Chapter 15 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 15 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

A patient, admitted with the diagnosis of stroke, has left hemiparesis involving the face, arm, and leg. The nurse explains that this stroke most likely involves which artery?

1. Right vertebral
2. Left posterior communicating
3. Left middle cerebral
4. Right middle cerebral

Correct Answer: 4

Rationale 1: The right vertebral area is not the most common site of damage causing a stroke.

Rationale 2: The posterior communicating arteries are part of the circle of Willis, but are not the most common areas involved in stroke.

Rationale 3: The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the left side of the brain controls the right side of the body.

Rationale 4: The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the right side of the brain controls the left side of the body.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-1

Question 2

Type: MCSA

A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times. What rationale would the nurse provide for this position?

1. The brain will compress the cerebral veins less in this position.
2. The ventricles of the brain will drain better in this position.
3. This position allows for less pain for the patient.
4. The cerebral spinal veins are valveless and drain by gravity.

Correct Answer: 4

Rationale 1: This statement is not physiologically correct.

Rationale 2: This statement is not physiologically correct.

Rationale 3: There is no reason that pain would be reduced in this position.

Rationale 4: The cerebral spinal veins drain best via gravity, an important characteristic to remember when caring for patients with the risk for increased intracranial pressure as would be present in intracranial surgeries.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-1

Question 3

Type: MCSA

The nurse is providing care for a patient who sustained a severe head injury. The nurse would intervene to prevent which occurrence that increases cerebral blood flow?

1. Oversedation
2. Hypothermia
3. Fever
4. Paralysis

Correct Answer: 3

Rationale 1: Sedation will decrease cerebral blood flow.

Rationale 2: Hypothermia will decrease cerebral blood flow.

Rationale 3: Fever increases the body’s metabolic rate and will increase cerebral blood flow.

Rationale 4: Paralysis, often initiated chemically, will decrease cerebral blood flow.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-1

Question 4

Type: MCSA

The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain. The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable?

1. There will be an increase in the blood flow to the brain.
2. There is a decrease in the blood–brain barrier.
3. There must be a decrease in another of the intracranial compartments.
4. There will be an increase in the production of cerebrospinal fluid.

Correct Answer: 3

Rationale 1: Blood flow to the brain would decrease as more space is taken up by the brain.

Rationale 2: The blood–brain barrier does not increase or decrease in response to changes in the brain.

Rationale 3: The contents of the intracranial vault include the brain, cerebral blood volume, and cerebrospinal fluid. The Monro–Kellie hypothesis states that as the content of one of the intrancranial compartments increases, it is at the expense of the other two. The correct answer is that if there is an increase in the volume of brain tissue, there will need to be a decrease in another of the intracranial compartments.

Rationale 4: An increased amount of cerebrospinal fluid would increase the pressure in the intracranial vault.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-2