N4 - test - Head Injuries and ICP

http://www.nursingcenter.com/prodev/ce_article.asp?tid=288367
answers in comments

1.
Which of these nursing diagnoses is appropriate for a patient who has increased intracranial pressure (ICP) as a result of a traumatic head injury?
a. post trauma syndrome
b. ineffective cerebral tissue perfusion
c. disturbed energy field
d. autonomic dysreflexia

2.
You should monitor a patient who has cerebral edema for
a. decreased blood flow to the brain.
b. leakage of fluid from the eye orbits.
c. loss of autoregulation.
d. increased urine output.

3.
Which of these positions is least likely to increase ICP?
a. prone
b. Trendelenburg
c. side-lying with the neck flexed
d. supine with the hands extended

4.
To minimize the possibility of increased ICP for a patient in the intensive care unit
a. secure all tracheostomy ties snugly.
b. encourage the patient to bear down when moving his bowels.
c. dim the lights whenever possible.
d. have the patient cough vigorously to expel mucus.

5.
Symptoms of increased ICP include
a. headache.
b. ear discharge.
c. nasal congestion.
d. nuchal rigidity.

6.
When assessing a patient for ICP, observe for
a. facial color.
b. facial symmetry.
c. facial swelling.
d. facial expression.

7.
Which of these Glasgow Coma Scale measurements indicates the gravest condition?
a. 3
b. 5
c. 8
d. 12

8.
Which of these patient assessments will provide an indication of the function of cranial nerves III, IV, and VI?
a. Determine the patient’s orientation to person, place, and time.
b. Check the patient’s pupil reactivity and extraocular eye movements.
c. Assess muscle strength and movement.
d. Use a cotton ball to determine sensation bilaterally.

9.
Which of the following is useful to assess the function of cranial nerve II?
a. Ask the patient to smile.
b. Have the patient stick out her tongue.
c. Ask the patient to push away your hand.
d. Have the patient read the Snellen chart.

10.
For a patient at risk for ICP, which laboratory test result is the most important to monitor?
a. hemoglobin and hematocrit
b. serum creatinine
c. CO2 level
d. serum albumin level

11.
Cushing’s triad consists of
a. tachycardia, irregular respiratory rate, and hypotension.
b. bradycardia, widening pulse pressure, and irregular respiratory rate.
c. decerebrate posturing, bradycardia, and hypertension.
d. positive Babinski reflex, widening pulse pressure, and bradycardia.

12.
When caring for a patient who is on an ICP monitor, once per shift
a. irrigate the catheter.
b. balance the monitor.
c. test CSF output for protein.
d. measure CSF output.

13.
A patient’s cerebral perfusion pressure is 80 mm Hg. Which of these interpretations is correct?
a. This level is extremely elevated and indicates cerebral edema.
b. This level indicates inadequate brain perfusion.
c. This level is within normal limits and should continue to be monitored.
d. This level indicates leakage of CSF; test CSF for glucose.

14.
Which of these positions will promote venous return for a patient on an ICP monitor?
a. prone with the head toward the side
b. head of bed elevated to 15 degrees
c. legs elevated on two pillows
d. high Fowlers

15.
A patient on a ventilator coughs repeatedly during suctioning. Which of these medications would be ordered to prevent ICP?
a. diphenhydramine parenterally
b. epinephrine subcutaneously
c. lidocaine per tube
d. prochlorperazine rectally

16.
A patient who has a head injury is draining clear fluid from the left ear. How can you quickly assess for CSF?
a. Collect the fluid on a 4 _ 4 and look for the halo sign.
b. Suction the ear and send the specimen to the laboratory.
c. Smell the drainage and observe for a sweet odor.
d. Place a small amount of the fluid in a test tube and monitor for a bluish tint.