NSG 4100 FINAL EXAM NEWEST 2025 ACTUAL
EXAM,COMPLETE QUESTIONS WITH ACTUAL
ANSWERS ALREADY GRADED A+.
what would require immediate intervention for a patient with head trauma? -
ANSWERS-- CSF drainage: meningitis infection can occur
- A depressed fracture - require surgery within 24 hrs
- A battle sign (bruising over the mastoid bone)
- Pts who pees ALOT - indicate dilute urine --> DI
- GCS - score <8
- Decorticate and Decerebrate posturing
- Changes in pupils
What would require immediate intervention for a patient with TBIs? - ANSWERS-
- Dolls eyes (dilation of eyes), fixation of pupils, paralysis of extremity --->
indicate herniation
- When Turing pt head to one side, and if eyes turn into the same direction = bad
response
- opposite direction = normal response
Clinical manifestations that require immediate intervention for acute SDH? -
ANSWERS-- Coma, increase BP, decreased HR, slow RR
What emergency procedure would be preformed for a patient with a epidural
hematoma? - ANSWERS-Burr holes - release blood accumulated in the between
the skull and dura bc it can cause neurological deficits and respiratory arrest
Early s/s of increased ICP - ANSWERS-- change in LOC - earliest
- disorientation, restlessness, increased respiratory effort (Kussmals), purposeless
movements, mental confusion,
- pupillary changes and impaired extraocular movements
-
late s/s of increased ICP (vital sign changes) - ANSWERS-- Cushing's Triad
, - bradycardia, bradypnea, widen pulse pressure (increased systolic, decreased
diastolic_
- increased BP and temp
Late signs of increased ICP - ANSWERS-- patient becomes erratic
- GCS score <8
- LOC continues to deteriorate
- Chain-stokes (rhythmic waxing and waning of ate and depth with brief episodes
of apnea
- Ataxic breathing - irregular breathing with random deep and shallow breath
- projectile vomiting
- hemiplegia
- decorticate
- decerebrate
- flaccidity before death
- loss of brain stem reflexes: pupillary, corneal, gag, and swallowing reflexes are
not present
(signs of approaching death)
Normal ICP pressure - ANSWERS-5-15 mmHg
Normal CPP - ANSWERS-70-100 mmHg
an ICP >25 indicates? - ANSWERS-worsening if pressure does not return within 5
minutes
a CPP <50mmHg indicates - ANSWERS-No blood glow and irreversible damage
What is the goal for a Craniotomy post op? - ANSWERS-- aimed at detecting and
reducing cerebral edema, relieve ing pain, preventing seizures, monitoring ICP,
and neurological status
Plan of care post op for a craniotomy? - ANSWERS-- reduce cerebral edema by
giving: mannitol, IV dexamethasone, and taper off when discontinuing
- relieve pain and decrease temp with:
- acetaminophen (mild)
- codeine and morphine - for intense pain
- prophylactic anticonvulsants: phenytoin and levetiracetam
- remove the ICP monitor as soon as ICP is regulated and is stable
, Post-op assessments for craniotomy? - ANSWERS-- Respiratory function ( s/s of
hypoxia, RR, pattern and ABGs)
- Temp (hyperthermia indicates infection; hypothermia during procedure)
- tx periorbital edema with cold compresses, this can last for 1-2 days
- neurological: Q15-60min, avoid head rotation, HOB 30 degrees, resposition
Q2H, promote deep breathing and IS use
- Assess foley - output >200ml indicate DI
What are complication of craniotomy? - ANSWERS-- increased ICP
- bleeding from site
- CSF leakage - emergency
- infections - assess with REEDA
- DI
- SIADH
- seizures
What pt are more susceptible to opportunistic variations of meningitis? -
ANSWERS-- college students
- Millitary personal
- dense community groups
- those who have not been vaccinated before
- tobacco users
- pt who have upper viral respiratory infections
- have otitis media
- pts with immune deficiencies
- pt with mastoiditis
- Aseptic meningitis can effect pt with (cancer, HIV, AIDS, weaken immune
system
Care of a client with encephalitis from herpes simplex? - ANSWERS-- Acyclovir -
early administration, continues for 3 weeks
- comfort measures to reduce headaches: cluster care, dim lights, limit noise, and
visitors, administer analgesics, place pt further away from the nurses station
- monitor for changes in LOC
- seizure precautions
Care of a client with encephalitis from arthropod-Borne virus? - ANSWERS-- No
TX; but report to the local health department
EXAM,COMPLETE QUESTIONS WITH ACTUAL
ANSWERS ALREADY GRADED A+.
what would require immediate intervention for a patient with head trauma? -
ANSWERS-- CSF drainage: meningitis infection can occur
- A depressed fracture - require surgery within 24 hrs
- A battle sign (bruising over the mastoid bone)
- Pts who pees ALOT - indicate dilute urine --> DI
- GCS - score <8
- Decorticate and Decerebrate posturing
- Changes in pupils
What would require immediate intervention for a patient with TBIs? - ANSWERS-
- Dolls eyes (dilation of eyes), fixation of pupils, paralysis of extremity --->
indicate herniation
- When Turing pt head to one side, and if eyes turn into the same direction = bad
response
- opposite direction = normal response
Clinical manifestations that require immediate intervention for acute SDH? -
ANSWERS-- Coma, increase BP, decreased HR, slow RR
What emergency procedure would be preformed for a patient with a epidural
hematoma? - ANSWERS-Burr holes - release blood accumulated in the between
the skull and dura bc it can cause neurological deficits and respiratory arrest
Early s/s of increased ICP - ANSWERS-- change in LOC - earliest
- disorientation, restlessness, increased respiratory effort (Kussmals), purposeless
movements, mental confusion,
- pupillary changes and impaired extraocular movements
-
late s/s of increased ICP (vital sign changes) - ANSWERS-- Cushing's Triad
, - bradycardia, bradypnea, widen pulse pressure (increased systolic, decreased
diastolic_
- increased BP and temp
Late signs of increased ICP - ANSWERS-- patient becomes erratic
- GCS score <8
- LOC continues to deteriorate
- Chain-stokes (rhythmic waxing and waning of ate and depth with brief episodes
of apnea
- Ataxic breathing - irregular breathing with random deep and shallow breath
- projectile vomiting
- hemiplegia
- decorticate
- decerebrate
- flaccidity before death
- loss of brain stem reflexes: pupillary, corneal, gag, and swallowing reflexes are
not present
(signs of approaching death)
Normal ICP pressure - ANSWERS-5-15 mmHg
Normal CPP - ANSWERS-70-100 mmHg
an ICP >25 indicates? - ANSWERS-worsening if pressure does not return within 5
minutes
a CPP <50mmHg indicates - ANSWERS-No blood glow and irreversible damage
What is the goal for a Craniotomy post op? - ANSWERS-- aimed at detecting and
reducing cerebral edema, relieve ing pain, preventing seizures, monitoring ICP,
and neurological status
Plan of care post op for a craniotomy? - ANSWERS-- reduce cerebral edema by
giving: mannitol, IV dexamethasone, and taper off when discontinuing
- relieve pain and decrease temp with:
- acetaminophen (mild)
- codeine and morphine - for intense pain
- prophylactic anticonvulsants: phenytoin and levetiracetam
- remove the ICP monitor as soon as ICP is regulated and is stable
, Post-op assessments for craniotomy? - ANSWERS-- Respiratory function ( s/s of
hypoxia, RR, pattern and ABGs)
- Temp (hyperthermia indicates infection; hypothermia during procedure)
- tx periorbital edema with cold compresses, this can last for 1-2 days
- neurological: Q15-60min, avoid head rotation, HOB 30 degrees, resposition
Q2H, promote deep breathing and IS use
- Assess foley - output >200ml indicate DI
What are complication of craniotomy? - ANSWERS-- increased ICP
- bleeding from site
- CSF leakage - emergency
- infections - assess with REEDA
- DI
- SIADH
- seizures
What pt are more susceptible to opportunistic variations of meningitis? -
ANSWERS-- college students
- Millitary personal
- dense community groups
- those who have not been vaccinated before
- tobacco users
- pt who have upper viral respiratory infections
- have otitis media
- pts with immune deficiencies
- pt with mastoiditis
- Aseptic meningitis can effect pt with (cancer, HIV, AIDS, weaken immune
system
Care of a client with encephalitis from herpes simplex? - ANSWERS-- Acyclovir -
early administration, continues for 3 weeks
- comfort measures to reduce headaches: cluster care, dim lights, limit noise, and
visitors, administer analgesics, place pt further away from the nurses station
- monitor for changes in LOC
- seizure precautions
Care of a client with encephalitis from arthropod-Borne virus? - ANSWERS-- No
TX; but report to the local health department
