complex exam 3

A patient with a brain tumor becomes increasingly difficult to arouse. Earlier the patient was alert and oriented. Which action is the priority?

Perform an immediate focused neurologic assessment

Which assessment finding is most concerning for impending cerebral herniation?

New unilateral fixed, dilated pupil

A patient has BP 188/62, HR 46, and irregular respirations. What should the nurse suspect?

Cushing response from increased ICP

Which position is most appropriate for a patient with increased ICP?

HOB elevated with head and neck midline

Why should extreme hip flexion be avoided in increased ICP?

It may interfere with venous drainage and increase ICP

Which nursing intervention should be questioned for a patient with increased ICP?

Frequent unnecessary stimulation

Which factors can worsen cerebral perfusion or ICP? Select all that apply

Hypoxia

Hypotension

Hypercarbia

Fever

Sharp head rotation

What is the normal ICP range?

0-15 mmHg

Which ICP range is considered elevated?

20-25 mmHg

A patient’s MAP is 82 mmHg and ICP is 24 mmHg. What is the CPP?

58 mmHg

A patient’s ICP increases while MAP remains unchanged. What happens to CPP?

Decreases

Which CPP is below target?

42 mmHg

Why can a benign brain tumor still become life-threatening?

Any expanding intracranial mass can cause edema, increased ICP, decreased CPP, and herniation

A frontal lobe tumor is most likely to produce

Personality/behavior changes and expressive aphasia

A patient with a temporal lobe tumor may demonstrate

Memory/personality changes or receptive aphasia

A cerebellar tumor would most likely affect

Balance and coordination

Which tumor location should make the nurse particularly alert for swallowing and respiratory pattern abnormalities?

Medulla

Dexamethasone is prescribed for a patient with brain tumor. What is its primary purpose in this situation?

Decrease cerebral edema

Which parameters should be monitored during dexamethasone therapy? Select all that apply.

Glucose

Potassium

Infection

GI bleeding

Fluid retention/HTN

Which patient should the nurse see first?

Brain tumor patient with a new fixed pupil and decreased LOC

Which presentation is classic for a ruptured cerebral aneurysm?

Sudden worse headache of my life

Which interventions help reduce rebleeding risk after SAH? Select all that apply.

Quiet environment

BP management

Stool softener

Avoid valsalva

Head midline

Why might a stool softener be prescribed after SAH?

Straining can increase pressure and contribute to rebleeding

A patient is on day 8 after SAH and suddenly develops expressive aphasia and right-sided weakness. What is the priority concern?

Cerebral vasospasm/delayed ischemia

Vasospasm is most likely during

Days 3-12

When does vasospasm risk peak?

Days 7-10

Which medication is emphasized for SAH-related vasospasm?

Nimodipine

Which finding during the vasospasm-risk period requires immediate escalation?

New unilateral weakness

A patient arrives with facial droop and unilateral weakness. What information is most time-sensitive?

Exact last-known well-time

Which assessment should occur rapidly in suspected stroke because it can mimic neurologic dysfunction?

Blood glucose

Why is urgent brain imaging required before assuming ischemic stroke?

Hemorrhage must be excluded

Which sequence best reflects early stroke priorities?

Last-known-well, neurologic assessment/NIHSS, glucose, urgent imaging

Thrombolytic therapy may be considered in appropriate patients within

Up to 4.5 hours

Which finding would make the nurse question thrombolytic eligibility?

BP 192/116 mmHg

Which platelet count is an exclusion?

Less than 100,000/mm3

Which INR is identified as concerning for thrombolytic therapy?

Greater than 1.7

A patient develops a sudden severe headache, vomiting, and a decreased LOC after thrombolytic administration. What should the nurse suspect?

Intracranial hemorrhage

Dysarthria means

Impaired articulation of speech

Aphasia means

Impaired language

Dysphagia means

Impaired swallowing

During an active generalized seizure, which action is appropriate?

Protect the patient from injury and support the airway

Which action is contraindicated during a seizure

Placing an object in the mouth

What is the priority sequence in status epilepticus?

ABCs, terminate seizure, identify/treat cause, prevent recurrence

Which medication is emphasized for initially stopping acute seizure activity?

Lorazepam

Which medication may follow lorazepam for seizure loading/control?

Phenytoin/fosphenytoin

Persistent status epilepticus may require: Select all that apply

Intubation

Continuous EEG

Midazolam

Deeper sedation/anesthesia

Phenobarbital

A GCS of 7 indicates

Severe TBI

Which GCS trend is most concerning?

15, 13, 11

Primary brain injury occurs

At the moment of trauma

The critical-care goal following TBI is largely to

Prevent secondary brain injury

Which conditions contribute to secondary brain injury? Select all that apply.

Hypoxia

Hypotension

Hypercarbia

Fever

Uncontrolled ICP

Which findings suggest a basilar skull fracture? Select all that apply.

Raccoon eyes

Battle sign

CSF rhinorrhea

CSG otorrhea

Halo sign

Which order should the nurse question for suspected basilar skull fracture?

Nasogastric tube insertion

Why are nasal tubes avoided with suspected basilar skull fracture?

Skull-base disruption creates risk associated with nasal instrumentation

A patient with a basilar skull fracture later develops fever, headache, and neck stiffness. What complication should the nurse suspect?

Meningitis

Which statement best distinguishes epidural from subdural bleeding?

Epidural is typically arterial and faster; subdural is typically venous and slower

An older adult taking anticoagulants develops increasing confusion several days after a fall. Which condition should the nurse suspect?

Subdural hematoma

Which finding overrides whether a hematoma is epidural or subdural and demands urgent action?

Declining LOC

Mannitol is prescribed after TBI primarily to

Decrease ICP

Why is infection a concern with invasive ICP monitoring?

The monitoring device creates an invasive route

A TBI patient develops very high urine output and hypernatremia. Which condition should the nurse suspect?

DI

Which phrase best helps distinguish DI?

DI = dry

Which treatment is emphasized for DI?

Vasopressin and fluid replacement

A TBI patient develops hyponatremia and water retention. What should the nurse suspect?

SIADH

Which treatment is emphasized for SIADH?

Fluid restriction with sodium replacement as indicated

A trauma patient may have a cervical spine injury and requires airway opening. Which maneuver should be used?

Jaw-thrust

Why is a high cervical SCI especially dangerous?

It can impair diaphragm function and ventilation

A patient with SCI has flaccid paralysis and loss of motor, sensory, and reflex activity below the lesion. Which condition is most likely?

Spinal shock

Which finding indicates the end of spinal shock?

Return of perianal reflex activity

Which findings characterize neurogenic shock?

Hypotension + bradycardia + hypothermia

Why might tachycardia be absent in neurogenic shock?

Loss of sympathetic tone prevents the usual compensatory response

Which treatments are emphasized for neurogenic shock?

Fluids and vasopressors

Which finding distinguishes neurogenic shock from many other shock states?

Bradycardia despite hypotension

A patient with SCI above T7 develops BP 212/110, HR 48, pounding headache, and facial flushing. What should the nurse suspect?

Autonomic dysreflexia

What is the first action for autonomic dysreflexia?

Sit the patient upright/elevate HOB

After positioning the patient upright, what trigger should be investigated first?

Bladder distention or catheter obstruction

Which can trigger autonomic dysreflexia? Select all that apply.

Bladder distention

Kinked catheter

Bowel impaction

Tight clothing

Pressure injury

Which finding is expected above the lesion during autonomic dysreflexia?

Flushing and sweating

Which patient should the nurse see first?

SCI patient with BP 210/108 and pounding headache

A patient is rescued from a house fire with facial burns, soot around the mouth, and hoarseness. What is the priority?

Prepare for early airway management

Why should the nurse not wait for obvious complete airway obstruction?

Progressive edema can make later intubation difficult

Pulmonary injury following burns may evolve over

24-48 hours

Which findings suggest inhalation injury? Select all that apply.

Facial burns

Soot

Hoarseness

Stridor

Closed-space exposure

Why can conventional pulse oximetry be misleading in carbon monoxide exposure?

It may not accurately reflect carbon monoxide poisoning

Which test is emphasized for suspected carbon monoxide exposure?

Carboxyhemoglobin

Which treatment is emphasized for carbon monoxide exposure?

100% oxygen

Using the Rule of Nines, one entire adult arm equals

9%

The anterior trunk equals

18%

One entire adult leg equals

18%

The perineum equals

1%

The burn-resuscitation formula is

2-4 mL LR x kg x % TBSA

A 70-kg patient has 40% TBSA burns. Using 4 mL/kg/% TBSA, what is the calculated 24 hour volume?

11,200 mL

How much of the 11,200 mL would be administered during the first 8 hours from the time of the burn?

5,600 mL

A burn occurred 2 hours ago, and the patient has just arrived for resuscitation. What happens to the first-half fluid deadline

The first half must be completed within the remaining 6 hours

What is the best indicator that burn fluid resuscitation is adequate?

Urine output

What adult urine output goal is emphasized?

30-50 mL/h or approximately 0.5 mL/kg/hr

A burn patient receiving calculated fluids has urine output of 10 mL/hr for two consecutive hours. What should the nurse conclude?

Perfusion/resuscitation may be inadequate

A patient has a circumferential full-thickness burn around the forearm. Which assessment is most important?

Distal neurovascular status

Which findings suggest vascular compromise from a circumferential extremity burn? Select all that apply.

Decreased pulses

Delayed capillary refill

Sensory changes

Color changes

Increasing distal compromise

Which procedure may be required to relieve constricting burn eschar?

Escharotomy