ATI CUSTOM: AH2- FA25- Exam 2
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Free ATI CUSTOM: AH2- FA25- Exam 2 Questions
1. A nurse is taking care of a client who has sustained a neurologic injury with increased intracranial pressure and decreased cerebral perfusion. Which of the following will keep cerebral perfusion pressure constant?
- A. Regulation of constriction and dilation of blood vessels in the brain
- B. Regulation of how much blood is pumped from the heart
- C. Regulation of catecholamines circulating throughout the body
- D. Regulation of the amount of carbon dioxide exhaled
Explanation
A. Regulation of constriction and dilation of blood vessels in the brain
The brain maintains a constant cerebral perfusion pressure (CPP) through cerebral autoregulation, which involves the constriction and dilation of cerebral blood vessels. This mechanism ensures stable blood flow to the brain despite fluctuations in systemic blood pressure. When perfusion pressure drops, cerebral vessels dilate to increase blood flow; when pressure rises, they constrict to prevent damage. This intrinsic regulation is essential for maintaining adequate oxygen and nutrient delivery to brain tissue.
The brain maintains a constant cerebral perfusion pressure (CPP) through cerebral autoregulation, which involves the constriction and dilation of cerebral blood vessels. This mechanism ensures stable blood flow to the brain despite fluctuations in systemic blood pressure. When perfusion pressure drops, cerebral vessels dilate to increase blood flow; when pressure rises, they constrict to prevent damage. This intrinsic regulation is essential for maintaining adequate oxygen and nutrient delivery to brain tissue.
2. A client in the hospital critical care unit is being evaluated for brain death. What neurological test should the nurse expect to be prescribed for this client?
- A. Computed tomography (CT)
- B. Electroencephalogram (EEG)
- C. Skull X-ray
- D. Pulmonary function tests (PFT)
Explanation
B. Electroencephalogram (EEG)
An electroencephalogram (EEG) is used to evaluate brain electrical activity and confirm the absence of cerebral function, which is essential in determining brain death. A flat or isoelectric EEG indicates no detectable brain activity. This test, along with clinical assessments (absence of brainstem reflexes and apnea test), helps confirm irreversible loss of all brain function.
An electroencephalogram (EEG) is used to evaluate brain electrical activity and confirm the absence of cerebral function, which is essential in determining brain death. A flat or isoelectric EEG indicates no detectable brain activity. This test, along with clinical assessments (absence of brainstem reflexes and apnea test), helps confirm irreversible loss of all brain function.
3. A nurse is teaching a group of nursing students about brain herniation. Which of the following interventions should the nurse include as a possible treatment for brain herniation?
- A. Reduce the temperature in the room
- B. Lower blood pressure
- C. Hyperventilate the client
- D. Decrease sedation
Explanation
C. Hyperventilate the client
Hyperventilation is used temporarily in the management of brain herniation to reduce intracranial pressure (ICP). By lowering the arterial carbon dioxide (PaCO₂) level, cerebral vasoconstriction occurs, which decreases cerebral blood flow and volume, thereby lowering ICP. This is an emergency measure used only short-term while definitive treatment, such as surgical decompression or osmotic therapy (e.g., mannitol), is initiated.
Hyperventilation is used temporarily in the management of brain herniation to reduce intracranial pressure (ICP). By lowering the arterial carbon dioxide (PaCO₂) level, cerebral vasoconstriction occurs, which decreases cerebral blood flow and volume, thereby lowering ICP. This is an emergency measure used only short-term while definitive treatment, such as surgical decompression or osmotic therapy (e.g., mannitol), is initiated.
4. A victim of a motor vehicle crash has an acute cervical spinal cord injury. Which problem should the nurse identify as the priority for this client?
- A. Changes in mobility
- B. Fluid maintenance
- C. Problems breathing and ventilation
- D. Altered blood flow
Explanation
C. Problems breathing and ventilation
An acute cervical spinal cord injury can impair the function of the phrenic nerve (C3–C5), which controls the diaphragm—the primary muscle of respiration. Injury at or above this level can cause respiratory muscle paralysis, leading to ineffective ventilation, hypoxia, or respiratory arrest. Therefore, airway and breathing management are the top priorities. The nurse should monitor oxygen saturation, assess for shallow or labored breathing, and be prepared for intubation or mechanical ventilation.
An acute cervical spinal cord injury can impair the function of the phrenic nerve (C3–C5), which controls the diaphragm—the primary muscle of respiration. Injury at or above this level can cause respiratory muscle paralysis, leading to ineffective ventilation, hypoxia, or respiratory arrest. Therefore, airway and breathing management are the top priorities. The nurse should monitor oxygen saturation, assess for shallow or labored breathing, and be prepared for intubation or mechanical ventilation.
5. The nurse is caring for a client in the neuro-intensive care unit who has neurologic dysfunction.
History and Physical
1345:
A 75-year-old is admitted to the neuro-intensive care unit following a fall in their home. Client reportedly hit their head when they fell. No witnessed loss of consciousness. Client has a history of heart failure.
Vital Signs
1345:
Blood pressure 140/60 mm Hg
Heart rate 55/min
Respiratory rate 10/min
Oxygen saturation 92% on room air
Temperature 36.1° C (97° F)
1530:
Blood pressure 168/54 mm Hg
Heart rate 52/min
Respiratory rate 10/min
Oxygen saturation 92% on room air
Temperature 36.1° C (97° F)
Nurses' Notes
1345:
Client reports head pain as 6 on a scale of 0 to 10. Client is confused, disoriented to place and time. Respirations even and unlabored. Skin warm and dry. Bowel sounds normoactive in all 4 quadrants. Pedal pulses palpable. Grips equal. Lower extremity strength equal.
1530:
Reports a headache as 9 on a scale of 0 to 10. Client is confused. Dyspnea noted with shallow respirations. 15 seconds of intermittent apnea noted.
Select the five findings that indicate Cushing's Triad and require immediate follow-up.
History and Physical
1345:
A 75-year-old is admitted to the neuro-intensive care unit following a fall in their home. Client reportedly hit their head when they fell. No witnessed loss of consciousness. Client has a history of heart failure.
Vital Signs
1345:
Blood pressure 140/60 mm Hg
Heart rate 55/min
Respiratory rate 10/min
Oxygen saturation 92% on room air
Temperature 36.1° C (97° F)
1530:
Blood pressure 168/54 mm Hg
Heart rate 52/min
Respiratory rate 10/min
Oxygen saturation 92% on room air
Temperature 36.1° C (97° F)
Nurses' Notes
1345:
Client reports head pain as 6 on a scale of 0 to 10. Client is confused, disoriented to place and time. Respirations even and unlabored. Skin warm and dry. Bowel sounds normoactive in all 4 quadrants. Pedal pulses palpable. Grips equal. Lower extremity strength equal.
1530:
Reports a headache as 9 on a scale of 0 to 10. Client is confused. Dyspnea noted with shallow respirations. 15 seconds of intermittent apnea noted.
Select the five findings that indicate Cushing's Triad and require immediate follow-up.
- A. Tachypnea
- B. Episodes of apnea
- C. Widening pulse pressure
- D. Increased blood pressure
- E. Shallow breathing
- F. Bradycardia
Explanation
B. Episodes of apnea
Episodes of apnea are an abnormal respiratory pattern caused by pressure on the brainstem, which controls breathing. In clients with increased intracranial pressure (ICP), intermittent apnea signifies that the medulla oblongata is being compressed. This is a critical finding in Cushing’s Triad, as irregular or absent respirations indicate the body is losing its ability to regulate vital functions, requiring immediate intervention to prevent respiratory arrest and herniation.
C. Widening pulse pressure
A widening pulse pressure—rising systolic and falling diastolic pressure—is a hallmark of Cushing’s Triad. This occurs because the body attempts to maintain cerebral perfusion by increasing systolic pressure in response to elevated ICP. The brain’s autoregulatory mechanism causes systemic hypertension as it tries to push blood past the compressed cerebral vessels, signifying worsening intracranial pressure and impending herniation.
D. Increased blood pressure
Elevated systolic blood pressure represents the body’s compensatory mechanism to maintain cerebral perfusion pressure (CPP) despite elevated ICP. The sympathetic nervous system triggers vasoconstriction to sustain brain perfusion. However, as ICP rises further, this increase in blood pressure becomes a dangerous sign of decompensation and brainstem involvement, demanding rapid treatment to lower ICP and stabilize the client.
E. Shallow breathing
Shallow breathing indicates reduced respiratory drive from pressure on the brainstem’s respiratory center. In Cushing’s Triad, the respiratory pattern becomes irregular—shallow breaths alternating with periods of apnea. This abnormal breathing pattern signals that the brain’s vital centers are failing to regulate gas exchange, necessitating immediate airway support and ventilatory management to prevent hypoxia and respiratory failure.
F. Bradycardia
Bradycardia occurs due to stimulation of the vagus nerve from rising intracranial pressure. As the brainstem becomes compressed, parasympathetic output increases, slowing the heart rate. A heart rate of 50–60 beats per minute in the context of elevated ICP is a classic and ominous finding of Cushing’s Triad. This is a late, preterminal sign requiring immediate medical intervention to prevent brain herniation and death.
Episodes of apnea are an abnormal respiratory pattern caused by pressure on the brainstem, which controls breathing. In clients with increased intracranial pressure (ICP), intermittent apnea signifies that the medulla oblongata is being compressed. This is a critical finding in Cushing’s Triad, as irregular or absent respirations indicate the body is losing its ability to regulate vital functions, requiring immediate intervention to prevent respiratory arrest and herniation.
C. Widening pulse pressure
A widening pulse pressure—rising systolic and falling diastolic pressure—is a hallmark of Cushing’s Triad. This occurs because the body attempts to maintain cerebral perfusion by increasing systolic pressure in response to elevated ICP. The brain’s autoregulatory mechanism causes systemic hypertension as it tries to push blood past the compressed cerebral vessels, signifying worsening intracranial pressure and impending herniation.
D. Increased blood pressure
Elevated systolic blood pressure represents the body’s compensatory mechanism to maintain cerebral perfusion pressure (CPP) despite elevated ICP. The sympathetic nervous system triggers vasoconstriction to sustain brain perfusion. However, as ICP rises further, this increase in blood pressure becomes a dangerous sign of decompensation and brainstem involvement, demanding rapid treatment to lower ICP and stabilize the client.
E. Shallow breathing
Shallow breathing indicates reduced respiratory drive from pressure on the brainstem’s respiratory center. In Cushing’s Triad, the respiratory pattern becomes irregular—shallow breaths alternating with periods of apnea. This abnormal breathing pattern signals that the brain’s vital centers are failing to regulate gas exchange, necessitating immediate airway support and ventilatory management to prevent hypoxia and respiratory failure.
F. Bradycardia
Bradycardia occurs due to stimulation of the vagus nerve from rising intracranial pressure. As the brainstem becomes compressed, parasympathetic output increases, slowing the heart rate. A heart rate of 50–60 beats per minute in the context of elevated ICP is a classic and ominous finding of Cushing’s Triad. This is a late, preterminal sign requiring immediate medical intervention to prevent brain herniation and death.
6. A nurse is providing care for a client who is at risk of cerebral aneurysm rupture. Which of the following interventions should the nurse include in the care plan?
- A. Reposition the client every shift.
- B. Keep lights turned to medium level in the evening.
- C. Administer hypotonic intravenous solutions.
- D. Maintain the head of the bed between 30° and 45°.
Explanation
D. Maintain the head of the bed between 30° and 45°.
Keeping the head of the bed elevated between 30° and 45° helps reduce intracranial pressure (ICP) and promote venous drainage from the brain. In a client at risk of cerebral aneurysm rupture, preventing increases in ICP is essential because elevated pressure can trigger aneurysm rupture, resulting in subarachnoid hemorrhage. This position also aids in maintaining adequate cerebral perfusion pressure (CPP) while minimizing the risk of sudden vascular stress.
Keeping the head of the bed elevated between 30° and 45° helps reduce intracranial pressure (ICP) and promote venous drainage from the brain. In a client at risk of cerebral aneurysm rupture, preventing increases in ICP is essential because elevated pressure can trigger aneurysm rupture, resulting in subarachnoid hemorrhage. This position also aids in maintaining adequate cerebral perfusion pressure (CPP) while minimizing the risk of sudden vascular stress.
7. A client is exhibiting signs of spinal shock. Which of the following cues would be consistent with this condition?
- A. Increased muscle tone and spasticity
- B. Increased sensation and proprioception
- C. Hyperreflexia and clonus
- D. Hypotension and bradycardia
Explanation
D. Hypotension and bradycardia
Spinal shock results from the sudden loss of all motor, sensory, and autonomic function below the level of a spinal cord injury. Hypotension and bradycardia occur because of loss of sympathetic tone, leading to vasodilation and unopposed parasympathetic influence. This results in decreased blood pressure, reduced cardiac output, and slowed heart rate. These are hallmark signs of neurogenic shock—a component often seen in acute spinal shock.
Spinal shock results from the sudden loss of all motor, sensory, and autonomic function below the level of a spinal cord injury. Hypotension and bradycardia occur because of loss of sympathetic tone, leading to vasodilation and unopposed parasympathetic influence. This results in decreased blood pressure, reduced cardiac output, and slowed heart rate. These are hallmark signs of neurogenic shock—a component often seen in acute spinal shock.
8. A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply.)
- A. A client who has a temperature of 37.2°C (99°F) and a heart rate of 88/min
- B. A client who has a heart rate of 132/min and a respiratory rate of 30/min
- C. A client who has a decrease in level of consciousness and a heart rate greater than 130/min
- D. A client who has bradypnea and a white blood cell (WBC) count of 10,000 mm³ (5,000–10,000/mm³)
- E. A client who has a temperature of 36°C (96.8°F) and a respiratory rate of 16/min
Explanation
B. A client who has a heart rate of 132/min and a respiratory rate of 30/min
Tachycardia and tachypnea are early clinical indicators of sepsis. The body increases heart and respiratory rates in response to systemic infection and tissue hypoperfusion. A respiratory rate above 20/min and a heart rate above 90/min meet Systemic Inflammatory Response Syndrome (SIRS) criteria, which can progress to sepsis if untreated.
C. A client who has a decrease in level of consciousness and a heart rate greater than 130/min
A declining level of consciousness suggests inadequate cerebral perfusion due to poor oxygen delivery from circulatory dysfunction. Combined with significant tachycardia, this indicates systemic infection with organ dysfunction, a hallmark of severe sepsis or septic shock.
Tachycardia and tachypnea are early clinical indicators of sepsis. The body increases heart and respiratory rates in response to systemic infection and tissue hypoperfusion. A respiratory rate above 20/min and a heart rate above 90/min meet Systemic Inflammatory Response Syndrome (SIRS) criteria, which can progress to sepsis if untreated.
C. A client who has a decrease in level of consciousness and a heart rate greater than 130/min
A declining level of consciousness suggests inadequate cerebral perfusion due to poor oxygen delivery from circulatory dysfunction. Combined with significant tachycardia, this indicates systemic infection with organ dysfunction, a hallmark of severe sepsis or septic shock.
9. A client with a spinal cord injury at the T1 level complains of a severe headache and an “anxious feeling.” Which is the most appropriate initial reaction by the nurse?
- A. Place the client in Trendelenburg position
- B. Administer anxiolytic medication
- C. Assess for a full bladder
- D. Assess pupillary response
Explanation
C. Assess for a full bladder
A severe headache and anxiety in a client with a spinal cord injury at or above T6 are classic signs of autonomic dysreflexia, a life-threatening emergency caused by excessive sympathetic discharge due to a noxious stimulus below the level of injury. The most common cause is a distended bladder. The nurse should immediately check for bladder distension, ensure catheter patency, or perform straight catheterization if needed to relieve the trigger and prevent complications such as stroke or seizures.
A severe headache and anxiety in a client with a spinal cord injury at or above T6 are classic signs of autonomic dysreflexia, a life-threatening emergency caused by excessive sympathetic discharge due to a noxious stimulus below the level of injury. The most common cause is a distended bladder. The nurse should immediately check for bladder distension, ensure catheter patency, or perform straight catheterization if needed to relieve the trigger and prevent complications such as stroke or seizures.
10. When planning immediate care for a client with moderate burns, what interventions should the nurse anticipate providing? (Select all that apply.)
- A. Use of topical antibiotics on the wounds
- B. Application of ice packs to the burned areas
- C. Mechanical ventilation for severe respiratory deterioration
- D. Laboratory studies to determine fluid-volume status
- E. Administration of tetanus immunization
- F. Immediate IV access with Lactated Ringer’s solution
Explanation
A. Use of topical antibiotics on the wounds
Topical antimicrobials such as silver sulfadiazine or bacitracin are applied to reduce the risk of infection. The skin’s protective barrier is lost in burn injuries, so infection prevention is a top priority in initial wound care.
D. Laboratory studies to determine fluid-volume status
Burns cause massive fluid shifts and electrolyte imbalances. Labs such as hematocrit, electrolytes, and BUN/creatinine help guide fluid resuscitation and monitor the client’s response to treatment.
E. Administration of tetanus immunization
Burn wounds create an entry point for Clostridium tetani, so tetanus prophylaxis is part of standard burn management, especially if immunization status is uncertain or outdated.
F. Immediate IV access with Lactated Ringer’s solution
Lactated Ringer’s is the preferred fluid for burn resuscitation because it closely resembles extracellular fluid composition. Early IV access ensures rapid replacement of fluids to maintain perfusion and prevent hypovolemic shock.
Topical antimicrobials such as silver sulfadiazine or bacitracin are applied to reduce the risk of infection. The skin’s protective barrier is lost in burn injuries, so infection prevention is a top priority in initial wound care.
D. Laboratory studies to determine fluid-volume status
Burns cause massive fluid shifts and electrolyte imbalances. Labs such as hematocrit, electrolytes, and BUN/creatinine help guide fluid resuscitation and monitor the client’s response to treatment.
E. Administration of tetanus immunization
Burn wounds create an entry point for Clostridium tetani, so tetanus prophylaxis is part of standard burn management, especially if immunization status is uncertain or outdated.
F. Immediate IV access with Lactated Ringer’s solution
Lactated Ringer’s is the preferred fluid for burn resuscitation because it closely resembles extracellular fluid composition. Early IV access ensures rapid replacement of fluids to maintain perfusion and prevent hypovolemic shock.
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