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Critical Care Nursing / Cerebrovascular Disorder- A Holistic Approach 11th Edition Test B, Exams of Nursing

Critical Care Nursing / Cerebrovascular Disorder- A Holistic Approach 11th Edition Test Bank(Q&A) Critical Care Nursing / Cerebrovascular Disorder- A Holistic Approach 11th Edition Test Bank(Q&A) Critical Care Nursing / Cerebrovascular Disorder- A Holistic Approach 11th Edition Test Bank(Q&A) Critical Care Nursing / Cerebrovascular Disorder- A Holistic Approach 11th Edition Test Bank(Q&A) Critical Care Nursing / Cerebrovascular Disorder- A Holistic Approach 11th Edition Test Bank(Q&A) Critical Care Nursing / Cerebrovascular Disorder- A Holistic Approach 11th Edition Test Bank(Q&A)

Typology: Exams

2023/2024

Available from 02/01/2024

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Download Critical Care Nursing / Cerebrovascular Disorder- A Holistic Approach 11th Edition Test B and more Exams Nursing in PDF only on Docsity! Critical Care Nursing / Cerebrovascular Disorder- A Holistic Approach 11th Edition Test Bank(Q&A) A patient is recovering from transphenoidal surgery for partial resection of a pituitary adenoma. The nurse should instruct the patient to avoid doing which action(s)? 1. Blowing the nose or sneezing 2. Deep breathing 3. Drinking more than 2 liters of fluid a day 4. Sitting up in bed higher than 30 degrees - ANSWER>>Correct Answer: 1 Rationale 1: These activities may cause the patch to dislodge, which could result in a cerebrospinal fluid leak (CSF) and increase the risk of infection. Rationale 2: Deep breathing is a post-operative activity that all post-operative patients should perform to prevent atelectasis. Rationale 3: Drinking 2 liters of fluid per day is a post-op activity that helps the body metabolize anesthesia, maintains hydration, and liquefies pulmonary secretions. Rationale 4: The head of the beds needs to be elevated at least 30 degrees or higher to reduce post-op edema. This also allows for better lung expansion to prevent atelectasis. A patient is diagnosed with a grade II astrocytoma. The nurse realizes that this patients prognosis is: 1. Excellent 2. Good as long as the tumor is treated soon 3. Good because the tumor is well defined 4. Poor because the tumor cells are irregularly shaped - ANSWER>>Correct Answer: 2 Rationale 1: Grade II tumor cells are less well defined and there is the possibility that a grade II tumor will transform to a higher grade. Excellent prognosis is not associated with this type of brain tumor. Rationale 2: Astrocytomas are the most common types of primary brain tumor and are graded from I to IV according to tissue histology. Grade I and grade II tumors are considered to be low-grade tumors and they have the most favorable survival rates and respond well to early treatment. Rationale 3: Grade I tumor cells are well defined and almost normally shaped. They have a low incidence of brain infiltration. Grade II tumor cells are less well defined and there is the possibility that a grade II tumor will transform to a higher grade. Rationale 4: Higher-grade (III and IV) tumor cells are abnormally shaped and have a pronounced ability to infiltrate normal brain tissue; therefore, the prognosis is poor. The nurse is assessing a patient with a meningioma. The nurse realizes that this patient will have: 1. A hearing disorder 2. A life expectancy of about 10 months 3. An excellent prognosis if the tumor is totally removed 4. Metastasis to other body organs - ANSWER>>Correct Answer: 3 Rationale 1: Other common benign brain tumors arise from nerve sheaths such as acoustic neuromas, which can lead to a hearing loss. 2. Determine the type and amount of medication to prescribe 3. Serve as a minor symptom that is nothing for the patient to worry about 4. Determine how long the patient has to stay in the hospital - ANSWER>>Correct Answer: 1 Rationale 1: Focal seizures, such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling, may occur. Other more specific symptoms, known as focal symptoms, occur in approximately one third of patients with brain tumors. Focal symptoms include hearing problems such as ringing or buzzing sounds or hearing loss, decreased muscle control, lack of coordination, decreased sensation, weakness or paralysis, difficulty with walking or speech, balance problems, or double vision. Because the symptoms are usually caused by invasion or compression from the tumor, these focal symptoms can help identify the location of the tumor. Rationale 2: The type and length of treatment of a tumor is based on location, grade, and type. These factors would be relevant to the treatment, whether it be surgical, radiation, or chemotherapy. Rationale 3: The neurologic changes present with a brain tumor are never taken lightly and should be noted as they are helpful with the diagnosis of an abnormality. Rationale 4: Treatment would determine length of hospital stay. During an assessment, a patient asks the nurse if something is burning. The nurse realizes that this patient could be demonstrating: 1. Engorged nasal passages 2. A focal seizure 3. A way to have the nurse leave to check if something is burning 4. Increased intracranial pressure - ANSWER>>Correct Answer: 2 Rationale 1: Engorged nasal passages usually result in the loss of smell, not the presence of unusual smells. Rationale 2: Focal symptoms can occur in patients with brain tumors. The nurse should question the patient about any experienced symptoms such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling. Rationale 3: This action is usually taken after the nurse has fully assessed the patient for neurologic changes. Priority care would include providing safety measures to protect the patient. Rationale 4: The initial changes associated with increased intracranial pressure are subtle changes in level of consciousness such as alertness, changes in orientation, and motor and sensory deficits. Seizure activity is a late sign. A patient with a brain tumor is having a diagnostic test to help determine response to therapy. This patient is most likely having a(n): 1. CT scan 2. PET scan 3. Angiogram 4. MRI - ANSWER>>Correct Answer: 4 Rationale 1: MRI scans are utilized more often than CT scans because they are more sensitive, and capable of detecting tumors too small to be noted on CT scans. Rationale 2: Positron emission tomography (PET) scans are not the most accurate method to diagnose or treat brain tumors. This method may have a role in grading a tumor for prognosis, localizing a tumor for biopsy, and mapping brain areas prior to surgery. Rationale 3: An angiogram is the diagnostic tool used for detecting vascular abnormalities, not tissue masses. Rationale 4: Functional MRIs may be used to assess the potential clinical outcomes of the tumor. The nurse is preparing to administer a medication to a patient to decrease the cerebral edema caused by a brain tumor. This medication is most likely a(n): 1. Antiseizure medication 2. Pain medication 3. Glucocorticoid 4. Antispasmodic - ANSWER>>Correct Answer: 3 Rationale 1: Antiseizure medication is used to reduce the excitability threshold of brain cells to the stimuli that result in seizure activity. These medications do not reduce cerebral edema. Rationale 2: Pain medications do not reduce cerebral edema or lower intracranial pressure. These medications can be dangerous in the neurologic patient as they can alter level of consciousness. Rationale 3: Glucocorticoids are the mainstay of treatment for vasogenic cerebral edema. These agents decrease the tissue swelling associated with brain tumors and manage some of the signs and symptoms that patients experience. Glucocorticoid therapy with dexamethasone has been the standard treatment for tumor-associated edema. Rationale 4: Antispasmodic medications do not cross the blood-brain barrier and have no effect on cerebral tissue. A patient is recovering from posterior fossa surgery. What should the nurse include in the patients plan of care? 1. Assess vital signs and level of consciousness every hour. 2. Maintain the patient flat in bed for at least 24 hours. The nurse is applying pneumatic compression boots on a post-operative craniotomy patient. The reason for this device is to reduce the risk of developing: 1. Meningitis 2. A deep vein thromboembolism 3. A cerebrospinal fluid leak 4. Seizures - ANSWER>>Correct Answer: 2 Rationale 1: Prophylaxis to prevent meningitis includes good hand washing, maintaining aseptic technique when handling external ventricular drains, tubes, and surgical sites, and administering antibiotic medications. Rationale 2: Prophylaxis for deep vein thromboembolism is recommended for most patients following surgery for malignant primary brain tumors. Pneumatic compression boots and graduated compression stockings have been shown to decrease the occurrence of venous thromboemboli without increasing intracranial pressure. Rationale 3: Prophylaxis to prevent a cerebral spinal fluid leak includes keeping the intracranial pressure at a normal level by keeping the head of the bed at 30 degrees and administering glucocorticoid medications. Rationale 4: Prophylaxis for seizures is the use of medications such as Dilantin (phenytoin) and Phenobarbital. A patient recovering from a craniotomy is complaining of a headache and has the head of the bed elevated. The nurse also sees a damp mark on the patients pillow. The nurse should: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Check the drainage for the presence of glucose. 2. Alert the physician. 3. Elevate the head of the bed to 45 degrees. 4. Plan for insertion of an external ventricular drain. 5. Apply an occlusive dressing to stop the leak. - ANSWER>>Correct Answer: 1,2 Rationale 1: A cerebrospinal fluid leak can be identified by clear fluid containing glucose that is leaking from the patients ear or nose and forming a halo as it settles on a pillowcase. The patient will complain of a headache. Rationale 2: The nurse should notify the health care provider regarding the presence of cerebrospinal fluid leakage in the event surgical intervention is required to close the tear. Rationale 3: Raising the head of the bed further would create more irritation to the dura and thus worsen the headache. A CSF leak may also be related to increased ICP and raising the head of the bed would increase the risk of herniation. Rationale 4: The insertion of an external ventricular drain would further deplete cerebrospinal fluid. As this is also an invasive procedure, there would be an increased risk for the development of meningitis. Rationale 5: An occlusive dressing would be contraindicated because the cerebrospinal fluid should be allowed to flow freely. This is to prevent an increase of intracerebral pressure. A patient with a brain tumor is prescribed an antiseizure medication. The nurse realizes that the purpose of this medication will be to: 1. Eliminate all seizure activity. 2. Reduce focal seizures. 3. Premedicate for status epilepticus. 4. Control the onset of seizure activity. - ANSWER>>Correct Answer: 4 Rationale 1: The majority of patients with brain tumors continue with some type of seizure, most commonly a focal seizure. Rationale 2: The majority of patients with brain tumors continue with some type of seizure, most commonly a focal seizure. Rationale 3: The use of seizure medication in the patient with a brain tumor is not to premedicate for status epilepticus. Rationale 4: The risk of seizures after craniotomy is extremely common and the risk of seizure development is partially dependent on the type of brain tumor. Recurrent seizures post craniotomy continues to cause significant clinical problems. The use of antiseizure medication is used to control the onset of seizure activity. A patient recovering from a glioma has concluded radiation therapy. The nurse realizes that the next step of treatment for this patient will most likely be: 1. Chemotherapy 2. An additional 6 weeks of radiation 3. Nothing, unless there is evidence the tumor has returned 4. Antiseizure medication - ANSWER>>Correct Answer: 1 2. Anterior cerebral artery 3. Posterior cerebral artery 4. Vertebrobasilar artery - ANSWER>>Correct Answer: 2 Rationale 1: Middle cerebral artery occlusions commonly produce hemiparesis, hypesthesia on the opposite side of the body, hemianopsia, and gaze preference toward the side of the lesion. Rationale 2: Anterior cerebral artery occlusions primarily affect frontal lobe function and can result in disinhibition, speech perseveration, altered mental status, impaired judgment, contralateral weakness, and urinary incontinence. Rationale 3: Posterior cerebral artery occlusions affect vision and thought, producing homonymous hemianopsia, cortical blindness, visual agnosia, altered mental status, and impaired memory. Rationale 4: Vertebrobasilar artery occlusion is difficult to detect because it results in a wide variety of cranial nerve, cerebellar, and brainstem deficits. A patient is diagnosed with an ischemic stroke with the onset of symptoms within the last 2 hours. The best course of treatment for this patient would be to: 1. Admit the patient to a neurosurgical unit for a surgery consultation. 2. Consider the administration of intravenous recombinant tissue-type plasminogen activator (rt-PA or alteplase). 3. Observe for continuing symptoms. 4. Provide intravenous fluids. - ANSWER>>Correct Answer: 2 Rationale 1: If the CT scan is positive for a hemorrhagic stroke, an immediate neurosurgical consult should be ordered. Immediate surgery for an ischemic stroke is not indicated at this time. The priority is to re-establish blood flow to limit neurologic deficits and preserve neurologic function. Once the patient has been stabilized and has recovered, carotid endarterectomy may be considered if indicated. Rationale 2: In the case of ischemic stroke, intravenous thrombolysis should be administered if the time since the onset of symptoms is less than 3 hours and the patient is eligible based on criteria. Rationale 3: Merely observing the patient is not sufficient because as the obstruction continues, the neurologic deficits worsen. The priority is to re-establish blood flow as soon as possible. Rationale 4: The use of IV fluids is a means to administer antihypertensive medications to control blood pressure. Fluid restriction may be indicated to assist in controlling hypertension but not so restricted to cause dehydration, which would increase blood viscosity, raising the risk of the development of more thromboemboli. A patient with an ischemic stroke has an oxygen saturation of 88%. What should be done to help this patient? 1. Position the patient on one side. 2. Elevate the head of the bed. 3. Provide low-dose oxygen. 4. Provide high-dose oxygen. - ANSWER>>Correct Answer: 4 Rationale 1: Positioning the patient on one side does not improve O2 saturation. Rationale 2: Raising the head of the bed assists in keeping the airway open as well as facilitating lung expansion to prevent atelectasis but will not improve oxygen saturation. Rationale 3: Low-dose oxygen does not provide adequate supplementation to maintain oxygen saturation, especially when it falls below 90%. It is helpful as an adjunct when the saturation is 90%, in order to raise saturation to more appropriate levels. Rationale 4: High-flow oxygen therapy is indicated when arterial blood gases or O2 saturation is less than 92%. Hypoventilation may cause an elevation in carbon dioxide, which could lead to cerebral vasodilation and further increase ICP. A patient being treated with warfarin (Coumadin) experiences an intracerebral hemorrhage. What should be considered to aid in the care of this patient? 1. Prepare the patient for surgery. 2. Prepare the patient for a ventriculostomy. 3. Prepare to administer vitamin K. 4. Prepare to administer protamine sulfate. - ANSWER>>Correct Answer: 3 Rationale 1: Surgery is indicated only after the cause of the bleed has been identified. This management will be based on the location and type of bleed. Rationale 2: A ventriculostomy is not used as a therapy in the management of the intracerebral hematoma. This therapy is limited and is only indicated if it would be beneficial in reducing intracranial pressure by controlling cerebrospinal fluid. Rationale 3: Since the patient has been receiving the anticoagulant warfarin (Coumadin), the appropriate drug is the administration of vitamin K to reverse the effects of this medication. Rationale 4: Protamine sulfate is the medication used to reverse heparin-associated ICH. The dose is dependent on the time since the cessation of heparin. A patient with a ruptured cerebral aneurysm is demonstrating drowsiness and confusion. On the Hunt and Hess scale, this patient would be rated as being a: 1. Grade 1 While conducting a health history the nurse suspects a patient with headaches is demonstrating signs of a brain tumor. How did the patient most likely describe the headaches to the nurse? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Worse in the morning 2. Worsen when coughing 3. Become severe when bending to tie shoes 4. Worse in the evening 5. Relieved by over-the-counter pain medication - ANSWER>>Correct Answer: 1,2,3 Rationale 1: The headache associated with a brain tumor is typically worse in the morning. Rationale 2: The headache associated with a brain tumor will worsen with coughing. Rationale 3: The headache associated with a brain tumor will worsen with a position change such as bending over. Rationale 4: The headache associated with a brain tumor is not worse in the evening. Rationale 5: The headache associated with a brain tumor will not respond to usual headache remedies. The nurse provides intravenous dexamethasone (Decadron) 10 mg to a patient with a metastatic brain tumor. What patient outcomes would indicate that the medication is effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Neurologic symptoms improve within 12 hours 2. Reduced intracranial pressure 3. Neurologic symptoms improve immediately 4. Reduced respiratory rate 5. Increased heart rate and blood pressure - ANSWER>>Correct Answer: 1,2 Rationale 1: Administration of dexamethasone can produce a reduction in cerebral edema and an improvement in neurologic symptoms most commonly in 12 to 24 hours Rationale 2: The decline in cerebral edema and ICP can persist for as long as 72 hours. Rationale 3: Administration of dexamethasone improves neurologic symptoms within 12 to 24 hours and not immediately. Rationale 4: Dexamethasone does not affect the respiratory rate. Rationale 5: Dexamethasone does not affect the heart rate or blood pressure. The nurse is concerned that a patient recovering from a craniotomy for a malignant brain tumor is at risk for developing a deep vein thrombosis. What interventions would be appropriate for the patient at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Apply graduated compression stockings as indicated. 2. Administer subcutaneous low-molecular weight heparin (LMWH) 5,000 units twice a day as prescribed. 3. Administer enoxaparin 40 mg each day. 4. Position with the legs of the bed elevated. 5. Perform bedside passive range of motion exercises every 8 hours. - ANSWER>>Correct Answer: 1,2,3 Rationale 1: Graduated compression stockings have been shown to decrease the occurrence of venous thrombosis without increasing intracranial pressure. Rationale 2: The use of low-molecular weight heparin is an alternative to the use of compression boots to reduce the risk for venous thrombosis. Rationale 3: The use of enoxaparin 40 mg each day is an alterative to the use of compression boots to reduce the risk for venous thrombosis. Rationale 4: Elevating the legs of the bed will not reduce the development of venous thrombosis in this patient. Rationale 5: Passive range of motion exercises every 8 hours will not reduce the development of venous thrombosis. A patient being treated for a cardiac dysrhythmia is demonstrating signs of an ischemic stroke. What assessment findings alerted the nurse to the development of this complication? Standard Text: Select all that apply. 1. Administering protamine sulfate 2. Administering vitamin K 3. Preparing for ventriculostomy placement 4. Preparing for surgery to clip the aneurysm 5. Preparing for endovascular embolization - ANSWER>>Correct Answer: 1,3 Rationale 1: Protamine sulfate is used to revere heparin-associated intracerebral hemorrhage. Rationale 2: Vitamin K is used to reverse the effects of warfarin (Coumadin). Rationale 3: A ventriculostomy may need to be performed and an external ventricular drain inserted to drain CSF. Rationale 4: Aneurysms are associated with subarachnoid hemorrhages. Rationale 5: This is a treatment for an aneurysm. While recovering from surgery to repair an aneurysm the nurse is concerned the patient is experiencing vasospasm. What did the nurse assess in the patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Increased lethargy 2. Elevated body temperature 3. Nuchal rigidity 4. Dysphagia 5. Ventricular dysrhythmia - ANSWER>>Correct Answer: 1,2,3,4 Rationale 1: A change in mental status such as lethargy is a symptom associated with vasospasm. Rationale 2: Elevated body temperature is a symptom associated with vasospasm. Rationale 3: Neck stiffness is a symptom associated with vasospasm. Rationale 4: Dysphagia is a symptom associated with vasospasm. Rationale 5: Ventricular dysrhythmia is not a symptom associated with vasospasm. A patient recovering from a stroke is demonstrating signs of dysphagia. The patient is scheduled for a barium swallow because this diagnostic test will: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Identify the presence of an aspiration 2. Identify the presence of abnormalities 3. Visualize the sequence of events of a swallow 4. Analyze muscle activities 5. Correct swallowing abnormalities - ANSWER>>Correct Answer: 1,2 Rationale 1: A barium swallow may identify the presence of an aspiration. Rationale 2: A barium swallow may identify subtle anatomic abnormalities. This test is especially useful if more than one abnormality is discovered. Rationale 3: Videofluoroscopy visualizes the sequence of events of a swallow. Rationale 4: Videofluoroscopy analyzes muscle activities. Rationale 5: The barium swallow does not correct swallowing abnormalities.