NR 340 Week 7 Exam Three 2020 with all the correct answers(Real Exam Graded A)

1)      A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?

1.                   Vomiting continues

2.                   Intracranial pressure (ICP) is increased

3.                   The client needs mechanical ventilation

4.                   Blood is anticipated in the cerebralspinal fluid (CSF)

2. Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn’t strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.

2)      A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?

1.                   To reduce intraocular pressure

2.                   To prevent acute tubular necrosis

3.                   To promote osmotic diuresis to decrease ICP

4.                   To draw water into the vascular system to increase blood pressure

3. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

3)      A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?

1.                   Urine output increases

2.                   Pupils are 8 mm and nonreactive

3.                   Systolic blood pressure remains at 150 mm Hg

4.                   ICP level of 12

4. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes, so urine output would increase; however, the reason mannitol was given was to decrease ICP. An ICP level of 12 is within normal limits. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given that mannitol is being given for renal dysfunction or blood pressure maintenance.

4)      Which of the following values is considered normal for ICP?

1.                   0 to 15 mm Hg

2.                   25 mm Hg

3.                   35 to 45 mm Hg

4.                   120/80 mm Hg

1. Normal ICP is 0-15 mm Hg.

5)      Which of the following signs and symptoms of increased ICP after head trauma would appear first?

1.                   Bradycardia

2.                   Large amounts of very dilute urine

3.                   Restlessness and confusion

4.                   Widened pulse pressure

3. The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there’s damage to the posterior pituitary.

6)      The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?

1.                   Sternal rub

2.                   Pressure on the orbital rim

3.                   Squeezing the sternocleidomastoid muscle

4.                   Nail bed pressure

4. Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

7)  The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

1.                   Side-lying, with legs pulled up and head bent down onto the chest

2.                   Side-lying, with a pillow under the hip 3.                Prone, in a slight Trendelenburg’s position

4.            Prone, with a pillow under the abdomen.

1. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae.

8)  A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:

1.                   A cerebral lesion

2.                   A temporal lesion

3.                   An intact brainstem

4.                   Brain death

  3. Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.

9)  The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?

1.                   Increasing temperature, increasing pulse, increasing respirations, decreasing systolic blood pressure.

2.                   Increasing temperature, decreasing pulse, decreasing respirations, increasing systolic blood

pressure.

3.                   Decreasing temperature, decreasing pulse, increasing respirations, decreasing systolic blood

pressure.

4.                   Decreasing temperature, increasing pulse, decreasing respirations, increasing systolic blood

pressure.