final study questions

A female patient has presented to the emergency department (ED) with complaints of a high fever and severe headache. The patient states that acetaminophen has had no appreciable effect on either symptom. The triage nurse recognizes the need to perform a rapid assessment for possible meningitis and should ask which of the following questions: "Have you had a nosebleed since this problem started?" "Have you noticed any tremors in your hands or arms?" "Have you done any travelling in the last few weeks?" "Are you having stiffness or pain in your neck?"

"Are you having stiffness or pain in your neck?"

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize? "You must lie flat for 24 hours after surgery." "You must avoid coughing, sneezing, and blowing your nose." "You must restrict your fluid intake." "You must report ringing in your ears immediately."

"You must avoid coughing, sneezing, and blowing your nose."

A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide? "You will have a steady and gradual decline in function." "Your type of MS is the least common, making it difficult to manage." "You must avoid stress and extreme fatigue, because these can trigger a relapse." "You should take your medications only during times of relapse."

"You must avoid stress and extreme fatigue, because these can trigger a relapse."

The nurse is caring for a patient that has developed oliguria. Oliguria is defined as urine output less than ___________mL/kg/hr

0.5ml/kg/hr

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? Trendelenburg's 30-degree head elevation Flat Side-lying

30 degree head elevation

The nurse is caring for a client in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is the normal range of intracranial pressure (ICP) for the client? 5 to 15 mm Hg 10 to 20 mm Hg 15 to 25 mm Hg 20 to 30 mm Hg

5-15

Which Glasgow Coma Scale score is indicative of a severe head injury? 7 9 11 13

7

The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate? A subarachnoid hemorrhage An overwhelming infection A normal finding; the fluid will be sent for testing to determine other factors Local trauma from the insertion of the needle

A normal finding; the fluid will be sent for testing to determine other factors

Myasthenia gravis occurs when antibodies attack which receptor sites? Serotonin Dopamine Acetylcholine GABA

Acetylcholine

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? Encouraging oral fluid intake Suctioning the client once each shift Elevating the head of the bed 90 degrees Administering a stool softener as ordered

Administering a stool softener as ordered

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? Decreased heart rate Bradycardia Alteration in level of consciousness (LOC) Slurred speech

Alteration in level of consciousness (LOC)

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? An absence seizure A myoclonic seizure A partial seizure A tonic-clonic seizure

An absence seizure

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? An epidural hematoma An extradural hematoma An intracerebral hematoma A subdural hematoma

An intracerebral hematoma

A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first? Initiate the code team response. Put a padded tongue blade into the client's mouth and restrain his extremities. Record the type of seizure and the time that it occurred. Assist the client to the floor, in a side-lying position, and protect him with linens.

Assist the client to the floor, in a side-lying position, and protect him with linens.

The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping? Help the family understand that the client could have died. Emphasize the importance of accepting the client's new limitations. Have the members of the family plan the client's inpatient care. Assist the family in setting appropriate short-term goals.

Assist the family in setting appropriate short-term goals.

evidence pt is not tolerating ventilation change?

BP of 80/50

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. Bradycardia Hypertension Bradypnea Hypotension Tachycardia

Bradycardia Hypertension Bradypnea

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Confusion and seizures Sunken eyeballs and spasticity Flaccidity and thirst Tetany and increased blood urea nitrogen (BUN) levels

Confusion and seizures

What interventions can the nurse encourage the client with diabetes insipidus to do in order to control thirst and compensate for urine loss? Come to the clinic for IV fluid therapy daily. Limit the fluid intake at night. Consume adequate amounts of fluid. Weigh daily.

Consume adequate amounts of fluid.

A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond? Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. Contusions are deep brain injuries. Contusions are microscopic brain injuries. Contusions occur when the brain is jarred and bounces off the skull on the opposite side from the blow.

Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.

pt with severe with severe sepsis starts bleeding from iv sites, bleeding during mouth care and blood in stool. what is this a sign of?

DIC

A nurse observes an abnormal posture response in an unconscious patient. She documents "extension and outward rotation of the upper extremities and plantar flexion of the feet." She is aware that this posture is a clinical indicator of which of the following? A brain lesion that causes a spontaneous response that changes with electrical activity in the brain Cerebral hemisphere pathology that will cause alterations in flaccidity and contraction of motor responses Decorticate positioning indicating damage to the upper midbrain Decerebrate positioning implying severe dysfunction and brain pathology

Decerebrate positioning implying severe dysfunction and brain pathology

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? Risk for infection Decreased cardiac output Impaired physical mobility Imbalanced nutrition: Less than body requirements

Decreased cardiac output

During hemodialysis, toxins and wastes in the blood are removed by which of the following? Diffusion Osmosis Ultrafiltration Filtration

Diffusion

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? Ecchymosis over the mastoid Bruising under the eyes Drainage of cerebrospinal fluid from the nose Drainage of cerebrospinal fluid from the ears

Ecchymosis over the mastoid

A patient admitted for the treatment of a nondepressed skull fracture has been leaking clear fluid from his nose, and glucose testing confirms that it is cerebrospinal fluid (CSF). This development necessitates what nursing action? Elevating the head of the bed to 30 degrees Performing gentle nasal suctioning at 20 to 30 mm Hg Insertion of a nasogastric (NG) tube to low suction Positioning the patient side-lying

Elevating the head of the bed to 30 degrees

The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available? Equipment to maintain infection control precautions Nasogastric tubing Extra lighting IV tensilon

Equipment to maintain infection control precautions

The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care should address what characteristic manifestation of this disease? Tinnitus Facial paralysis Pain at the base of the tongue Diplopia

Facial paralysis

The victim of a motor vehicle accident has been admitted with massive trauma, including traumatic brain injury. Emergency treatment of increased intracranial pressure (ICP) has failed to resolve the problem, and monitoring reveals the ominous presence of Cushing's triad. What assessment findings would be consistent with this clinical phenomenon? PaO2 70 mm Hg; RR 12 breaths per minute; HR 116 beats per minute Temperature 104°F (40°C); RR 33 breaths per minute; HR 111 beats per minute HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute pH 7.2; PaO2 72 mm Hg; HCO3 20 mEq/L

HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute

A nurse is performing an ECG on a client who is experiencing chest pain which of the following statements should the nurse make

I will need to apply electrodes to your chest and extremities

bp 80/40, hr 126 what are the best following orders?

IV fluids to raise blood pressure

The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside? Nebulizer and thermometer Intubation tray and suction apparatus Blood pressure apparatus Incentive spirometer

Intubation tray and suction apparatus

During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? It suggests onset of metabolic problems. It indicates paralysis on the right side of the body. It indicates paralysis of cranial nerve X (CN X). It indicates an injury at the midbrain level.

It indicates an injury at the midbrain level.

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? It results from inadequate delivery of nutrients and oxygen to the cells. It results from initial damage to the brain from the traumatic event. It refers to the permanent deficits seen after the rehabilitation process. It refers to the difficulties suffered by the client and family related to the changes in the client.

It results from initial damage to the brain from the traumatic event.

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP? Keep the client's neck in a neutral position (no flexing). Avoid sedation. Cluster all procedures together. Keep the head of the client's bed flat.

Keep the client's neck in a neutral position (no flexing)

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? Dextrose 5% in water (D5W) Half-normal saline (0.45% NSS) One-third normal saline (0.33% NSS) Lactated Ringer's

Lactated Ringer's

A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of: Increasing intracranial pressure (ICP) An epidural hematoma Leakage of cerebrospinal fluid (CSF) Meningitis

Leakage of cerebrospinal fluid (CSF)

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? Have the client avoid physical exertion Emphasize complete bed rest Look for signs of increased intracranial pressure Look for a halo sign

Look for signs of increased intracranial pressure

A client is admitted to the neurologic intensive care unit (ICU) with a suspected diffuse axonal injury. Which primary neuroimaging diagnostic tool would be used on this client to evaluate the brain structure? Magnetic resonance imaging (MRI) Positron emission tomography (PET) scan X-ray of the head Ultrasound of the head

MRI

The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? MS is a progressive demyelinating disease of the nervous system. MS usually occurs more frequently in men. MS typically has an acute onset. MS is sometimes caused by a bacterial infection.

MS is a progressive demyelinating disease of the nervous system.

The nurse is educating a client with myasthenia gravis about medications. The nurse is sure to include which of the following? Medications must be taken on time. Medications can be taken whenever convenient. Medications are best taken while the client is in a reclining position. There is no conflict with the disorder and dental work.

Medications must be taken on time.

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? Symptoms will evolve over a period of 1 week. Monitoring is needed as rapid neurologic deterioration may occur. The crash cart with defibrillator is kept nearby. Bleeding continues into the intracerebral area.

Monitoring is needed as rapid neurologic deterioration may occur

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? Insertion of a nasogastric (NG) tube Urine testing for acetone Serum sodium concentration testing Out of bed to the chair three times a day

NG tube insertion

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? Give the patient some mouthwash to gargle with. Request an antihistamine for the postnasal drip. Ask the patient to cough to observe the sputum color and consistency. Notify the physician of a possible cerebrospinal fluid leak.

Notify the physician of a possible cerebrospinal fluid leak

The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? Acetaminophen may be administered for aches. Observe for any signs of behavioral changes. A light meal may be eaten if desired. Follow up with regular physician is encouraged.

Observe for any signs of behavioral changes

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury? Restrain the client as ordered. Administer opioids PRN as prescribed. Arrange for friends and family members to sit with the client. Pad the side rails of the client's bed.

Pad the side rails of the client's bed.

Nursing assessment for the patient receiving peritoneal dialysis would include which of the following to detect the most serious complication of this procedure? Palpate the abdominal wall for rebound tenderness. Inspect the catheter site for leakage of dialysate. Observe for evidence of bleeding. Measure fluid drainage to estimate incomplete recovery of fluid.

Palpate the abdominal wall for rebound tenderness.

Family members of a client with traumatic brain injury are extremely distressed about their loved one. How can the nurse best assist the family to cope during this acute phase? Provide factual information and emotional support. Allow family members distance and space to deal with the changes to the client. Wait for the family members to approach with questions. Reassure them that progress will be made, but it takes time.

Provide factual information and emotional support.

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The health care team is concerned about the complication of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? Assess frequent vital signs. Reposition frequently. Assess for pupillary response frequently. Record intake and output.

Record intake and output

A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has? Benign Primary progressive Relapsing-remitting (RR) Disabling

Relapsing-remitting (RR)

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? Disturbed sensory perception (visual) related to neurologic trauma Feeding self-care deficit related to neurologic trauma Impaired verbal communication related to confusion Risk for injury related to neurologic deficit

Risk for injury related to neurologic deficit

A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease? Blood urea nitrogen (BUN) level of 12 mg/dl Blood glucose level of 90 mg/dl Serum sodium level of 134 mEq/L Serum potassium level of 5.8 mEq/L

Serum potassium level of 5.8 mEq/L

A client is having a tonic-clonic seizure. What should the nurse do first? Elevate the head of the bed. Restrain the client's arms and legs. Place a tongue blade in the client's mouth. Take measures to prevent injury.

Take measures to prevent injury.

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? Take small meals of soft consistency Increase the intake of calcium and proteins. Include additional servings of fruits and raw vegetables Include fish, liver, and chicken in diet

Take small meals of soft consistency

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern? Temperature increase from 98.0°F to 99.6°F Urinary output increase from 40 to 55 mL/hr Heart rate decrease from 100 to 90 bpm Pulse oximetry decrease from 99% to 97% room air

Temperature increase from 98.0°F to 99.6°F

The circulating nurse in an outpatient surgery center is assessing a client who is scheduled to receive moderate sedation which principle should guide the client care of the client receiving this form of anesthesia? The client should be informed the client will remember most of the procedure The client should begin a course of anti-emetics the day before surgery The client must never be left unattended by the nurse The client must be able to maintain their own airway

The client must never be unattended by the nurse

A 13-year-old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. Which assessment finding would rule out discharging the client? The client reports a headache. The client reports pain at the site where the ball hits his head. The client is visibly fatigued. The client's speech is slightly slurred.

The client's speech is slightly slurred.

A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose? The muscles will become fatigued and the patient will not be able to chew food or swallow pills. There should not be a problem, since the medication was only delayed by about 2 hours. The patient will go into cardiac arrest. The patient will require a double dose prior to lunch.

The muscles will become fatigued and the patient will not be able to chew food or swallow pills.

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? Place a cooling blanket beneath the client Provide oxygen or anticonvulsants, whichever is available Turn the client to the side during a seizure and do not restrain movements Suction the client's mouth and pharynx

Turn the client to the side during a seizure and do not restrain movements

a nurse is caring for a pt admitted with acute infection of diabetic foot ulcer. what is needed to confirm sepsis

WBC under 4,000, or above 10,000 or 10% bands HR above 90 temp above 100.4 or lower than 96.8 RR: above 20 PaCO2: less than 32

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a positive edrophonium (Tensilon) test. Kernig's sign. a positive sweat chloride test. Brudzinski's sign.

a positive edrophonium (Tensilon) test.

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? acute chronic subacute intracerebral

acute

The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern? Airway clearance Risk of injury Deficient fluid volume Risk for impaired skin integrity

airway clearance

Which of the following types of skull fractures may be evident by Battle's sign? Basilar Simple Comminuted Depressed

basilar

nurse caring for pt intubate with ARBS what is most important to report to health provider?

bloody drainage from NG tube

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? Extreme thirst Intake and output Nutritional status Body temperature

body temperature

what action should the nurse take to reduce the risk of ventilator associated pneumonia

brush the clients teeth with a suction toothbrush every 12 hours

A nurse is caring for a client who has a central venous catheter and develops shortness of breath which of the following action should the nurse take first clamp the catheter position the client in left lateral Trendelenburg initiate oxygen therapy auscultate breath sounds

clamp the catheter: the greatest risk to this client is injury from further air entering the central venous catheter

While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? concussion laceration contusion skull fracture

concussion

The initial sign of increasing intracranial pressure (ICP) includes decreased level of consciousness. herniation. vomiting. sore throat.

decreased LOC

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfite IV the client respiratory rate is 10 and deep tendon reflexes are absent which of the following action should the nurse take

discontinue the medication fusion

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? Jacksonian Absence Generalized Sensory

generalized

A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? immediately in 2 to 3 days after 1 week upon transfer to a rehabilitation unit

immediately

A nurse is obtaining a electrocardiogram for a client who has atrial fibrillation which of the following action should the nurse take

inspected the electro pads and instruct the client not to talk during the test

Based on the pathophysiologic changes that occur as renal failure progresses, the nurse identifies the following indicators associated with the disease. Select all that apply. Hyperkalemia Metabolic alkalosis Anemia Hyperalbuminemia Hypocalcemia

kyperkalemia anemia hypocalcemia

which are the following are the first organ systems affected by sepsis

lungs and kidneys

The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? Glycerin Isosorbide Mannitol Urea

mannitol

nurse is caring for pt diagnosed with ARDS when high pressure ventilator alarm is going off. Pt is 82, restless and anxious. What intervention is first priority?

manually ventilate patient

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? Change the client's position as indicated. Monitor serum electrolytes. Maintain NPO status. Monitor arterial blood gas (ABG) values.

monitor serum electrolytes

A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess? Sleep pattern Mood and affect Appetite Muscle spasms

muscle spasms

A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis? Anxiety Powerlessness Ineffective denial Risk for disuse syndrome

powerlessness

pt has following s/s :temp high, HR high, RR high, lactate of 4.1, chest x ray shows fluid in right lobe what is this called?

progressive shock

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? Capillary refill of 2 seconds Shivering Cool, dry skin Urine output of 100 mL/hr

shivering

what assessment is best indication of perfusion?

skin color, temperature, LOC, urine output

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? Epidural Subdural Intracerebral Cerebral

subdural

nurse is caring for sepsis following major abdominal surgery. what symptoms indicate sepsis?

thrombocytopenia, high BUN & creatinine, restlessness, lactate 3.8

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? unequal response equal response rapid response constricted response

unequal response

best indicator of adequate fluid treatment?

urine output increases to 50ml

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client reports a headache. reports generalized weakness. sleeps for short periods of time. vomits.

vomits