ICU Exam 2 Questions With 100%
Verified Answers
The nurse is caring for a patient with increased intracranial pressure
(ICP). The patient has a nursing diagnosis of "ineffective cerebral
tissue perfusion." What would be an expected outcome that the
nurse would document for this diagnosis?
A) Copes with sensory deprivation.
B) Registers normal body temperature.
C) Pays attention to grooming.
D) Obeys commands with appropriate motor responses. -
correct answer ✅Answer: D
Rationale: An expected outcome of the diagnosis of ineffective
cerebral tissue perfusion in a patient with increased intracranial
pressure (ICP) would include obeying commands with appropriate
motor responses. Vitals signs and neurologic status are assessed
every 15 minutes to every hour. Coping with sensory deprivation
would relate to the nursing diagnosis of "disturbed sensory
perception." The outcome of "registers normal body temperature"
relates to the diagnosis of "potential for ineffective
thermoregulation." Body image disturbance would have a potential
outcome of "pays attention to grooming."
,ICU Exam 2 Questions With 100%
Verified Answers
The nurse has created a plan of care for a patient who is at risk for
increased ICP. The patient's care plan should specify monitoring for
what early sign of increased ICP?
A) Disorientation and restlessness
B) Decreased pulse and respirations
C) Projectile vomiting
D) Loss of corneal reflex -
correct answer ✅Answer: a
Rationale: Early indicators of ICP include disorientation and
restlessness. Later signs include decreased pulse and respirations,
projectile vomiting, and loss of brain stem reflexes, such as the
corneal reflex.
When planning the care of a newborn addicted to cocaine who is
experiencing withdrawal, which of the following would be least
appropriate to include?
A) Wrapping the newborn snugly in a blanket
B) Waking the newborn every hour
C) Checking the newborn's fontanels
,ICU Exam 2 Questions With 100%
Verified Answers
D) Offering a pacifier -
correct answer ✅Answer: B
Rationale: Stimuli need to be decreased. Waking the newborn
every hour would most likely be too stimulating. Measures such as
swaddling the newborn tightly and offering a pacifier help to
decrease irritable behaviors. A pacifier also helps to satisfy the
newborn's need for nonnutritive sucking. Checking the fontanels
provides evidence of hydration.
The nurse is assessing a newborn and suspects that the newborn
was exposed to drugs in utero because the newborn is exhibiting
signs of neonatal abstinence syndrome. Which of the following
would the nurse expect to assess? (Select all that apply.)
A) Tremors
B) Diminished sucking
C) Regurgitation
D) Shrill, high-pitched cry
E) Hypothermia
F) Frequent sneezing -
correct answer ✅Answer: A, C, D, F
, ICU Exam 2 Questions With 100%
Verified Answers
Rationale: Signs and symptoms of neonatal abstinence syndrome
include tremors, frantic sucking, regurgitation or projectile
vomiting, shrill high-pitched cry, fever, and frequent sneezing.
The patient reports to the nurse of being afraid to speak up
regarding a desire to end care for fear of upsetting spouse and
children. Which principle in the nursing code of ethics ensures that
the nurse will promote the patient's cause?
A) Advocacy
B) Responsibility
C) Confidentiality
D) Accountability -
correct answer ✅Answer: A
Rationale: Nurses advocate for patients when they support the
patient's cause. A nurse's ability to adequately advocate for a
patient is based on the unique relationship that develops and the
opportunity to better understand the patient's point of view.
Responsibility refers to respecting one's professional obligations
and following through on promises. Confidentiality deals with
privacy issues, and accountability refers to answering for one's
actions.
Verified Answers
The nurse is caring for a patient with increased intracranial pressure
(ICP). The patient has a nursing diagnosis of "ineffective cerebral
tissue perfusion." What would be an expected outcome that the
nurse would document for this diagnosis?
A) Copes with sensory deprivation.
B) Registers normal body temperature.
C) Pays attention to grooming.
D) Obeys commands with appropriate motor responses. -
correct answer ✅Answer: D
Rationale: An expected outcome of the diagnosis of ineffective
cerebral tissue perfusion in a patient with increased intracranial
pressure (ICP) would include obeying commands with appropriate
motor responses. Vitals signs and neurologic status are assessed
every 15 minutes to every hour. Coping with sensory deprivation
would relate to the nursing diagnosis of "disturbed sensory
perception." The outcome of "registers normal body temperature"
relates to the diagnosis of "potential for ineffective
thermoregulation." Body image disturbance would have a potential
outcome of "pays attention to grooming."
,ICU Exam 2 Questions With 100%
Verified Answers
The nurse has created a plan of care for a patient who is at risk for
increased ICP. The patient's care plan should specify monitoring for
what early sign of increased ICP?
A) Disorientation and restlessness
B) Decreased pulse and respirations
C) Projectile vomiting
D) Loss of corneal reflex -
correct answer ✅Answer: a
Rationale: Early indicators of ICP include disorientation and
restlessness. Later signs include decreased pulse and respirations,
projectile vomiting, and loss of brain stem reflexes, such as the
corneal reflex.
When planning the care of a newborn addicted to cocaine who is
experiencing withdrawal, which of the following would be least
appropriate to include?
A) Wrapping the newborn snugly in a blanket
B) Waking the newborn every hour
C) Checking the newborn's fontanels
,ICU Exam 2 Questions With 100%
Verified Answers
D) Offering a pacifier -
correct answer ✅Answer: B
Rationale: Stimuli need to be decreased. Waking the newborn
every hour would most likely be too stimulating. Measures such as
swaddling the newborn tightly and offering a pacifier help to
decrease irritable behaviors. A pacifier also helps to satisfy the
newborn's need for nonnutritive sucking. Checking the fontanels
provides evidence of hydration.
The nurse is assessing a newborn and suspects that the newborn
was exposed to drugs in utero because the newborn is exhibiting
signs of neonatal abstinence syndrome. Which of the following
would the nurse expect to assess? (Select all that apply.)
A) Tremors
B) Diminished sucking
C) Regurgitation
D) Shrill, high-pitched cry
E) Hypothermia
F) Frequent sneezing -
correct answer ✅Answer: A, C, D, F
, ICU Exam 2 Questions With 100%
Verified Answers
Rationale: Signs and symptoms of neonatal abstinence syndrome
include tremors, frantic sucking, regurgitation or projectile
vomiting, shrill high-pitched cry, fever, and frequent sneezing.
The patient reports to the nurse of being afraid to speak up
regarding a desire to end care for fear of upsetting spouse and
children. Which principle in the nursing code of ethics ensures that
the nurse will promote the patient's cause?
A) Advocacy
B) Responsibility
C) Confidentiality
D) Accountability -
correct answer ✅Answer: A
Rationale: Nurses advocate for patients when they support the
patient's cause. A nurse's ability to adequately advocate for a
patient is based on the unique relationship that develops and the
opportunity to better understand the patient's point of view.
Responsibility refers to respecting one's professional obligations
and following through on promises. Confidentiality deals with
privacy issues, and accountability refers to answering for one's
actions.
