Description
Introduction to Critical Care Nursing 5th Edition Sole Klein Moseley Test Bank
ISBN-13: 978-1416056560
ISBN-10: 1416056564
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Sole: Introduction to Critical Care Nursing, 5th Edition
Chapter 13: Nervous System Alterations
Test Bank
MULTIPLE RESPONSE
- Mr. Jones is in the intensive care unit following a motor vehicle crash. He is oriented to person, place, and time; can move all extremities; and follows commands. His pulse is 75 beats/min, his blood pressure is 120/70 mm Hg, and his respirations are 18 breaths/min and regular. Which assessment finding the nurse best indicates the earliest finding that Mr. Jones’ intracranial pressure is increasing?
| a. | Blood pressure of 130/60 | c. | Heart rate of 53 beats/min |
| b. | Flexion posturing | d. | Orientation to person only |
ANS: D
A change in the level of consciousness is the earliest symptom of increased intracranial pressure.
Incorrect:
A: Changes in vital signs, such as a widening pulse pressure, appear late in the course of neurological dysfunction.
B: Abnormal postures may occur as the patient’s intracranial pressure changes; however, the fist sign of increased intracranial pressure is a change in level of consciousness.
C: Changes in vital signs, such as a slow bounding pulse, appear late in the course of neurological dysfunction.
DIF: Cognitive Level: Analysis REF: Page 385
OBJ: Complete an assessment on a critically ill patient with nervous system injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?
| a. | 54 mm Hg | c. | 90 mm Hg |
| b. | 72 mm Hg | d. | 126 mm Hg |
ANS: C
CPP = MAP – ICP. In this case, CPP = 108 mm Hg – 18 mm Hg = 90 mm Hg.
Incorrect:
A: CPP = MAP – ICP. In this case, CPP = 108 mm Hg – 18 mm Hg = 90 mm Hg.
B: CPP = MAP – ICP. In this case, CPP = 108 mm Hg – 18 mm Hg = 90 mm Hg.
D: CPP = MAP – ICP. In this case, CPP = 108 mm Hg – 18 mm Hg = 90 mm Hg.
DIF: Cognitive Level: Comprehension REF: Page 375
OBJ: Complete an assessment on a critically ill patient with nervous system injury.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity/Physiological Adaptation.
- While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation the nurse?
| a. | Both pressures are high | c. | ICP is high; CPP is normal |
| b. | Both pressures are low | d. | ICP is high; CPP is low |
ANS: C
The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range.
Incorrect:
A: The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range.
B: The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range.
D: The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range.
DIF: Cognitive Level: Comprehension REF: Page 375
OBJ: Complete an assessment on a critically ill patient with nervous system injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- The nurse is caring for a patient with a sustained ICP of 18 mm Hg for the past 30 minutes during the morning assessment and hygiene interventions. What is the best nursing action?
| a. | Avoid hyperoxygenation during endotracheal suctioning. |
| b. | Change ventriculostomy dressing using strict aseptic technique. |
| c. | Place the patient in the Trendelenburg position. |
| d. | Provide rest periods between interventions. |
ANS: D
Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished spacing nursing care activities to allow for rest between activities.
Incorrect:
A: If endotracheal suctioning is needed, it is important to provide hyperoxygenation to prevent further increases in ICP associated with hypoxemia.
B: Changing a dressing will not assist in reducing ICP.
C: Elevation of the head up to 30 degrees will aid in facilitating venous drainage and decrease the risk of venous outflow obstruction, which can increase ICP.
DIF: Cognitive Level: Application REF: Pages 388 and 389
OBJ: Describe nursing and medical management of patients with increased ICP.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
- While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient’s left naris. What is the best nursing action?
| a. | Have the patient blow the nose until clear. |
| b. | Insert bilateral cotton nasal packing. |
| c. | Place a nasal drip pad under the nose. |
| d. | Suction the left nares until the drainage clears. |
ANS: C
In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment.
Incorrect:
A: Patients should be instructed not to blow their nose because that action may further aggravate the dural tear.
B: In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing.
D: Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.
DIF: Cognitive Level: Application REF: Page 408
OBJ: Describe the nursing and medical management of patients with skull fractures.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
- The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later the nurse assesses a GCS score of 3. What is the best nursing action?
| a. | Apply noxious stimuli to arouse the patient. |
| b. | Continue to monitor the patient. |
| c. | Lower the patient’s head of the bed. |
| d. | Notify the physician immediately. |
ANS: D
These are classic symptoms of epidural and acute subdural hematomas: injury, lucid period, and progressive deterioration. The physician must be notified of this neurological emergency so appropriate interventions can be implemented.
Incorrect:
A: The GCS score is indicative of no motor movement. The patient exhibited an acute change in neurological status that requires immediate action.
B: The patient exhibited an acute change in neurological status that requires immediate action.
C: The patient’s acute neurological changes warrant immediate action and should include head of the bed elevation.
DIF: Cognitive Level: Analysis REF: Page 412
OBJ: Describe nursing and medical management of patients with increased ICP.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
- The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding the nurse indicates an appropriate response to therapy?
| a. | A decrease in CPP and low urine specific gravity |
| b. | A decrease in ICP and an increase in urine output |
| c. | An improvement in GCS score and a decrease in urine output |
| d. | An increase in CPP and high urine specific gravity |
ANS: B
Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output.
Incorrect:
A: CPP should improve with administration of mannitol.
C: Although the GCS score may improve, the urine output should increase in response to mannitol administration.
D: Although the CPP should improve, the urine specific gravity would be low secondary to diuresis and increased water content in the urine.
DIF: Cognitive Level: Application REF: Page 401 | Table 13-8
OBJ: Describe nursing and medical management of patients with increased ICP.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
- The nurse is caring for a mechanically ventilated, brain injured patient. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow?
| a. | Altered cerebral spinal fluid production and reabsorption |
| b. | Decreased cerebral blood volume due to vessel constriction |
| c. | Increased cerebral blood volume due to vessel dilation |
| d. | No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal) |
ANS: C
Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume.
Incorrect:
A: To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow.
B: Cerebral vessels dilate when CO2 levels increase, increasing cerebral blood volume.
D: PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume.
DIF: Cognitive Level: Knowledge REF: Page 390 | Table 13-6
OBJ: Describe the pathophysiology of increased intracranial pressure.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- The nurse assesses a patient’s GCS score to be 3. What is the best interpretation the nurse?
| a. | Does not open eyes, no motor response, and no verbal response |
| b. | Opening eyes spontaneously, obeys verbal commands, and is oriented |
| c. | Opening eyes to voice, localizing to pain, and is disoriented but converses |
| d. | Opens eyes to pain, localizes to pain, and uses inappropriate words |
ANS: A
These findings would result in a GCS score of 3
Incorrect:
B: These findings would result in a GCS score of 15.
C: These findings would result in a GCS score of 12.
D: These findings would result in a GCS score of 10.
DIF: Cognitive Level: Comprehension. REF: Page 384 | Figure 13-10
OBJ: Complete an assessment on a critically ill patient with nervous system injury.
TOP: Nursing Process Step: Assessment.
MSC: NCLEX: Physiological Integrity
- The nurse is caring for a patient with a previous GCS score of 15. Nursing assessment 4 hours later notes a GCS score of 8. The nurse anticipates which action?
| a. | Bispectral index (BIS) monitoring |
| b. | Computerized axial tomography (CAT) scan |
| c. | Continuous electroencephalography (EEG) |
| d. | Jugular bulb oxygen saturation monitoring |
ANS: B
A computerized axial tomography scan of the head is often done emergently when a patient’s neurological status declines.
Incorrect:
A: Bispectral index monitoring is used to monitor and assess level of sedation.
C: Continuous EEG monitoring is most useful for the assessment of seizure/electrical activity of the brain.
D: Jugular bulb oxygen saturation monitoring is used to assess cerebral blood flow.
DIF: Cognitive Level: Application REF: Page 394
OBJ: Describe nursing and medical management of patients with increased ICP.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation the nurse?
| a. | The patient is exhibiting extension posturing. |
| b. | The patient is exhibiting flexion posturing. |
| c. | The patient is exhibiting purposeful movement. |
| d. | The patient is withdrawing to stimulation. |
ANS: C
This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness.
Incorrect:
A: This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness, not extension posturing.
B: This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness, not flexion posturing.
D: This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness, not withdrawal from the stimuli.
DIF: Cognitive Level: Comprehension REF: Page 384 | Figure 13-10
OBJ: Complete an assessment on a critically ill patient with nervous system injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- An awake, alert patient arrives at the ED following a fall down a flight of stairs. The physician suspects a basilar skull fracture. Which assessment findings should the nurse anticipate?
| a. | Babinski’s reflex and tinnitus | c. | Flexion and extension posturing |
| b. | Brudzinski’s and Kernig’s signs | d. | Rhinorrhea and raccoon eyes |
ANS: D
Basilar skull fractures are difficult to detect on x-ray study. Diagnosis is made clinical presentation, which may include drainage of cerebrospinal fluid (CSF) from the nose (rhinorrhea), drainage of CSF from the ear (otorrhea), Battle’s sign, and/or the presence of “raccoon eyes.”
Incorrect:
A: Babinski’s reflex is a sign of an upper motor neuron lesion.
B: Brudzinski’s and Kernig’s signs are indicative of meningeal irritation associated most often with meningitis.
C: Flexion and extension posturing are seen in neurologically injured patients who most often are in a comatose state.
DIF: Cognitive Level: Knowledge REF: Page 407 | Table 13-9
OBJ: Complete an assessment on a critically ill patient with nervous system injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18/min, and a temperature of 102° F. To reduce the risk of increased ICP in this patient, what are the priority nursing actions?
| a. | Ensure adequate periods of rest between nursing interventions. |
| b. | Insert an oral airway and monitor respiratory rate and depth. |
| c. | Maintain neutral head alignment and avoid extreme hip flexion. |
| d. | Reduce ambient room temperature and administer antipyretics. |
ANS: D
In this scenario, the patient’s temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased ICP. Cooling measures should be implemented.
Incorrect:
A: The priority need in this scenario is to reduce the patient’s temperature and decrease metabolic demands.
B: Insertion of an oral airway in an alert patient is contraindicated. The priority intervention is to reduce the patient’s temperature and decrease metabolic demands.
C: The patient is alert. The priority intervention is to reduce the patient’s temperature and decrease metabolic demands.
DIF: Cognitive Level: Application REF: Page 400
OBJ: Describe nursing and medical management of patients with increased ICP.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
- The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action?
| a. | Assist the patient to the floor and provide soft head support. |
| b. | Insert a nasogastric tube and connect to continuous wall suction. |
| c. | Open the patient’s mouth and insert a padded tongue blade. |
| d. | Restrain the patient’s extremities until the seizure subsides. |
ANS: A
To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported.
Incorrect:
B: Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration.
C: Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patient’s jaws will be clenched shut. Forceful insertion may lead to further injury.
D: Restraining a patient during seizure activity can be traumatizing and is not standard of care.
DIF: Cognitive Level: Application REF: Page 423
OBJ: Describe the pathophysiology and management for status epilepticus.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
- Ten days following surgery to clip an anterior communicating artery aneurysm, a transcranial Doppler detects cerebral vasospasm in a patient. The nurse anticipates which therapeutic intervention?
| a. | Fluid restriction | c. | Nitroprusside (Nipride) |
| b. | Nicardipine (Nimodipine) | d. | Phenytoin (dilantin) |
ANS: B
Nicardipine, a calcium channel blocker, has a vasodilatory effect.
Incorrect:
A: Vasospasm is often treated with volume expansion to increase cerebral perfusion pressure.
C: Induced hypertension maintaining blood pressure between 150 and 160 mm Hg systolic or higher is standard treatment. Nitroprusside, a potent arterial vasodilator, has potential to decrease blood pressure outside of desired parameters.
D: Phenytoin will help control seizure activity, not reduce vasospasm.
DIF: Cognitive Level: Comprehension REF: Page 420
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity/Pharmacological and Parenteral Therapies
- The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24/min, and 50 mL of urine via Foley catheter for the past 4 hours. What is the best action the nurse?
| a. | Administer acetaminophen as ordered for the headache. |
| b. | Assess for a kinked Foley catheter or bowel impaction. |
| c. | Begin an infusion of sodium nitroprusside (Nipride). |
| d. | Notify the physician of the patient’s blood pressure. |
ANS: B
Autonomic dysreflexia, characterized an exaggerated response of the sympathetic nervous system can be triggered a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distention. Other causes that should be ruled out prior to pharmacological intervention include fecal impaction.
Incorrect:
A: Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus on identifying the underlying cause.
C: Pharmacological intervention should only be implemented if symptoms persist following correction of the underlying cause.
D: Assessing for underlying causes of autonomic dysreflexia should precede contacting the physician.
DIF: Cognitive Level: Application REF: Page 429 | Box 13-6
OBJ: Describe nursing and medical management of patients with a spinal cord injury.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
- The nurse admits a patient to the ED with new onset of slurred speech and right-sided weakness. What is the priority nursing action?
| a. | Assess for the presence of a headache. |
| b. | Assess the patient’s general orientation. |
| c. | Determine the patient’s drug allergies. |
| d. | Determine the time of symptom onset. |
ANS: D
Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms.
Incorrect:
A: To ensure appropriate intervention, determining the time of symptom onset is the priority action.
B: To ensure appropriate intervention, determining the time of symptom onset is the priority action.
C: To ensure appropriate intervention, determining the time of symptom onset is the priority action.
DIF: Cognitive Level: Application REF: Page 417
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- Which patient being cared for in the ED should the charge nurse evaluate first?
| a. | A patient with a complete spinal injury at the C-5 dermatome level |
| b. | A patient with a Glasgow Coma Scale score of 15 on 3 L nasal cannula |
| c. | An alert patient with a subdural bleed who is complaining of a headache |
| d. | An ischemic stroke patient with a blood pressure of 190/100 mm Hg |
ANS: A
A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise.
Incorrect:
B: A GCS score of 15 indicates a neurologically intact patient.
C: The patient is alert and not in danger of any immediate compromise.
D: The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg.
DIF: Cognitive Level: Analysis REF: Page 426
OBJ: Describe nursing and medical management of patients with a spinal cord injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- The nurse admits a patient to the ED with a suspected cervical spine injury. What is the priority nursing action?
| a. | Keep the neck in the hyperextended position. |
| b. | Maintain proper head and neck alignment. |
| c. | Prepare for immediate endotracheal intubation. |
| d. | Remove cervical collar upon arrival to the ED. |
ANS: B
Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury.
Incorrect:
A: To reduce the risk of further injury, the neck and head must be kept in the neutral position.
C: Immediate endotracheal intubation is not indicted with a suspected cervical spine injury unless the patient’s airway is compromised.
D: The use of assist devices to maintain immobilization of the C- spine is indicated until injury has been ruled out.
DIF: Cognitive Level: Comprehension REF: Page 435
OBJ: Describe nursing and medical management of patients with a spinal cord injury.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
- The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action?
| a. | Maintain body temperature. | c. | Pad all bony prominences. |
| b. | Monitor blood pressure. | d. | Use proper hand washing. |
ANS: B
Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.
Incorrect:
A: Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.
C: Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.
D: Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.
DIF: Cognitive Level: Comprehension REF: Page 435
OBJ: Describe nursing and medical management of patients with a spinal cord injury.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
- The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24-hour dose for the 70-kg patient?
| a. | 2478 mg | c. | 10,794 mg |
| b. | 5000 mg | d. | 12,750 mg |
ANS: C
The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg x 70 kg) + (5.4 mg x 70 kg) x 23 hours = 10,794 mg.
Incorrect:
A: The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg x 70 kg) + (5.4 mg x 70 kg) x 23 hours = 10,794 mg.
B: The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg x 70 kg) + (5.4 mg x 70 kg) x 23 hours = 10,794 mg.
D: The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg x 70 kg) + (5.4 mg x 70 kg) x 23 hours = 10,794 mg.
DIF: Cognitive Level: Comprehension REF: Page 435
OBJ: Describe nursing and medical management of patients with a spinal cord injury.
TOP: Nursing process: Intervention MSC: NCLEX: Physiological Integrity
- The nurse is preparing to monitor ICP with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring (choose all that apply)?
| a. | Administer a heparin flush solution |
| b. | Manually flush the device “prn” to maintain catheter patency |
| c. | Record ICP as a “mean” value |
| d. | Use a pressurized flush system |
| e. | Zero-reference the transducer system at the level of the foramen of Munro |
ANS: C, E
Neither heparin nor pressure bags or pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero-referenced at the level of the foramen of Munro. Manually flushing the device may result in an increase in ICP.
Incorrect:
A: Neither heparin nor pressure bags or pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero-referenced at the level of the foramen of Munro. Manually flushing the device may result in an increase in ICP.
B: Neither heparin nor pressure bags or pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero-referenced at the level of the foramen of Munro. Manually flushing the device may result in an increase in ICP.
D: Neither heparin nor pressure bags or pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero-referenced at the level of the foramen of Munro. Manually flushing the device may result in an increase in ICP.
DIF: Cognitive Level: Knowledge REF: Page 392
OBJ: Describe nursing and medical management of patients with increased intracranial pressure.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- In an unconscious patient, eye movements are tested the oculocephalic response. Which statements regarding the testing of this reflex are true (choose all that apply)?
| a. | Doll’s eyes absent indicate a disruption in normal brainstem processing. |
| b. | Doll’s eyes present indicate brainstem activity. |
| c. | Eye movement in the opposite direction as the head when turned indicates an intact reflex. |
| d. | Eye movement in the same direction as the head when turned indicates an intact reflex. |
| e. | Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. |
| f. | Presence of cervical injuries is a contraindication to the assessment of this reflex. |
ANS: A, B, C, E, F
In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll’s eye): turn the patient’s head quickly from side to side while holding the eyes open. Note movement of eyes. The doll’s eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement.
DIF: Cognitive Level: Analysis REF: Page 382 | Table 13-2
OBJ: Complete an assessment on a critically ill patient with nervous system injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient’s plan of care (choose all that apply)?
| a. | Compare frequent neurological assessments with baseline. |
| b. | Maintain CO2 level at 50 mm Hg. |
| c. | Maintain mean arterial pressure less than 130 mm Hg and systolic blood pressure less than 220 mm Hg. |
| d. | Prepare for therapeutic thrombolytic administration. |
| e. | Restrain affected limb to prevent injury. |
ANS: A, C
The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure 120 mm Hg. In hemorrhagic stroke the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy.
Incorrect:
B: The CO2 should be maintained within normal limits; this value is elevated.
D: The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy.
E: Restraints should be avoided.
DIF: Cognitive Level: Analysis REF: Page 415
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
