Neuro CCRN Study questions with answers and rationales, Exams of Nursing

Download Neuro CCRN Study questions with answers and rationales and more Exams Nursing in PDF only on Docsity! Neuro CCRN Study questions with answers and rationales A postcraniotomy patient suddenly stops responding and begins to have a tonic- clonic seizure. Which of the following drugs is considered the preferred first-line antiepileptic agent to give during a seizure? A. Diazepam B. Lorazepam C. Phenytoin D. Phenobarbital ✔B Benzodiazepines are used as a first-line drug during a seizure. They potentiate GABA, which is an inhibitory neurotransmitter. Even though diazepam is also a benzodiazepine and can be used first for a seizure, it has a shorter antiepileptic effect than lorazepam. Lorazepam is considered the preferred first-line antiepileptic agent to treat a seizure. Phenytoin is recommended as a second-line antiepileptic. It works by inhibiting the sodium channels, preventing depolarization. Phenobarbital can also be used but is typically given to patients who have failed third-line antiepileptic agents. A family member of a patient in the ICU, who recently experienced a TBI, asks the nurse how long the patient will have to be on seizure medications as the patient has not had a seizure. Which of the following would be the nurse's best answer? A. The patient will have to be on seizure medications for the rest of her life. B. Ask the neurologist that question. C. Typically, following trauma, seizure medications are given for 7 days if no seizures occur. D. The neurologist will reevaluate her during the 3-month follow-up clinic visit. ✔C The Brain Trauma Foundation's recommendation for antiepileptic prophylaxis is 7 days following a TBI, if no seizure occurs in the interval. This is the same recommendation for supratentorial postcraniotomy patients. The use of prophylactic antiepileptic therapy after ischemic strokes is not recommended but ICH strokes have a higher incidence of seizures and may require short-term prophylaxis. A patient is diagnosed with an ischemic stroke but is 4.0 hours out from the initial onset of stroke symptoms. Which of the following is an additional exclusion if considering using the 4.5-hour window to administer IV tPA? A. If taking oral anticoagulants, INR must be < 2.5 B. Has a baseline NIH Stroke Scale < 20 C. History of both stroke and diabetes D. Patient is younger than 50 years old ✔C Based on some recent studies, some stroke centers extend the window of opportunity to administer IV tPA in an ischemic stroke to 4.5 hours. There is additional exclusion criteria used for the 3- to 4.5-hour time interval. These include: (a) history of both stroke and diabetes, (b) patients receiving oral anticoagulation therapy regardless of INR, (c) patients older than 80 years of age, and (d) baseline NIH Stroke Scale greater than 25. When is it recommended to administer antihypertensive agents to a patient with acute ischemic stroke who is not a candidate for tPA? A. Systolic > 220 mmHg B. Diastolic > 105 mmHg C. Systolic > 180 mmHg D. Diastolic > 90 mmHg ✔A Current American Stroke Association guidelines recommend allowing systolic BP to elevate for perfusion if the patient is not a candidate for tPA. The recommendation is to treat the BP if systolic BP is greater than 220 mmHg or diastolic BP greater than 120 mmHg. If the patient is a candidate for thrombolysis, the BP is treated if systolic pressure is greater than 180 mmHg and diastolic pressure is higher than 105 mmHg to lower risk of bleeding. Which of the following should be treated to prevent infarct expansion and worsening of cerebral edema in acute ischemic stroke patients? A. Hypernatremia B. Fever C. Hyperkalemia D. Metabolic alkalosis ✔B Fever is clearly associated with infarct expansion and worsening of cerebral edema. The mechanism is probably due to an increase in cerebral metabolic rate and oxygen consumption. Currently, the recommendation is to achieve normothermia after acute ischemic strokes. Hyponatremia and hyperglycemia are other metabolic abnormalities that have been shown to worsen infarcts and neurological outcomes following strokes. When administering hyperosmolar therapy to manage an increased ICP, when would the nurse hold the dose of mannitol? A. ICP > 20 mmHg B. Urine output > 200 mL/hr C. Serum osmolality > 320 mOsm/kg D. Sodium levels < 125 mEq/L ✔C Hyperosmolar therapy is commonly used to manage an increased ICP. Mannitol or HS can be used as hyperosmolar therapy. Monitoring serum sodium and osmolality levels is recommended during treatment, as is holding hyperosmolar therapy if serum osmolality > 320 mOsm/kg. The concern for sodium with hyperosmolar therapy is the development of hypernatremia, not hyponatremia. Urine output is followed during the infusion of 3% NaCl. Cerebral edema, coma, and cerebral herniation are potential complications when serum osmolality is lowered too rapidly, causing fluid to shift out of the vascular space into the tissue. A patient with a history of MG is admitted because of increased weakness. His vital capacity and negative inspiratory force were evaluated by the respiratory therapist and impending respiratory failure was predicted. He stated he had been feeling bad lately and had been doubling his dose of pyridostigmine. Which of the following is the most likely cause for the respiratory failure? A. Cushing's syndrome B. Steroid overdose C. Myasthenia crisis D. Cholinergic crisis ✔D In an MG patient, both a myasthenia crisis and a cholinergic crisis can result in respiratory weakness and failure. The hint in this question is that the patient was taking double his dose of pyridostigmine, which is an anticholinesterase inhibitor. Cholinergic crisis is a result of exaggerated cholinergic activity and is characterized by respiratory failure, bradycardia, urinary retention, and increased oral secretions. Myasthenia crisis is typically a result of failure to take medications or ineffectiveness of the medications. A myasthenia crisis can be a clinical emergency with a need for rapid intervention. Which of the following is considered the initial intervention of choice for a hemodynamically unstable patient in a myasthenia crisis? A. IV immunoglobulin B. IV steroids C. Plasmaphoresis D. Anticholinesterase inhibitors ✔A Rapid treatment with IVIG or plasmaphoresis is comparable in efficacy but in hemodynamically unstable patients, plasmaphoresis is contraindicated. Rapid intervention with IVIG is the most appropriate intervention. Concomitant administration of ste- roids may be given but steroids alone have been found to exacerbate muscle weakness within 5 to 10 days. Anticholinesterase inhibitors are typically held during a myasthenia crisis due to aggravation of secretions and can be restarted when the patient has improved clinically. Following a gunshot wound to the head, an MRI was ordered by the physician. Which of the following is the most appropriate response by the nurse? A. Take the patient to get an MRI as ordered B. Inform the physician a CT scan is a better radiographic study for TBIs C. Remind the physician of the concern of metal fragments remaining within the cranium D. Discuss with the physician the need for immediate surgery ✔C In penetrating brain injuries, especially gunshot wounds, metal fragments, or bullets, may remain within the cranium. An MRI has the risk of moving the metal objects or creating heat because of the high magnetic field. Reminding the physician of the patient's mechanism of injury would be the most appropriate response. An MRI actually provides a greater structural detail than a CT. There was no indication in the scenario indicating the patient needed to be taken emergently to surgery. Ms. K is a 22-year-old female who was thrown from a vehicle and admitted for a TBI. The report from the previous nurse states she is localizing to pain and pupils are equal and reactive to light. During your assessment, you note her left pupil is dilated and unresponsive. Which of the following would be the most likely cause for the change in neurological status? A. Left-sided EDH B. Bilateral cerebral edema C. Right-sided acute SDH D. Right-sided EDH ✔A The dilated, nonreactive pupil is on the left side indicating that the mass lesion, such as a hematoma, would also be on the left side. Uncal herniation is a lateral transtentorial herniation and results in ipsilateral pupil dilation. In bilateral cerebral edema, the herniation would be a central herniation resulting in bilateral pupillary dilation. Following a blunt TBI, Ms. G is in the ICU with a ventriculostomy, mechanically ventilated, and receiving propofol for sedation. The family asks the nurse how long Mrs. G will be in the ICU and on sedation. Which of the following would be the best answer by the ICU nurse? A. Most patients only have to have ICP monitoring for 24 hours after their injury B. She will typically be sedated and monitored for at least 2 to 3 days until the peak period of cerebral edema is reached C. You will have to ask the neurosurgeon when he plans to take her to surgery D. Sedation is required in managing her brain injury and may continue indefinitely ✔B Cerebral edema tends to peak 2 to 3 days after a TBI. Close monitoring and sedation are typically performed on severe injuries for several days following the trauma. ICP is monitored typically longer than 24 hours and the greatest risk period for neurological deterioration is within 3 to 4 days post injury. Which of the following ventilator techniques used to manage ARDS should be avoided in a TBI patient with an increased ICP? A. Positive end-expiratory pressure (PEEP) B. Pressure release ventilation (PRV) C. Pressure control ventilation (PC) D. Permissive hypercapnia ✔D Permissive hypercapnia is a technique used to manage ARDS by manipulating ventilators based on hypoxia only and not treating hypercapnia. This can worsen ICP in a neurological patient due to the cerebral vasodilation effect of hypercapnia. Even though aggressive hyperventilation is no longer recommended, hypercapnia should be avoided. The use of PEEP can be used to assist with oxygenation in a neurological patient with ARDS but caution should be exercised as to the amount of PEEP. Increasing intrathoracic pressure with high levels of PEEP can cause a decrease in venous drainage from the brain with an increase in ICP. The other modes of ventilation are accept- able in the management of neurological patients with ARDS. A patient has been in the ICU for 5 days following a craniotomy for a tumor resection. He has been on decadron, propofol, and fentanyl to manage an elevated ICP and cerebral edema. He is now developing metabolic acidosis and hyperkalemia. Which of the following would be the most likely cause? A. Cushing's disease B. Long-term neurological and cognitive dysfunction (LNCD) C. Sepsis D. Propofol infusion syndrome ✔D Long-term or high-dose use of propofol has been found to cause propofol infusion syndrome. Symptoms include metabolic acidosis, hyperkalemia, rhabdomyolysis, renal failure, and myocardial failure. The use of exogenous steroids can result in Cushing's syndrome but does not typically present with metabolic acidosis or hyperkalemia. Sepsis identifiers are tachycardia, fever, leukocytosis, and tachypnea. LNCD may be caused by the presence of delirium and use of sedation but is a complication experienced after the ICU and does not present with metabolic acidosis or hyperkalemia. During testing for brain death, which two complications may occur during the apnea testing and should be closely monitored? A. Hypercapnia and metabolic acidosis B. Hypotension and cardiac arrhythmias C. Bradycardia and hypertension D. Aspiration and hypoxia ✔B During an apnea test used to determine brain death, hypercapnia and respiratory acidosis are expected and part of the criteria. The complication of hypercapnia and respiratory acidosis is hypotension and arrhythmias. The patient should be on a cardiac monitor and BP must be monitored closely. Hemodynamic instability is an indication to stop the apnea test before completion. Bradycardia can occur, but the patient will typically become hypotensive, not hypertensive. A decrease in oxygen saturation can occur and supplemental oxygen is frequently administered during the test but the risk of aspiration is not increased during apnea testing. Which CNs should be assessed prior to allowing patients with neurological injury to drink liquids? A. III, IV, and VI B. V, VII, and VIII C. IX, X, and XII