ATI Care of the Patient Experiencing an Intracranial Dysfunction, Chapter 9: Perrin: Understanding the Essentials of Critical Care Nursing: Chamberlain
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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 [Show Less]