Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?

Increased ICP

Decreased cerebral blood flow (CBF)

Increased cerebral perfusion pressure (CPP)

Normal intracranial pressure

Answer and Explanation

The Correct Answer is B

A.   Increased ICP would be a concern when the MAP falls below 70 mm Hg because reduced blood pressure can lead to inadequate cerebral blood flow and worsen ICP.
B.   Decreased cerebral blood flow (CBF) is also a concern with low MAP, but the priority is maintaining MAP at a sufficient level to ensure adequate perfusion.
C.   Increased CPP is unlikely with a low MAP, as CPP is a product of MAP and ICP.
D.   Normal ICP would be a good outcome; however, with a low MAP, the nurse should be concerned about insufficient cerebral perfusion and the risk of increased ICP.

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Correct Answer is B

Explanation

A. Using child-like statements may be demeaning and does not support effective communication. It is
important to speak at the client’s level and provide respect.
B. Incorporating nonverbal cues, such as gestures, facial expressions, and pictures, can help facilitate understanding and communication with a person who has aphasia.
C. Using a higher-pitched tone of voice does not aid comprehension and may be perceived as patronizing.
D. Asking multiple-choice questions is helpful, but it is not the most general approach. Using clear, simple language with nonverbal cues is more beneficial.

A. Movement of the eye in the sideward direction occurs, with neck extension B. When flexing the neck, eye movement is in the upward direction C. Movement of the eye is in the opposite direction of the turned head D. When extending the neck, eye movement is in the downward direction

Correct Answer is C

Explanation

A. The oculocephalic reflex test should cause the eyes to move in the opposite direction to the head turn, indicating intact brainstem function.
B. Movement of the eyes in an upward direction upon neck flexion indicates an abnormal response, suggesting a lesion.
C. A lesion could result in abnormal eye movement, as the eyes should move opposite to head movement.
D. Eye movement in the downward direction during neck extension is not a normal response and suggests a brainstem issue.

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Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

After performing an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which patient behavior supports the nurse's assessment findings?

Correct Answer is C

Explanation

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