? - ANSWER
loss of auto-regulation and hypoxic insult to brain tissue
Nursing Mgmt. ICP: What is the maintenance goal of ICP? - ANSWER ICP
< 20 mmHg
Nursing Mgmt. ICP: What is the maintenance goal of CPP? - ANSWER <
70 mmHg
Nursing Mgmt. ICP: Care should be ________ to allow rest. - ANSWER
spaced
Nursing Mgmt. ICP: Suctioning should be _______. - ANSWER
minimum/PRN
Nursing Mgmt. ICP: What should the HOB be at? - ANSWER 30-45
degrees (Semi-Fowler's); keep neck in neutral position
,Nursing Mgmt. ICP: Why should hyperthermia be avoided? - ANSWER to
help reduce metabolic and oxygen demand
Nursing Mgmt. ICP: How should the patient be kept? - ANSWER
normovolemic
What is normovolemic? - ANSWER normal blood volume
What electrolytes should be monitored with ICP mgmt.? - ANSWER sodium
--> seizures
What all should be monitored with ICP mgmt.? - ANSWER ICP,
electrolytes, ABG's vital signs, daily weights, strict I&O, diabetes insipidus
(DI), and SIADH
What tubes should be placed with increased ICP? - ANSWER NG tube or
orogastric tube
Which tube is preferred with patients who have facial fractures or skull
fractures? - ANSWER orogastric tube
Nursing Mgmt. ICP: What forms of management should be given? -
ANSWER airway, pain and anxiety (sedate)
Nursing Mgmt. ICP: How should the transducer be kept? - ANSWER at
level with the drain
What is diabetes insipidus? - ANSWER a disorder caused by inadequate
amounts of ADH which causes excessive water loss
What are the signs and symptoms of diabetes insipidus? - ANSWER
polyuria, low urine specific gravity, increased diuresis, increased sodium,
decreased potassium
What is the nursing management of diabetes insipidus? - ANSWER
vasopressin
What is SIADH? - ANSWER abnormal stimulation to the hypothalamic area
of the brain, causing excessive secretion of antidiuretic hormone
(Vasopressin)
, What are the signs and symptoms of SIADH? - ANSWER oliguria, high
urine specific gravity, fluid retention, decreased diuresis, decreased
sodium, increased potassium
What is the nursing management of SIADH? - ANSWER fluid restrictions
administer potassium
sodium restriction
diuretics
Demeclocycline drug use to suppress vasopressin
What is the normal urine specific gravity? - ANSWER 1.000-1.030
Nursing Mgmt. ICP: What should be avoided with increased ICP? -
ANSWER extreme hip flexion, valsalva maneuver, coughing, sneezing,
hypoxemia, and sudden arousal from sleep
What is the valsalva maneuver? - ANSWER Exhaling forcibly with the
glottis closed
What is hypoxemia? - ANSWER low oxygen in the blood
Nursing Mgmt. ICP: Why should extreme hip flexion be avoided? -
ANSWER to protect the patient from injury
Medical Mgmt. ICP: Adequate oxygenation - ANSWER goal PaO2, airway
vigilance/watching, mechanical ventilation, adequate hematocrit
Medical Mgmt. ICP: What is normal hematocrit levels? - ANSWER men:
42-54%
women: 38-46%
Medical Mgmt. ICP: What is the PaO2 goal? - ANSWER > 80 mmHg
Medical Mgmt. ICP: Carbon Dioxide Management - ANSWER goal PaCO2
and avoid hyperventilation
Medical Mgmt. ICP: What is the goal PaCO2? - ANSWER 35-45 mmHg
