NUR 230 Exam 4 Questions with Correct Answers Best Rated Solution, Exams of Nursing

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NUR 230 Exam 4 Questions with Correct Answers Best Rated Solution - *personality* - voluntary eye movement - voluntary motor movement - speech - higher cognitive functioning - memory retention - Correct answer What are the primary functions of the frontal lobe? integration of voluntary somatic, visual, and auditory data - Correct answer What are the primary functions of the temporal lobe? - interpretation of spatial information - interpretation of sensory information - Correct answer What are the primary functions of the parietal lobe? sight processing - Correct answer What are the primary functions of the occipital lobe? level of consciousness - Correct answer What is the single most important indicator of neurological function? - eye opening response - verbal response - motor response - Correct answer Which three factors are included in the Glasgow Coma Scale? 7 - Correct answer A score of _____ or less on the Glasgow Coma Scale is commonly accepted as the definition of a coma. - spontaneous (4) - responds to voice (3) - responds to pain (2) - no response (1) - Correct answer From best to worst, what are the possible scores a patient can get for the eye opening response of the Glasgow Coma Scale? - oriented (5) - confused (4) - inappropriate (3) - does not make sense (2) - no verbal response (1) - Correct answer From best to worst, what are the possible scores a patient can get for the verbal response of the Glasgow Coma Scale? - obeys commands (6) - localizes pain (5) - withdraws to pain (4) - flexion to pain (3) - extension to pain (2) - no motor activity (1) - Correct answer From best to worst, what are the possible scores a patient can get for the motor response of the Glasgow Coma Scale? - have patient occlude one nostril and identify a common smell - repeat test for other nostril - Correct answer How is the olfactory nerve assessed? olfactory - Correct answer Cranial nerve I is the ___________ nerve. - have patient look directly at you, then have them indicate when an object is moved into the periphery - use Snelling chart to test for visual acuity - Correct answer How is the optic nerve assessed? optic - Correct answer Cranial nerve II is the _________ nerve. - coulometer (III) - trochlear (IV) - abduces (VI) - Correct answer Which nerves are assessed together, as they are responsible for the six cardinal directions of gaze? - have patient hold their head still and follow the movement of your finger in the six positions of gaze - assess pupillary response using the penlight - Correct answer How are the coulometer (III), trochlear (IV), and abduces (VI) nerves assessed? trigeminal - Correct answer Cranial nerve V is the _______ nerve. facial - Correct answer Cranial nerve VII is the ________ nerve. acoustic (vestibulocochlear) - Correct answer Cranial nerve VIII is the _________ nerve. - have patient close their eyes and identify a pinprick in the ophthalmic, maxillary, and mandibular areas on both sides of the face - have patient clench their teeth - Correct answer How is the trigeminal nerve assessed? have patient to close eyes tightly, raise their eyebrows, purse their lips, smile, and frown - Correct answer How is the facial nerve assessed? 60 and 100 (70 is optimal) - Correct answer Normal CPP is between ______ and ______. 50 - Correct answer CPP of less than ______ is associated with ischemia and neuronal death. 30 - Correct answer CPP of less than ______ is incompatible with life. inversely - Correct answer The impending signs of brain herniation R/T increased ICP are ___________ related to the signs of shock. (inversely or directly) - changes in LOC - headache - papilledema - motor & sensory function changes - projectile vomiting with no nausea - decorticate & decelerate posturing - poikilothermic (specifically, hyperthermia) - seizures - *Cushing's triad* (occurs right before herniation) - *fixed, unilateral dilated pupil* (occurs right before herniation) - Correct answer What are the S/S of increased ICP? - space-occupying lesion(s) - cerebral infarction - obstruction to the outflow of CSF - ingested or accumulated toxin - abscess(is) - Correct answer Typical causes of increased ICP include... - vasodilation: increases - vasoconstriction: decreases - Correct answer With ICP, vasodilation of vessels ________ ICP, while vasoconstriction of vessels ________ ICP. (increases or decreases) - PCO2: increased - PO2: decreased - Correct answer With ICP, vasodilation is related to ________ levels of PCO2 and ________ levels of PO2. (increased or decreased) - CSF: moves out of the cranium - brain: herniation into the foramen magnum - blood: shunted elsewhere - Correct answer How do the components within the cranium compensate when the volume of one increases? - 70 and 150 - 60 - Correct answer Normal MAP should be between ______ and ______, but must be at least ______ for perfusion to occur. - manifold (Osmitrol) - dexamethasone (Decadron) - fosphenytoin (Cerebryx) - Correct answer What are the three main treatment options used to decrease cerebral edema? - coma - pupils fixed and dilated - no motor response - profound hypotension - tachycardia - respiratory arrest - Correct answer What are the *late* S/S indicating that the brain has herniated? True. This poses a greater risk for brain herniation. - Correct answer T or F? A lumbar puncture is contraindicated for patients with increased ICP. - manifold (Osmitrol) - dexamethasone (Decadron) - anti-seizure medications - vasoactive medications (to maintain BP) - antibiotics - IV fluids - induced hypothermia - induced barbiturate coma - Correct answer Treatment options used to decrease ICP include... hypertonic saline solution - Correct answer Which solution may be given in place of manifold? - provide ventricular fluid drainage - helps determine prognosis - accurate measure of CPP - sustained pressure waves can be detected - Correct answer What are the benefits of invasive ICP monitoring? - intraventricular catheter - subarachnoid screw - fiber optic device - Correct answer Methods of ICP monitoring include... - *must be level with the foramen of Monroe* (use tragus of the ear as a reference point) - *must be adjusted every time the patient is moved* - Correct answer Nursing management for the external transducer of an intraventricular catheter includes... - intracranial hypertension - Cushing's stress ulcer - neurogenic pulmonary edema - diabetes insipid us - SIADH - Correct answer Complications related to increased ICP include... - ICP <20 - CPP >60 - GCS >9 - RR <24 - SaO2 >94% - no skin breakdown - no further deterioration in LOC - maintain patent airway - Correct answer Goal values for patients with increased ICP include... - *monitor neurological status Q1 hour* - limit activities that increase ICP - provide comfort measures - elevate HOB to ~30 degrees - maintain head in neutral alignment - decrease excessive stimuli - Correct answer Nursing interventions for patients with increased ICP include... - suctioning - coughing - blowing the nose - agitation (moving the patient) - fever - pain - waking up - Correct answer Activities that may increase ICP include... males age 15-44 - Correct answer Traumatic head injuries most typically occur in this age group and this gender... - immediately after the injury - within two hours after the injury - 3 weeks after the injury - Correct answer Death caused by head trauma typically occurs during one of these three time periods... - facial paralysis - Battle's sign (common with basilar fracture) - raccoon eyes (common with basilar fracture) - logorrhea - rhinorrhea - Correct answer What are the S/S specific to a skull fracture? - *fearfulness and anxiousness* - impaired speech and language ability - impaired comprehension ability - impaired spatial discrimination - Correct answer What are the S/S of a left-sided stroke? - *CT scan (first line)* followed by MRI if necessary - CT angiography - cardiac imaging - trans cranial Doppler - lumbar puncture (to identify subarachnoid hemorrhage) - blood studies - Correct answer Diagnostic tests for identifying a stroke include... sudden, severe headache - Correct answer What is the most common sign of a subarachnoid hemorrhagic stroke? - antiplatelet therapy (i.e. aspirin, clopidogrel) - antihyperlipidemic agents (i.e. statins) - carotid endarterectomy - transluminal angioplasty - stenting - extracranial-intracranial bypass - Correct answer Drug and surgical therapy used to prevent strokes from occurring include... - before therapy initiation: <185/<110 - 24 hours following therapy: <180/<105 - Correct answer Appropriate blood pressure levels for patients receiving fibrinolysis therapy include... - *must meet screening criteria* - *must be administered within 3-4.5 hours of symptom onset* - *insert urinary catheter, NG tube, and multiple IVs BEFORE administration* - control blood pressure for 24 hours - maintain strict bedrest for 24 hours - Correct answer Nursing management for patients receiving fibrinolysis therapy include.... - symptom onset <3 hours (may go up to 4.5 hours) before therapy - clinical diagnosis of ischemic stroke with measurable NIHSS deficit - age >18 - no evidence of intracranial bleeding - BP <185/<110 - platelets >100,000 - blood glucose >50 - no seizures during episode - Correct answer *Inclusion* criteria for receiving fibrinolysis therapy includes... - stroke or cerebral trauma within the past 3 months - MI within the past 3 months - major surgery within the past 14 days - GI/GU hemorrhage within the past 21 days - history of previous intracranial hemorrhage - arterial puncture at non-compressible site within the past 7 days - BP >185/>110 - taking oral anticoagulants - pregnancy - Correct answer *Exclusion* criteria for fibrinolysis therapy includes... - *0.9 mg/kg with a maximum dose of 90 mg* - 10% of total dose received over 1 minute - 90% of remaining dose received over 60 minutes - avoid anticoagulants or aspirin for 24 hours following administration - assess frequently for S/S of bleeding - assess neurological status frequently - *stop therapy if sudden decrease in LOC is experienced* - Correct answer Nursing management for administration of IV tape includes... - thrombolytic therapy (i.e. IV tape or intra-arterial tape) - stent retrievers - MERCI retrievers - Correct answer Treatment options for ischemic strokes may include... >220/>120 - Correct answer For ischemic strokes, blood pressure should only be treated if it reaches which level? - *maintain SBP <160* - aneurysm clipping or coiling - evacuation of hematomas - resection or radiosurgery of AVM - nifedipine (for subarachnoid hemorrhage) - *DO NOT give anticoagulants* - *DO NOT give platelet inhibitors* - Correct answer Treatment options for hemorrhagic strokes may include... - LOC - cognition - motor abilities - cranial nerve function - sensation - proprioception - cerebellar function - deep tendon reflexes - Correct answer Which factors does the NIHSS assess? - perform passive ROM exercises immediately - position on affected side only 30 minutes at a time - trochanter roll at hip - hand cones or splints - arm support - heel elevation - Correct answer Proper positioning for a patient who has had a stroke includes... - *address needs within 72 hours of stroke onset* - determine results of swallowing evaluation - provide mouth care before and after feeding - maintain high Fowler's position 30 minutes following feeding - promote self-feeding & use of assistive devices - Correct answer Nursing management for the nutrition of a stroke patient should include... The patient can see at 20 feet what people with normal vision can see 40 feet away. - Correct answer If a patient has 20/40 (or 20/60, 20/80, etc.) vision, this indicates... - myopia - hyperopia - presbyopia - astigmatism - aphasia - Correct answer Types of refractive errors include... - R: redness - S: sensitivity - V: vision problems - P: pain - Correct answer Possible complications of contact lenses include... (remember the acronym RSVP) - cataracts - glaucoma - macular degeneration - diabetic retinopathy - corneal diseases - Correct answer Causes of total blindness may include... - *begin ocular irrigation for chemical exposure* - stabilize foreign objects - cover the eye(s) with dry, sterile patches - instruct patient not to blow nose - elevate HOB 45 degrees - Correct answer Emergency management of eye trauma includes... - eye irritation & redness - mucopurulent drainage - tear production - itching - burning - Correct answer What are the S/S of conjunctivitis (pink eye)? - maintaining droplet precautions - aggressive antibiotic therapy (must cross the BBB) - administration of corticosteroids - administration of analgesia - darkened room - cool cover for eyes - manage fever - observe for seizures - Correct answer Nursing management of patients with bacterial meningitis includes... - diuretics - corticosteroids - antiviral drugs - ant seizure drugs - Correct answer Treatment options for encephalitis include... - paralysis - seizures - memory loss - cognitive impairment - language impairment - visual problems - Correct answer What are the S/S of supratentorial brain tumors? - *autonomic nervous system dysfunction* - ataxia - vertigo - vomiting - drooling - hearing loss - visual impairment - Correct answer What are the S/S of infratentorial brain tumors? - temozolamide (Deodar) - bevacizumab (Elastin) - carmustine (Glade) wafer - Opted system - radiation - radio surgical procedures - Correct answer Non-surgical treatment options for brain tumors include... - Burr hole - craniotomy - craniotomy - cranioplasty - stereotaxic - shunts - Correct answer Surgical treatment options for brain tumors include... - HOB 30 degrees - avoid neck and hip flexion - *may turn, NOT tilt* side to side, or remain in supine position - Correct answer Describe proper patient positioning for supratentorial access following brain surgery. - HOB flat - turned on *opposite side of access* - remain NPO for 24 hours - Correct answer Describe proper patient positioning for infratentorial access following brain surgery.