Critical Care Final Exam Practice Questions

A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? (Select all that apply).

a. Nausea and vomiting

b. Hyperthermia

c. Bradycardia

d. Increased weight

e. Decreased serum sodium

f. Decreased level of consciousness

a,d,e,f

A nurse is caring for a child with a diagnosis of meningitis. What clinical findings indicate an increase in intracranial pressure? (Select all that apply).

a. Irritability

b. Bradycardia

c. Hyperalertness

d. Decreased pulse pressure

e. Decreased systolic blood pressure

a,b

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma?

a. Monitor the client for signs of brain injury.

b. Check for hemorrhaging from the oral and nasal cavities.

c. Elevate the foot of the bed if the client develops symptoms of shock.

d. Observe for clinical indicators of decreased intracranial pressure and temperature.

a

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? (Select all that apply).

a. Vomiting

b. Irritability

c. Hypotension

d. Increased respirations

e. Decreased level of consciousness

a,b,e

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?

a. 6

b. 9

c. 12

d. 15

a

A client is scheduled for a computed tomography (CT) of the brain with contrast. When reviewing the client's medical record, what significant finding should the nurse report to the primary healthcare provider before the diagnostic procedure?

a. The client takes metformin daily.

b. The client has not been nothing by mouth (NPO).

c. The client reports an allergy to gadolinium.

d. The client was not prescribed a bowel prep.

a

After a head injury, a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider before assessing the patient about the response to secretion of ADH?

a. Serum osmolarity increases

b. Urine concentration decreases

c. Glomerular filtration decreases

d. Tubular reabsorption of water increases

d

What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? (Select all that apply).

a. Providing adequate fluids within easy reach

b. Reporting an increasing urine specific gravity

c. Administering prescribed erythromycin

d. Assessing for and reporting changes in neurological status

e. Monitoring for constipation, weight loss, hypotension, and tachycardia

a,d,e

A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause?

a. Increased serum glucose

b. Deficient renal perfusion

c. Inadequate antidiuretic hormone (ADH) secretion

d. Excess amounts of intravenous (IV) fluid

c

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone?

a. Increased blood urea nitrogen (BUN) and hypotension

b. Hyperkalemia and poor skin turgor

c. Hyponatremia and decreased urine output

d. Polyuria and increased specific gravity of urine

c

A construction worker fell off the roof of a two-story building and was taken to the hospital in an unconscious state. During the initial assessment, what clinical finding should the nurse report immediately?

a. Reactive pupils

b. Depressed fontanel

c. Bleeding from the ears

d. Increased body temperature

c

After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority?

a. Moving the client as little as possible

b. Preparing the client for mannitol administration

c. Stimulating the client to maintain responsiveness

d. Monitoring the client for increasing intracranial pressure

d

A client who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO 2 of 33 mm Hg. What action is most important for the nurse to take?

a. Encourage the client to slow the breathing rate.

b. Auscultate the client's lungs and suction if indicated.

c. Advise the healthcare provider that the client needs supplemental oxygen.

d. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure.

d

Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing?

a. Spinal shock

b. Hypovolemic shock

c. Transtentorial herniation

d. Increasing intracranial pressure

d

A client is at risk for increased intracranial pressure (ICP). Which assessment finding reflects an increase in ICP?

a. Unequal pupil size

b. Decreasing systolic blood pressure

c. Tachycardia

d. Decreasing body temperature

a

A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question?

a. Continue anticonvulsants

b. Teach isometric exercises

c. Continue osmotic diuretics

d. Keep head of bed at 30 degrees

b

A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)?

a. Pulse 50 bpm and BP 140/60 mm Hg

b. Pulse 56 bpm and BP 130/110 mm Hg

c. Pulse 60 bpm and BP 126/96 mm Hg

d. Pulse 120 bpm and BP 80/60 mm Hg

a

A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects what client response?

a. Ventricular fibrillation

b. Dysfunction of the vagus nerve

c. Retention of sensation but paralysis of the lower extremities

d. Respiratory paralysis and cessation of diaphragmatic contractions

d

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)?

a. Hypertension and bradycardia

b. Flaccid paralysis and numbness

c. Absence of sweating and pyrexia

d. Escalating tachycardia and shock

a

Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care?

a. Spinal shock

b. Brain herniation

c. Hypovolemic shock

d. Increased intracranial pressure

d

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

a. Thready, weak pulse

b. Narrowing pulse pressure

c. Regular, shallow breathing

d. Lowered level of consciousness

d

A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment?

a. The injury results in loss of the reflex arc.

b. The injury is above the sixth thoracic vertebra.

c. There has been a partial transection of the cord.

d. There is a flaccid paralysis of the lower extremities.

b

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency?

a. Hemorrhage

b. Hypovolemic shock

c. Gastrointestinal atony

d. Autonomic hyperreflexia

d

When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Which functions will the nurse assess? (Select all that apply).

a. Balance

b. Breathing

c. Pulse rate

d. Fat metabolism

e. Temperature regulation

b,c

A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes to painful stimuli, makes incomprehensible sounds, and flexes to pain. Using the Glasgow Coma Scale, which score will the nurse document in the client's medical record?

a. 8

b. 9

c. 12

d. 15

a

A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document? Record your answer using a whole number.

3

A client comes into the emergency department with neurologic deficits after falling off a ladder. Which client assessment will the nurse perform for the Glasgow Coma Scale?

a. Breathing patterns

b. Deep tendon reflexes

c. Eye accommodation to light

d. Motor response to verbal commands

d

A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern?

a. Flexing

b. Localizing

c. Extending

d. Withdrawing

c

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client?

a. Nausea

b. Lethargy

c. Sunset eyes

d. Hyperthermia

b

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take?

a. Assess the client's airway.

b. Place pads on the side rails.

c. Notify the healthcare provider.

d. Leave and obtain the crash cart.

a

A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase?

a. Inhibiting urinary tract infections

b. Preventing contractures and atrophy

c. Avoiding flexion or hyperextension of the spine

d. Preparing the client for vocational rehabilitation

c

A client is admitted with head trauma after a fall. The client is being prepared for a supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication primarily is given to do what?

a. Lower blood pressure

b. Prevent hypoglycemia

c. Increase cardiac output

d. Decrease fluid in the brain

d

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what?

a. Sodium

b. Potassium

c. Chloride

d. Calcium

a

The nurse is teaching a client who underwent a hypophysectomy for hyperpituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? (Select all that apply).

a. Nose blowing

b. Teeth brushing

c. Bending forward

d. Breathing through the mouth

e. Lying in a semi-Fowler's position

a,b,c

The laboratory reports of a client who underwent a hypophysectomy show an intracranial pressure (ICP) of 20 mmHg. Which action made by the client is responsible for this condition?

a. Drinking lots of water

b. Eating high-fiber foods

c. Bending over at the waist

d. Bending knees when lowering body

c

During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? (Select all that apply).

a. Cortisol

b. Thyroid

c. Estrogen

d. Testosterone

e. Progesterone

b,d

A client has a mean arterial blood pressure (MAP) of 97 mmHg and an intracranial pressure (ICP) of 12 mmHg. What is the cerebral perfusion pressure (CPP) for this client? Record your answer using a whole number.

85

Four clients who sustained head injuries are presented below. Which client has the least score on the Glasgow coma scale?

a. Client A

b. Client B

c. Client C

d. Client D

c

A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed?

a. Assessing for crepitus

b. Assessing for bleeding

c. Maintaining a patent airway

d. Performing neurologic assessment

c

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?

a. Hazy

b. Yellow

c. Brown

d. Colorless

b

The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take?

a. Notify the primary healthcare provider immediately

b. Apply a warm, moist compress to the incision site

c. Increase the intravenous fluid rate by 20 mL/hr

d. Monitor vital signs more frequently

a

A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

a. Feel for a pulse

b. Begin chest compressions

c. Leave to call for assistance

d. Perform the abdominal thrust maneuver

b

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding?

a. Dull sound on percussion

b. Vocal fremitus on palpation

c. Rales with rhonchi on auscultation

d. Absence of breath sounds on auscultation

d

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?

a. Fluid volume

b. Skin integrity

c. Physical mobility

d. Urinary elimination

b

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first?

a. Obtain vital signs

b. Initiate a cardiac arrest code

c. Administer oxygen using a face mask

d. Encourage the use of an incentive spirometer

c

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?

a. Level of consciousness and pupil size

b. Characteristics of pain and blood pressure

c. Quality of respirations and presence of pulses

d. Observation of abdominal contusions and other wounds

c

Which color tag will be given by the triage nurse to a client assigned to class IV, during a mass casualty situation?

a. Red

b. Black

c. Green

d. Yellow

b

The nurse is caring for different clients in a mass casualty event. Which client is assigned the lowest priority for care?

a. Client with red tag

b. Client with black tag

c. Client with green tag

d. Client with yellow tag

b

The difference between ethics and morals is that ethics

a. is more concerned with the "why" of behavior.

b. provides a framework for evaluation of the behavior.

c. is broader in scope than morals.

d. concentrates on the right or wrong behavior based on religion and culture values.

a

A client's wife has been informed by the physician that her spouse has a permanent C2-C3 spinal injury, which has resulted in permanent quadriplegia. The wife states that she does not want the physician or nursing staff to tell the client about his injury. The client is awake, alert, and oriented when he asks his nurse to tell him what has happened. The nurse has conflicting emotions about how to handle the situation and is experiencing:

a. autonomy.

b. moral distress.

c. moral doubt.

d. moral courage.

b

Critical care nurses can best enhance the principle of autonomy by

a. presenting only the information to prevent relapse in a patient.

b. assisting with only tasks that cannot be done by the patient.

c. providing the patient with all of the information and facts.

d. guiding the patient toward the best choices for care.

c

Which of the following ethical principles is most important when soliciting informed

consent from a client?

a. Nonmaleficence

b. Fidelity

c. Beneficence

d. Veracity

d

Fidelity includes faithfulness and promise-keeping to clients, and it incorporates the

added concepts of

a. confidentiality and privacy.

b. truth and reflection.

c. autonomy and paternalism.

d. beneficence and nonmaleficence.

a

Which statement best reflects the concept of allocation of resources within the critical

care setting?

a. Limitations of resources force reexamination of goals of critical care for clients.

b. Care is provided equally to all those who need the resources.

c. Equal access is available for those with the same condition or diagnosis.

d. Technologic advances are available to most of those in a given community.

a

When deciding whether to withdraw or withhold treatment, it is important to

a. examine one's own beliefs to guide the family to a correct decision.

b. approach the family with honesty and provide clear information.

c. simply follow the advance directive if available.

d. allow the physician to approach the family.

b

The Code of Ethics for Nursing provides a framework for the nurse in ethical decision

making and

a. is usurped by state or federal laws.

b. allows the nurse to focus on the good of society rather than the uniqueness of the

client.

c. was recently adopted by the American Nurses Association.

d. provides society with a set of expectations of the profession.

d

Ethical decisions are best made by

a. following the guidelines of a framework or model.

b. having the client discuss alternatives with the physician or nurse.

c. prioritizing the greatest good for the greatest number of persons.

d. careful consideration by the Ethics Committee after all diagnostic data are

reviewed.

a

The first step of the ethical decision-making process is

a. consulting with an authority.

b. identifying the health problem.

c. delineating the ethical problem from other types of problems.

d. identifying the client as the primary decision maker.

b

Values clarification can assist the client to clarify his or her own values to facilitate

effective decision making. Which of the following nursing activities is incorporated into this

intervention?

a. Avoid the use of open-ended questions.

b. Use multiple sessions to cross-examine the client to ensure he or she is clear about

personal values.

c. Use appropriate questions to assist the client in reflecting on the situation and what

is personally important.

d. Encourage members of the health care team to relate how they would make the

decision.

c

Institutional ethics committees (IECs) review ethical cases that are problematic for the

practitioner. Major functions of IECs include

a. consultation with purely binding recommendations.

b. support and education to health care providers.

c. conflict resolution for moral dilemmas.

d. recommendations that are binding in all cases.

b

In the ethical decision-making process, after the identification of alternative options

has been established,

a. an outcome for each action must be predicted.

b. the team must determine which options to present to the patient or family.

c. the choice of one option compromises the option not chosen.

d. "no action" is not an option in this step of the decision-making process.

a

A client's wife has been informed by the physician that her spouse has a permanent

C2-C3 spinal injury, which has resulted in permanent quadriplegia. The wife states that she does not want the physician or nursing staff to tell the client about his injury. The client is awake, alert, and oriented when he asks his nurse to tell him what has happened. Based on which ethical principles does the nurse answer the patient's questions?

a. Veracity

b. Justice

c. Autonomy

d. Nonmaleficence

c

Which of the following is/are criteria for defining an ethical dilemma? (Select all that

apply.)

a. An awareness of different options

b. An issue in which only one viable option exists

c. The choice of one option compromises the option not chosen

d. An issue that has different options

a,c,d

A score of 6 on the Glasgow Coma Scale (GCS) indicates

a. a vegetative state.

b. paraplegia.

c. coma.

d. obtundation.

c

The GCS is an invalid measure for the patient with

a. hemiplegia.

b. Parkinson disease.

c. mental retardation.

d. intoxication.

d

Which of the following choices is an acceptable and recommended method of noxious stimulation?

a. Nipple pinch

b. Nail bed pressure

c. Supraorbital pressure

d. Sternal rub

b

Which of the following denotes the most serious prognosis?

a. Decorticate posturing

b. Decerebrate posturing

c. Absence of Babinski reflex

d. GCS score of 14

b

How much of a size difference between the two pupils is still considered normal?

a. 1 mm

b. 1.5 mm

c. 2 mm

d. 2.5 mm

a

An oval pupil is indicative of

a. cortical dysfunction.

b. intracranial hypertension.

c. hydrocephalus.

d. metabolic coma.

b

Decerebrate posturing (abnormal extension) indicates dysfunction in which area of the

central nervous system?

a. Cerebral cortex

b. Thalamus

c. Cerebellum

d. Brainstem

d

The initial history for the neurologically impaired patient needs to be

a. limited to the chief complaint.

b. comprehensive, including events preceding hospitalization.

c. directed to level of consciousness and pupillary reaction.

d. information that only the patient can provide.

b

The most important aspect of the neurologic examination is

a. medical history.

b. physical examination.

c. level of consciousness.

d. pupillary responses.

c

While starting an intravenous line on the right hand of an unconscious patient, the patient reaches over with his left hand and tries to remove the noxious stimuli. This response is called

a. decorticate posturing.

b. decerebrate posturing.

c. withdrawal.

d. localization.

d

Before performing the doll's eye or oculocephalic reflex, the nurse must verify

a. the absence of cervical injury.

b. the depth and rate of respiration.

c. a physician's order to perform the maneuver.

d. the patient's ability to follow a verbal command.

a

With an intact oculocephalic reflex, the

a. patient's eyes move in the same direction the head is turned.

b. patient's eyes move in the opposite direction to the movement of the patient's head.

c. patient's eyes remain midline.

d. doll's eye reflex is absent.

b

The oculovestibular reflex, or cold caloric test,

a. should not be performed on an unconscious patient because of the risk of aspiration.

b. has an abnormal response of rapid nystagmus-like deviation to the side of the body

that is tested.

c. is a routine test of the nursing neurologic examination.

d. is one of the final clinical assessments of brainstem function.

d

Symptoms of late stages of intracranial hypertension include

a. decreased perfusion of cerebral tissue.

b. widening pulse pressure values.

c. increased perfusion pressure across the blood-brain barrier.

d. decreased intracranial pressure.

b

The clinical manifestations of the Cushing reflex are

a. bradycardia, systolic hypertension, and widening pulse pressure.

b. tachycardia, systolic hypotension, and tachypnea.

c. headache, nuchal rigidity, and hyperthermia.

d. bradycardia, aphasia, and visual field disturbances.

a

A patient is admitted to the critical care unit with a subdural hematoma. The GCS is

used to assess his level of consciousness. In assessing the patient's best motor response, the movement that receives the lowest score is

a. decerebrate posturing.

b. localizing pain.

c. withdrawing from pain.

d. decorticate posturing.

a

Which of the following procedures is the diagnostic study of choice for acute head

injury?

a. Magnetic resonance imaging

b. Computed tomography

c. Transcranial Doppler

d. Electroencephalography

b

MRI is superior to CT for which of the following?

a. Brain death determination

b. Detection of central nervous system infection

c. Estimation of intracranial pressure

d. Identification of subarachnoid hemorrhage

b

The most serious complication of lumbar puncture in a critically ill patient is

a. bacterial meningitis.

b. dural tear.

c. brainstem herniation.

d. spinal cord trauma.

c

The patient is ordered a CT scan with contrast. Which question should the nurse ask

the conscious patient before the procedure?

a. Are you allergic to penicillin?

b. Are you allergic to iodine-based dye?

c. Are you allergic to latex?

d. Are you allergic to eggs?

b

Which of the following patients may need sedation before having an MRI scan?

a. Claustrophobic patient

b. Comatose patient

c. Elderly patient

d. Patient with a spinal cord injury

a

Which type of ICP monitoring device has the most accurate ICP measurement and

provides access to CSF for sampling?

a. Subarachnoid bolt or screw

b. Subdural or epidural catheter

c. Intraventricular catheter

d. Fiberoptic transducer tipped catheter

c

Studies have shown that the intraparenchymal catheter has a better result than the

intraventricular catheter. Identify the answer that supports this statement.

a. The intraparenchymal catheter allows for CSF drainage.

b. The intraparenchymal catheter has increased monitoring time.

c. The intraparenchymal catheter has a longer insertion time for monitoring ICP.

d. The intraparenchymal catheter has decreased device-related complications.

d

The most clinically significant ICP waveform is

a. A waves.

b. B waves.

c. C waves.

d. D waves.

a

A critical care patient is diagnosed with massive head trauma. The patient is receiving

brain tissue oxygen pressure (PbtO2) monitoring. The nurse recognized that the goal of this

treatment is to maintain PbtO2

a. greater than 20 mm Hg.

b. less than 15 mm Hg.

c. between 15 and 20 mm Hg.

d. between 10 and 20 mm Hg.

a

The patient's ICP reading has gradually climbed from 15 to 23 mm Hg. The nurse's

primary action is to:

a. drain off 7 mm of CSF from the catheter.

b. notify the physician.

c. place the patient in a high Fowler position to decrease the pressure.

d. check level of consciousness.

b

According to the 2007 Brain Trauma Foundation guidelines, the recommended CPP

range is

a. 10 to 30 mm Hg.

b. 30 to 50 mm Hg.

c. 50 to 70 mm Hg.

d. 70 to 85 mm Hg.

c

d

A 76-year-old right-handed patient has been admitted to the critical care unit with an

intracerebral hemorrhage. A CT of her head reveals a large left parietal area bleed. Patient assessment includes T 98.7°F, P 98 beats/min and thready, R 8 breaths/min, and BP 168/100 mm Hg. The patient's initial treatment plan should involve

a. placing her in the Trendelenburg position.

b. administering an antihypertensive agent.

c. initiating induced hypertensive therapy.

d. intubation to support airway and breathing.

Which intervention should be considered LAST in treating uncontrolled intracranial

hypertension?

a. Sedatives

b. Analgesics

c. Barbiturates

d. Hyperventilation

c

Which patient position is optimal to prevent elevated ICP pressures?

a. The head of the bed elevated 30 to 40 degrees

b. Supine with the patient's neck in a neutral alignment

c. Individualized head position to maximize cerebral perfusion pressure and minimize

ICP measurements

d. The head of the bed elevated with flexion of the hips

c

The target range for PaCO2 when using hyperventilation to lower ICP is

a. 25 to 30 mm Hg.

b. 25 to 35 mm Hg.

c. 35 to 40 mm Hg.

d. 35 ± 2 mm Hg.

d

One of the earliest and most important signs of increased ICP is

a. Cushing triad.

b. decerebrate posturing (abnormal extension).

c. a decrease in the level of consciousness.

d. an increase in pupillary size.

c

Which of the following independent nursing measures can assist in reducing increased

ICP?

a. Decreasing the ventilator rate

b. Decreasing noxious stimuli

c. Frequent orientation checks

d. Administration of loop diuretics

b

The osmotic diuretic that has been most effective in the reduction of increased ICP is

a. mannitol.

b. furosemide (Lasix).

c. urea.

d. glycerol.

a

A patient becomes flaccid with fixed and dilated pupils. The patient's ICP falls from

65 to 12 mm Hg. What should the nurse suspect is happening?

a. The patient is having a seizure.

b. The patient's brain has herniated.

c. The patient's cerebral edema is resolving.

d. The patient is excessively dehydrated from the mannitol.

b

A patient's ICP is 34 mm Hg, and his cerebral perfusion pressure is 65 mm Hg. Which

of the following is the most appropriate intervention?

a. These are normal values, and no interventions are required.

b. Administer mannitol 1 to 2 g/kg IV.

c. Have the patient lie flat in bed.

d. Suction the patient to see if improving his airway will help his ICP.

b

Which of the following is the most common complication after high-dose barbiturate

therapy?

a. Hypothermia

b. Hypotension

c. Myocardial depression

d. Decreased CVP

b