Understanding the Essentials of Critical Care Nursing 2nd Edition BY Kathleen – Test Bank

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Understanding the Essentials of Critical Care Nursing 2nd Edition BY Kathleen – Test Bank

Chapter 2 Care of the Critically Ill Patient
1) ʺResiliencyʺ in the American Association of Critical-Care Nurses synergy model refers to a personʹs:
1. Motivation to reduce anxiety through positive self-talk.
2. Ability to bounce back quickly after an insult.
3. Physical strength to endure extreme physical stressors.
4. Ability to return to a state of equilibrium.
Answer: 2
Explanation: 1. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The
degree of resiliency is placed along a continuum between being unable to mount a response to
having strong reserves. Other characteristics of this model include: vulnerability, stability,
complexity, predictability, resource availability, participation in care, and participation in
decision making. #1 and #3 do not define resiliency and are not related to the synergy model
patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium
and range between unresponsive to therapies and at high risk for death to stable and
responsive to therapy.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Safe, Effective Care Environment–Management of Care
2. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The
degree of resiliency is placed along a continuum between being unable to mount a response to
having strong reserves. Other characteristics of this model include: vulnerability, stability,
complexity, predictability, resource availability, participation in care, and participation in
decision making. #1 and #3 do not define resiliency and are not related to the synergy model
patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium
and range between unresponsive to therapies and at high risk for death to stable and
responsive to therapy.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Safe, Effective Care Environment–Management of Care
3. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The
degree of resiliency is placed along a continuum between being unable to mount a response to
having strong reserves. Other characteristics of this model include: vulnerability, stability,
complexity, predictability, resource availability, participation in care, and participation in
decision making. #1 and #3 do not define resiliency and are not related to the synergy model
patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium
and range between unresponsive to therapies and at high risk for death to stable and
responsive to therapy.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Safe, Effective Care Environment–Management of Care
4. The correct definition of ʺresiliencyʺ is the ability to bounce back quickly after an insult. The
degree of resiliency is placed along a continuum between being unable to mount a response to
having strong reserves. Other characteristics of this model include: vulnerability, stability,
complexity, predictability, resource availability, participation in care, and participation in
decision making. #1 and #3 do not define resiliency and are not related to the synergy model
patient characteristics. #4, ʺstability,ʺ is defined as the ability to return to a state of equilibrium
and range between unresponsive to therapies and at high risk for death to stable and
responsive to therapy.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 2-1: Explain the characteristics of the critically ill patient described in the AACN synergy model
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 22
2) Which of the following is the AACNʹs synergy model patient characteristic described as ʺthe intricate
entanglement of two or more systemsʺ?
1. Complexity
2. Predictability
3. Participation in care
4. Resource availability
Answer: 1
Explanation: 1. #2, #3, and #4 are other terms used in the synergy model.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
2. #2, #3, and #4 are other terms used in the synergy model.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
3. #2, #3, and #4 are other terms used in the synergy model.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
4. #2, #3, and #4 are other terms used in the synergy model.
Nursing Process: Planning
Cognitive Level: Comprehension
Category of Need: Psychosocial Integrity
Learning Outcome: 2-1: Explain the characteristics of the critically ill patient described in the AACN synergy model
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 23
3) Which of the following stressors is one of the primary concerns of critically ill patients and should therefore be
included routinely in patient assessments?
1. Inability to control elimination
2. Lack of family support
3. Hunger
4. Altered ability to communicate
Answer: 4
Explanation: 1. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and
nose, being restricted by tubes/lines, being unable to sleep, and not being able to control
themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar
to not being able to control oneʹs self, the interpretation by Cornock does not include this
aspect as a stressor. Lack of family support and hunger were not identified as stressors by his
research.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Psychosocial Integrity
2. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and
nose, being restricted by tubes/lines, being unable to sleep, and not being able to control
themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar
to not being able to control oneʹs self, the interpretation by Cornock does not include this
aspect as a stressor. Lack of family support and hunger were not identified as stressors by his
research.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Psychosocial Integrity
3. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and
nose, being restricted by tubes/lines, being unable to sleep, and not being able to control
themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar
to not being able to control oneʹs self, the interpretation by Cornock does not include this
aspect as a stressor. Lack of family support and hunger were not identified as stressors by his
research.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Psychosocial Integrity
4. Other items included in Cornockʹs categories are: being thirsty, having tubes in the mouth and
nose, being restricted by tubes/lines, being unable to sleep, and not being able to control
themselves. #1, #2, and #3 are incorrect. Although the inability to control elimination is similar
to not being able to control oneʹs self, the interpretation by Cornock does not include this
aspect as a stressor. Lack of family support and hunger were not identified as stressors by his
research.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Learning Outcome: 2-2: Discuss the concerns expressed by critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 24
4) A patient has just completed a preoperative education session prior to undergoing coronary artery bypass
surgery. Which statement by the patient would indicate that he needs additional teaching by the nurse? (Select
all that apply.)
1. ʺI understand that I will have to blink my eyes to respond after the breathing tube is in my throat.ʺ
2. ʺI will be given frequent mouth care to help me when I am thirsty.ʺ
3. ʺI will be able to move about freely in bed and into the chair without help while connected to the
electronic equipment for monitoring.ʺ
4. ʺI may need something to help me rest due to the unfamiliar lights and sounds of the ICU unit.ʺ
Answer: 1, 2, 4
Explanation: 1. (Note: This requires multiple responses to be correct.)
The question is asking for the response that reflects inaccurate information. #3 reflects that the
patient did not understand the physical limitations and the need for assistance when moving
and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation
required by the patient in ICU. Alternate method of communication discussed in advance of
tube placement will assist in better communication after the tube is inserted to assist the
breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to
the inability of the patient to drink. Due to environmental lights, sounds, and difference in
sleeping environment, additional aids, such as drug management, may be needed to assist the
patient to rest at night.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
2. (Note: This requires multiple responses to be correct.)
The question is asking for the response that reflects inaccurate information. #3 reflects that the
patient did not understand the physical limitations and the need for assistance when moving
and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation
required by the patient in ICU. Alternate method of communication discussed in advance of
tube placement will assist in better communication after the tube is inserted to assist the
breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to
the inability of the patient to drink. Due to environmental lights, sounds, and difference in
sleeping environment, additional aids, such as drug management, may be needed to assist the
patient to rest at night.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
3. (Note: This requires multiple responses to be correct.)
The question is asking for the response that reflects inaccurate information. #3 reflects that the
patient did not understand the physical limitations and the need for assistance when moving
and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation
required by the patient in ICU. Alternate method of communication discussed in advance of
tube placement will assist in better communication after the tube is inserted to assist the
breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to
the inability of the patient to drink. Due to environmental lights, sounds, and difference in
sleeping environment, additional aids, such as drug management, may be needed to assist the
patient to rest at night.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 25
4. (Note: This requires multiple responses to be correct.)
The question is asking for the response that reflects inaccurate information. #3 reflects that the
patient did not understand the physical limitations and the need for assistance when moving
and getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation
required by the patient in ICU. Alternate method of communication discussed in advance of
tube placement will assist in better communication after the tube is inserted to assist the
breathing process. While intubated, oral hygiene is needed to prevent mucosal drying due to
the inability of the patient to drink. Due to environmental lights, sounds, and difference in
sleeping environment, additional aids, such as drug management, may be needed to assist the
patient to rest at night.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 2-2: Discuss the concerns expressed by critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 26
5) When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse should:
1. Clearly explain what care is to be done before starting the activity.
2. Perform the activity then let the patient rest without explaining the care.
3. Make sure the patient always responds and is cooperative before giving care.
4. Explain to the family that the patient will not understand or remember any of the discomfort associated
with care.
Answer: 1
Explanation: 1. By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and
apologizing if discomfort is involved will also minimize the stress of the critically ill patient by
hearing what is about to occur. Even the unresponsive patient has been known to explain
procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient
is not informed, autonomy and the right to choose have been violated; in addition the stress of
the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some
unresponsive patients will never respond; therefore, the care would not be performed as
needed. Cooperation is also not possible in some cases whereby the patient has altered
thinking. Although the nurse desires these, the care should not be stopped just because they
cannot be obtained. Explaining should still be done and the care should proceed as needed. #4
is incorrect: The nurse cannot always reassure the family that the patient will not remember.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
2. By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and
apologizing if discomfort is involved will also minimize the stress of the critically ill patient by
hearing what is about to occur. Even the unresponsive patient has been known to explain
procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient
is not informed, autonomy and the right to choose have been violated; in addition the stress of
the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some
unresponsive patients will never respond; therefore, the care would not be performed as
needed. Cooperation is also not possible in some cases whereby the patient has altered
thinking. Although the nurse desires these, the care should not be stopped just because they
cannot be obtained. Explaining should still be done and the care should proceed as needed. #4
is incorrect: The nurse cannot always reassure the family that the patient will not remember.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
3. By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and
apologizing if discomfort is involved will also minimize the stress of the critically ill patient by
hearing what is about to occur. Even the unresponsive patient has been known to explain
procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient
is not informed, autonomy and the right to choose have been violated; in addition the stress of
the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some
unresponsive patients will never respond; therefore, the care would not be performed as
needed. Cooperation is also not possible in some cases whereby the patient has altered
thinking. Although the nurse desires these, the care should not be stopped just because they
cannot be obtained. Explaining should still be done and the care should proceed as needed. #4
is incorrect: The nurse cannot always reassure the family that the patient will not remember.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 27
4. By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
reassurance, respect, and assessment of the patientʹs mental status. Seeking permission and
apologizing if discomfort is involved will also minimize the stress of the critically ill patient by
hearing what is about to occur. Even the unresponsive patient has been known to explain
procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient
is not informed, autonomy and the right to choose have been violated; in addition the stress of
the unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some
unresponsive patients will never respond; therefore, the care would not be performed as
needed. Cooperation is also not possible in some cases whereby the patient has altered
thinking. Although the nurse desires these, the care should not be stopped just because they
cannot be obtained. Explaining should still be done and the care should proceed as needed. #4
is incorrect: The nurse cannot always reassure the family that the patient will not remember.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Learning Outcome: 2-3: Describe strategies a nurse might utilize to communicate with a ventilated patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 28
6) Which of the following communication strategies is most appropriate for a critical care nurse to use when
communicating with a ventilated patient? The nurse should:
1. Use professional terminology and provide the patient with detailed information.
2. Use simple language and explain in other terms if the patient does not seem to understand.
3. Provide minimal information so the patient is not overwhelmed.
4. Discuss issues primarily with the family because the patient is unlikely to understand the information.
Answer: 2
Explanation: 1. Simple laymanʹs language of information is better understood and by repeating or rephrasing
the patient gains a better understanding when in a stressful situation. #1 is incorrect.
Individuals who are not familiar with health care often do not understand professional
language. Confusion and a lack of understanding often result if the information is presented
only in professional terminology. #3 is incorrect. Minimal disclosure of information will
increase the stress of the patient by increasing confusion and concerns from the lack of
understanding about the illness or treatment process. Complete disclosure is the right of the
patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or
communicating only with the patientʹs family denies the patient the right of choice and the
respect or dignity expected. Legally and ethically, except under very specific restrictions, the
patient has a right to know, and it is the health care professionalsʹ responsibility to explain
clearly for informed consent to occur.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
2. Simple laymanʹs language of information is better understood and by repeating or rephrasing
the patient gains a better understanding when in a stressful situation. #1 is incorrect.
Individuals who are not familiar with health care often do not understand professional
language. Confusion and a lack of understanding often result if the information is presented
only in professional terminology. #3 is incorrect. Minimal disclosure of information will
increase the stress of the patient by increasing confusion and concerns from the lack of
understanding about the illness or treatment process. Complete disclosure is the right of the
patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or
communicating only with the patientʹs family denies the patient the right of choice and the
respect or dignity expected. Legally and ethically, except under very specific restrictions, the
patient has a right to know, and it is the health care professionalsʹ responsibility to explain
clearly for informed consent to occur.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
3. Simple laymanʹs language of information is better understood and by repeating or rephrasing
the patient gains a better understanding when in a stressful situation. #1 is incorrect.
Individuals who are not familiar with health care often do not understand professional
language. Confusion and a lack of understanding often result if the information is presented
only in professional terminology. #3 is incorrect. Minimal disclosure of information will
increase the stress of the patient by increasing confusion and concerns from the lack of
understanding about the illness or treatment process. Complete disclosure is the right of the
patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or
communicating only with the patientʹs family denies the patient the right of choice and the
respect or dignity expected. Legally and ethically, except under very specific restrictions, the
patient has a right to know, and it is the health care professionalsʹ responsibility to explain
clearly for informed consent to occur.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 29
4. Simple laymanʹs language of information is better understood and by repeating or rephrasing
the patient gains a better understanding when in a stressful situation. #1 is incorrect.
Individuals who are not familiar with health care often do not understand professional
language. Confusion and a lack of understanding often result if the information is presented
only in professional terminology. #3 is incorrect. Minimal disclosure of information will
increase the stress of the patient by increasing confusion and concerns from the lack of
understanding about the illness or treatment process. Complete disclosure is the right of the
patient and the obligation of health care professionals. #4 is incorrect. Disclosing information or
communicating only with the patientʹs family denies the patient the right of choice and the
respect or dignity expected. Legally and ethically, except under very specific restrictions, the
patient has a right to know, and it is the health care professionalsʹ responsibility to explain
clearly for informed consent to occur.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Learning Outcome: 2-3: Describe strategies a nurse might utilize to communicate with a ventilated patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 30
7) During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment
strategy would be most helpful for the nurse to validate these observations?
1. Glasgow Scale
2. Maslowʹs hierarchy levels
3. Critical-Care Pain Observation Tool (CPOT)
4. Vital signs trends
Answer: 3
Explanation: 1. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug
management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2,
and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate
the sedation level that is used with patients who are intubated. But this scale does not identify
the source of the problem that has increased the patientʹs facial changes or movement.
Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions
in the body, and it would not help identify the source of the changes noted in the patient. Vital
signs might tell the nurse that a change has occurred but it does not indicate the source of the
discomfort or problem.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Needs: Physiological Integrity–Reduction of Risk Potential
2. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug
management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2,
and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate
the sedation level that is used with patients who are intubated. But this scale does not identify
the source of the problem that has increased the patientʹs facial changes or movement.
Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions
in the body, and it would not help identify the source of the changes noted in the patient. Vital
signs might tell the nurse that a change has occurred but it does not indicate the source of the
discomfort or problem.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Needs: Physiological Integrity–Reduction of Risk Potential
3. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug
management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2,
and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate
the sedation level that is used with patients who are intubated. But this scale does not identify
the source of the problem that has increased the patientʹs facial changes or movement.
Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions
in the body, and it would not help identify the source of the changes noted in the patient. Vital
signs might tell the nurse that a change has occurred but it does not indicate the source of the
discomfort or problem.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Needs: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 31
4. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug
management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2,
and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate
the sedation level that is used with patients who are intubated. But this scale does not identify
the source of the problem that has increased the patientʹs facial changes or movement.
Maslowʹs hierarchy of needs prioritizes the needs based on essential to higher level functions
in the body, and it would not help identify the source of the changes noted in the patient. Vital
signs might tell the nurse that a change has occurred but it does not indicate the source of the
discomfort or problem.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Needs: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 2-4: Explain the use of sedation, pain, and delirium scales with critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 32
8) Nurses in many ICUs are required to automatically attempt to wean sedation for their ventilated patients when
the patients meet certain parameters. Which of the following parameters would indicate that a patient in ICU is
ready for such an interruption in sedation, also sometimes known as a sedation vacation? The patient: (Select
all that apply.)
1. Activated the ventilator alarms but the alarms stopped spontaneously.
2. Frowned when turned but otherwise showed no muscular tension.
3. Had a MAP of 75 and heart rate of 76.
4. Was sleeping but awakened with verbal stimuli.
Answer: 1, 2, 3, 4
Explanation: 1. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted
when the patient meets the following criteria:
 VAMASS is less than or equal to target VAMASS.
 Sedation is not being used to treat delirium.
 Patient is not receiving neuromuscular blocking agents.
 Patient is hemodynamically stable.
 Patient is stable on the ventilator.
 Patientʹs pain is controlled.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted
when the patient meets the following criteria:
 VAMASS is less than or equal to target VAMASS.
 Sedation is not being used to treat delirium.
 Patient is not receiving neuromuscular blocking agents.
 Patient is hemodynamically stable.
 Patient is stable on the ventilator.
 Patientʹs pain is controlled.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted
when the patient meets the following criteria:
 VAMASS is less than or equal to target VAMASS.
 Sedation is not being used to treat delirium.
 Patient is not receiving neuromuscular blocking agents.
 Patient is hemodynamically stable.
 Patient is stable on the ventilator.
 Patientʹs pain is controlled.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 33
4. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted
when the patient meets the following criteria:
 VAMASS is less than or equal to target VAMASS.
 Sedation is not being used to treat delirium.
 Patient is not receiving neuromuscular blocking agents.
 Patient is hemodynamically stable.
 Patient is stable on the ventilator.
 Patientʹs pain is controlled.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2-4: Explain the use of sedation, pain, and delirium scales with critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 34
9) A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM-ICU). Which
of the following nursing diagnoses would have the highest priority based on this positive score?
1. Injury, Risk for
2. Family Processes, Altered
3. Social Interaction, Impaired
4. Memory Impaired
Answer: 1
Explanation: 1. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is
incorrect. Mental impairment falls in the Self-esteem level, which is the next highest level.
(Note: No example of the Self-actualization level was given and is the highest level of need
according to Maslowʹs theory)
Nursing Process: Implementation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
2. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is
incorrect. Mental impairment falls in the Self-esteem level, which is the next highest level.
(Note: No example of the Self-actualization level was given and is the highest level of need
according to Maslowʹs theory)
Nursing Process: Implementation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
3. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is
incorrect. Mental impairment falls in the Self-esteem level, which is the next highest level.
(Note: No example of the Self-actualization level was given and is the highest level of need
according to Maslowʹs theory)
Nursing Process: Implementation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
4. Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is
incorrect. Mental impairment falls in the Self-esteem level, which is the next highest level.
(Note: No example of the Self-actualization level was given and is the highest level of need
according to Maslowʹs theory)
Nursing Process: Implementation
Cognitive Level: Analysis
Category of Need: Safe, Effective Care Environment–Management of Care
Learning Outcome: 2-4: Explain the use of sedation, pain, and delirium scales with critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 35
10) A nurse is beginning an intravenous infusion of morphine sulfate on her post-op ventilated patient. When
initiating the infusion and for the first few hours, the nurse should do which of the following?
1. Anticipate that the patient will begin to experience the effect of the morphine 5 minutes after the start of
the infusion.
2. Begin the infusion at the lowest ordered dose and increase the rate every 5 minutes if the patient
continues to have pain.
3. Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate each
time.
4. Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough pain.
Answer: 4
Explanation: 1. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine
sulfate, start to act immediately; however, they will not provide significant analgesia until the
infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is
increased, loading doses must be administered in order to provide immediate analgesia and
maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill
patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the
pain medication with intermittent boluses and increases in infusion until the drug attains
steady state and the patient experiences pain relief. In response to anticipated painful
procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates
are repeatedly increased versus the administration of intermittent boluses as a means of
responding to acute pain, the risk for excessive analgesia dosing exists.
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine
sulfate, start to act immediately; however, they will not provide significant analgesia until the
infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is
increased, loading doses must be administered in order to provide immediate analgesia and
maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill
patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the
pain medication with intermittent boluses and increases in infusion until the drug attains
steady state and the patient experiences pain relief. In response to anticipated painful
procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates
are repeatedly increased versus the administration of intermittent boluses as a means of
responding to acute pain, the risk for excessive analgesia dosing exists.
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine
sulfate, start to act immediately; however, they will not provide significant analgesia until the
infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is
increased, loading doses must be administered in order to provide immediate analgesia and
maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill
patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the
pain medication with intermittent boluses and increases in infusion until the drug attains
steady state and the patient experiences pain relief. In response to anticipated painful
procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates
are repeatedly increased versus the administration of intermittent boluses as a means of
responding to acute pain, the risk for excessive analgesia dosing exists.
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 36
4. Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine
sulfate, start to act immediately; however, they will not provide significant analgesia until the
infusion reaches ʺsteady state.ʺ At the initiation of an infusion and when the infusion rate is
increased, loading doses must be administered in order to provide immediate analgesia and
maintain the desired analgesia until the infusion reaches steady state. Thus, a critically ill
patient often will receive an IV bolus of an analgesic followed by an ongoing infusion of the
pain medication with intermittent boluses and increases in infusion until the drug attains
steady state and the patient experiences pain relief. In response to anticipated painful
procedures (e.g., turning) the patient might receive an additional bolus. When IV infusion rates
are repeatedly increased versus the administration of intermittent boluses as a means of
responding to acute pain, the risk for excessive analgesia dosing exists.
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 37
11) Which of the following strategies should the nurse include in the plan of care when trying to minimize sleep
disruptions for a patient in an ICU? (Select all that apply.)
1. Instituting a short course of therapy for sleeping agents
2. Accurate scoring and vigilance in sedation and sedation scoring
3. Managing the environment to reduce lighting, sounds, and so on
4. Minimizing staff interruptions during sleep periods
5. Scheduling treatments only during the day or at least 4 hours apart at night
Answer: 1, 2, 3, 4
Explanation: 1. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize
the rest benefits that will shorten the duration of care based on research findings. #5 is
incorrect. Planning the care for only the day hours or at least 4 hours is not practical to
improve the outcomes of the client, because some medications, therapies, and assessments
need to be made around the clock for the greatest benefits to patients. The minimum time for
resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep
fragmentation and improve restful sleep.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
2. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize
the rest benefits that will shorten the duration of care based on research findings. #5 is
incorrect. Planning the care for only the day hours or at least 4 hours is not practical to
improve the outcomes of the client, because some medications, therapies, and assessments
need to be made around the clock for the greatest benefits to patients. The minimum time for
resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep
fragmentation and improve restful sleep.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
3. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize
the rest benefits that will shorten the duration of care based on research findings. #5 is
incorrect. Planning the care for only the day hours or at least 4 hours is not practical to
improve the outcomes of the client, because some medications, therapies, and assessments
need to be made around the clock for the greatest benefits to patients. The minimum time for
resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep
fragmentation and improve restful sleep.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
4. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize
the rest benefits that will shorten the duration of care based on research findings. #5 is
incorrect. Planning the care for only the day hours or at least 4 hours is not practical to
improve the outcomes of the client, because some medications, therapies, and assessments
need to be made around the clock for the greatest benefits to patients. The minimum time for
resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep
fragmentation and improve restful sleep.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 38
5. (Note: This requires multiple responses to be correct.)
#1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize
the rest benefits that will shorten the duration of care based on research findings. #5 is
incorrect. Planning the care for only the day hours or at least 4 hours is not practical to
improve the outcomes of the client, because some medications, therapies, and assessments
need to be made around the clock for the greatest benefits to patients. The minimum time for
resting that is suggested is to not interrupt less than 2 hours of sleep in order to minimize sleep
fragmentation and improve restful sleep.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 39
12) A nurse is confirming the medication orders and schedule for sedative administration to a patient with
delirium. Which of the following schedules would maximize the effectiveness of the drugs? Administration of
medication:
1. Only in the early morning.
2. Only at bedtime (HS).
3. Around the clock with higher dosages in the evening.
4. Only on an as-needed (PRN) basis.
Answer: 3
Explanation: 1. Timing given around the clock with a greater dosage in the evening will match the symptom of
undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are
incorrect. Timing would not reflect the symptoms nor control the condition equally throughout
the 24-hour period. Additional dosages besides the dosage around the clock can be given on a
PRN basis when acute exacerbations occur.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Timing given around the clock with a greater dosage in the evening will match the symptom of
undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are
incorrect. Timing would not reflect the symptoms nor control the condition equally throughout
the 24-hour period. Additional dosages besides the dosage around the clock can be given on a
PRN basis when acute exacerbations occur.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Timing given around the clock with a greater dosage in the evening will match the symptom of
undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are
incorrect. Timing would not reflect the symptoms nor control the condition equally throughout
the 24-hour period. Additional dosages besides the dosage around the clock can be given on a
PRN basis when acute exacerbations occur.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. Timing given around the clock with a greater dosage in the evening will match the symptom of
undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are
incorrect. Timing would not reflect the symptoms nor control the condition equally throughout
the 24-hour period. Additional dosages besides the dosage around the clock can be given on a
PRN basis when acute exacerbations occur.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 40
13) Which of the following patients would be considered at risk for nutritional imbalances? A patient: (Select all
that apply.)
1. Who is a stable post-MI.
2. With renal dysfunctions/failure.
3. With slightly elevated liver enzymes.
4. With burns or excessive trauma.
5. Who is intubated and sedated.
Answer: 1, 2, 4, 5
Explanation: 1. (Note: This requires multiple responses to be correct.)
All of these patients need additional calories, alterations in types of nutrition given, or an
alternate form of nutritional delivery to maintain or achieve nutritional balance based on
physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and
alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver
enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods,
and an increase protein may be needed.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. (Note: This requires multiple responses to be correct.)
All of these patients need additional calories, alterations in types of nutrition given, or an
alternate form of nutritional delivery to maintain or achieve nutritional balance based on
physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and
alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver
enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods,
and an increase protein may be needed.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. (Note: This requires multiple responses to be correct.)
All of these patients need additional calories, alterations in types of nutrition given, or an
alternate form of nutritional delivery to maintain or achieve nutritional balance based on
physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and
alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver
enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods,
and an increase protein may be needed.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. (Note: This requires multiple responses to be correct.)
All of these patients need additional calories, alterations in types of nutrition given, or an
alternate form of nutritional delivery to maintain or achieve nutritional balance based on
physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and
alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver
enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods,
and an increase protein may be needed.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 41
5. (Note: This requires multiple responses to be correct.)
All of these patients need additional calories, alterations in types of nutrition given, or an
alternate form of nutritional delivery to maintain or achieve nutritional balance based on
physiological needs for each condition. #3 is incorrect. Although the liver does filter drugs and
alter the breakdown of drugs, nutrition is rarely modified just for slightly elevated liver
enzymes. Severe liver damage or failure will result in restrictions of alcohol and fatty foods,
and an increase protein may be needed.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 2-6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 42
14) While members of the multidisciplinary team are reviewing a patientʹs nutritional status, they note the
following values. Which of the values would need additional investigation?
1. A serum albumin of more than 3.5 g/dL or 35 g/L
2. A weight increase of 1.5 kg in a day
3. A serum hemoglobin of 11.7 g/dL or 117 mmol/L
4. A serum magnesium of 1.6 mg/dL or 132 mEq/L
Answer: 2
Explanation: 1. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid.
Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are
incorrect. These lab values are at the lower end of the normal levels for adults and do not
require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL,
then the declining lab may reflect changes in the protein status of the body that should be
further assessed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid.
Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are
incorrect. These lab values are at the lower end of the normal levels for adults and do not
require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL,
then the declining lab may reflect changes in the protein status of the body that should be
further assessed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid.
Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are
incorrect. These lab values are at the lower end of the normal levels for adults and do not
require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL,
then the declining lab may reflect changes in the protein status of the body that should be
further assessed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid.
Additional assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are
incorrect. These lab values are at the lower end of the normal levels for adults and do not
require additional assessment or interventions. However, if the albumin drops below 3.5 g/dL,
then the declining lab may reflect changes in the protein status of the body that should be
further assessed.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 2-6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 43
15) A nurse has inserted a nasogastric tube and is planning to confirm placement of the tube prior to starting
enteral feedings. Which of the following is the most accurate method for confirming placement? By:
1. Obtaining a radiological x-ray of the abdomen.
2. Checking gastric aspirate for a pH of less than 7.
3. Instilling 30 mL of air while listening with a stethoscope when placed over the fundus of the stomach.
4. Determining the presence of carbon dioxide.
Answer: 1
Explanation: 1. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to
validate placement. #2 and #3 might be procedures used to validate placement; however, the
pH in #2 is too high and air auscultation has been shown to be inaccurate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to
validate placement. #2 and #3 might be procedures used to validate placement; however, the
pH in #2 is too high and air auscultation has been shown to be inaccurate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to
validate placement. #2 and #3 might be procedures used to validate placement; however, the
pH in #2 is too high and air auscultation has been shown to be inaccurate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to
validate placement. #2 and #3 might be procedures used to validate placement; however, the
pH in #2 is too high and air auscultation has been shown to be inaccurate.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 2-6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 44
16) Which of the following nursing diagnoses should receive the highest priority when caring for a patient who is
receiving total parenteral nutrition?
1. Infection, Risk for
2. Trauma, Risk for
3. Skin Integrity, Impaired
4. Fluid Volume, Risk for Imbalance
Answer: 1
Explanation: 1. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the
central vein access route, and the declining nutritional status that the patient is in when this
therapy is started. Absolute sterility, close assessment of glucose balances that are maintained
by additional insulin treatment, and the need to maximize nutritional intake for healing to
occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning
process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding
trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and
avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but
preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized
by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the
essential nutrition needed. Standards of care for pump regulation minimize both the fluid
overload and fluid deficits that might occur if solutions were freely hung to be regulated by
drop methods.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
2. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the
central vein access route, and the declining nutritional status that the patient is in when this
therapy is started. Absolute sterility, close assessment of glucose balances that are maintained
by additional insulin treatment, and the need to maximize nutritional intake for healing to
occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning
process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding
trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and
avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but
preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized
by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the
essential nutrition needed. Standards of care for pump regulation minimize both the fluid
overload and fluid deficits that might occur if solutions were freely hung to be regulated by
drop methods.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 45
3. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the
central vein access route, and the declining nutritional status that the patient is in when this
therapy is started. Absolute sterility, close assessment of glucose balances that are maintained
by additional insulin treatment, and the need to maximize nutritional intake for healing to
occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning
process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding
trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and
avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but
preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized
by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the
essential nutrition needed. Standards of care for pump regulation minimize both the fluid
overload and fluid deficits that might occur if solutions were freely hung to be regulated by
drop methods.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
4. #1 is the greatest risk for the parenteral nutrition patient due to the high glucose present, the
central vein access route, and the declining nutritional status that the patient is in when this
therapy is started. Absolute sterility, close assessment of glucose balances that are maintained
by additional insulin treatment, and the need to maximize nutritional intake for healing to
occur will minimize the risk of infection. #2, #3, and #4 are still important in the planning
process for the care to this patient, but the infection risk can be deadly to this patient. Avoiding
trauma at the site or other parts of the body should be routinely done to ʺdo no harmʺ and
avoid injury where possible. Skin integrity will be impaired due to poor nutritional intake, but
preventive measures can be done to decrease the risk. Fluid volume imbalances are minimized
by accurate regulators to limit fluid overload or to run at the appropriate rate to provide the
essential nutrition needed. Standards of care for pump regulation minimize both the fluid
overload and fluid deficits that might occur if solutions were freely hung to be regulated by
drop methods.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 2-6: Compare and contrast the use of enteral and parenteral nutrition in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 46
17) When planning care to meet the needs of family members of a critically ill patient, the nurse should include:
(Select all that apply.)
1. Expressing an attitude of hope, honesty, open communication, and caring.
2. Stating specific facts about the patientʹs condition in timely manner.
3. Planning regular times for family visits throughout the day.
4. Limiting the number of visitors to significant others.
5. Communicating to a single family member to cut down time wasted repeating information to all visitors.
Answer: 1, 2, 3
Explanation: 1. (Note: This requires multiple responses to be correct.)
#1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient.
An open access by the significant others of the patient has been validated by research to
improve medical outcomes. A sense of concern for the patient will reduce stress within the
family, and clear simple explanations will maximize the communication process to a stressed
family member. #4: Although some number limitations are needed, the persons are not to be
screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic
for the patient. If the visitor (family or friend) increases problems with the patient, then the
visitor should be restricted access until the condition improves. #5: Although communicating
with a single person will minimize the repeating of information, a core group of individuals
can be used to distribute information to other family members, particularly if a large
population is present. Therefore, restricting to one person is too limiting but a minimal core
group can be helpful in other situations, especially if the nurse is needed at the bedside. A case
manager, clergy, or staff support person could also be used to pass on information when the
nursing staff is too busy caring for the patient.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
2. (Note: This requires multiple responses to be correct.)
#1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient.
An open access by the significant others of the patient has been validated by research to
improve medical outcomes. A sense of concern for the patient will reduce stress within the
family, and clear simple explanations will maximize the communication process to a stressed
family member. #4: Although some number limitations are needed, the persons are not to be
screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic
for the patient. If the visitor (family or friend) increases problems with the patient, then the
visitor should be restricted access until the condition improves. #5: Although communicating
with a single person will minimize the repeating of information, a core group of individuals
can be used to distribute information to other family members, particularly if a large
population is present. Therefore, restricting to one person is too limiting but a minimal core
group can be helpful in other situations, especially if the nurse is needed at the bedside. A case
manager, clergy, or staff support person could also be used to pass on information when the
nursing staff is too busy caring for the patient.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 47
3. (Note: This requires multiple responses to be correct.)
#1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient.
An open access by the significant others of the patient has been validated by research to
improve medical outcomes. A sense of concern for the patient will reduce stress within the
family, and clear simple explanations will maximize the communication process to a stressed
family member. #4: Although some number limitations are needed, the persons are not to be
screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic
for the patient. If the visitor (family or friend) increases problems with the patient, then the
visitor should be restricted access until the condition improves. #5: Although communicating
with a single person will minimize the repeating of information, a core group of individuals
can be used to distribute information to other family members, particularly if a large
population is present. Therefore, restricting to one person is too limiting but a minimal core
group can be helpful in other situations, especially if the nurse is needed at the bedside. A case
manager, clergy, or staff support person could also be used to pass on information when the
nursing staff is too busy caring for the patient.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
4. (Note: This requires multiple responses to be correct.)
#1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient.
An open access by the significant others of the patient has been validated by research to
improve medical outcomes. A sense of concern for the patient will reduce stress within the
family, and clear simple explanations will maximize the communication process to a stressed
family member. #4: Although some number limitations are needed, the persons are not to be
screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic
for the patient. If the visitor (family or friend) increases problems with the patient, then the
visitor should be restricted access until the condition improves. #5: Although communicating
with a single person will minimize the repeating of information, a core group of individuals
can be used to distribute information to other family members, particularly if a large
population is present. Therefore, restricting to one person is too limiting but a minimal core
group can be helpful in other situations, especially if the nurse is needed at the bedside. A case
manager, clergy, or staff support person could also be used to pass on information when the
nursing staff is too busy caring for the patient.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
5. (Note: This requires multiple responses to be correct.)
#1, #2, #3 are appropriate approaches when meeting the family needs of the critically ill patient.
An open access by the significant others of the patient has been validated by research to
improve medical outcomes. A sense of concern for the patient will reduce stress within the
family, and clear simple explanations will maximize the communication process to a stressed
family member. #4: Although some number limitations are needed, the persons are not to be
screened by staff. If the patient wants the visitor to come in, then the visit will be therapeutic
for the patient. If the visitor (family or friend) increases problems with the patient, then the
visitor should be restricted access until the condition improves. #5: Although communicating
with a single person will minimize the repeating of information, a core group of individuals
can be used to distribute information to other family members, particularly if a large
population is present. Therefore, restricting to one person is too limiting but a minimal core
group can be helpful in other situations, especially if the nurse is needed at the bedside. A case
manager, clergy, or staff support person could also be used to pass on information when the
nursing staff is too busy caring for the patient.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 48
Learning Outcome: 2-7: Discuss ways to identify and meet the needs of families of critically ill patients
18) Which of the following statements describing the needs of family members of critically ill patients has not been
validated by research?
1. ʺ ʹNot knowing is the worst partʹ of waiting.ʺ
2. Families in the waiting room have no effect on patient outcomes.
3. ʺHoveringʺ in the proximity phase is characterized by confusion and tension.
4. A unified message from staff minimizes family stressors.
Answer: 2
Explanation: 1. #2 is an incorrect statement that is not supported by research. In fact the family support has
been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to
the findings about the family needs of the critically ill patient. Therefore, communication
should remain open and freely given with a single message to minimize confusion and stress.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
2. #2 is an incorrect statement that is not supported by research. In fact the family support has
been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to
the findings about the family needs of the critically ill patient. Therefore, communication
should remain open and freely given with a single message to minimize confusion and stress.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
3. #2 is an incorrect statement that is not supported by research. In fact the family support has
been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to
the findings about the family needs of the critically ill patient. Therefore, communication
should remain open and freely given with a single message to minimize confusion and stress.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
4. #2 is an incorrect statement that is not supported by research. In fact the family support has
been proven to clinical outcomes. #1, #3, and #4 are supported by research and are accurate to
the findings about the family needs of the critically ill patient. Therefore, communication
should remain open and freely given with a single message to minimize confusion and stress.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Psychosocial Integrity
Learning Outcome: 2-7: Discuss ways to identify and meet the needs of families of critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 49
19) Which of the following is not one of the family needs identified in Leskeʹs 1991 research?
1. Proximity
2. Information
3. Assurance
4. Timeliness
Answer: 4
Explanation: 1. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts
that are presented include: Support and Comfort. (This question is asking which concept is
NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings.
Nursing Process: Planning
Cognitive Level: Knowledge
Category of Need: Psychosocial Integrity
2. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts
that are presented include: Support and Comfort. (This question is asking which concept is
NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings.
Nursing Process: Planning
Cognitive Level: Knowledge
Category of Need: Psychosocial Integrity
3. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts
that are presented include: Support and Comfort. (This question is asking which concept is
NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings.
Nursing Process: Planning
Cognitive Level: Knowledge
Category of Need: Psychosocial Integrity
4. Timeliness is not a term/concept that is presented in Leskeʹs research findings. Other concepts
that are presented include: Support and Comfort. (This question is asking which concept is
NOT included.) #1, #2, #3 are concepts that are presented by Leskeʹs research findings.
Nursing Process: Planning
Cognitive Level: Knowledge
Category of Need: Psychosocial Integrity
Learning Outcome: 2-7: Discuss ways to identify and meet the needs of families of critically ill patients
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 50
20) When planning care for the families of critically ill patients, the nurse would include which of the strategies by
Miracle (2006) to meet family needs? (Select all that apply.)
1. Regular family conferences to meet patient goals/progress
2. Frequent verbal communication to clarify the purpose of unit, equipment, procedures, waiting areas,
phones, and so on
3. A way to contact family through a specific family member by phone if needed
4. Information about how to contact the primary doctor if needed
5. A consistent nurse and unified staff responses if that nurse is not available
Answer: 1, 2, 4, 5
Explanation: 1. (Note: This requires multiple responses to be correct.)
Each of these strategies is suggested to minimize stress and maximize communication to meet
the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets,
rules, and regulations are better received and retained more than verbal instructions. Written
communications can be reread and clearly understood as a cross-reference by the family
during the stressful period of waiting for their patientʹs recovery. Frequently repeating
information is better for retention but often is a waste of the nurseʹs time for basic information
that remains the same for all patients. By printing information, this allows the nurse to give
more information about the patientʹs condition rather than focusing on basic rules and
regulations.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Psychosocial Integrity
2. (Note: This requires multiple responses to be correct.)
Each of these strategies is suggested to minimize stress and maximize communication to meet
the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets,
rules, and regulations are better received and retained more than verbal instructions. Written
communications can be reread and clearly understood as a cross-reference by the family
during the stressful period of waiting for their patientʹs recovery. Frequently repeating
information is better for retention but often is a waste of the nurseʹs time for basic information
that remains the same for all patients. By printing information, this allows the nurse to give
more information about the patientʹs condition rather than focusing on basic rules and
regulations.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Psychosocial Integrity
3. (Note: This requires multiple responses to be correct.)
Each of these strategies is suggested to minimize stress and maximize communication to meet
the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets,
rules, and regulations are better received and retained more than verbal instructions. Written
communications can be reread and clearly understood as a cross-reference by the family
during the stressful period of waiting for their patientʹs recovery. Frequently repeating
information is better for retention but often is a waste of the nurseʹs time for basic information
that remains the same for all patients. By printing information, this allows the nurse to give
more information about the patientʹs condition rather than focusing on basic rules and
regulations.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 51
4. (Note: This requires multiple responses to be correct.)
Each of these strategies is suggested to minimize stress and maximize communication to meet
the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets,
rules, and regulations are better received and retained more than verbal instructions. Written
communications can be reread and clearly understood as a cross-reference by the family
during the stressful period of waiting for their patientʹs recovery. Frequently repeating
information is better for retention but often is a waste of the nurseʹs time for basic information
that remains the same for all patients. By printing information, this allows the nurse to give
more information about the patientʹs condition rather than focusing on basic rules and
regulations.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Psychosocial Integrity
5. (Note: This requires multiple responses to be correct.)
Each of these strategies is suggested to minimize stress and maximize communication to meet
the family needs of the critically ill patient. #2 is incorrect. Written communication, pamphlets,
rules, and regulations are better received and retained more than verbal instructions. Written
communications can be reread and clearly understood as a cross-reference by the family
during the stressful period of waiting for their patientʹs recovery. Frequently repeating
information is better for retention but often is a waste of the nurseʹs time for basic information
that remains the same for all patients. By printing information, this allows the nurse to give
more information about the patientʹs condition rather than focusing on basic rules and
regulations.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Psychosocial Integrity
Learning Outcome: 2-7: Discuss ways to identify and meet the needs of families of critically ill patients
21) A physician suggests that a ventilated patient needing immediate transport to CT scan and having severe pain
be given IV fentanyl rather than morphine sulfate for pain management. One reason the physician might
recommend the use of fentanyl is:
1. It has a more rapid onset and a shorter duration of action.
2. It is not likely to cause respiratory depression.
3. Rapid administration does not have any hemodynamic consequences.
4. Weaning of a continuous infusion is never needed due to its short half-life.
Answer: 1
Explanation: 1. Fentanyl is a commonly used medication.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. Fentanyl is a commonly used medication.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. Fentanyl is a commonly used medication.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. Fentanyl is a commonly used medication.
Cognitive Level: Application
Nursing Process: Planning
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain, and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 52
22) A ventilated patient is receiving midazolam (Versed) for sedation. The nurse would recognize that the patient
is receiving an appropriate dose of midazolam when the patient is:
1. Awake with a heart rate of 124 and attempting to pull out the IV.
2. Awake with a respiratory rate of 38 and a heart rate of 132.
3. Asleep but withdrawing to noxious stimuli with a heart rate of 80.
4. Asleep but awakening to light touch with a heart rate of 72.
Answer: 4
Explanation: 1. Commonly used medication: Midazolam and AACN Sedation Assessment Scale
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
2. Commonly used medication: Midazolam and AACN Sedation Assessment Scale
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
3. Commonly used medication: Midazolam and AACN Sedation Assessment Scale
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
4. Commonly used medication: Midazolam and AACN Sedation Assessment Scale
Cognitive Level: Application
Nursing Process: Evaluation
Category of Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain, and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 53
23) A nurse is caring for a ventilated post-op patient who she suspects is experiencing pain. Which method of
assessing if the patient is actually in pain should the nurse try first?
1. Attempting an analgesic trial
2. Asking a family member if she thinks the patient is in pain
3. Observing the patientʹs face for grimacing
4. Asking the patient if he is in pain
Answer: 4
Explanation: 1. McCaffery described a hierarchy of pain assessment techniques, including:
 Patient self-report.
 Search for a potential cause of a change in patient behavior.
 Observation of patient behaviors when patient self-report is not possible.
 Surrogate report of a patientʹs pain or patientʹs behavior change.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Physiological Adaptations
2. McCaffery described a hierarchy of pain assessment techniques, including:
 Patient self-report.
 Search for a potential cause of a change in patient behavior.
 Observation of patient behaviors when patient self-report is not possible.
 Surrogate report of a patientʹs pain or patientʹs behavior change.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Physiological Adaptations
3. McCaffery described a hierarchy of pain assessment techniques, including:
 Patient self-report.
 Search for a potential cause of a change in patient behavior.
 Observation of patient behaviors when patient self-report is not possible.
 Surrogate report of a patientʹs pain or patientʹs behavior change.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Physiological Adaptations
4. McCaffery described a hierarchy of pain assessment techniques, including:
 Patient self-report.
 Search for a potential cause of a change in patient behavior.
 Observation of patient behaviors when patient self-report is not possible.
 Surrogate report of a patientʹs pain or patientʹs behavior change.
Nursing Process: Assessment
Cognitive Level: Knowledge
Category of Need: Physiological Integrity–Physiological Adaptations
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain, and delirium in the critically ill patient
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 54
24) A nurse is administering haldoperidol (Haldol) IV push to a delirious patient. Which of the following is it most
important for the nurse to monitor? The patientʹs:
1. Heart rate.
2. Respiratory rate.
3. PR interval.
4. QT interval.
Answer: 4
Explanation: 1. The patient needs to be monitored for such adverse effects as QT prolongation and
dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is
administered IV push.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. The patient needs to be monitored for such adverse effects as QT prolongation and
dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is
administered IV push.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
3. The patient needs to be monitored for such adverse effects as QT prolongation and
dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is
administered IV push.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. The patient needs to be monitored for such adverse effects as QT prolongation and
dysrhythmias (torsades de pointes), which can result in sudden death, especially if the drug is
administered IV push.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 2-5: Evaluate the effectiveness of pharmacological and nonpharmacological management of sedation,
pain, and delirium in the critically ill patient

 

Chapter 10 Care of the Patient with a Cerebral or Cerebrovascular Disorder
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 259
1) A patient is recovering from transphenoidal surgery for partial resection of a pituitary adenoma. The nurse
should caution the patient NOT to do which of the following?
1. Blow his nose or sneeze
2. Deep breathe
3. Drink more than 2 liters of fluid a day
4. Sit up in bed higher than 30 degrees
Answer: 1
Explanation: 1. These activities may cause the patch to dislodge which could result in a cerebrospinal fluid
leak (CSF) and increase the risk of infection. #2 is incorrect. Deep breathing is a post -operative
activity that all post-op patients should perform to prevent atelectasis. Coughing would be
contraindicated in this patient as is would raise intracranial pressure. #3 is incorrect. Drinking
2 liters of fluid per day is a post-op activity that helps the body metabolize anesthesia,
maintains hydration and liquefies pulmonary secretions. #4 is incorrect. The head of the beds
needs to be elevated at least 30 degrees of higher to reduce post -op edema. This also allows for
better lung expansion to prevent atelectasis.
Nursing Process: Intervention
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. These activities may cause the patch to dislodge which could result in a cerebrospinal fluid
leak (CSF) and increase the risk of infection. #2 is incorrect. Deep breathing is a post -operative
activity that all post-op patients should perform to prevent atelectasis. Coughing would be
contraindicated in this patient as is would raise intracranial pressure. #3 is incorrect. Drinking
2 liters of fluid per day is a post-op activity that helps the body metabolize anesthesia,
maintains hydration and liquefies pulmonary secretions. #4 is incorrect. The head of the beds
needs to be elevated at least 30 degrees of higher to reduce post -op edema. This also allows for
better lung expansion to prevent atelectasis.
Nursing Process: Intervention
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. These activities may cause the patch to dislodge which could result in a cerebrospinal fluid
leak (CSF) and increase the risk of infection. #2 is incorrect. Deep breathing is a post -operative
activity that all post-op patients should perform to prevent atelectasis. Coughing would be
contraindicated in this patient as is would raise intracranial pressure. #3 is incorrect. Drinking
2 liters of fluid per day is a post-op activity that helps the body metabolize anesthesia,
maintains hydration and liquefies pulmonary secretions. #4 is incorrect. The head of the beds
needs to be elevated at least 30 degrees of higher to reduce post -op edema. This also allows for
better lung expansion to prevent atelectasis.
Nursing Process: Intervention
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. These activities may cause the patch to dislodge which could result in a cerebrospinal fluid
leak (CSF) and increase the risk of infection. #2 is incorrect. Deep breathing is a post -operative
activity that all post-op patients should perform to prevent atelectasis. Coughing would be
contraindicated in this patient as is would raise intracranial pressure. #3 is incorrect. Drinking
2 liters of fluid per day is a post-op activity that helps the body metabolize anesthesia,
maintains hydration and liquefies pulmonary secretions. #4 is incorrect. The head of the beds
needs to be elevated at least 30 degrees of higher to reduce post -op edema. This also allows for
better lung expansion to prevent atelectasis.
Nursing Process: Intervention
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary
tumors
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 260
2) A patient is diagnosed with a grade II astrocytoma. The nurse realizes that this patientʹs 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: 2
Explanation: 1. 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 have the most favorable survival rates and respond favorably to early treatment.
#3 is incorrect. 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. #4 is not correct.
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. #1 is not correct. Excellent
prognosis is not associated with this type of brain tumor
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
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 have the most favorable survival rates and respond favorably to early treatment.
#3 is incorrect. 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. #4 is not correct.
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. #1 is not correct. Excellent
prognosis is not associated with this type of brain tumor
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. 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 have the most favorable survival rates and respond favorably to early treatment.
#3 is incorrect. 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. #4 is not correct.
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. #1 is not correct. Excellent
prognosis is not associated with this type of brain tumor
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. 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 have the most favorable survival rates and respond favorably to early treatment.
#3 is incorrect. 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. #4 is not correct.
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. #1 is not correct. Excellent
prognosis is not associated with this type of brain tumor
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 261
Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary
tumors
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 262
3) 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: 3
Explanation: 1. The most common benign brain tumors arise from the meninges and are called meningiomas.
They are usually well circumscribed, may be attached to the dura, and are associated with an
excellent prognosis when gross-total resection is possible. #1 is not correct. Other common
benign brain tumors arise from nerve sheaths as with acoustic neuromas which can lead to a
hearing loss. A noncancerous primary brain tumor may be life threatening if it compromises a
vital structure or undergoes malignant transformation. #2 is not correct. Meningiomas are
usually benign and do not affect life expectancy. #4 is not correct. Meningiomas are
encapsulated and benign therefore do not metastasize to other organs.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. The most common benign brain tumors arise from the meninges and are called meningiomas.
They are usually well circumscribed, may be attached to the dura, and are associated with an
excellent prognosis when gross-total resection is possible. #1 is not correct. Other common
benign brain tumors arise from nerve sheaths as with acoustic neuromas which can lead to a
hearing loss. A noncancerous primary brain tumor may be life threatening if it compromises a
vital structure or undergoes malignant transformation. #2 is not correct. Meningiomas are
usually benign and do not affect life expectancy. #4 is not correct. Meningiomas are
encapsulated and benign therefore do not metastasize to other organs.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. The most common benign brain tumors arise from the meninges and are called meningiomas.
They are usually well circumscribed, may be attached to the dura, and are associated with an
excellent prognosis when gross-total resection is possible. #1 is not correct. Other common
benign brain tumors arise from nerve sheaths as with acoustic neuromas which can lead to a
hearing loss. A noncancerous primary brain tumor may be life threatening if it compromises a
vital structure or undergoes malignant transformation. #2 is not correct. Meningiomas are
usually benign and do not affect life expectancy. #4 is not correct. Meningiomas are
encapsulated and benign therefore do not metastasize to other organs.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. The most common benign brain tumors arise from the meninges and are called meningiomas.
They are usually well circumscribed, may be attached to the dura, and are associated with an
excellent prognosis when gross-total resection is possible. #1 is not correct. Other common
benign brain tumors arise from nerve sheaths as with acoustic neuromas which can lead to a
hearing loss. A noncancerous primary brain tumor may be life threatening if it compromises a
vital structure or undergoes malignant transformation. #2 is not correct. Meningiomas are
usually benign and do not affect life expectancy. #4 is not correct. Meningiomas are
encapsulated and benign therefore do not metastasize to other organs.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary
tumors
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 263
4) A patient with increased intracranial pressure is diagnosed with a brain tumor. The nurse realizes that this
patient most likely has:
1. An astrocytoma.
2. A meningioma.
3. A tumor less than 1 mm in size.
4. A tumor greater than 1 mm in size.
Answer: 4
Explanation: 1. Brain tumors appear to cause symptoms by different mechanisms. One mechanism is the
development of cerebral edema. Cerebral edema appears to develop once tumors have
increased in size beyond 1 mm. The new blood vessels that feed the tumor lack the normal
blood-brain barrier and are more permeable to macromolecules, proteins, and ions, resulting
in vasogenic cerebral edema. Simultaneously, macrophages and inflammatory mediators that
increase vascular permeability and edema are released. #1 is not correct. Astrocytoma are
grade I and II tumors that grow slowly and the first is symptoms are seizures. A late symptom
is increased intracranial pressure. #2 is not correct. Meningioma are extremely slow growing
tumors there is a low incidence of the development of increased intracranial pressure. #3 is not
correct. Tumors of less than 1 mm in size do not result in the development of cerebral edema as
there is minimal displacement of cerebral tissue.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Brain tumors appear to cause symptoms by different mechanisms. One mechanism is the
development of cerebral edema. Cerebral edema appears to develop once tumors have
increased in size beyond 1 mm. The new blood vessels that feed the tumor lack the normal
blood-brain barrier and are more permeable to macromolecules, proteins, and ions, resulting
in vasogenic cerebral edema. Simultaneously, macrophages and inflammatory mediators that
increase vascular permeability and edema are released. #1 is not correct. Astrocytoma are
grade I and II tumors that grow slowly and the first is symptoms are seizures. A late symptom
is increased intracranial pressure. #2 is not correct. Meningioma are extremely slow growing
tumors there is a low incidence of the development of increased intracranial pressure. #3 is not
correct. Tumors of less than 1 mm in size do not result in the development of cerebral edema as
there is minimal displacement of cerebral tissue.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. Brain tumors appear to cause symptoms by different mechanisms. One mechanism is the
development of cerebral edema. Cerebral edema appears to develop once tumors have
increased in size beyond 1 mm. The new blood vessels that feed the tumor lack the normal
blood-brain barrier and are more permeable to macromolecules, proteins, and ions, resulting
in vasogenic cerebral edema. Simultaneously, macrophages and inflammatory mediators that
increase vascular permeability and edema are released. #1 is not correct. Astrocytoma are
grade I and II tumors that grow slowly and the first is symptoms are seizures. A late symptom
is increased intracranial pressure. #2 is not correct. Meningioma are extremely slow growing
tumors there is a low incidence of the development of increased intracranial pressure. #3 is not
correct. Tumors of less than 1 mm in size do not result in the development of cerebral edema as
there is minimal displacement of cerebral tissue.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 264
4. Brain tumors appear to cause symptoms by different mechanisms. One mechanism is the
development of cerebral edema. Cerebral edema appears to develop once tumors have
increased in size beyond 1 mm. The new blood vessels that feed the tumor lack the normal
blood-brain barrier and are more permeable to macromolecules, proteins, and ions, resulting
in vasogenic cerebral edema. Simultaneously, macrophages and inflammatory mediators that
increase vascular permeability and edema are released. #1 is not correct. Astrocytoma are
grade I and II tumors that grow slowly and the first is symptoms are seizures. A late symptom
is increased intracranial pressure. #2 is not correct. Meningioma are extremely slow growing
tumors there is a low incidence of the development of increased intracranial pressure. #3 is not
correct. Tumors of less than 1 mm in size do not result in the development of cerebral edema as
there is minimal displacement of cerebral tissue.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-1: List the common manifestations of brain tumors and explain their causation
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 265
5) An elderly patient is not concerned that he has a brain tumor because he has not had any headaches, only a
slight increase in forgetfulness. The nurse realizes that this patient most likely:
1. Does not have a brain tumor because brain tumors rarely present with cognitive changes.
2. Does not have a tumor because forgetfulness is seen in children with a brain tumor.
3. Could have a brain tumor even though he does not have a headache.
4. Has the beginnings of Alzheimerʹs disease.
Answer: 3
Explanation: 1. Because older adults have age-related brain atrophy, they are less likely to present with
generalized symptoms of increased intracranial pressure such as headache and papilledema;
instead they are more likely to present with mental changes. Mental and/or personality
changes can be caused by the tumor itself, by increased intracranial pressure, or by
involvement of the parts of the brain that control personality. These can range from problems
with short-term memory, speech, communication, and/or concentration changes to severe
intellectual problems and confusion. #1 is not correct. The presence of a brain tumor in the
elderly often manifests in the elderly with cognitive changes as forgetfulness. #2 is not correct.
The manifestation of forgetfulness is a symptom of the presence of a tumor the elderly, not
pediatric population. #4 is not correct. Alzheimer disease has many more symptoms other than
forgetfulness such as language problems. A CT scan would be negative for the presence of a
tumor.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Because older adults have age-related brain atrophy, they are less likely to present with
generalized symptoms of increased intracranial pressure such as headache and papilledema;
instead they are more likely to present with mental changes. Mental and/or personality
changes can be caused by the tumor itself, by increased intracranial pressure, or by
involvement of the parts of the brain that control personality. These can range from problems
with short-term memory, speech, communication, and/or concentration changes to severe
intellectual problems and confusion. #1 is not correct. The presence of a brain tumor in the
elderly often manifests in the elderly with cognitive changes as forgetfulness. #2 is not correct.
The manifestation of forgetfulness is a symptom of the presence of a tumor the elderly, not
pediatric population. #4 is not correct. Alzheimer disease has many more symptoms other than
forgetfulness such as language problems. A CT scan would be negative for the presence of a
tumor.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. Because older adults have age-related brain atrophy, they are less likely to present with
generalized symptoms of increased intracranial pressure such as headache and papilledema;
instead they are more likely to present with mental changes. Mental and/or personality
changes can be caused by the tumor itself, by increased intracranial pressure, or by
involvement of the parts of the brain that control personality. These can range from problems
with short-term memory, speech, communication, and/or concentration changes to severe
intellectual problems and confusion. #1 is not correct. The presence of a brain tumor in the
elderly often manifests in the elderly with cognitive changes as forgetfulness. #2 is not correct.
The manifestation of forgetfulness is a symptom of the presence of a tumor the elderly, not
pediatric population. #4 is not correct. Alzheimer disease has many more symptoms other than
forgetfulness such as language problems. A CT scan would be negative for the presence of a
tumor.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 266
4. Because older adults have age-related brain atrophy, they are less likely to present with
generalized symptoms of increased intracranial pressure such as headache and papilledema;
instead they are more likely to present with mental changes. Mental and/or personality
changes can be caused by the tumor itself, by increased intracranial pressure, or by
involvement of the parts of the brain that control personality. These can range from problems
with short-term memory, speech, communication, and/or concentration changes to severe
intellectual problems and confusion. #1 is not correct. The presence of a brain tumor in the
elderly often manifests in the elderly with cognitive changes as forgetfulness. #2 is not correct.
The manifestation of forgetfulness is a symptom of the presence of a tumor the elderly, not
pediatric population. #4 is not correct. Alzheimer disease has many more symptoms other than
forgetfulness such as language problems. A CT scan would be negative for the presence of a
tumor.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-1: List the common manifestations of brain tumors and explain their causation
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 267
6) A patient tells the nurse that the doctor asked him repeatedly about an area on his arm that has been getting
numb and ʺfeels funny.ʺ This information is important because it will:
1. Possibly pinpoint the location of a brain tumor.
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: 1
Explanation: 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. #2 and #4 are not correct. 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. Treatment would determine length of
hospital stay. #3 is not correct. The neurological changes present with a brain tumor are never
taken lightly and should be noted as they are helpful with the diagnosis of an abnormality.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. 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. #2 and #4 are not correct. 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. Treatment would determine length of
hospital stay. #3 is not correct. The neurological changes present with a brain tumor are never
taken lightly and should be noted as they are helpful with the diagnosis of an abnormality.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. 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. #2 and #4 are not correct. 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. Treatment would determine length of
hospital stay. #3 is not correct. The neurological changes present with a brain tumor are never
taken lightly and should be noted as they are helpful with the diagnosis of an abnormality.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 268
4. 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. #2 and #4 are not correct. 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. Treatment would determine length of
hospital stay. #3 is not correct. The neurological changes present with a brain tumor are never
taken lightly and should be noted as they are helpful with the diagnosis of an abnormality.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-1: List the common manifestations of brain tumors and explain their causation
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 269
7) During an assessment, the patient asks the nurse if she smells ʺsomething burning.ʺ 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: 2
Explanation: 1. Focal symptoms occur in approximately one third of patients with brain tumors. The nurse
should question the patient about any experienced symptoms. Even if the patient does not
mention them, the nurse should question the patient, paying special attention to the time of
day when they occurred and what exacerbated them. The nurse should also question the
patient concerning any indications of focal symptoms or seizures. #1 is not correct. Engorged
nasal passages usually result in the loss of smell, not the presence of unusual smells. #3 is not
correct. 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. #4 is not
correct. The initial changes associated with increased intracranial pressure are subtle changes
in level of consciousness such as alertness, changes in orientation, motor and sensory deficits.
Seizure activity is a late sign.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Focal symptoms occur in approximately one third of patients with brain tumors. The nurse
should question the patient about any experienced symptoms. Even if the patient does not
mention them, the nurse should question the patient, paying special attention to the time of
day when they occurred and what exacerbated them. The nurse should also question the
patient concerning any indications of focal symptoms or seizures. #1 is not correct. Engorged
nasal passages usually result in the loss of smell, not the presence of unusual smells. #3 is not
correct. 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. #4 is not
correct. The initial changes associated with increased intracranial pressure are subtle changes
in level of consciousness such as alertness, changes in orientation, motor and sensory deficits.
Seizure activity is a late sign.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. Focal symptoms occur in approximately one third of patients with brain tumors. The nurse
should question the patient about any experienced symptoms. Even if the patient does not
mention them, the nurse should question the patient, paying special attention to the time of
day when they occurred and what exacerbated them. The nurse should also question the
patient concerning any indications of focal symptoms or seizures. #1 is not correct. Engorged
nasal passages usually result in the loss of smell, not the presence of unusual smells. #3 is not
correct. 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. #4 is not
correct. The initial changes associated with increased intracranial pressure are subtle changes
in level of consciousness such as alertness, changes in orientation, motor and sensory deficits.
Seizure activity is a late sign.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 270
4. Focal symptoms occur in approximately one third of patients with brain tumors. The nurse
should question the patient about any experienced symptoms. Even if the patient does not
mention them, the nurse should question the patient, paying special attention to the time of
day when they occurred and what exacerbated them. The nurse should also question the
patient concerning any indications of focal symptoms or seizures. #1 is not correct. Engorged
nasal passages usually result in the loss of smell, not the presence of unusual smells. #3 is not
correct. 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. #4 is not
correct. The initial changes associated with increased intracranial pressure are subtle changes
in level of consciousness such as alertness, changes in orientation, motor and sensory deficits.
Seizure activity is a late sign.
Cognitive Level: Application
Nursing Process: Assessment
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-1: List the common manifestations of brain tumors and explain their causation
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 271
8) A patient with a brain tumor is having a diagnostic test to help with his response to therapy. This patient is
most likely having a(n):
1. CT scan.
2. PET scan.
3. Angiogram.
4. MRI.
Answer: 4
Explanation: 1. The introduction of MRI is one of the most important advances in the diagnosis and care of
patients with brain tumors. An MRI allows for assistance with preoperative diagnosis,
localization for operative planning, and tumor surveillance for progression and response to
therapy. #1 is not correct. MRI scans are utilized more often than CT scans because they are
more sensitive, capable of detecting tumors too small to be noted on CT scans. #2 is not correct.
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. #3 is not correct. An angiogram is
the diagnostic tool used for detecting vascular abnormalities, not tissue masses.
Cognitive Level: Analysis
Nursing Process: Implementation
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. The introduction of MRI is one of the most important advances in the diagnosis and care of
patients with brain tumors. An MRI allows for assistance with preoperative diagnosis,
localization for operative planning, and tumor surveillance for progression and response to
therapy. #1 is not correct. MRI scans are utilized more often than CT scans because they are
more sensitive, capable of detecting tumors too small to be noted on CT scans. #2 is not correct.
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. #3 is not correct. An angiogram is
the diagnostic tool used for detecting vascular abnormalities, not tissue masses.
Cognitive Level: Analysis
Nursing Process: Implementation
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. The introduction of MRI is one of the most important advances in the diagnosis and care of
patients with brain tumors. An MRI allows for assistance with preoperative diagnosis,
localization for operative planning, and tumor surveillance for progression and response to
therapy. #1 is not correct. MRI scans are utilized more often than CT scans because they are
more sensitive, capable of detecting tumors too small to be noted on CT scans. #2 is not correct.
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. #3 is not correct. An angiogram is
the diagnostic tool used for detecting vascular abnormalities, not tissue masses.
Cognitive Level: Analysis
Nursing Process: Implementation
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 272
4. The introduction of MRI is one of the most important advances in the diagnosis and care of
patients with brain tumors. An MRI allows for assistance with preoperative diagnosis,
localization for operative planning, and tumor surveillance for progression and response to
therapy. #1 is not correct. MRI scans are utilized more often than CT scans because they are
more sensitive, capable of detecting tumors too small to be noted on CT scans. #2 is not correct.
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. #3 is not correct. An angiogram is
the diagnostic tool used for detecting vascular abnormalities, not tissue masses.
Cognitive Level: Analysis
Nursing Process: Implementation
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary
tumors
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 273
9) The nurse is preparing to administer a medication to help decrease the cerebral edema around a patientʹs brain
tumor. This medication is most likely a(n):
1. Antiseizure medication.
2. Pain medication.
3. Glucocorticoid.
4. Antispasmodic.
Answer: 3
Explanation: 1. 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. The decrease in cerebral edema may occur because
glucocorticoids directly affect vascular endothelial cell function and restore normal capillary
permeability. Dexamethasone may cause cerebral vasoconstriction. Glucocorticoid therapy
with dexamethasone has been the standard treatment for tumor-associated edema. #1 is not
correct. 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. #2 is
not correct. Pain medications do not cerebral edema or lower intracranial pressure. These
medications can be dangerous in the neuro patient as they can alter level of consciousness. The
opiod class is usually contraindicated. The usual pain medication given for comfort is codeine
as it provides good pain relief without altering level of consciousness. #4 is not correct.
Antispasmodic medications do not cross the blood-brain barrier and have no effect on cerebral
tissue.
Cognitive Level: Application
Nursing Process: Implementation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
2. 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. The decrease in cerebral edema may occur because
glucocorticoids directly affect vascular endothelial cell function and restore normal capillary
permeability. Dexamethasone may cause cerebral vasoconstriction. Glucocorticoid therapy
with dexamethasone has been the standard treatment for tumor-associated edema. #1 is not
correct. 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. #2 is
not correct. Pain medications do not cerebral edema or lower intracranial pressure. These
medications can be dangerous in the neuro patient as they can alter level of consciousness. The
opiod class is usually contraindicated. The usual pain medication given for comfort is codeine
as it provides good pain relief without altering level of consciousness. #4 is not correct.
Antispasmodic medications do not cross the blood-brain barrier and have no effect on cerebral
tissue.
Cognitive Level: Application
Nursing Process: Implementation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 274
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. The decrease in cerebral edema may occur because
glucocorticoids directly affect vascular endothelial cell function and restore normal capillary
permeability. Dexamethasone may cause cerebral vasoconstriction. Glucocorticoid therapy
with dexamethasone has been the standard treatment for tumor-associated edema. #1 is not
correct. 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. #2 is
not correct. Pain medications do not cerebral edema or lower intracranial pressure. These
medications can be dangerous in the neuro patient as they can alter level of consciousness. The
opiod class is usually contraindicated. The usual pain medication given for comfort is codeine
as it provides good pain relief without altering level of consciousness. #4 is not correct.
Antispasmodic medications do not cross the blood-brain barrier and have no effect on cerebral
tissue.
Cognitive Level: Application
Nursing Process: Implementation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
4. 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. The decrease in cerebral edema may occur because
glucocorticoids directly affect vascular endothelial cell function and restore normal capillary
permeability. Dexamethasone may cause cerebral vasoconstriction. Glucocorticoid therapy
with dexamethasone has been the standard treatment for tumor-associated edema. #1 is not
correct. 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. #2 is
not correct. Pain medications do not cerebral edema or lower intracranial pressure. These
medications can be dangerous in the neuro patient as they can alter level of consciousness. The
opiod class is usually contraindicated. The usual pain medication given for comfort is codeine
as it provides good pain relief without altering level of consciousness. #4 is not correct.
Antispasmodic medications do not cross the blood-brain barrier and have no effect on cerebral
tissue.
Cognitive Level: Application
Nursing Process: Implementation
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
Learning Outcome: 10-2: Explain why glucocorticoids are administered to patients with brain tumors
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 275
10) A patient is recovering from posterior fossa surgery. Which of the following should the nurse include in the
plan of care?
1. Assess the patientʹs vital signs and level of consciousness every hour.
2. Maintain the patient flat in bed for at least 24 hours.
3. Maintain the patientʹs neck in hyperextension.
4. Observe the patient for the development of diabetes insipidus.
Answer: 1
Explanation: 1. The tumor was near the brainstem which has vasomotor control over the vital signs. There is
also potential for cerebral edema and increased intracranial pressure so assessment of level of
consciousness is very important. #2 is not correct. The head of the bed needs to be elevated
from 10 to 60 degrees to promote venous drainage from the brain. This is to help prevent
cerebral edema and control intracranial pressure. #3 is not correct. The neck needs to remain in
a neutral position to promote venous drainage and to reduce stress on the surgical site. This is
accomplished by the application of a stiff dressing or the use of a soft cervical collar. #4 is not
correct. This complication is associated with pressure on the pituitary gland and
transphenoidal hypophesectomy.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. The tumor was near the brainstem which has vasomotor control over the vital signs. There is
also potential for cerebral edema and increased intracranial pressure so assessment of level of
consciousness is very important. #2 is not correct. The head of the bed needs to be elevated
from 10 to 60 degrees to promote venous drainage from the brain. This is to help prevent
cerebral edema and control intracranial pressure. #3 is not correct. The neck needs to remain in
a neutral position to promote venous drainage and to reduce stress on the surgical site. This is
accomplished by the application of a stiff dressing or the use of a soft cervical collar. #4 is not
correct. This complication is associated with pressure on the pituitary gland and
transphenoidal hypophesectomy.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. The tumor was near the brainstem which has vasomotor control over the vital signs. There is
also potential for cerebral edema and increased intracranial pressure so assessment of level of
consciousness is very important. #2 is not correct. The head of the bed needs to be elevated
from 10 to 60 degrees to promote venous drainage from the brain. This is to help prevent
cerebral edema and control intracranial pressure. #3 is not correct. The neck needs to remain in
a neutral position to promote venous drainage and to reduce stress on the surgical site. This is
accomplished by the application of a stiff dressing or the use of a soft cervical collar. #4 is not
correct. This complication is associated with pressure on the pituitary gland and
transphenoidal hypophesectomy.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 276
4. The tumor was near the brainstem which has vasomotor control over the vital signs. There is
also potential for cerebral edema and increased intracranial pressure so assessment of level of
consciousness is very important. #2 is not correct. The head of the bed needs to be elevated
from 10 to 60 degrees to promote venous drainage from the brain. This is to help prevent
cerebral edema and control intracranial pressure. #3 is not correct. The neck needs to remain in
a neutral position to promote venous drainage and to reduce stress on the surgical site. This is
accomplished by the application of a stiff dressing or the use of a soft cervical collar. #4 is not
correct. This complication is associated with pressure on the pituitary gland and
transphenoidal hypophesectomy.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary
tumors
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 277
11) A patient with a brain tumor is going to have an ablative procedure to treat the mass. A potential reason for
this procedure would be:
1. To preserve eloquent areas of the brain.
2. The tumor is in an easy-to-reach area of the brain.
3. The tumor is too large to resect.
4. The tumor is small and is in a hard-to-reach area of the brain.
Answer: 4
Explanation: 1. An alternative to surgery are ablative procedures that cause cell death and necrosis of the
tumor over time. They are most appropriate for people with smaller tumors in nonaccessible
areas. #1 is not correct. This procedure is not designed to preserve but to destroy blood supply
to a tumor. #2 is not correct. If a tumor is too large, it is initially treated with radiation to shrink
to a more manageable size for surgical removal. This is then followed with chemotherapy. #3 is
not correct. The ablation procedure is used for small, nonaccessible tumors.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity– Reduction of Risk Potential
2. An alternative to surgery are ablative procedures that cause cell death and necrosis of the
tumor over time. They are most appropriate for people with smaller tumors in nonaccessible
areas. #1 is not correct. This procedure is not designed to preserve but to destroy blood supply
to a tumor. #2 is not correct. If a tumor is too large, it is initially treated with radiation to shrink
to a more manageable size for surgical removal. This is then followed with chemotherapy. #3 is
not correct. The ablation procedure is used for small, nonaccessible tumors.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity– Reduction of Risk Potential
3. An alternative to surgery are ablative procedures that cause cell death and necrosis of the
tumor over time. They are most appropriate for people with smaller tumors in nonaccessible
areas. #1 is not correct. This procedure is not designed to preserve but to destroy blood supply
to a tumor. #2 is not correct. If a tumor is too large, it is initially treated with radiation to shrink
to a more manageable size for surgical removal. This is then followed with chemotherapy. #3 is
not correct. The ablation procedure is used for small, nonaccessible tumors.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity– Reduction of Risk Potential
4. An alternative to surgery are ablative procedures that cause cell death and necrosis of the
tumor over time. They are most appropriate for people with smaller tumors in nonaccessible
areas. #1 is not correct. This procedure is not designed to preserve but to destroy blood supply
to a tumor. #2 is not correct. If a tumor is too large, it is initially treated with radiation to shrink
to a more manageable size for surgical removal. This is then followed with chemotherapy. #3 is
not correct. The ablation procedure is used for small, nonaccessible tumors.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity– Reduction of Risk Potential
Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary
tumors
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 278
12) The nurse is planning the care for a patient who had a supratentoral craniotomy. Which of the following
should be included in this plan of care?
1. Apply a soft cervical collar.
2. Keep the head of the bed elevated at a 30-degree angle.
3. Keep the head of the bed flat.
4. Position the patient on the side of the tumor.
Answer: 2
Explanation: 1. Postoperatively patients are usually positioned with the head of their bed elevated 30 degrees.
This facilitates venous drainage from the head and neck, preventing increases in intracranial
pressure and increasing patient comfort. #1 is not correct. This patient had surgery involving
the supretetorium therefore a cervical collar is not necessary. If the patient has had posterior
fossa surgery, a stiff dressing or cervical collar may be applied to prevent the patient from
hyperflexing or extending her neck, causing stress on the surgical site. #3 is not correct. The
head of the bed needs to be elevated at least 10 degrees or greater up to 60 degrees in order to
facilitate venous drainage from the operative site. This prevents increased intracranial pressure
and herniation. An elevation of greater than 60 degrees would increase the risk of brain
herniation. #4 is not correct. This patient had a small tumor resected. If a large tumor was
resected, the patient would usually not be permitted to turn her head to the operative side
because it may cause a shift in cerebral contents.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Postoperatively patients are usually positioned with the head of their bed elevated 30 degrees.
This facilitates venous drainage from the head and neck, preventing increases in intracranial
pressure and increasing patient comfort. #1 is not correct. This patient had surgery involving
the supretetorium therefore a cervical collar is not necessary. If the patient has had posterior
fossa surgery, a stiff dressing or cervical collar may be applied to prevent the patient from
hyperflexing or extending her neck, causing stress on the surgical site. #3 is not correct. The
head of the bed needs to be elevated at least 10 degrees or greater up to 60 degrees in order to
facilitate venous drainage from the operative site. This prevents increased intracranial pressure
and herniation. An elevation of greater than 60 degrees would increase the risk of brain
herniation. #4 is not correct. This patient had a small tumor resected. If a large tumor was
resected, the patient would usually not be permitted to turn her head to the operative side
because it may cause a shift in cerebral contents.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. Postoperatively patients are usually positioned with the head of their bed elevated 30 degrees.
This facilitates venous drainage from the head and neck, preventing increases in intracranial
pressure and increasing patient comfort. #1 is not correct. This patient had surgery involving
the supretetorium therefore a cervical collar is not necessary. If the patient has had posterior
fossa surgery, a stiff dressing or cervical collar may be applied to prevent the patient from
hyperflexing or extending her neck, causing stress on the surgical site. #3 is not correct. The
head of the bed needs to be elevated at least 10 degrees or greater up to 60 degrees in order to
facilitate venous drainage from the operative site. This prevents increased intracranial pressure
and herniation. An elevation of greater than 60 degrees would increase the risk of brain
herniation. #4 is not correct. This patient had a small tumor resected. If a large tumor was
resected, the patient would usually not be permitted to turn her head to the operative side
because it may cause a shift in cerebral contents.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 279
4. Postoperatively patients are usually positioned with the head of their bed elevated 30 degrees.
This facilitates venous drainage from the head and neck, preventing increases in intracranial
pressure and increasing patient comfort. #1 is not correct. This patient had surgery involving
the supretetorium therefore a cervical collar is not necessary. If the patient has had posterior
fossa surgery, a stiff dressing or cervical collar may be applied to prevent the patient from
hyperflexing or extending her neck, causing stress on the surgical site. #3 is not correct. The
head of the bed needs to be elevated at least 10 degrees or greater up to 60 degrees in order to
facilitate venous drainage from the operative site. This prevents increased intracranial pressure
and herniation. An elevation of greater than 60 degrees would increase the risk of brain
herniation. #4 is not correct. This patient had a small tumor resected. If a large tumor was
resected, the patient would usually not be permitted to turn her head to the operative side
because it may cause a shift in cerebral contents.
Nursing Process: Planning
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary
tumors
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 280
13) The nurse is applying pneumatic compression boots on a postoperative 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: 2
Explanation: 1. 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. An alternative is the use of compression boots prior,
during, and for 24 hours after the surgery followed by low-dose heparin 5000 units twice a
day or enoxaparin 40 mg/day. #1 is not correct. Prophyalxis to prevent meningitis includes
good hand washing, maintaining aseptic technique when handling external ventricular drains,
tubes and surgical sites and administering antibiotic medications. #3 is not correct. Prophyaxis
to prevent a cerebral spinal fluid leak includes keeping the intracranial pressure at normal
level by keeping the head of the bed at 30 degrees and administering glucocorticoid
medications. #4 is not correct. Prophylaxis for seizures is the use of medications such as
Dilantin (phenytoin) and Phenobarbital.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
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. An alternative is the use of compression boots prior,
during, and for 24 hours after the surgery followed by low-dose heparin 5000 units twice a
day or enoxaparin 40 mg/day. #1 is not correct. Prophyalxis to prevent meningitis includes
good hand washing, maintaining aseptic technique when handling external ventricular drains,
tubes and surgical sites and administering antibiotic medications. #3 is not correct. Prophyaxis
to prevent a cerebral spinal fluid leak includes keeping the intracranial pressure at normal
level by keeping the head of the bed at 30 degrees and administering glucocorticoid
medications. #4 is not correct. Prophylaxis for seizures is the use of medications such as
Dilantin (phenytoin) and Phenobarbital.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. 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. An alternative is the use of compression boots prior,
during, and for 24 hours after the surgery followed by low-dose heparin 5000 units twice a
day or enoxaparin 40 mg/day. #1 is not correct. Prophyalxis to prevent meningitis includes
good hand washing, maintaining aseptic technique when handling external ventricular drains,
tubes and surgical sites and administering antibiotic medications. #3 is not correct. Prophyaxis
to prevent a cerebral spinal fluid leak includes keeping the intracranial pressure at normal
level by keeping the head of the bed at 30 degrees and administering glucocorticoid
medications. #4 is not correct. Prophylaxis for seizures is the use of medications such as
Dilantin (phenytoin) and Phenobarbital.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 281
4. 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. An alternative is the use of compression boots prior,
during, and for 24 hours after the surgery followed by low-dose heparin 5000 units twice a
day or enoxaparin 40 mg/day. #1 is not correct. Prophyalxis to prevent meningitis includes
good hand washing, maintaining aseptic technique when handling external ventricular drains,
tubes and surgical sites and administering antibiotic medications. #3 is not correct. Prophyaxis
to prevent a cerebral spinal fluid leak includes keeping the intracranial pressure at normal
level by keeping the head of the bed at 30 degrees and administering glucocorticoid
medications. #4 is not correct. Prophylaxis for seizures is the use of medications such as
Dilantin (phenytoin) and Phenobarbital.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-4: Summarize strategies used to prevent common complications post craniotomy
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 282
14) A patient recovering from a craniotomy is complaining of a headache with the head of the bed elevated. The
nurse also sees a damp mark on the patientʹs pillow. The nurse should: (Select all that apply.)
1. Alert the physician.
2. Check the drainage for the presence of glucose.
3. Elevate the head of the patientʹs bed to 45 degrees.
4. Plan for insertion of an external ventricular drain.
5. Apply an occlusive dressing to stop the leak.
Answer: 1, 2
Explanation: 1. (Note: This requires multiple responses to be correct.)
Cerebrospinal fluid leakages occur when there is a tear in the dura allowing an opening to
develop between the subarachnoid space and the outside. A cerebrospinal fluid leak can be
identified by clear fluid containing glucose that is leaking from the patientʹs ear or nose and
forming a halo as it settles on a pillowcase. These leaks may be problematic because they may
result in CSF depletion. The patient will complain of a headache, which is usually more severe
when the patient is in the upright position and is alleviated when the patient is supine. #3 is
not correct. 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. #4 is not correct. 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. #5 is not
correct. 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.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. (Note: This requires multiple responses to be correct.)
Cerebrospinal fluid leakages occur when there is a tear in the dura allowing an opening to
develop between the subarachnoid space and the outside. A cerebrospinal fluid leak can be
identified by clear fluid containing glucose that is leaking from the patientʹs ear or nose and
forming a halo as it settles on a pillowcase. These leaks may be problematic because they may
result in CSF depletion. The patient will complain of a headache, which is usually more severe
when the patient is in the upright position and is alleviated when the patient is supine. #3 is
not correct. 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. #4 is not correct. 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. #5 is not
correct. 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.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 283
3. (Note: This requires multiple responses to be correct.)
Cerebrospinal fluid leakages occur when there is a tear in the dura allowing an opening to
develop between the subarachnoid space and the outside. A cerebrospinal fluid leak can be
identified by clear fluid containing glucose that is leaking from the patientʹs ear or nose and
forming a halo as it settles on a pillowcase. These leaks may be problematic because they may
result in CSF depletion. The patient will complain of a headache, which is usually more severe
when the patient is in the upright position and is alleviated when the patient is supine. #3 is
not correct. 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. #4 is not correct. 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. #5 is not
correct. 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.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. (Note: This requires multiple responses to be correct.)
Cerebrospinal fluid leakages occur when there is a tear in the dura allowing an opening to
develop between the subarachnoid space and the outside. A cerebrospinal fluid leak can be
identified by clear fluid containing glucose that is leaking from the patientʹs ear or nose and
forming a halo as it settles on a pillowcase. These leaks may be problematic because they may
result in CSF depletion. The patient will complain of a headache, which is usually more severe
when the patient is in the upright position and is alleviated when the patient is supine. #3 is
not correct. 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. #4 is not correct. 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. #5 is not
correct. 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.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
5. (Note: This requires multiple responses to be correct.)
Cerebrospinal fluid leakages occur when there is a tear in the dura allowing an opening to
develop between the subarachnoid space and the outside. A cerebrospinal fluid leak can be
identified by clear fluid containing glucose that is leaking from the patientʹs ear or nose and
forming a halo as it settles on a pillowcase. These leaks may be problematic because they may
result in CSF depletion. The patient will complain of a headache, which is usually more severe
when the patient is in the upright position and is alleviated when the patient is supine. #3 is
not correct. 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. #4 is not correct. 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. #5 is not
correct. 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.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-4: Summarize strategies used to prevent common complications post craniotomy
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 284
15) A patient with a brain tumor is prescribed an antiseizure medication. The nurse realizes that the patient will
have to take this medication for:
1. The rest of his life.
2. At least 5 years.
3. A week if he is seizure free.
4. The next 6 months if he is seizure free.
Answer: 3
Explanation: 1. Antiepilepsy prophylaxis can be provided for the first week following brain surgery. #1, #2,
and #4 are not correct. After a week, antiepilepsy drugs should be discontinued for patients
who do not have a history of seizures. These medications are continued only in those patients
that have a history of seizures.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Antiepilepsy prophylaxis can be provided for the first week following brain surgery. #1, #2,
and #4 are not correct. After a week, antiepilepsy drugs should be discontinued for patients
who do not have a history of seizures. These medications are continued only in those patients
that have a history of seizures.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. Antiepilepsy prophylaxis can be provided for the first week following brain surgery. #1, #2,
and #4 are not correct. After a week, antiepilepsy drugs should be discontinued for patients
who do not have a history of seizures. These medications are continued only in those patients
that have a history of seizures.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. Antiepilepsy prophylaxis can be provided for the first week following brain surgery. #1, #2,
and #4 are not correct. After a week, antiepilepsy drugs should be discontinued for patients
who do not have a history of seizures. These medications are continued only in those patients
that have a history of seizures.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-4: Summarize strategies used to prevent common complications post craniotomy
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 285
16) 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: 1
Explanation: 1. Radiation is one of the most effective treatments for gliomas and is the foundation for nearly
all treatment regimens for malignant brain tumors. The current standard of care is localized
field radiation with a total dose of 60 Gy in 30 fractions. Usually, patients begin radiation
treatments within 2 to 4 weeks after tumor resection. Treatments are given daily for 4 to 6
weeks. Adjunctive chemotherapy may be also provided, usually after the completion of
radiation therapy. Grade III anaplastic astrocytomas are often treated with procarbazine,
lomustine, and vincristine, whereas grade IV glioblastoma multiforme tumors are usually
treated with carmustine, paclitaxel, and temozolomide. #2 is not correct. Additional treatments
of radiation have not been shown to decrease morbidity or mortality in the treatment of
gliomas. Adjunct treat of chemotherapy has been proven to improve outcome. #3 is not correct.
Chemotherapy, both systemic and local, is used after the completion of radiation therapy. This
is a secondary therapy that is used after tumor shrinkage and ablation of tumor blood supply
has occurred. #4 is not correct. Antiseizure medications are only used if the patient develops
seizures.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Radiation is one of the most effective treatments for gliomas and is the foundation for nearly
all treatment regimens for malignant brain tumors. The current standard of care is localized
field radiation with a total dose of 60 Gy in 30 fractions. Usually, patients begin radiation
treatments within 2 to 4 weeks after tumor resection. Treatments are given daily for 4 to 6
weeks. Adjunctive chemotherapy may be also provided, usually after the completion of
radiation therapy. Grade III anaplastic astrocytomas are often treated with procarbazine,
lomustine, and vincristine, whereas grade IV glioblastoma multiforme tumors are usually
treated with carmustine, paclitaxel, and temozolomide. #2 is not correct. Additional treatments
of radiation have not been shown to decrease morbidity or mortality in the treatment of
gliomas. Adjunct treat of chemotherapy has been proven to improve outcome. #3 is not correct.
Chemotherapy, both systemic and local, is used after the completion of radiation therapy. This
is a secondary therapy that is used after tumor shrinkage and ablation of tumor blood supply
has occurred. #4 is not correct. Antiseizure medications are only used if the patient develops
seizures.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 286
3. Radiation is one of the most effective treatments for gliomas and is the foundation for nearly
all treatment regimens for malignant brain tumors. The current standard of care is localized
field radiation with a total dose of 60 Gy in 30 fractions. Usually, patients begin radiation
treatments within 2 to 4 weeks after tumor resection. Treatments are given daily for 4 to 6
weeks. Adjunctive chemotherapy may be also provided, usually after the completion of
radiation therapy. Grade III anaplastic astrocytomas are often treated with procarbazine,
lomustine, and vincristine, whereas grade IV glioblastoma multiforme tumors are usually
treated with carmustine, paclitaxel, and temozolomide. #2 is not correct. Additional treatments
of radiation have not been shown to decrease morbidity or mortality in the treatment of
gliomas. Adjunct treat of chemotherapy has been proven to improve outcome. #3 is not correct.
Chemotherapy, both systemic and local, is used after the completion of radiation therapy. This
is a secondary therapy that is used after tumor shrinkage and ablation of tumor blood supply
has occurred. #4 is not correct. Antiseizure medications are only used if the patient develops
seizures.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. Radiation is one of the most effective treatments for gliomas and is the foundation for nearly
all treatment regimens for malignant brain tumors. The current standard of care is localized
field radiation with a total dose of 60 Gy in 30 fractions. Usually, patients begin radiation
treatments within 2 to 4 weeks after tumor resection. Treatments are given daily for 4 to 6
weeks. Adjunctive chemotherapy may be also provided, usually after the completion of
radiation therapy. Grade III anaplastic astrocytomas are often treated with procarbazine,
lomustine, and vincristine, whereas grade IV glioblastoma multiforme tumors are usually
treated with carmustine, paclitaxel, and temozolomide. #2 is not correct. Additional treatments
of radiation have not been shown to decrease morbidity or mortality in the treatment of
gliomas. Adjunct treat of chemotherapy has been proven to improve outcome. #3 is not correct.
Chemotherapy, both systemic and local, is used after the completion of radiation therapy. This
is a secondary therapy that is used after tumor shrinkage and ablation of tumor blood supply
has occurred. #4 is not correct. Antiseizure medications are only used if the patient develops
seizures.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-3: Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary
tumors
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 287
17) A patient is diagnosed with an intracerebral hemorrhage. Which of the following is the most common cause of
this disorder?
1. Hypertension
2. Atrial fibrillation
3. Atherosclerosis
4. Hyperinsulinemia
Answer: 1
Explanation: 1. The most common causes of intracerebral hemorrhage are hypertension, trauma, illicit drug
use (particularly amphetamines and cocaine), vascular malformations, and bleeding diathesis.
Intracerebral hemorrhage results from hypertension when the arteries in the brain become
brittle, susceptible to cracking, and rupture. #2 is not correct. Atrial fibrillation increases the
risk of the development of an ischemic cerebrovascular accident. This is due to the pooling of
blood in the atria that occurs with the loss of atrial kick. #3 is not correct. Atherosclerosis is the
cause of hypertension which can lead to intracranial hemorrhage. #4 is not correct.
Hyperinsulinemia is a risk factor for the development of atherosclerosis and hypertension
which may eventually lead to an intracranial hemorrhage, however, is not a primary cause.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. The most common causes of intracerebral hemorrhage are hypertension, trauma, illicit drug
use (particularly amphetamines and cocaine), vascular malformations, and bleeding diathesis.
Intracerebral hemorrhage results from hypertension when the arteries in the brain become
brittle, susceptible to cracking, and rupture. #2 is not correct. Atrial fibrillation increases the
risk of the development of an ischemic cerebrovascular accident. This is due to the pooling of
blood in the atria that occurs with the loss of atrial kick. #3 is not correct. Atherosclerosis is the
cause of hypertension which can lead to intracranial hemorrhage. #4 is not correct.
Hyperinsulinemia is a risk factor for the development of atherosclerosis and hypertension
which may eventually lead to an intracranial hemorrhage, however, is not a primary cause.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. The most common causes of intracerebral hemorrhage are hypertension, trauma, illicit drug
use (particularly amphetamines and cocaine), vascular malformations, and bleeding diathesis.
Intracerebral hemorrhage results from hypertension when the arteries in the brain become
brittle, susceptible to cracking, and rupture. #2 is not correct. Atrial fibrillation increases the
risk of the development of an ischemic cerebrovascular accident. This is due to the pooling of
blood in the atria that occurs with the loss of atrial kick. #3 is not correct. Atherosclerosis is the
cause of hypertension which can lead to intracranial hemorrhage. #4 is not correct.
Hyperinsulinemia is a risk factor for the development of atherosclerosis and hypertension
which may eventually lead to an intracranial hemorrhage, however, is not a primary cause.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 288
4. The most common causes of intracerebral hemorrhage are hypertension, trauma, illicit drug
use (particularly amphetamines and cocaine), vascular malformations, and bleeding diathesis.
Intracerebral hemorrhage results from hypertension when the arteries in the brain become
brittle, susceptible to cracking, and rupture. #2 is not correct. Atrial fibrillation increases the
risk of the development of an ischemic cerebrovascular accident. This is due to the pooling of
blood in the atria that occurs with the loss of atrial kick. #3 is not correct. Atherosclerosis is the
cause of hypertension which can lead to intracranial hemorrhage. #4 is not correct.
Hyperinsulinemia is a risk factor for the development of atherosclerosis and hypertension
which may eventually lead to an intracranial hemorrhage, however, is not a primary cause.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-5: Compare and contrast the mechanisms of hemorrhagic and ischemic strokes
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 289
18) A patient tells the nurse that he is experiencing the ʺworst headacheʺ he has ever had. The nurse realizes that
this description is often seen in:
1. Intracranial hemorrhage.
2. Ischemic stroke.
3. Subarachnoid hemorrhage.
4. A brain tumor.
Answer: 3
Explanation: 1. Subarachnoid hemorrhage is rupture of an aneurysm that releases blood directly into the
cerebrospinal fluid under arterial pressure. The blood spreads rapidly, immediately increasing
intracranial pressure. If bleeding continues, deep coma or death may result. Typically the
bleeding lasts only a few seconds but there is risk of rebleeding. The classic symptom is a
sudden, severe headache that begins abruptly and is described as ʺthe worst headache of my
life.ʺ #1 is not correct. Intracrananial hemorrhage is a local hematoma in the brain that is
manifested by neurologic symptoms such as a change in level of consciousness, sensory and
motor deficits. #2 is not correct. Ischemic stroke is characterized confusion, difficulty speaking,
visual disturbances, sensory and motor deficits. Headache does occur but the accompanying
symptoms are the defining characteristics. #4 is not correct. The headache associated with a
brain tumor is worse in the morning but improves during the day. It worsens with coughing,
exercise, and changes in position. This type of headache does not respond to usual headache
treatment.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Subarachnoid hemorrhage is rupture of an aneurysm that releases blood directly into the
cerebrospinal fluid under arterial pressure. The blood spreads rapidly, immediately increasing
intracranial pressure. If bleeding continues, deep coma or death may result. Typically the
bleeding lasts only a few seconds but there is risk of rebleeding. The classic symptom is a
sudden, severe headache that begins abruptly and is described as ʺthe worst headache of my
life.ʺ #1 is not correct. Intracrananial hemorrhage is a local hematoma in the brain that is
manifested by neurologic symptoms such as a change in level of consciousness, sensory and
motor deficits. #2 is not correct. Ischemic stroke is characterized confusion, difficulty speaking,
visual disturbances, sensory and motor deficits. Headache does occur but the accompanying
symptoms are the defining characteristics. #4 is not correct. The headache associated with a
brain tumor is worse in the morning but improves during the day. It worsens with coughing,
exercise, and changes in position. This type of headache does not respond to usual headache
treatment.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 290
3. Subarachnoid hemorrhage is rupture of an aneurysm that releases blood directly into the
cerebrospinal fluid under arterial pressure. The blood spreads rapidly, immediately increasing
intracranial pressure. If bleeding continues, deep coma or death may result. Typically the
bleeding lasts only a few seconds but there is risk of rebleeding. The classic symptom is a
sudden, severe headache that begins abruptly and is described as ʺthe worst headache of my
life.ʺ #1 is not correct. Intracrananial hemorrhage is a local hematoma in the brain that is
manifested by neurologic symptoms such as a change in level of consciousness, sensory and
motor deficits. #2 is not correct. Ischemic stroke is characterized confusion, difficulty speaking,
visual disturbances, sensory and motor deficits. Headache does occur but the accompanying
symptoms are the defining characteristics. #4 is not correct. The headache associated with a
brain tumor is worse in the morning but improves during the day. It worsens with coughing,
exercise, and changes in position. This type of headache does not respond to usual headache
treatment.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. Subarachnoid hemorrhage is rupture of an aneurysm that releases blood directly into the
cerebrospinal fluid under arterial pressure. The blood spreads rapidly, immediately increasing
intracranial pressure. If bleeding continues, deep coma or death may result. Typically the
bleeding lasts only a few seconds but there is risk of rebleeding. The classic symptom is a
sudden, severe headache that begins abruptly and is described as ʺthe worst headache of my
life.ʺ #1 is not correct. Intracrananial hemorrhage is a local hematoma in the brain that is
manifested by neurologic symptoms such as a change in level of consciousness, sensory and
motor deficits. #2 is not correct. Ischemic stroke is characterized confusion, difficulty speaking,
visual disturbances, sensory and motor deficits. Headache does occur but the accompanying
symptoms are the defining characteristics. #4 is not correct. The headache associated with a
brain tumor is worse in the morning but improves during the day. It worsens with coughing,
exercise, and changes in position. This type of headache does not respond to usual headache
treatment.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-5: Compare and contrast the mechanisms of hemorrhagic and ischemic strokes
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 291
19) A patient with an embolic stroke is demonstrating urinary incontinence, contralateral weakness, and altered
mental status. This location of the embolism is most likely the:
1. Middle cerebral artery.
2. Anterior cerebral artery.
3. Posterior cerebral artery.
4. Vertebrobasilar artery.
Answer: 2
Explanation: 1. 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. #1 is not correct. 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. #3 is not correct. Posterior cerebral artery
occlusions affect vision and thought, producing homonymous hemianopsia, cortical blindness,
visual agnosia, altered mental status, and impaired memory. #4 is not correct. Vertebrobasilar
artery occlusion is difficult to detect because it results in a wide variety of cranial nerve,
cerebellar, and brainstem deficits.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptation
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. #1 is not correct. 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. #3 is not correct. Posterior cerebral artery
occlusions affect vision and thought, producing homonymous hemianopsia, cortical blindness,
visual agnosia, altered mental status, and impaired memory. #4 is not correct. Vertebrobasilar
artery occlusion is difficult to detect because it results in a wide variety of cranial nerve,
cerebellar, and brainstem deficits.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptation
3. 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. #1 is not correct. 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. #3 is not correct. Posterior cerebral artery
occlusions affect vision and thought, producing homonymous hemianopsia, cortical blindness,
visual agnosia, altered mental status, and impaired memory. #4 is not correct. Vertebrobasilar
artery occlusion is difficult to detect because it results in a wide variety of cranial nerve,
cerebellar, and brainstem deficits.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptation
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 292
4. 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. #1 is not correct. 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. #3 is not correct. Posterior cerebral artery
occlusions affect vision and thought, producing homonymous hemianopsia, cortical blindness,
visual agnosia, altered mental status, and impaired memory. #4 is not correct. Vertebrobasilar
artery occlusion is difficult to detect because it results in a wide variety of cranial nerve,
cerebellar, and brainstem deficits.
Nursing Process: Assessment
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptation
Learning Outcome: 10-5: Compare and contrast the mechanisms of hemorrhagic and ischemic strokes
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 293
20) 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 thrombolysis (rtPA).
3. Observe for continuing symptoms.
4. Provide intravenous fluids.
Answer: 2
Explanation: 1. Computerized tomography is the current minimal standard imaging study to rule out
hemorrhagic events and to identify patients who are eligible for rtPA therapy. It should be
performed within 45 minutes and interpreted within 20 minutes of the patientʹs arrival to the
hospital emergency department. . In the case of ischemic stroke, intravenous thrombolysis
(rtPA) should be administered if the time since the onset of symptoms is less than 3 hours and
the patient is eligible based on criteria. #1 is not correct. 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 endartarectomy may be considered if indicated. #3 is not
correct. 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. #4 is
not correct. 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 and this
would increase the risk of the development of more thromboemboli.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Computerized tomography is the current minimal standard imaging study to rule out
hemorrhagic events and to identify patients who are eligible for rtPA therapy. It should be
performed within 45 minutes and interpreted within 20 minutes of the patientʹs arrival to the
hospital emergency department. . In the case of ischemic stroke, intravenous thrombolysis
(rtPA) should be administered if the time since the onset of symptoms is less than 3 hours and
the patient is eligible based on criteria. #1 is not correct. 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 endartarectomy may be considered if indicated. #3 is not
correct. 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. #4 is
not correct. 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 and this
would increase the risk of the development of more thromboemboli.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 294
3. Computerized tomography is the current minimal standard imaging study to rule out
hemorrhagic events and to identify patients who are eligible for rtPA therapy. It should be
performed within 45 minutes and interpreted within 20 minutes of the patientʹs arrival to the
hospital emergency department. . In the case of ischemic stroke, intravenous thrombolysis
(rtPA) should be administered if the time since the onset of symptoms is less than 3 hours and
the patient is eligible based on criteria. #1 is not correct. 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 endartarectomy may be considered if indicated. #3 is not
correct. 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. #4 is
not correct. 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 and this
would increase the risk of the development of more thromboemboli.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. Computerized tomography is the current minimal standard imaging study to rule out
hemorrhagic events and to identify patients who are eligible for rtPA therapy. It should be
performed within 45 minutes and interpreted within 20 minutes of the patientʹs arrival to the
hospital emergency department. . In the case of ischemic stroke, intravenous thrombolysis
(rtPA) should be administered if the time since the onset of symptoms is less than 3 hours and
the patient is eligible based on criteria. #1 is not correct. 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 endartarectomy may be considered if indicated. #3 is not
correct. 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. #4 is
not correct. 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 and this
would increase the risk of the development of more thromboemboli.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-6: Describe emergent management of the patient with an ischemic stroke
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 295
21) A patient is admitted to an intensive care unit with an ischemic stroke. Currently the patientʹs oxygen
saturation is 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: 4
Explanation: 1. The nurse should monitor all CVA patientsʹ oxygen saturations. 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. #1 is not correct. Positioning the patient on one side does not improve O2
saturation. It does, however reduce the chance of aspiration if the patient has secretions they
will be less likely aspirated while in the side-lying position. #2 is not correct. Raising the head
of the bed assists in keeping the airway open as well as facilitating lung expansion to prevent
atelectasis. #3 is not correct. Low dose oxygen does not provide adequate supplementation to
maintain oxygen saturation, especially when it falls below 90%. It is help as an adjunct when
the saturation is 90% in order to raise it to more appropriate levels.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. The nurse should monitor all CVA patientsʹ oxygen saturations. 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. #1 is not correct. Positioning the patient on one side does not improve O2
saturation. It does, however reduce the chance of aspiration if the patient has secretions they
will be less likely aspirated while in the side-lying position. #2 is not correct. Raising the head
of the bed assists in keeping the airway open as well as facilitating lung expansion to prevent
atelectasis. #3 is not correct. Low dose oxygen does not provide adequate supplementation to
maintain oxygen saturation, especially when it falls below 90%. It is help as an adjunct when
the saturation is 90% in order to raise it to more appropriate levels.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. The nurse should monitor all CVA patientsʹ oxygen saturations. 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. #1 is not correct. Positioning the patient on one side does not improve O2
saturation. It does, however reduce the chance of aspiration if the patient has secretions they
will be less likely aspirated while in the side-lying position. #2 is not correct. Raising the head
of the bed assists in keeping the airway open as well as facilitating lung expansion to prevent
atelectasis. #3 is not correct. Low dose oxygen does not provide adequate supplementation to
maintain oxygen saturation, especially when it falls below 90%. It is help as an adjunct when
the saturation is 90% in order to raise it to more appropriate levels.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 296
4. The nurse should monitor all CVA patientsʹ oxygen saturations. 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. #1 is not correct. Positioning the patient on one side does not improve O2
saturation. It does, however reduce the chance of aspiration if the patient has secretions they
will be less likely aspirated while in the side-lying position. #2 is not correct. Raising the head
of the bed assists in keeping the airway open as well as facilitating lung expansion to prevent
atelectasis. #3 is not correct. Low dose oxygen does not provide adequate supplementation to
maintain oxygen saturation, especially when it falls below 90%. It is help as an adjunct when
the saturation is 90% in order to raise it to more appropriate levels.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-6: Describe emergent management of the patient with an ischemic stroke
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 297
22) A patient being treated with Coumadin experiences an intracerebral hemorrhage. Which of the following
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: 3
Explanation: 1. Since the patient has been receiving the anticoagulant Coumadin (warfarin) the appropriate
drug is the administration of Vitamin K to reverse the effects of this medication. #1 is incorrect.
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. #2 is not correct. A ventriculostomy is not used as a
therapy in the management of the intracerebral hematoma. This therapy is limited and would
only indicated if it would be beneficial in reducing intracranial pressure by controlling
cerebrospinal fluid. #4 is not correct. Protamine sulfate is the medication used to reverse
heparin-associated ICH. The dose is dependent on the time since the cessation of heparin.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Since the patient has been receiving the anticoagulant Coumadin (warfarin) the appropriate
drug is the administration of Vitamin K to reverse the effects of this medication. #1 is incorrect.
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. #2 is not correct. A ventriculostomy is not used as a
therapy in the management of the intracerebral hematoma. This therapy is limited and would
only indicated if it would be beneficial in reducing intracranial pressure by controlling
cerebrospinal fluid. #4 is not correct. Protamine sulfate is the medication used to reverse
heparin-associated ICH. The dose is dependent on the time since the cessation of heparin.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. Since the patient has been receiving the anticoagulant Coumadin (warfarin) the appropriate
drug is the administration of Vitamin K to reverse the effects of this medication. #1 is incorrect.
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. #2 is not correct. A ventriculostomy is not used as a
therapy in the management of the intracerebral hematoma. This therapy is limited and would
only indicated if it would be beneficial in reducing intracranial pressure by controlling
cerebrospinal fluid. #4 is not correct. Protamine sulfate is the medication used to reverse
heparin-associated ICH. The dose is dependent on the time since the cessation of heparin.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. Since the patient has been receiving the anticoagulant Coumadin (warfarin) the appropriate
drug is the administration of Vitamin K to reverse the effects of this medication. #1 is incorrect.
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. #2 is not correct. A ventriculostomy is not used as a
therapy in the management of the intracerebral hematoma. This therapy is limited and would
only indicated if it would be beneficial in reducing intracranial pressure by controlling
cerebrospinal fluid. #4 is not correct. Protamine sulfate is the medication used to reverse
heparin-associated ICH. The dose is dependent on the time since the cessation of heparin.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-6: Describe emergent management of the patient with an ischemic stroke
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 298
23) 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.
2. Grade 2.
3. Grade 3.
4. Grade 4.
Answer: 3
Explanation: 1. A grade 3 is evidenced by drowsiness, confusion, or mild focal deficit. #1 is not correct. A
grade 1 is asymptomatic or is evidenced by minimal headache and slight nuchal rigidity. #2 is
not correct. A grade 2 is evidenced by moderate-to-severe headache, nuchal rigidity, and no
neurological deficit other than cranial nerve palsy. #4 is not correct. And in a grade 4, there is
stupor, moderate-to-severe hemiparesis, possible early decerebrate rigidity, and vegetative
disturbances.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. A grade 3 is evidenced by drowsiness, confusion, or mild focal deficit. #1 is not correct. A
grade 1 is asymptomatic or is evidenced by minimal headache and slight nuchal rigidity. #2 is
not correct. A grade 2 is evidenced by moderate-to-severe headache, nuchal rigidity, and no
neurological deficit other than cranial nerve palsy. #4 is not correct. And in a grade 4, there is
stupor, moderate-to-severe hemiparesis, possible early decerebrate rigidity, and vegetative
disturbances.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. A grade 3 is evidenced by drowsiness, confusion, or mild focal deficit. #1 is not correct. A
grade 1 is asymptomatic or is evidenced by minimal headache and slight nuchal rigidity. #2 is
not correct. A grade 2 is evidenced by moderate-to-severe headache, nuchal rigidity, and no
neurological deficit other than cranial nerve palsy. #4 is not correct. And in a grade 4, there is
stupor, moderate-to-severe hemiparesis, possible early decerebrate rigidity, and vegetative
disturbances.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. A grade 3 is evidenced by drowsiness, confusion, or mild focal deficit. #1 is not correct. A
grade 1 is asymptomatic or is evidenced by minimal headache and slight nuchal rigidity. #2 is
not correct. A grade 2 is evidenced by moderate-to-severe headache, nuchal rigidity, and no
neurological deficit other than cranial nerve palsy. #4 is not correct. And in a grade 4, there is
stupor, moderate-to-severe hemiparesis, possible early decerebrate rigidity, and vegetative
disturbances.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-7: Compare and contrast intracerebral hemorrhage and subarachnoid hemorrhage
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 299
24) A patient develops cerebral vasospasm after a ruptured cerebral aneurysm. Collaborative treatment should be
focused on:
1. Reducing blood pressure.
2. Dehydrating the patient.
3. Concentrating red blood cells.
4. Volume expansion.
Answer: 4
Explanation: 1. Vasospasm management is hypertensive, hypervolemic, and hemodilution (HHH) therapy.
Volume expansion raises the blood pressure and decreases blood viscosity. #1 is not correct.
Blood pressure needs to be maintained 10-60 mm Hg above baseline and/or kept between
150-200 mm Hg systolic blood pressure. #2 is not correct. Dehydration is not desirable as it will
increase blood viscosity and increase the risk of clot formation. #3 is not correct. Keeping the
RBCʹs concentrated is also not desirable as this can lead to the formation of blood clots.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. Vasospasm management is hypertensive, hypervolemic, and hemodilution (HHH) therapy.
Volume expansion raises the blood pressure and decreases blood viscosity. #1 is not correct.
Blood pressure needs to be maintained 10-60 mm Hg above baseline and/or kept between
150-200 mm Hg systolic blood pressure. #2 is not correct. Dehydration is not desirable as it will
increase blood viscosity and increase the risk of clot formation. #3 is not correct. Keeping the
RBCʹs concentrated is also not desirable as this can lead to the formation of blood clots.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. Vasospasm management is hypertensive, hypervolemic, and hemodilution (HHH) therapy.
Volume expansion raises the blood pressure and decreases blood viscosity. #1 is not correct.
Blood pressure needs to be maintained 10-60 mm Hg above baseline and/or kept between
150-200 mm Hg systolic blood pressure. #2 is not correct. Dehydration is not desirable as it will
increase blood viscosity and increase the risk of clot formation. #3 is not correct. Keeping the
RBCʹs concentrated is also not desirable as this can lead to the formation of blood clots.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. Vasospasm management is hypertensive, hypervolemic, and hemodilution (HHH) therapy.
Volume expansion raises the blood pressure and decreases blood viscosity. #1 is not correct.
Blood pressure needs to be maintained 10-60 mm Hg above baseline and/or kept between
150-200 mm Hg systolic blood pressure. #2 is not correct. Dehydration is not desirable as it will
increase blood viscosity and increase the risk of clot formation. #3 is not correct. Keeping the
RBCʹs concentrated is also not desirable as this can lead to the formation of blood clots.
Nursing Process: Planning
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-8: Describe the three most common complications following rupture of an ancurysm and
subarachnoid hemorrhage
Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 300
25) While providing fluids to swallow morning medication to a patient recovering from a stroke, the nurse notices
that the patient coughs repeatedly and has difficulty clearing the throat. Which of the following should the
nurse do?
1. Change the patientʹs diet to full liquid.
2. Change the patientʹs diet to soft.
3. Request a physical therapy consult.
4. Request a swallowing evaluation by speech therapy.
Answer: 4
Explanation: 1. When given consecutive sips of water, the patient coughed and needed to clear the throat. This
is an assessment finding that might indicate dysphagia. Dysphagia, or difficulty swallowing, is
very common post stroke and is a major risk factor for developing aspiration pneumonia. The
nurse should keep the patient NPO and ask the MD for a speech therapy order for a
swallowing evaluation. #1 and #2 are not correct. This patient needs to be made NPO
immediately. A nutritional consult needs to be done in order to determine an alternative means
of providing nutrition for this patient, such enteral or parenteral routes. #3 is not correct. A PT
consult would be done but it would be for promoting mobility and preventing muscle atrophy.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. When given consecutive sips of water, the patient coughed and needed to clear the throat. This
is an assessment finding that might indicate dysphagia. Dysphagia, or difficulty swallowing, is
very common post stroke and is a major risk factor for developing aspiration pneumonia. The
nurse should keep the patient NPO and ask the MD for a speech therapy order for a
swallowing evaluation. #1 and #2 are not correct. This patient needs to be made NPO
immediately. A nutritional consult needs to be done in order to determine an alternative means
of providing nutrition for this patient, such enteral or parenteral routes. #3 is not correct. A PT
consult would be done but it would be for promoting mobility and preventing muscle atrophy.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
3. When given consecutive sips of water, the patient coughed and needed to clear the throat. This
is an assessment finding that might indicate dysphagia. Dysphagia, or difficulty swallowing, is
very common post stroke and is a major risk factor for developing aspiration pneumonia. The
nurse should keep the patient NPO and ask the MD for a speech therapy order for a
swallowing evaluation. #1 and #2 are not correct. This patient needs to be made NPO
immediately. A nutritional consult needs to be done in order to determine an alternative means
of providing nutrition for this patient, such enteral or parenteral routes. #3 is not correct. A PT
consult would be done but it would be for promoting mobility and preventing muscle atrophy.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. When given consecutive sips of water, the patient coughed and needed to clear the throat. This
is an assessment finding that might indicate dysphagia. Dysphagia, or difficulty swallowing, is
very common post stroke and is a major risk factor for developing aspiration pneumonia. The
nurse should keep the patient NPO and ask the MD for a speech therapy order for a
swallowing evaluation. #1 and #2 are not correct. This patient needs to be made NPO
immediately. A nutritional consult needs to be done in order to determine an alternative means
of providing nutrition for this patient, such enteral or parenteral routes. #3 is not correct. A PT
consult would be done but it would be for promoting mobility and preventing muscle atrophy.
Nursing Process: Evaluation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 10-9: Discuss screening for dysphagia in the stroke survivor

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