2024/2025 Newest NURS 2400 Exam #2 COMPREHENSIVE QUESTIONS AND 100% CORRECT VERIFIED ANS, Exams of Nursing

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2024 /2025 Newest NURS 2400 Exam # 2

COMPREHENSIVE QUESTIONS AND 100% CORRECT

VERIFIED ANSWERS GRADED A

(Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) Select the main structures below that play a role with altering intracranial pressure: A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater A, C and D (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production

D. Leaking proteins into the brain barrier B and D (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees A, B, D and E (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP

C

(Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is: A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg B (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery. B (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would?

A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning C (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) A patient has a ventriculostomy. Which finding would you immediately report to the doctor? A. Temperature 98.4 'F B. CPP 70 mmHg C. ICP 24 mmHg D. PaCO2 35 C (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) External ventricular drains monitor ICP and are inserted where? A. Subarachnoid space B. Lateral Ventricle C. Epidural space D. Right Ventricle B

(Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) Which of the following is contraindicated in a patient with increased ICP? A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications A (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature? A. Rectal B. Oral C. Axillary A (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Bradycardia B. Decerebrate posturing C. Restlessness

D. Unequal pupil size C (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing A, D, E and F (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) You're maintaining an external ventricular drain. The ICP readings should be? A. 5 to 15 mmHg B. 20 to 35 mmHg C. 60 to 100 mmHg D. 5 to 25 mmHg A

(Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12 C (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing B (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck

D. Flexion of the hips D (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? A. The eyes will move in the same direction as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed position as the head is moved side to side. D (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication? A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria. B (Registered Nurse RN Increased Intracranial Pressure (ICP) NCLEX Questions) What assessment finding requires immediate intervention if found while a patient is receiving

Mannitol? A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/ D. Patient complains of dry mouth and thirst B As the nurse monitors the client who has suffered from a car accident with trauma to the head, they note that Cushing's triad includes changes in mental status and vital signs. These include all of the following except: A. Bradycardia B. Hypertension C. Tachycardia D.Irregular respirations Here is the link to the rationals Start at 8: https://www.youtube.com/watch?v=B0QOW-HadUk&feature=youtu.be&t=1m28s C In reviewing the new medication orders of a client w/ cerebral edema, who is comatose, which of the following medications should the nurse clarify with the prescribing physician? A. Mannitol (Osmitrol) 20% 100cc IV q B. Bexamethasone (Decadron) 2mg IV bid C. Phenytoin Na (Dilantin) 100 mg IV PRN

D. meperidine HCL (Demerol) 25 mg IV Q6H prn Here is the link to the rationals Start at 8: https://www.youtube.com/watch?v=B0QOW-HadUk&feature=youtu.be&t=1m28s D Which of the following is the earliest sign of increased ICP that a nurse should watch out for? A. Decreased LOC B. Carotid bruit C. Projectile vomiting D. Seizures Here is the link to the rationals Start at 9: https://www.youtube.com/watch?v=B0QOW-HadUk&feature=youtu.be&t=1m28s A What is the normal range for ICP? A. 5-10 mmHg B. 20-30 mmHg C. 5-15 mmHg D. 35-40 mmHg C Which of the following are examples of loop diuretics? (Select all that apply.) A. Mannitol B. Furosemide C. Urea D. Glycerol E. Glucose F. Ethcrynic acid B and F

Which of the following are examples of osmotic diuretics? (Select all that apply.) A. Mannitol B. Furosemide C. Urea D. Glycerol E. Glucose F. Ethcrynic acid A, C, D and E Which class of medications has this mechanism of action? Works by increasing the osmolarity of the blood, thereby drawing water out of edematous brain tissue and into the vascular system for elimination via the kidneys. Osmotic diretics Which class of medications has this mechanism of action? Inhibits the sodium and chloride reabsorption at the ascending loop of Henle. They cause a reduction in the rate of CSF production, thus reducing the ICP. Loop diuretics If a client with IICP begins to develop hyperthermia, what order can the nurse expect from the physician? A. Loop Diuretics (Lasix) B. Osmotic Diuretics (Mannitol) C. Antipyretics (Acetaminophen) C What classifications of medications can a nurse expect to be ordered for a client with IICP? (Select all that apply.) A. Vasopressors

B. Histamine H2 antagonists C. Proton pump inhibotrs D. Anticonvulsants A, B, C and D Which diagnostic tests can a nurse expect to be ordered for a client with IICP? (Select all that apply.) A. CT Scan B. Lumbar puncture C. MRI D. Serum osmolality E. Chest x-ray F. Arterial blood gases A, C, D and F An ER nurse gets a call from an incoming ambulance that they have a peds. client showing later signs of IICP. What will the nurse anticipate seeing in the client upon assessment? (Select all that apply.) A. Increased LOC B. Decreased LOC C. Cushing Triad D. Decreased systolic pressure E. Increased systolic pressure F. Irregular respiration G. Bradycardia H. Widened pulse pressure I. Fixed and dilated pupils B, C, E, F, G, H, and I An infant is suspected of having IICP, if this is the case, what would the nurse expect to see in the early stages? (Select all that apply.) A. Irritability

B. Sunk fontanel C. Bulging fontanel D. Increased head circumference E. Decreased head circumference F. Little to no crying G. High-pitched, shrill cry A, C, D and G A child is presented in the ER with possible IICP, what s/s would the nurse expect to see in the early stages? (Select all that apply.) A. Headache B. Nausea and vomiting C. Dizziness D. Vertigo E. Some change in LOC F. Downward deviation of the eyes (Sunsetting) A, B, C, D, E and F A client comes in with with an ICP of greater than 20 mmHg. Which what should the nurse do? A. Treat it as a medical emergency B. Check their vitals q2hr C. Document that the client is improving A What can alter the ICP? (Select all that apply.) A. Blood B. Bowels C. CSF (Cerebral spinal fluids) D. Brain A, C and D

Which system of the body is responsible for the following?

• Regulating all bodily functions
• Muscle movements
• Emotions
• Mental abilities A. Cardiovascular system B. Neurological system C. Limbic system B What is the brain protected by? (Select all that apply.) A. Meninges B. Skull C. CSF D. Blood E. Nerves A, B and C Which part of the cerebrum controls this? Impulse Control A. Frontal lobe B. Parietal lobe C. Occipital lobe D. Temporal Lobe A Which part of the cerebrum controls this? Sensory, knowledge and numbers

A. Frontal lobe B. Parietal lobe C. Occipital lobe D. Temporal Lobe B Which part of the cerebrum controls this? Vision A. Frontal lobe B. Parietal lobe C. Occipital lobe D. Temporal Lobe C Which part of the cerebrum controls this? Memory, Personality and Auditory A. Frontal lobe B. Parietal lobe C. Occipital lobe D. Temporal Lobe D Which part of the diencephalon does this? Relays information and acts as the center for pain A. Thalamus B. Hypothalamus C. Epithalmus

A

Which part of the diencephalon does this? Acts as the autonomic control center, controls mood and controls sleep cycles A. Thalamus B. Hypothalamus C. Epithalmus B Which part of the diencephalon does this? Controls the limbic system A. Thalamus B. Hypothalamus C. Epithalmus C Which part of the brain does the following? Connects pathways Influences BP by controlling vasodilation Regulates RR, depth and rhythm A. Brain stem B. Cerebellum C. Cerebrum D. Diencephalon A

Which of the following is the normal range of ICP for an infant? A. 2-4 mmHg B. 5-15 mmHg C. 3-7 mmHg D. 1.5-6 mmHg D Which of the following is the normal range of ICP for children? A. 2-4 mmHg B. 5-15 mmHg C. 3-7 mmHg D. 1.5-6 mmHg C Which of the following is the normal range of ICP for an adult? A. 2-4 mmHg B. 5-15 mmHg C. 3-7 mmHg D. 1.5-6 mmHg B Monro-Kellie hypothesis states that if the volume _______ in brain, CSF or blood, then the volume of the others must _______. A. increase; decrease B. decrease; decrease C. increase; increase D. decrease; increase A

The brain requires constant what? (Select all that apply.) A. Potassium B. Calcium C. O D. Nitrogen E. Glucose C and E When blood flow decreases, how does the body compensate? (Select all that apply.) A. Stretch receptors (Vasoconstriction) B. Stretch receptors (Vasodialtion) C. Chemical auto regulation B and C CCP = _______ - ______ A. MAP-ICP B. ICP-MAP A Which equation is used to determine the MAP? A. MAP= SBP + 2(DBP)/ B. MAP= SBP + 3(DBP)/ A Which of the following would be sedatives that a nurse could anticipate orders for in a client with IICP? (Select all that apply.) A. Propofol B. Succinylcholine

C. Midazollam D. Pentobarbital E. Cisatracurium A, C and D Which of the following would be muscle relaxants that a nurse could anticipate orders for in a client with IICP? (Select all that apply.) A. Propofol B. Succinylcholine C. Midazollam D. Pentobarbital E. Cisatracurium B and E If elevated ICP is known, maintain MAP for a cerebral perfusion pressure at or above ___ mmHg. A. 30 B. 50 C. 60 D. 80 C Which ICP monitoring system is described below?

• Hole drilled into skull & catheter is inserted through the brain into the lateral ventricle.
• Continuous measurements
• Therapeutic drainage of CSF
• Most accurate A. External ventricular drain B. Subdural screw C. Epidural sensor

A

Which ICP monitoring system is described below? Hole drilled into skull and bolt is placed into the subdural space. A. External ventricular drain B. Subdural screw C. Epidural sensor B Which ICP monitoring system is described below? Least invasive monitoring where the sensor is placed in between skull and dural tissue. A. External ventricular drain B. Subdural screw C. Epidural sensor C All of the following are factors that influence what?

• Body temperature
• CO2 and O2 levels
• Body position
• Arterial and venous pressure
• Vomiting and bearing down A. ICP B. Body weight C. Mental status A

A client comes into the ED with irregular breathing from IICP. The nurse needs to explain to the client's spouse about there breathing, since they do not know what cheyne-stokes. How would they explain it? A. Hypoventilation then apnea B. Apnea then hypoventilation C. Apnea then hyperventilation D. Hyperventilation then apnea D Decerebrate positioning means what? A. Arms and legs extended B. Arms and legs pulled to the core A Decorticate positioning means what? A. Arms and legs extended B. Arms and legs pulled to the core B Cushing triad has which of the following symptoms? (Select all that apply.) A. Decreased systolic B. Increased systolic C. Decreased HR D. Increased HR E. Increased RR F. Decreased RR B, C and F

S/S of IICP are what? (Select all that apply.) A. Reflex postive Babinski (toes fan out) B. Headaches C. Increased LOC D. Sezuires E. Emesis F. Hemiplagia G. Decreased LOC A, B, D, E, F and G How would you place the head of the bed for a client who has IICP? (Select all that apply.) A. 45-55 degrees B. 90 degrees C. 30-35 degrees D. Head mid-line E. No flextion of neck or hips C, D and E A nurse comes unto shift and finds out they will be caring for a client with IICP. What classifications of medications could they anticipate? (Select all that apply.) A. Barbiturates (Central nerve depressant) B. Vasopressors C. IV fluids D. Anti-hypertensives E. Anti-convulsants F. Anti-pyretics G. Loop diuretics H. Corticosteroids A, B, C, D, E, F, G and H

Registered Nurse RN Hypotonic, Hypertonic & Isotonic Solutions When the cell presents with the same concentration on the inside and outside with no shifting of fluids this is called? A. Hypotonic B. Hypertonic C. Isotonic D. Osmosis C Registered Nurse RN Hypotonic, Hypertonic & Isotonic Solutions Which of the following is not a hypertonic fluid? A. 3% Saline B. D5W C. 10% Dextrose in Water (D10W) D. 5% Dextrose in Lactated Ringer's B Registered Nurse RN Hypotonic, Hypertonic & Isotonic Solutions What type of fluid would a patient with severe hyponatremia most likely be started on? A. Hypotonic B. Hypertonic C. Isotonic D. Colloid B Registered Nurse RN Hypotonic, Hypertonic & Isotonic Solutions When administering a hypertonic solution the nurse should closely watch for? A. Signs of dehydration

B. Pulmonary Edema C. Fluid volume deficient D. Increased Lactate level B Registered Nurse RN Hypotonic, Hypertonic & Isotonic Solutions A patient with cerebral edema would most likely be order what type of solution? A. 3% Saline B. 0.9% Normal Saline C. Lactated Ringer's D. 0.225% Normal Saline A Registered Nurse RN Hypotonic, Hypertonic & Isotonic Solutions _______ solutions cause cell dehydration and help increase fluid in the extracellular space. A. Hypotonic B. Osmosis C. Isotonic D. Hypertonic D Registered Nurse RN Hypotonic, Hypertonic & Isotonic Solutions D5W solutions are sometimes considered a hypotonic solution as well as an isotonic solution because after the body metabolizes the dextrose the solution acts as a hypotonic solution. A. True B. False A Registered Nurse RN Hypotonic, Hypertonic & Isotonic Solutions

Which solution below is NOT a hypertonic solution? A. 5% Dextrose in 0.9% Saline B. 5% Saline C. 5% Dextrose in Lactated Ringer's D. 0.33% saline (1/3 NS) D Registered Nurse RN Hypotonic, Hypertonic & Isotonic Solutions The doctor orders an isotonic fluid for a patient. Which of the following is not an isotonic fluid? A. 0.9% Normal Saline B. Lactated Ringer's C. 0.45% Saline D. 5% Dextrose in 0.225% saline C Registered Nurse RN Hypotonic, Hypertonic & Isotonic Solutions A patient is being admitted with dehydration due to nausea and vomiting. Which fluid would you expect the patient to be started on? A. 5% Dextrose in 0.9% Saline B. 0.33% saline C. 0.225% saline D. 0.9% Normal Saline D Registered Nurse RN Hypotonic, Hypertonic & Isotonic Solutions Isotonic fluids cause shifting of water from the extracellular space to the intracellular space. A. True B. False B