NCLEX Study questions for Chapter 22

A physician order for additional mannitol (Osmitrol) has been written for a client with increased ICP. Which assessment finding would cause the nurse to question this order? The client is hypovolemic. Urine myoglobin is present. Serum albumin is low. Osmotic gap less than 10

The client is hypovolemic. An osmotic gap of greater than 10 indicates mannitol is still present and that additional doses will not be as effective.

The nurse assesses clear fluid coming from the nose and ears of a client admitted to the Emergency Department after a fall. The fluid is found to be cerebral spinal fluid. Based on this information, the nurse plans care for a client with which type of fracture? Basilar Linear Depressed Open

Basilar Otorrhea and rhinorrhea are common with basilar skull fracture.

A client has been in the ICU for 6 weeks for treatment of a traumatic head injury. Brain death has just been declared. Which assessment findings would the nurse anticipate? Select all that apply. Apnea Constricted pupils Loss of brainstem reflexes Presence of coma Normal temperature

Loss of brainstem reflexes; Presence of coma; Normal temperature; Apnea Loss of brainstem reflexes is a criterion for declaring brain death. Pupils will be fixed and dilated. Presence of coma is a criterion for declaring brain death. The client must not be hypothermic when brain death is declared. Apnea is a criterion for declaring brain death.

A client who sustained a head injury has been diagnosed with SIADH. Which nursing action is necessary? Administer oral salt tablets as ordered. Administer intranasal vasopressin. Maintain fluid restriction. Restrict daily intake of protein.

Maintain fluid restriction. The client with SIADH retains too much water. Treatment includes fluid restriction.

A client sustained a closed head injury in a fall from a tree that happened 2 hours ago. There is MRI evidence of a contusion. The client has just begun to regain consciousness and has a current Glasgow Coma Scale (GCS) score of 11. The nurse should plan care for a client with which level of injury from this contusion? Severe Extreme Mild Moderate

Moderate Longer loss of consciousness and a GCS of 11 point to moderate damage from contusion.

A client presents to the Emergency Department with a head injury received in a fall at home. On admission, the client's Glasgow Coma Scale (GCS) score is 12. Within 20 minutes of arrival, the GCS is 8. What should the nurse do? Prepare the client for intubation. Lower the head of the bed to 30 degrees. Repeat the client's blood pressure reading. Turn up the client's IV.

Prepare the client for intubation The client with a GCS lower than 9 will likely be intubated immediately.

A client is made hypothermic as treatment for a severe traumatic brain injury. The nurse should monitor for which complications of this therapy? Select all that apply. Atrial fibrillation Decreased urine output Increased blood glucose Acidosis Shivering

Shivering; Acidosis; Atrial fibrillation Shivering can increase ICP and should be avoided in this client. Acidosis is a complication of hypothermia treatment. There is no indication to monitor for increased blood glucose as a result of this therapy. Decreased urine output is not a complication of this therapy. Atrial fibrillation is a complication of hypothermia treatment.

A client who sustained a closed head injury has elevation of ICP. Currently the client is putting out nearly a liter of pale urine each hour. The client is diagnosed with diabetes insipidus (DI). The nurse prepares for interventions based on which pathophysiology? The client is retaining sodium. The client has too much circulating vasopressin (DDAVP). The client is producing too much growth hormone (GH). The client is not producing enough antidiuretic hormone (ADH).

The client is not producing enough antidiuretic hormone (ADH). DI is a result of a deficiency in antidiuretic hormone.

A client was admitted to the ICU after sustaining a closed head injury. Several hours later, the nurse assesses that the client is more lethargic and confused, is mumbling her speech, and is very difficult to arouse. The nurse takes action on this assessment for which reason? The client is oversedated. The client's brain injury may be worsening. The client's ICP may be decreasing. The client is overtired from the events of the day.

The client's brain injury may be worsening. The signs are indicative of deterioration in the client's level of consciousness associated with a worsening of a brain injury.

Which nursing action would help to optimize the client's cerebral perfusion pressure (CPP)? Have the client assist with moving up in bed by pushing with his feet. When turning the client, treat the body as one continuous unit. Position the client in high Fowler's position. Treat fever with antipyretics as ordered. Keep the client's head turned to the side.

When turning the client, treat the body as one continuous unit. Treat fever with antipyretics as ordered. The client's hips should not flex more than 90 degrees. In high Fowler's position, this is a greater possibility than with the head of the bed lower. The head should be kept in a neutral position to maintain venous return. The client's head, neck, and hips should be moved at one time in a "log-rolling" method to prevent decrease of venous return. Hyperthermia increases cerebral metabolism, which increases blood flow. This blood flow must be controlled within a narrow window. Too much increase in blood flow will increase ICP and decrease perfusion. This pushing action initiates Valsalva's maneuver, which increases ICP, decreasing CPP.