Page 472 - Critical Care Nursing Demystified

CORRECT ANSWERS AND RATIONALES 457

Chapter 5

1. B. Thrombolytic therapy breaks down fibrin that is present in blood to cause blood
clotting. With the absence or decrease of fibrin, hemorrhaging and internal bleeding is
a strong possibility.
2. C. In order to cause contraction of the quadriceps muscle, the patient should be sitting
with the legs dangling downward as the test is performed.
3. D. The gastrocnemius muscle should contract, causing plantar flexion of the foot when
this test is performed.
4. C. These nerves are specific to eye movement, pupillary constriction, and accommodation.
5. B. A GCS of 7 or less generally describes a comatose state in the patient with a neu-
rologic deficit. A: Requires a GCS of 15 to be considered normal and in good health.
C: The patient who is oriented to person, place, and time would earn a 5 on the GCS.
D: The patient would earn a 5 on the GCS for the best motor response giving the patient
a total of 10 points for C and D. In actuality, this patient was only assigned 6 points,
describing a patient in a comatose state.
6. D. Responses do occur, but not very well and not very often. A: The patient would be
alert. B: The patient would be lethargic. C: The patient would be considered stuporous.
7. A. B describes a basilar skull fracture. C describes a depressed skull fracture. D describes
a linear skull fracture.
8. C. According to the muscle strength grading scale, a trace of muscle strength exists at Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
the 1/5 level.
9. D. The hypoglossal (12th cranial nerve) is responsible for tongue movement. A:
Abducens (6th cranial nerve) controls the lateral deviation of the eye. B: Facial (7th cra-
nial nerve) controls tears, salivation, facial expressions, and eyes closing. C: Vagus (10th
cranial nerve) controls the voluntary acts of swallowing and phonation and the invol-
untary acts of the heart, lungs, and digestive tract.
10. A. Bleeding that is extending into the subarachnoid space will compromise the patient’s
ability to appropriately respond to verbal commands or questions. Pressure on the
brain from bleeding will create cerebral edema, causing a deterioration in the patient’s
level of consciousness. B, C, and D are responses that can be attributed to neurological
deficits created by other factors such as traumatic brain injury, seizure activity, or side
effects of medications.

Chapter 6

1. C. This describes the primary survey; E – exposure, where the patient is undressed and
examined for additional injuries; A – definitive care—the time when specific injuries
are addressed such as surgery or suturing; B – secondary survey where a more detailed
approach is conducted in a head-to-toe examination of the patient; D – the ABCs of
trauma care are initiated at the trauma scene.