ATI Care of the Patient Experiencing an Intracranial Dysfunction, Chapter 9: Perrin: Understanding the Essentials of Critical Care Nursing: Chamberlain College of Nursing NR 341 (A Graded) Latest Questions and Complete Solutions Perrin: Understanding the Essentials of Critical Care Nursing Chapter 9: Care of the Patient Experiencing an Intracranial Dysfunction MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the questions 1) A patient with a head injury has a p2Oof 88 and a pCO2 of 58. The nurse realizes that which of the following will occur? A) Cerebral blood vessels will dilate B) Cerebral blood vessels will constrict C) Blood will be shunted from the cerebral cortex D) Blood flow to the cerebral cortex will slow Answer: A Explanation: A) Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such a when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation B) Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such a when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation C) Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such a when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation D) Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such a when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Physiological Adaptation 2) A patient who has suffered a traumatic brain injury has a blood pressure increase from 130/60 to 170/65 mm Hg. The nurse should respond to this increase in blood pressure by: A) Alerting the physician and preparing to administer an antihypertensive agent. B) Documenting the blood pressure and completing a neurological assessment. C) Providing the patient with immediate pain and/or antianxiety medication. D) Weighing the patient to determine if the patient is fluid overloaded. Answer: B Explanation: A) Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such a when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential B) Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such a when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential C) Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such a when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential D) Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. Autoregulation also ensures that cerebral blood vessels dilate in response to a perceived increase in requirements for cerebral blood flow such a when there is an increase in cerebral metabolism, a drop in cerebral oxygen levels, or an increase in cerebral carbon dioxide levels. Nursing Process: Assessment Cognitive Level: Analysis Category of Need: Physiological Integrity–Reduction of Risk Potential 3) When providing care to a patient who has increased intracranial pressure, the nurse should be concerned about which of the following patient findings because it is likely to result in an additional increase in intracranial pressure? A) Blood pressure of 150/65 B) Respiratory rate of 24 C) Temperature of 99°F (37.2°C) D) Serum sodium of 110 mEq/L Answer: D Explanation: A) The secondary causes are extracranial or systemic processes that contribute to increases in ICP. If these conditions are allowed to exist, they often contribute to secondary injury, producing ongoing increases in ICP and additional damage to the patient who has sustained a brain injury. However, they are often remediable and how to manage them is discussed in detail throughout this chapter. These secondary causes include airway obstruction, hypoxia or hypercarbia from hypoventilation, hypertension or hypotension, position, hyperthermia, seizures, and metabolic disorders, including hyponatremia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential B) The secondary causes are extracranial or systemic processes that contribute to increases in ICP. If these conditions are allowed to exist, they often contribute to secondary injury, producing ongoing increases in ICP and additional damage to the patient who has sustained a brain injury. However, they are often remediable and how to manage them is discussed in detail throughout this chapter. These secondary causes include airway obstruction, hypoxia or hypercarbia from hypoventilation, hypertension or hypotension, position, hyperthermia, seizures, and metabolic disorders, including hyponatremia. Nursing Process: Evaluation Cognitive Level: Application Category of Need: Physiological Integrity–Reduction of Risk Potential