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Multiple Choice Questions and Interventions/Rationales

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1. If a patient presents with increased intracranial pressure. His ICP is greater than 20. You are getting him set up for Mannitol. What lab value is most important to have as a baseline?
A. Serum Osmolarity
B. Hemoglobin
D. White blood count

2. Arterial Blood Gas report shows an increase of PaCO2. PaCO2 is 48mmHg. What is this doing to the brain?
A. Vasodilation with/ increased cerebral blood flow
B. Vasoconstriction with an increase of venous blood flow
C. Vasoconstriction with an decrease of venous blood flow.
D. Nothing, the value means the brain is being perfused.

3. A surgeon is about to place a catheter in the patient’s brain to relieve pressure through drainage and to get a accurate reading of ICP to make sure he has a good handle on the patient's treatment and progress. Which cranial catheter do you believe would be best fit for this situation?
A. Epidural probe
B. Intraventricular catheter
C.Subdural catheter
D. Bolt

4. With a classic sign of increased urinary output. What increased intracranial pressure complication is the patient heading towards?
A. Brainstem herination
B. Diabetes Insipidus
D. Diabetes Mellitus

5. A patient presents into the emergency room using inappropriate words when asked questions about how he got a bump on his head, opens his eyes and withdraws in response to pain. What is his Glasgow Coma Scale?
A. 9
B. 10
C. 8
D. 7

Nursing Interventions and Rationales-
Perfusion- Ineffective peripheral tissue (pgs 608-614)
1. Measure capillary refill- determine the adequacy of systemic circulation
2. Palate arterial pulses bilaterally to assess for equality (bilateral femoral, popliteal, dorsalis pedis, and posterior tibial)- to evaluate distribution and quality of blood flow, and success or failure of therapy.
3. Monitor client’s nutrition and fluid status- Protein-energy malnutrition and weight loss make ischemic tissues more prone to breakdown. Dehydration reduces blood volume and compromises peripheral circulation.

Cellular Regulation- Impaired Gas Exchange (pgs. 386-390)
1. Encourage frequent position changes, coughing and deep-breathing exercises with incentive spirometer, chest physiotherapy- promotes optimal chest expansion and drainage of secretions.
2. Encourage client and significant other to stop smoking- to reduce health risks and/or prevent further decline in lung function.
3. Maintain adequate intake and output- help with mobilization of secretions but avoid fluid overload.

What medications do you take for an INR of 4?
The medication a person is on with an INR of 4 is Coumadin. Coumadin is an anticoagulant drug. It helps to prevent blood clots from forming. In turn, it thins out the blood so a person is at a greater risk of bleeding. INR should stay in a therapeutic range of 2.0-3.0. An INR of 4 is out of the therapeutic range which increases the risk of bleeding.
3 interventions and rationales for this medication (pgs. 120-124)
1. Assess skin color and moisture, urinary output, level of consciousness or mentation- changes in these signs may be indicative of blood loss affecting systemic circulation or local organ function such as kidneys or brains
2. Dietary measures- to promote blood clotting with foods high in vitamin k
3. Maintain patency of vascular access- fluid administration or blood replacement as necessary/indicated.

Nurse’s Pocket Guide. Diagnoses, Prioritized interventions and rationales.
Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr
Edition 12
F.A Davis Company 2009-2011

2Multiple Choice Questions and Interventions/Rationales Empty Interventions on Sun Nov 13, 2011 2:31 pm


I wanted to say I like your interventions. They are realistic and something a nurse student can perform. Good Job.

3Multiple Choice Questions and Interventions/Rationales Empty Response on Sun Nov 13, 2011 5:14 pm


The interventions that you listed are more realistic than those of other books and websites I've read. I feel that when a new nurse enters the field for the first time they will need to keep things as simple and realistic as possible. INR may seem cut and dry but I just feel more comfortable being at the bedside as a student nurse.

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