Scenarios and items in this section focus on perianesthesia concepts related to intracranial and musculoskeletal considerations of neurologic function and orthopedics. These concepts are considered together because:
• Vascular and nerve functions are intricately interrelated; altered nerve function often alters local blood flow
• Intracranial vascular alterations or tissue edema produces autoregulatory and compensatory shifts and may alter neurologic and musculoskeletal function
• Musculoskeletal procedures (both orthopedic and neurologic) share common patient management concepts, including methods to treat and monitor pain, concerns about blood loss and hemostasis, and circulation-promoting positions
• Postoperative nursing assessments involve monitoring neurovascular status and motor and sensory function after both orthopedic and spine-related surgical procedures
| ESSENTIAL CORE CONCEPTS | AFFILIATED CORE CURRICULUM CHAPTERS |
|---|---|
| Nursing Process | Chapters 3, 33, 40, 49 |
| Assessment | |
| Planning and Implementation | |
| Evaluation | |
| Intracranial Concerns | Chapters 33, 40 |
| Anatomy: Structure and Function | |
| Blood-Brain Barrier | |
| Cerebrospinal Fluid | |
| Cranial Nerves | |
| Lobes and Ventricles | |
| Vessels and Spaces | |
| Physiology | |
| Intracranial Pressure Dynamics | |
| Autoregulation | |
| Herniation | |
| Hyperventilation | |
| Pharmacology | |
| Position, Ventilation, and Rest | |
| Neuronal Excitation | |
| Neuromuscular Junction: Transmitters | |
| Pathology | |
| Interventions and Anesthetic Consequences | |
| Trauma, Tumors, Shunts, and Bleeding | |
| Perianesthesia Specifics | |
| Consciousness | |
| Glasgow Coma Scale | |
| Motor and Sensory Responses | |
| Pupil Reaction | |
| Reflexes and Vital Signs | |
| Musculoskeletal: Spine and Orthopedics | Chapters 33, 40, 49, 53 |
| Anatomy: Structure and Function | Chapters 49, 53 |
| Ascending Tracts | |
| Descending Tracts | |
| Primary Extremity Nerves | |
| Vertebrae, Disks, Bones, and Nerves | |
| White Matter, Gray Matter, and Dura Mater | |
| Physiologic Neurotransmission | |
| Sympathetic: Adrenergic Response to Norepinephrine | |
| Parasympathetic: Cholinergic Response to Acetylcholine | |
| Neurologic and Vascular Concerns | |
| Autonomic Hyperreflexia | |
| Circulation: Capillary Refill, Temperature, and Color | |
| Compartment Syndrome | |
| Disks, Lesions, and Fractures | |
| Edema, Embolism, and Ecchymosis | |
| Innervation: Pain, Sensation, and Motor Control | |
| Perianesthesia Specifics | |
| Neurologic Function and Complications | |
| Neurovascular Monitoring | |
| Pain Management | |
| Position and Comfort | |
| Cardiorespiratory Risk Assessment |
ITEMS 8.1–8.40
8.1. To alter the course of malignant hyperthermia (MH), dantrolene sodium primarily:
a. contracts vascular smooth muscle.
b. reverses cellular acidosis.
c. relaxes skeletal muscle.
d. augments hypothalamic temperature regulation.
8.2. A 48-year-old, nonsmoking, conversant, healthy woman sustained a pelvic fracture in a motor vehicle accident 28 hours ago. She has received morphine by patient-controlled analgesia (PCA), cefazolin, dexamethasone, and midazolam since hospital admission. The pre-anesthesia nurse considers the patient’s potential for fat embolism, closely monitors her pulmonary status, and:
a. encourages active leg movement.
b. reports disorientation agitation.
c. releases traction 10 minutes each hour.
d. limits intravenous (IV) fluid volume.
8.3. The patient most likely to develop autonomic hyperreflexia had a/an:
a. 2-level anterior and posterior cervical fusion today.
b. anterior cord syndrome from incomplete T8 injury 3 days ago.
c. re-exploration after resection of lumbar tumor 2 weeks ago.
d. motor vehicle accident with cord transection at T2 5 months ago.
8.4. Documented post-craniotomy diabetes insipidus is treated with:
a. vasopressin and fluid replacement.
b. long-acting antihyperglycemics and bicarbonate.
c. 10% dextrose infusion and furosemide.
d. fluid restriction and hypertonic saline.
NOTE: Consider the scenario and items 8.5-8.6 together.
After 45 minutes in the PACU following her L4-5 decompression and fusion, a 64-year-old female patient is quickly responsive to touch and name call, oriented to her environment, dozes when undisturbed, and has three documented blood pressures of greater than 195/106 mmHg.
8.5. Of the following factors, the most likely contributor to the patient’s blood pressure measures is:
a. moderate analgesia.
b. postspinal meningeal irritation.
c. evolving epidural hematoma.
d. preoperative hypertension.
8.6. Untreated hypertension increases the patient’s potential to develop any of the following adverse outcomes except:
a. release of blood vessel suture.
b. intrapulmonary rales.
c. myocardial hypoperfusion.
d. post-dural cerebral spinal fluid (CSF) leak.
8.7. Administering epinephrine to a patient who receives electroconvulsive therapy (ECT) 3 times weekly and regularly uses the antidepressant amitriptyline is most likely to result in:
a. unpredictable responses to ECT energy.
b. uncontrolled adrenergic stimulation.
c. profound vagal effect.
d. exaggerated agitation when wakening from ECT.
8.8. The incidence of post–dural puncture headache (PDPH) among ambulatory surgery patients is:
a. low; a small 27-gauge needle limits fluid leakage during local anesthetic injection.
b. high; patients must sit and stand early to prepare for discharge.
d. high; ambulatory surgery unit (ASU) patients should not receive large volumes of pre-hydrating fluid for vascular expansion.
8.9. After spinal anesthesia, a patient must meet the facility’s discharge criteria and also should:
a. repeat each postoperative instruction.
b. urinate spontaneously.
c. indicate pinprick sensation at S-2 dermatome.
d. stand without orthostatic hyper-tension.
8.10. The patient with the least probable risk to develop an injury related to intraoperative positioning has:
a. Crohn’s disease, treated with a 4-hour proctocolectomy and continent ileostomy.
b. arthritis, a 2-year-old left hip arthroplasty, and is a 64-year-old woman.
c. non–insulin-dependent diabetes, is a 48-year-old man, and had a 50-minute surgery to revise an abdominal scar.
d. a gastrostomy tube after gastric bypass surgery and weighs 88 kg at age 24 years.
8.11. Wide blood pressure variability after carotid endarterectomy most likely occurs because of intraoperative:
a. fluid shifts and third spacing.
b. vascular manipulation.
c. intentional hypotensive technique.
d. vagal nerve compression and trauma.
8.12. After craniotomy to remove an acoustic neuroma, the nurse asks the patient to clench his teeth to assess function of the:
a. spinal accessory nerve.
b. temporomaxillary nerve.
c. glossopharyngeal nerve.
d. trigeminal nerve.
8.13. The patient most likely to develop malignant hyperthermia crisis is a:
a. 65-year-old woman with a fractured hip.
b. 32-year-old man with Down syndrome.
c. 15-year-old boy with muscular dystrophy.
d. 6-month-old girl with cleft palate.
8.14. A 72-year-old man is admitted to Phase I PACU after repair of a right inguinal hernia with IV moderate sedation and analgesia with tissue infiltration of local anesthetic. Intraoperatively, the patient received 50 mcg of fentanyl and 2 mg of midazolam, both approximately 60 minutes ago. The patient is now restless and combative. A senior surgical resident orders 3 mg midazolam in the PACU. The PACU nurse’s most appropriate response is to:
a. tactfully consult with a second physician.
b. evaluate causes for behavior and question the dose.
c. ignore the order and restrain the patient.
d. administer midazolam as ordered.
8.15. During patient assessment after spinal anesthesia, the PACU nurse considers the increased potential for both post–dural puncture headache (PDPH) and:
a. hypotension.
b. euphoria and diaphoresis.
c. respiratory stimulation and alkalosis.
d. tachycardia with vasoconstriction.
NOTE: Consider the scenario and items 8.16-8.17 together.
A female patient’s myasthenia gravis is treated by her neurologist with pyridostigmine. The patient is in the PACU after an abdominal exploratory laparotomy and resection of a ruptured appendix.
8.16. While reviewing the surgeon’s routine pre-printed postoperative orders, the PACU nurse questions the order for:
a. hydrocortisone 100 mg.
b. ketorolac 30 mg.
c. gentamycin 80 mg.
d. neostigmine 10 mg.
8.17. If the patient develops myasthenic crisis, the PACU nurse would expect to observe:
a. exophthalmos and hyperventilation.
b. mydriasis and dry mouth.
c. bradycardia and abdominal cramps.
d. ptosis and respiratory failure.
NOTE: Consider the scenario and items 8.18-8.19 together.
A male patient’s intraoperative blood loss was 800 mL during a second right total knee replacement with spinal anesthetic. The patient received 2 units of packed red blood cells (RBCs) and 500 mL hetastarch during this surgery in addition to 2600 mL lactated Ringer’s solution. In PACU, his hemoglobin is 10.3 g/dL, blood pressure rises to 194/96, central venous pressure (CVP) is 15 cm H2O, heart rate is 96 bpm in normal sinus rhythm, he has an audible S3 heart sound, and the patient states he has “a pounding headache.”
8.18. The patient’s signs and symptoms are most probably related to acute:
a. intravascular hemolysis.
b. circulatory overload.
c. anxiety from spinal headache.
d. myocardial ischemia.
8.19. When assessing the patient, the PACU nurse considers that a hemolytic blood reaction usually produces symptoms of:
a. chills and chest or flank pain.
b. hypertension and dyspnea.
c. hypothermia and headache.
d. urticaria and hypotension.
NOTE: Consider items 8.20-8.21 together.
8.20. After exploration and excision of an intramedullary tumor and thoracic laminectomy, fusion, and instrumentation, an essential nursing aspect of the female patient’s postoperative care is:
a. 100% immobility to “seat” instruments.
b. skeletal traction to prevent adhesions.
c. hypotension to minimize bleeding.
d. log rolling to ensure alignment.
NOTE: The scenario continues.
Thirty minutes later, the female patient reports new and sudden tingling in her left toes and severe back pain that does not decrease with pain medications. Neurologic assessment reveals decreased strength with both dorsiflexion and plantar flexion. Pedal and posterior tibial pulses are strong, and capillary refill is normal.
8.21. The female patient’s symptoms probably result from:
a. intraspinal hematoma.
b. dural tear.
c. spinal muscle spasm.
d. nerve entrapment.
NOTE: Consider items 8.22-8.27 together.
8.22. A spinal anesthetic is planned for a male patient’s knee arthrotomy and meniscus repair. The local anesthetic medication with longest duration of sensory anesthesia is:
a. 1% tetracaine in dextrose.
b. 10% procaine with meperidine.
c. 0.75% bupivacaine in saline.
d. 0.5% lidocaine with fentanyl.
8.23. An anesthesia provider may add epinephrine to a spinal anesthetic solution primarily to:
a. increase the anesthetic duration.
b. decrease duration of anesthetic effect.
c. increase vascular absorption of medication.
d. decrease potential for hypotension.
8.24. Achieving the desired level of dermatome blockade from the patient’s spinal anesthetic is most determined by:
a. age and adding epinephrine to the solution.
b. body weight and extremity position.
c. anesthesiologist’s experience and the needle size.
d. body position and density of anesthetic solution.
8.25. The patient is admitted to the PACU awake, alert, and slightly diaphoretic with pale color. Blood pressure is 84/52, heart rhythm sinus at a rate of 56 bpm, respiratory rate 20 breaths per minute, and oxygen saturation 98%. Preoperative blood pressure was 104/60, with pulse 64 bpm. The patient denies pain and complains of nausea. The PACU nurse’s intervention is directed toward minimizing:
a. potential for aspiration.
b. fluid volume deficit.
c. increased intrathoracic pressure.
d. local anesthetic movement in CSF.
8.26. Thirty minutes after PACU admission, the patient can raise his right knee from the bed. The nurse assesses his motor block at approximately derma-tome:
a. S1 to S2.
b. L2 to L3.
c. T12 to L1.
d. T4 to L5.
8.27. With a motor block at this level, the PACU nurse anticipates the patient’s sensory block is:
a. higher than both sympathetic and motor block.
b. the same level as both motor and sympathetic block.
c. higher than motor but below sympathetic block.
d. equal to sympathetic block but below motor block.
8.28. Which of the following is the best indicator of neurologic change?
a. Change in level of consciousness
b. Pupillary changes
c. Motor changes
d. Vital sign changes
8.29. A 56-year-old man is scheduled for craniotomy to clip a leaking cerebral aneurysm. The patient is settled into the preanesthesia area for nursing observation and to await the neurosurgeon’s arrival. The preanesthesia nurse specifically observes this patient for:
a. hyperventilation.
b. headache and neck stiffness.
c. tachycardia.
d. hypotension.
8.30. When applying a 100-mcg transdermal fentanyl patch to a patient with severe left calf injury, the nurse should:
a. pre-medicate the patient with 3 mL IV fentanyl.
b. rinse the skin with water.
c. shave chest hair.
d. scrub with povidone-iodine and apply patch below left knee.
NOTE: Consider the scenario and items 8.31-8.40 together.
Forty minutes after evacuation of a left occipital subdural hematoma, a male patient is drowsy but rouses when his name is called; the patient follows commands to move his extremities, open his eyes, and deep breathe. Pupils are equal and pinpoint. A suction drain into the cranium is compressed and draining small amounts of red fluid.
8.31. The PACU nurse documents that this patient is:
a. disoriented.
b. stuporous.
c. lethargic.
d. awake.
8.32. Adverse influences on the patient’s current level of consciousness could include any of the following factors except:
a. hypoxia.
b. hypocapnia.
c. hypoglycemia.
d. hypothermia.
NOTE: The scenario continues.
Twenty minutes later, the patient requires a louder voice and a stronger tap at his shoulder to arouse. The patient drifts to sleep immediately unless continuously stimulated. Pupils are equal, about 2 mm in size, and briskly reactive, and the patient slowly and weakly moves all extremities on command.
8.33. The PACU nurse’s most appropriate intervention is to:
a. notify the neurosurgeon.
b. reassess the patient in 15 minutes.
c. administer naloxone 0.8 mg per protocol.
d. empty and recompress the patient’s intracranial drain.
NOTE: The scenario continues.
The neurosurgeon requests dexamethasone 12 mg and frequent observation until he arrives in PACU. Within 20 minutes, the patient is considerably more difficult to rouse; eyes occasionally open to heavy touch, and the patient does not vocalize or move his right side when asked. His left arm moves fistlike toward his chest. The nurse applies the Glasgow Coma Scale to objectively grade the patient’s neurologic function.
8.34. According to the Glasgow Coma Scale, this patient’s motor response would best be described as:
a. flaccid.
b. decerebrate.
c. localizing.
d. abnormal flexion.
8.35. The bedside nurse most appropriately elicits a pain response by:
a. twisting the nipple of the patient’s left breast.
b. applying nail bed pressure.
c. applying pressure to the patient’s left eye orbit.
d. pinching the patient’s right trapezius muscle vigorously.
NOTE: The scenario continues.
Further neurologic reassessments indicate that the patient consistently grimaces and flexes both arms and wrists toward his chest and extends his legs, pointing his toes downward and inward.
8.36. The nurse documents the patient’s current response as:
a. decerebrate rigidity.
b. asynchronous reflex.
c. decorticate posturing.
d. withdrawal reaction.
8.37. With these clinical signs, the patient could imminently develop:
a. transtentorial (central) herniation.
b. cranial “blowout” with wound dehiscence.
c. hydrocephalic shunting.
d. compensatory cerebrospinal fluid displacement.
8.38. The PACU nurse anticipates that the patient’s pupils would most likely dilate:
a. equally.
b. contralaterally.
c. ipsilaterally.
d. bilaterally.
NOTE: The scenario continues.
The anesthesiologist intubates the patient, and the neurosurgeon requests a mannitol infusion and a stat computed tomography (CT) scan.
8.39. In this situation, the patient’s neurologic status is best protected when his:
a. respiratory rate and depth are increased.
b. airway is vigorously and regularly suctioned.
c. body position is flat and supine.
d. consciousness is continuously raised with stir-up regimen.
8.40. Dexamethasone was administered to the patient primarily to:
a. support physiologic stress responses.
b. reduce intracranial volume.
c. increase blood flow to cerebral cells.
d. decrease seizure threshold.
ITEMS 8.41–8.72
NOTE: Consider items 8.41-8.42 together.
8.41. A patient received nitrous oxide with a total of 750 mcg of fentanyl in divided doses during a 2½-hour left thumb replantation because of a traumatic power saw injury. The PACU nurse most expects to observe fentanyl-induced:
a. dilated pupils and vomiting.
b. hypoventilation and pupillary con-striction.
c. hypertension and hyperventilation.
d. bradycardia and emergence shivering.
8.42. Nursing care priorities for this patient focus on respiratory monitoring, neurovascular assessment, and providing:
a. ice to the inner midforearm to reduce posttrauma metabolic demand.
b. limited analgesia for quick detection of neurovascular changes.
c. a comfortable arm position that facilitates venous return.
d. fluid restriction to minimize extremity edema.
8.43. Awareness of sensory stimuli and degree of alertness occur through the:
a. limbic-pyramidal system.
b. reticular activating system.
c. corpus callosum system.
d. thalamic projection system.
8.44. Interrelationship between the cerebral hemispheres occurs through commissures of the:
a. corpus callosum.
b. longitudinal fissure.
c. lateral ventricle gyri.
d. central sulcus.
8.45. The most serious potential compromise to a diabetic surgical patient’s recovery immediately after hip arthroplasty is:
a. absent responsiveness from unrecognized hypoglycemia.
b. infection from zealous glucose sampling.
c. hypercalcemia from citrated blood products.
d. altered intestinal flora from dual antibiotic therapy.
8.46. Mannitol’s effectiveness occurs by:
a. hydrostatic pressure to increase renal excretion.
b. diffusion pressure to decrease electrolyte shifts.
c. oncotic pressure to increase solute removal.
d. osmotic pressure to decrease intracellular fluid.
8.47. Three hours ago during her 2-level lumbar diskectomy and fusion, a female patient’s neurosurgeon injected a single epidural dose of preservative-free morphine 5 mg. Now in the PACU, the patient is drowsy, responds quickly to name call, and follows commands. When planning the patient’s care, the PACU nurse reasons that any residual respiratory effects from this morphine sulfate (Duramorph) dose:
a. will not develop after only a single dose.
b. most likely will appear within 8 hours.
c. will require nalbuphine to treat opioid overdose.
d. probably occurred while the patient was intubated in the operating room (OR).
8.48. During the clonic phase of a seizure, the patient may elicit the following signs:
8.49. Development of anisocoria in a 25-year-old man with a repair of a congenital arteriovenous malformation most likely reflects:
a. meningeal irritation.
b. undocumented cocaine use.
c. previous iridectomy.
d. temporal lobe displacement.
8.50. A 46-year-old healthy patient who is a smoker had a fusion of thoracic vertebrae T6 to T7 and T7 to T8 today. The most likely consequences related to his intraoperative position include any of the following except:
a. corneal abrasion.
b. impaired ear circulation.
c. sciatic nerve stretch.
d. skin redness at his ribs and iliac crest.
NOTE: Consider the scenario and items 8.51-8.54 together.
The anesthesiologist inserted an epidural catheter into the female patient’s lumbar spine before her left total hip replacement. The anesthesiologist injected a total of 200 mcg fentanyl into the epidural catheter during surgery. Upon admission to PACU, the patient is awake and alert and denies pain. Blood pressure is 146/88, heart rate 86 bpm, and respiratory rate 16 breaths/min. Fifteen minutes later, the patient complains of moderate hip pain. The pharmacy is still preparing the fentanyl solution ordered by the anesthesiologist for continuous infusion.
8.51. In this situation, the PACU nurse’s most appropriate intervention is to:
a. administer morphine sulfate 15 mg intramuscularly.
b. sedate the patient with midazolam for amnesia to pain.
c. inject fentanyl 150 mcg intravenously.
d. titrate IV morphine 2- to 3-mg doses to comfort.
8.52. The PACU nurse inspects the insertion site of the patient’s epidural catheter and ensures that the epidural tubing is clearly labeled and has no injection ports to mistakenly inject any other medication. Before starting her epidural infusion, the nurse determines the catheter is located in the epidural space by:
a. aspirating less than 0.5 mL clear fluid.
b. ensuring 1 mL serosanguineous fluid flows from port.
c. observing 2 mL clear amber fluid drips from port.
d. injecting a 0.5-mL fentanyl test dose with ease.
8.53. Forty minutes later, the patient states less pain; fentanyl 1 mg, diluted in 100 mL normal saline, infuses epidurally at 8 mL/hr. While monitoring for the specific effects of epidurally injected fentanyl, the PACU nurse least expects to observe:
a. nausea with emesis.
b. respirations 8 breaths/min.
c. blood pressure 76/40.
d. strong left foot dorsiflexion.
8.54. During assessment for PACU discharge, the patient complains of “a lot of pain in my back where that tube is,” indicating the epidural catheter, and mentions right leg weakness and heaviness. Assessment reveals diminished right dorsiflexion and plantar flexion, a change from the strong and equal leg activity noted upon PACU admission. The PACU nurse’s most appropriate response is to:
a. transfer the patient to the orthopedic unit for frequent neurovascular assessment.
b. reassure the patient that symptoms are common and recede without consequence.
c. reposition the patient’s leg and then increase the epidural infusion rate to decrease back spasm.
d. defer transfer from PACU for physician consultation and neurologic examination.
8.55. A healthy 22-year-old college student had surgery to repair his right shoulder rotator cuff. The patient received succinylcholine, fentanyl, and nitrous oxide anesthesia. The patient is sedated and drowsy, breathes shallowly 14 times per minute, and has weak motor reflexes. A likely explanation for this situation is:
a. unusual narcotic and muscle relaxant overdose.
b. abnormal acetylcholine movement from the cell.
c. atypical pseudocholinesterase effect.
d. genetically inhibited glycopyrrolate response.
8.56. After a total hip replacement and general anesthesia, a patient is admitted to the PACU with an A-frame in place and is able to strongly dorsiflex and plantar flex her ankle. A loss of strength in the lower extremities is noted 30 minutes later. This loss of strength is most likely caused by which of the following?
a. The A-frame is causing pressure on the tibial and the peroneal nerves.
b. The A-frame is causing pressure resulting in decreased circulation.
c. Postoperative pain
d. Nerve damage from the surgery
NOTE: Consider the scenario and items 8.57-8.60 together.
The preanesthesia nurse observes a 57-year-old female patient who just received a brachial plexus block before repair of a wrist fracture. Lidocaine with epinephrine was injected by axillary approach. Before injection, the patient received midazolam 1 mg to decrease anxiety. Five minutes later, the patient mentions blurred vision and “not feeling right.” Further assessment indicates tachycardia (heart rate 120 bpm) with palpitations, circumoral numbness, restlessness, dizziness, and tinnitus. Her current blood pressure is 160/72.
8.57. The perianesthesia nurse provides oxygen to the patient, informs the anesthesia provider of these symptoms, and:
a. prepares flumazenil to reverse midazolam.
b. encourages relaxation to decrease hyperventilation.
c. anticipates development of muscle tremors.
d. obtains labetalol to oppose adrenergic stimulation.
NOTE: The scenario continues.
The patient’s symptoms abate. After observation by the preanesthesia nurse and family visitation, surgery proceeded uneventfully 2 hours later. Now, 6 hours after the brachial plexus block, the patient is alert, engaged in lively conversation with her daughter, tolerates food and fluids without nausea, and has urinated. Her vital signs have been stable since surgery. The patient requests to go home and receives approval from the anesthesiologist and surgeon.
8.58. To prepare for discharge, the perianesthesia nurse in Phase II ensures the patient has:
a. return of normal motor and sensory function in her hand.
b. strong train-of-four response to nerve stimulation.
c. adequate palmar circulation, assessed by Allen’s test.
d. analgesic prescription and rapid capillary refill.
8.59. The patient learns to care for her plaster-casted arm by understanding the need for:
a. extremity elevation and resting the still-numbed arm against a table edge.
b. leaving the casted arm open to the air for 24 hours and applying ice.
c. preventing compression of the cast, which should be dry within 30 minutes.
d. controlling skin pruritus by spreading lotion under cast edge with a covered pen.
8.60. The patient is instructed to contact the orthopedic surgeon when any of the following occur except:
a. the right hand appears more purple than the left.
b. body temperature is 38.5° C at home.
c. the analgesic prescription slightly reduces her severe wrist pain for 2 hours.
d. she thinks her cast feels “warm” when discharged from Phase II.
8.62. After the patient’s open reduction of a fracture to the left femoral neck, her spinal anesthetic continues to the T10 dermatome. Postoperative nursing considerations include:
a. promoting hip adduction and limiting flexion to 90 degrees.
b. assuring anatomic alignment and repositioning the patient only on her left side.
c. providing lateral leg supports and applying ice to the left hip.
d. inspecting sheets below hip for drainage and supporting the patient’s legs behind the knees.
NOTE: Consider the scenario and items 8.63-8.66 together.
A female patient had a left lateral frontal lobotomy anterior to the central sulcus for placement of grids to map and control seizure activity. The patient opens her eyes, nods her head, and breathes well.
8.63. One primary assessment after surgery in the left frontal area is to identify this patient’s ability to:
a. state her name.
b. hear music.
c. comprehend instructions.
d. focus on an object.
8.64. The patient’s nurse is assessing function at:
a. Rolando’s area.
b. Broca’s area.
c. Brodmann’s area.
d. Wernicke’s area.
8.65. The patient’s cranial nerve function is considered normal when neurologic assessment reveals ocular responses that are:
a. nystagmic and convergent.
b. consensual and equal.
c. constricted and exophthalmic.
d. conjugate and brisk.
8.66. The patient’s upper arm function is best tested by asking her to:
a. sustain outstretched arms.
b. squeeze the nurse’s hand.
c. adduct her shoulder.
d. hyperextend her hand and wrist.
8.67. Daily production of cerebrospinal fluid in adults is:
a. 100 mL.
b. 500 mL.
c. 1000 mL.
d. 2000 mL.
8.68. A patient with intracranial changes known as Cushing‘s triad has:
a. systolic increase, diastolic decrease, and bradycardia.
b. diastolic decrease, elevated glucose, and oliguria.
c. diastolic increase, decreased aldosterone, and polyuria.
d. systolic decrease, tachycardia, and hyperthermia.
8.69. Contralateral crossing of corticospinal tracts occurs at the:
a. brainstem.
b. dorsal horn.
c. cerebellum.
d. hippocampus.
NOTE: Consider the scenario and items 8.70-8.72 together.
A 12-year-old patient is in Phase I PACU after posterior fusion of L1 to L5 vertebrae and insertion of instrumentation to treat her scoliosis.
8.70. The nurse determines that the most important immediate nursing priority for the patient is:
a. mobilizing fluid volume with low-dose furosemide to relieve accumulated facial edema.
b. assisting the patient to use the bed trapeze for self-reposition and early mobility.
d. positioning her flat and nearly prone to drain secretions and relieve gastric distention.
8.71. Some of the patient’s intraoperative blood loss was returned by an autotransfusion technique. Physiologic advantages of retransfusion include reduced potential for disease and:
a. retained cell “freshness” for reinfusion 2 days later.
b. immediate availability without need to filter small particles.
c. normal potassium levels, preserved platelet number and function.
d. risk of coagulopathy; processing reverses heparin and replaces thrombin.
8.72. To safely administer an autotransfusion of washed and processed blood cells from lost intraoperative blood, nursing responsibilities include the following except to:
a. complete autotransfusion within 4 hours and flush tubing with saline.
b. monitor temperature and infuse peripherally with morphine PCA.
c. report abdominal cramping and circumoral tingling.
d. observe for chills, hematuria, and increased wound drainage.
ITEMS 8.73–8.99
8.73. An interscalene block would not be used in which of the following types of surgery?
a. Total shoulder replacement
b. Reduction of a dislocated shoulder
c. Carpal tunnel release
d. Reduction of arm fracture
8.74. A patient who has received an interscalene block for shoulder surgery complains of numbness in his hand. The radial pulse is present and strong, and hand movement is intact. The perianesthesia nurse’s immediate plan of care includes which of the following?
a. Inform the physician of the abnormal sensation.
b. Medicate for pain.
c. Reposition the arm.
d. Observe the patient and discharge to the receiving unit when stable.
NOTE: Consider the scenario and items 8.75-8.77 together.
After calibration of the subarachnoid monitoring system, the patient’s intracranial pressure measures 18 mmHg.
8.75. Interventions to prevent further increases may include all the following except:
a. semi-Fowler’s position with knees extended.
b. mechanical ventilation at 12 breaths per minute and 600 mL tidal volume.
c. nitroprusside infusion to increase cerebral blood flow.
d. immediate infusion of hyperosmotic solution.
8.76. Nursing responsibility with regard to invasively monitoring the patient’s intracranial pressure includes:
a. administering scheduled steroid doses to suppress infection.
b. flushing the catheter system to ensure system patency.
c. reporting C waves promptly and calculating intracranial compliance.
d. recognizing plateau waves and identifying leaks at skull insertion site.
8.77. The Monro-Kellie hypothesis describes intracranial volume as a relationship among:
a. cerebral perfusion and mean arterial and systolic blood pressures.
b. oxygen and carbon dioxide partial pressures and cardiac index.
c. cerebrospinal fluid density, cerebral blood flow, and cellular oxygenation.
d. brain, cerebral blood, and cerebrospinal fluid volumes.
8.78. A cerebral perfusion pressure calculated at 43 mmHg probably represents:
a. inadequate brain blood flow.
b. compensated autoregulation.
c. normal cerebral circulation.
d. ischemia with active CSF loss.
NOTE: Consider the scenario and items 8.79-8.82 together.
A male patient is scheduled for a craniotomy to remove an infratentorial meningioma.
8.79. Characteristics of a meningioma that most increase the patient’s potential for:
a. intraoperative hemorrhage.
b. malignancy-related death.
c. fluid volume excess.
d. postoperative hypertension.
8.80. Postoperatively the PACU nurse observes yellow-tinged drainage at the patient’s posterior dressing. To confirm or refute a cerebrospinal fluid leak, the nurse most appropriately:
8.81. Immediate postsurgical complications after the patient’s infratentorial surgery are most likely indicated by:
a. receptive aphasia.
b. serosanguineous nasal drainage.
c. altered respiratory pattern.
d. muscle paralysis.
8.82. Nursing intervention to best promote positive respiratory outcomes after the patient’s infratentorial surgery includes:
a. mechanical ventilation with positive end-expiratory pressure (PEEP).
b. log-roll turns with neck support.
c. regular tracheobronchial suction.
d. achieving a functional Phase II block.
8.83. The PACU nurse is most concerned when, after left supratentorial craniotomy, the patient develops:
a. dilation of the right pupil.
b. weakness of the left arm.
c. inability to move the right leg.
d. nystagmus involving the left eye.
8.84. Nursing management of a patient with a ventriculostomy drain includes:
a. securing the system’s “zero” point near the eye or by physician order.
b. ensuring system sterility and a minimum of 30 mL/hr drainage.
c. providing low, negative pressure suction to facilitate system patency.
d. complying with physician-specified volumes of fluid drainage.
NOTE: Consider the scenario and items 8.85-8.88 together.
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