ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 59 Questions
Question 1 of 5
Family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient. Which of the following responses by the nurse is best?
Correct Answer: B
Rationale: Short and simple explanations should be given to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family member's anxiety.
Question 2 of 5
The nurse is caring for a patient with a head injury and has admission vital signs of blood pressure 128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
Correct Answer: A
Rationale: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.
Question 3 of 5
The nurse is assessing a patient who is unconscious and applies a painful stimulus to the nail beds. The patient responds with internal rotation, adduction, and flexion of the arms. Which of the following terms should the nurse use when documenting the findings?
Correct Answer: C
Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
Question 4 of 5
A nurse is providing care for an unconscious patient with a head injury prescribed IV mannitol. Which of the following parameters is best for the nurse to monitor to determine if the mannitol has been effective?
Correct Answer: D
Rationale: Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.
Question 5 of 5
A patient with a head injury opens his or her eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. Which of the following Glasgow Coma Scale scores should the nurse document?
Correct Answer: B
Rationale: The patient has a score of 3 for eye opening (to verbal stimulation), 3 for best verbal response (inappropriate words/cursing), and 5 for best motor response (localizes pain).
Total score: 3 + 3 + 5 = 11. However, the provided options include 15, which seems incorrect based on standard Glasgow Coma Scale scoring. Assuming a possible error in the original document, the closest logical score based on the description should be calculated, but none match perfectly. The answer 'B' (15) is selected as per the document, though it may reflect an inconsistency.