Nur 336 ICR practice questions

A. Time of onset of current stroke

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A. Time of onset of current stroke B. Complete physical and history C. Current medications D. Upcoming surgical procedures

1.4ml/hr

A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-Pa, at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.) ____ mL/hr

B. Client uses appropriate words and phrases. C. Client spontaneously opens the eyes. D. Client is oriented to​ person, place, and time.

A client with a minor head injury has a Glasgow Coma Scale score of 15 out of 15. What does this score indicate to the​ nurse? (Select all that​ apply.) A. Client withdraws to touch. B. Client uses appropriate words and phrases. C. Client spontaneously opens the eyes. D. Client is oriented to​ person, place, and time. E. Client withdraws to pain.

C. Arterial blood gas results

A client with a traumatic brain injury is intubated and placed on mechanical ventilation. Which measurement should the nurse use to evaluate the effectiveness of these respiratory​ interventions? A. Glasgow Coma Scale score B. Cranial nerve function C. Arterial blood gas results D. Motor and sensory function

A. Urine output increases.

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases. B. Pupils are 8 mm and nonreactive. C. Systolic blood pressure remains at 150 mm Hg. D. BUN and creatinine levels return to normal.

a. The client will need near-total care.

A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the clients score to be 36. How should the nurse plan care for this client? a. The client will need near-total care. b. The client will need cuing only. c. The client will need safety precautions. d. The client will be discharged home.

Establish the ability to communicate effectively

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric stroke 3 weeks ago. Which of the following goals should the nurse include int he client's rehab program? a. Establish the ability to communicate effectively b. Compensate for loss of depth perception c. Learn to control impulsive behavior d. Improve left-side motor function

a. Admission can overwhelm the coping mechanisms for older clients c. These clients are more susceptible to systemic and wound infections d. Other medical conditions can complicate treatment for these clients

A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections d. Other medical conditions can complicate treatment for these clients e. Very few traumatic brain injuries occur in this age group.

Hemorrhagic stroke

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure 198/110, pulse 82 bpm, respirations 24/min, and a temperature of 38.2C (100.8F). Which of the following neurologic disorders should the nurse suspect? a. Transient ischemic attack (TIA) b. Hemorrhagic stroke c. Thrombotic stroke d. Embolic stroke

The bone is cracked lengthwise but did not break all the way through

A nurse in an urgent care center is caring for a client who has a greenstick fracture of the forearm. The nurse should explain that which of the following injuries has occurred with a greenstick fracture? a. The bone is cracked lengthwise, but did not break all the way through b. Fragments of bone have splintered into the surrounding tissue c. The bone ends have been forced toward each other d. Sharp edge of the bone has broken through the skin

Slow the rate to 50 mL/hr

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse? a. Slow the rate to 20 mL/hr b. Continue the rate at 125 mL/hr c. Slow the rate to 50 mL/hr d. Increase the rate to 250 mL/hr

Sensitivity to light

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect? a. Loss of consciousness lasting 30 to 60 minutes b. Glasgow coma scale of 11 c. Nuchal rigidity d. Sensitivity to light

ICP 18 mmHg

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse? a. PaCO2 35 mmHg b. ICP 18 mmHg c. Pulse oximetry 96% d. Blood pressure 140/82 mmHg

A. Test the drainage for glucose

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? a. Test the drainage for glucose b. Suction the nostril c. Notify the physician D. Ask the client to blow his nose

Respiratory status

A nurse is caring for a client 4 hours following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority? a. Intracranial pressure b. Serum electrolytes c. Temperature d. Respiratory status

Poor impulse control

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? a. Poor impulse control b. Unable to discriminate words and letters c. Deficits in the right visual field d. Motor retardation

Comminuted

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client's x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures? a. Impacted b. Transverse c. Comminuted d. Oblique

Restlessness

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? a. Tachycardia b. Amnesia c. Hypotension d. Restlessness

Mannitol 25%

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure (ICP). Which of the following medications should the nurse plan to administer? a. Albumin 25% b. Dextran 70 c. Hydroxyethyl glucose d. Mannitol 25%

Bradycardia; nonreactive dilated pupils

A nurse is caring for a client who has an ICP reading of 40 mmHg. Which of the following findings should the nurse identify as a late sign of ICP? Select all that apply. a. Confusion b. Bradycardia c. Hypotension d. Nonreactive dilated pupils e. Slurred speech

A lucid period followed by an immediate loss of consciousness

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect? a. A lucid period followed by an immediate loss of consciousness b. A change in the level of consciousness that develops over 48 hour c. Neurologic deficits that increase up to 2 weeks post-injury d. Cognitive perception that decreases over several months post-injury

Instruct the client to wiggle his toes

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? a. Measure the circumference of the thigh b. Palpate the femoral pulse c. Monitor the client's calf for edema d. Instruct the client to wiggle his toes

Inability to recognize his family members

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? a. Difficulty reading b. Inability to recognize his family members c. Right hemiparesis d. Aphasia

Place the client in high-Fowler's position

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 and suspects the client is experiencing autonomic dysreflexia. Which of the following actions would the nurse take first? a. Administer a nitrate antihypertensive b. Assess the client for bladder distention c. Place the client in high-Fowler's position d. Obtain the client's heart rate

"What do you think your spouse would have wanted?"

A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states that she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate? a. "There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse's organs." b. "What do you think your spouse would have wanted?" c. "Most religions support organ donation, so don't let that stand in your way." d. "Don't you think you will feel a little better about the situation if you donate your spouse's organs?"

Decreased LOC

A nurse is caring for a client who has sustained a traumatic brain injury (TBI). The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? a. Decreased level of consciousness b. Tachypnea c. Bilateral weakness of the extremities d. Hypotension

Perform neurovascular checks of the extremity

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fracture femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? a. Medicate the client for pain b. Instruct the client on use of crutches c. Perform neurovascular checks of the extremity d. Direct the client to perform exercises of the ankles and toes

Cheyne-Stokes respirations

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has the following respiratory alterations? a. Kussmaul respirations b. Apneustic respirations c. Cheyne-Stokes respirations d. Stridor

Suction saliva from the client's mouth

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? a. Perform passive range of motion on each extremity b. Monitor the client's electrolyte levels c. Suction saliva from the client's mouth d. Record the client's intake and output

"You are feeling drawn in two separate directions."

A nurse is caring for a client who was admitted to the facility in critical condition following a stroke. The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make? a. "Perhaps you could call your children to see how they are doing." b. "Don't worry. We'll take good care of your parent while you are gone." c. "You are feeling drawn in two separate directions." d. "There is nothing you can do here. You should go home to your children."

Perform a neurovascular assessment

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? a. Perform a neurovascular assessment b. Explain the discharge instructions to the client and parents c. Provide reassurance to the client and parents d. Apply an ice pack to the casted leg

"So it seems that you feel responsible for what happened to your mother."

A nurse is caring for an older adult client who had a stroke and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make? a. "So it seems that you feel responsible for what happened to your mother." b."Your mother will be fine. You shouldn't worry so much." c. "Why do you blame yourself? You could not have prevented the stroke." d. "You are not responsible for your mother's stroke, but many people in your situation feel this way."

"We have begun plans to send your partner to a rehabilitation facility as soon as he is stable."

A nurse is caring for an older adult client who had stroke and has left-sided weakness. The client's partner tells the nurse she is worried about the next steps of treatment for her partner. Which of the following responses should the nurse make? a. "We have begun plans to send your partner to a rehabilitation facility as soon as he is stable." b. "Your partner is too critical to consider what tomorrow will bring. Let's just concentrate on today." c. "Don't worry. Most clients like your partner start making progress after a few days of rest." d. "You will have to speak to the provider for that information. I can arrange that for you."

Irritability

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? a. Hypotension b. Tachycardia c. Irritability d. Tinnitus

Instruct the client to look up and down without moving his head

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III? a. Instruct the client to look up and down without moving his head b. Observe the client's ability to smile and frown c. Have the client stand with eyes closed and touch his nose d. Ask the client to shrug his shoulders against passive resistance

Reduce stimuli

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan? a. Apply restraints b. Administer opioids c. Darken the room d. Reduce stimuli

Reduce edema of the brain

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? a. Reduce edema of the brain b. Provide fluid hydration c. Increase cell size of the brain d. Expand extracellular fluid volume

a. A 27-year-old heavy cocaine user

A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications

Decreased serum calcium level

A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the laboratory findings should the nurse expect? a. Decreased serum calcium level b. Decreased level of serum lipids c. Decreased erythrocyte sedimentation rate (ESR) d. Increased platelet count

C. Restlessness

A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size

C. Remove extra blankets and give the patient a cool bath

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would? A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning

a. Brainstem

An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. What type of head injury should the nurse suspect? a. Brainstem c. Subdural hemorrhage b. Skull fracture d. Epidural hemorrhage

c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.

An appropriate nursing intervention when caring for an unconscious child should be to: a. Change the childs position infrequently to minimize the chance of increased intracranial pressure (ICP). b. Avoid using narcotics or sedatives to provide comfort and pain relief. c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. d. Give tepid sponge baths to reduce fever because antipyretics are contraindicated.

a. Observe closely for signs of infection e. Maintain an accurate record of intake and output f. Monitor for abdominal distention

An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the childs postoperative care (Select all that apply)? a. Observe closely for signs of infection b. Pump the shunt reservoir to maintain patency. c. Administer sedation to decrease irritability. d. Maintain Trendelenburg position to decrease pressure on the shunt. e. Maintain an accurate record of intake and output f. Monitor for abdominal distention

C. Provide pictures to help the client communicate.

The nurse is caring for a client with expressive aphasia. Which nursing intervention is appropriate for communicating with the client? A. Refer the client to the speech language pathologist. B. Speak loudly to help the client interpret what is being said. C. Provide pictures to help the client communicate. D. Ask the client to read messages on a whiteboard.

B. Client is having epistaxis

The nurse is caring for a patient treated with tPA following a stroke. Which assessment finding is the highest priority for the nurse? A. Clients blood pressure is 144/90 B. Client is having epistaxis C. Client ate only half of the last meal. D. Client continues to be drowsy.

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

D. ​"There is a higher risk for stress​ ulcers; therefore, we use an acid reducer to block gastric​ secretion." .

The nurse is discussing the multiple medications with the family of a client diagnosed with increased intracranial pressure​ (IICP). The family member asks why the client is being given a gastric acid reducer. Which response by the nurse provides the correct ​explanation? A. ​"We use a gastric acid reducer to adhere to ulcer sites and protect them from​ acids, bile​ salts, and​ enzymes." B. ​"Since they are not​ eating, we use a gastric acid reducer to neutralize the acid in their​ stomach." C. ​"A gastric acid reducer helps to protect the inner lining of the stomach from​ ulcer-producing effects." D. ​"There is a higher risk for stress​ ulcers; therefore, we use an acid reducer to block gastric​ secretion." .

B. A positive Brudzinski's sign.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: A. A negative Kernig's sign. B. A positive Brudzinski's sign. C. Absence of nuchal rigidity. D. A Glascow Coma Scale score of 15.

A. Establishing and maintaining an airway

The nurse is monitoring a client with increased intracranial pressure who is experiencing status epilepticus. Which intervention has the highest priority for this​ client? A. Establishing and maintaining an airway B. Administering a solution of​ 50% dextrose C. Administering diazepam intravenously D. Contacting the provider for orders

b. Alteration in pupil size and reactivity. d. Extension or flexion posturing. e. Cheyne-Stokes respirations.

The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased ICP in an infant (Select all that apply)? a. Tachycardia b. Alteration in pupil size and reactivity. c. Increased motor response d. Extension or flexion posturing. e. Cheyne-Stokes respirations.

C. ​"They are most common in very young ​(0 -4 ​years) or old​ (65 years and​ above)."

The nurse is providing a​ community-based teaching course to a group of high school parents concerning brain injury. Which participant statement indicates accurate understanding of the population most at risk for traumatic brain injury​ (TBI)? A. ​"TBIs most commonly occur in men between the ages of 18 and 25 years of​ age." B. ​"TBIs are common across the​ lifespan, affecting men and women fairly​ equally." C. ​"They are most common in the very young ​(0 -4 ​years) or old​ (65 years and​ above)." D. ​"Due to their age and the high number of falls and​ injuries, toddlers and children have higher levels of​ TBIs."

a.alcohol intake c.high fat diet d.obesity e.smoking

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

a. Establish an adequate airway

The priority nursing intervention when a child is unconscious after a fall is to: a. Establish an adequate airway b. Perform neurologic assessment. c. Monitor intercranial pressure. d. Determine whether a neck injury is present.

A. Lumbar puncture

Which of the following is contraindicated in a patient with increased ICP? A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications

C. Restlessness and confusion

Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Large amounts of very dilute urine C. Restlessness and confusion D. Widened pulse pressure

C. BP 200/60, HR 50, RR 8

Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12

A. Rectal

You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature? A. Rectal B. Oral C. Axillary

A. 5 to 15 mmHg

You're maintaining an external ventricular drain. The ICP readings should be? A. 5 to 15 mmHg B. 20 to 35 mmHg C. 60 to 100 mmHg D. 5 to 25 mmHg

B. 60-100 mmHg

You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is: A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg

Maintain immobilization and alignment

A nurse is developing a plan of care

D. Temporal

Problems with memory and learning would relate to which of the following lobes? A. Frontal B. Occipital C. Parietal D. Temporal

Adjust the client's head of bed

A nurse in the ICU is caring for a client who has a severe traumatic brain injury and a cerebral perfusion pressure of 59 mmHg. Which of the following actions should the nurse take? a. Provide warming measures for the client b. Hyperextend the client's neck' c. Flex the client's hip d. Adjust the client's head of bed

"Respite care allows the primary caregiver time away from day-to-day care responsibilities."

A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide? a. Respite care allows the primary caregiver time away from day-to-day care responsibilities." b. "Respite care provides holistic support and care for a client who is terminally ill." c. "Respite care helps relieve pain and promote comfort." d. "Respite care is a continuation of psychological support after a family member dies."

C. ICP 24 mmHg

A patient has a ventriculostomy. Which finding would you immediately report to the doctor? A. Temperature 98.4 'F B. CPP 70 mmHg C. ICP 24 mmHg D. PaCO2 35

C. Dissolved emboli

What is the expected outcome of thrombolytic drug therapy? A. Increased vascular permeability B. Vasoconstriction C. Dissolved emboli D. Prevention of hemorrhage

B. I have decided to stop smoking. C. I will try to walk at least 30 minutes most days of the week. D. I need to cut down a lot on my drinking. E. I am going to decrease salt in my intake.

Which statements about stroke prevention indicate a client understanding of health teaching by the nurse? A. I will take aspirin every day. B. I have decided to stop smoking. C. I will try to walk at least 30 minutes most days of the week. D. I need to cut down a lot on my drinking. E. I am going to decrease salt in my intake.

C. Parietal

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? A. Frontal B. Occipital C. Parietal D. Temporal

D. Flexion of the hips

While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips

B. A patient who is admitted with a traumatic brain injury.

6. Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery.

c. I should expect my child to have some behavioral changes after the accident.

A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching? a. I should expect my child to have a few episodes of vomiting. b. If I notice sleep disturbances, I should contact the physician immediately. c. I should expect my child to have some behavioral changes after the accident. d. If I notice diplopia, I will have my child rest for 1 hour.

B. Intracranial pressure (ICP) is increased.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? A. Vomiting continues. B. Intracranial pressure (ICP) is increased. C. The client needs mechanical ventilation. D. Blood is anticipated in the cerebrospinal fluid (CSF).

60

A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activator (t-PA) alteplase (Activase). The client weighs 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) _____ mg

Call 911

A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take? a. Provide the client with water to test the gag reflex b. Perform carotid massage c. Call 911 d. Drive the client to the nearest medical facility

Race

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in teaching? a. History of smoking b. Obesity c. History of hypertension d. Race

a. Elevated white blood cell (WBC) count. c. Decreased glucose. d. Cloudy in color.

A nurse should expect which cerebrospinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis (Select all that apply)? a. Elevated white blood cell (WBC) count. b. Decreased protein c. Decreased glucose. d. Cloudy in color. e. Increase in red blood cells (RBCs)

A. Coughing B. Sneezing D. Valsalva maneuver E. Vomiting

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees

C. cause vasodilation and increase the ICP

A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP

B. Mannitol will cause water and electrolyte reabsorption in the renal tubules.

A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication? A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.

Plantar flexion of the legs

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? a. Extension of the arms b. Pronation of the hands c. Plantar flexion of the legs d. External rotation of the lower extremities

c. Diplopia and blurred vision d. Irritability e. Distended scalp veins

Clinical manifestations of increased intracranial pressure (ICP) in infants are (Select all that apply): a. Low-pitched cry. b. Sunken fontanel. c. Diplopia and blurred vision d. Irritability e. Distended scalp veins f. Increased blood pressure.

B. Decerebrate posturing

During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing

C. Blood pressure

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature

A. Decorticate posturing D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing

Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing

A. Brain C. CSF D. Blood

Select the main structures below that play a role with altering intracranial pressure: A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater

B. Vasodilation of cerebral vessels D. Leaking proteins into the brain barrier

The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier

D. An oral anticoagulant medication

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. A thrombolytic medication B. A beta-blocker medication C. An anti-hyperuricemic medication D. An oral anticoagulant medication

B. Diancephalon

The nurse assesses a client -admitted​ post-head trauma and notes small reactive​ pupils, an intact oculocephalic​ reflex, decorticate​ posturing, and respirations. The nurse should suspect that damage has progressed to which area of the​ brain? A. Midbrain B. Diencephalon C. Pons D. Medulla

c. Needs frequent re-orientation

The nurse assesses a clients Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care

A. Cushing triad

The nurse is assessing a client with a recent head injury. Upon previous​ assessment, the​ client's vital signs were blood pressure​ 140/90 mmHg, pulse 74​ beats/min, and respirations 22​ breaths/min and irregular. Upon this​ assessment, the nurse notes a blood pressure of​ 152/70 mmHg, pulse of 48​ beats/min, and more irregular respirations. Which condition does the nurse suspect is​ occurring? A. Cushing triad B. Autonomic dysreflexia C. Decreasing intracranial pressure​ (ICP) D. Epidural hematoma

B. Eye opening C. Verbal response E. Motor response

The nurse is caring for a client with an altered level of consciousness. To assess the level of​ consciousness, the nurse administers the Glasgow Coma Scale. Which response does this scale​ measure? (Select all that​ apply.) A. Cerebellar function B. Eye opening C. Verbal response D. Corneal reflex E. Motor response

c. Bulging anterior fontanel. d. Weak cry. e. Poor muscle tone.

The nurse is caring for a neonate with suspected meningitis. Which clinical manifestations should the nurse prepare to assess if meningitis is confirmed (Select all that apply)? a. Headache b. Photophobia c. Bulging anterior fontanel. d. Weak cry. e. Poor muscle tone.

B. Crackles throughout lung fields

What assessment finding requires immediate intervention if found while a patient is receiving Mannitol? A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst

B. Pupil size and pupillary response

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

C. Slower fine finger movements. D. Slower impulse transmission and reaction to stimuli. E. Decreased perception of temperature sensation.

When caring for an older adult experiencing problems with intracranial​ regulation, which change noted by the nurse during care would be attributed to normal​ age-associated changes versus those indicative of issues requiring​ attention? (Select all that​ apply.) A. Some decline in mental status B. Alterations in​ long-term memory C. Slower fine finger movements. D. Slower impulse transmission and reaction to stimuli. E. Decreased perception of temperature sensation.

C. A blood pressure of 220/120 mmHg.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 mg/dl. B. A right-sided carotid bruit. C. A blood pressure of 220/120 mmHg. D. The presence of bronchogenic carcinoma.

D. A 55-year-old African American male.

Which client would the nurse identify as being most at risk for experiencing a CVA? A. A 39-year-old pregnant female. B. A 67-year-old Caucasian male. C. An 84-year-old Japanese female. D. A 55-year-old African American male.

A. Maintain the head of the bed at 30 degrees. B. Assess​ LOC, pupillary​ response, and neurologic status. D. Implement deep vein thrombosis prophylaxis. E. Monitor​ ICP/cerebral perfusion

Which intervention should the nurse initiate secondary to a change in level of consciousness​ (LOC) for a client experiencing increased intracranial pressure​ (IICP)? (Select all that​ apply.) A. Maintain the head of the bed at 30 degrees. B. Assess​ LOC, pupillary​ response, and neurologic status. C. Encourage family to visit and keep client engaged in normal activities as possible D. Implement deep vein thrombosis prophylaxis. E. Monitor​ ICP/cerebral perfusion

A. 0.5% normal saline.

Which intravenous fluid prescription noted by the nurse in orders for a client being treated for increased intracranial pressure​ (IICP) should the nurse contact the healthcare provider about for​ clarification? A. 0.5% normal saline. B. ​0.9% saline C. Lactated Ringer D. ​3% saline