NUS 211 Test 3

A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? "Are you allergic to seafood or iodine?" "How much do you weigh?" "When did you last take any medication?" "When did you last have something to eat or drink?"

"Are you allergic to seafood or iodine?"

A patient with a head injury is being assessed for altered LOC and increased intracranial pressure (ICP). The patient's last ICP reading was 16 mm Hg. The nurse understands that treatment for increased ICP will be initiated at a pressure greater than: 18 mm Hg. 21 mm Hg. 20 mm Hg. 19 mm Hg.

21 mm Hg.

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? Local trauma from the insertion of the needle A normal finding; the fluid will be sent for testing to determine other factors An overwhelming infection A subarachnoid hemorrhage

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

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? Slurred speech Decreased heart rate Bradycardia Alteration in level of consciousness (LOC)

Alteration in level of consciousness (LOC)

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient? Access for intravenous (IV) fluids Aspiration of a brain abscess Visualization of a hemorrhage To assess visual acuity

Aspiration of a brain abscess

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture? Basilar Comminuted Simple Linear

Basilar

The nurse is caring for a client with head trauma. Which assessment finding(s) would indicate an increasing intracranial pressure (ICP) in this client? Select all that apply. Elevated systolic blood pressure Stiff neck Brisk pupil response Generalized pain Wide pulse pressure Glasgow Coma Scale of 15

Elevated systolic blood pressure Wide pulse pressure

The client with a brain tumor may be at increased risk for aspiration. What does the nurse determine is the most important nursing intervention? Assistance with self-care Evaluation of gag reflex and ability to swallow Frequent reorientation Monitoring vital signs

Evaluation of gag reflex and ability to swallow

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? Herniation Monro-Kellie hypothesis Autoregulation Cushing response

Herniation

A patient is being cared for after suffering a traumatic brain injury in a motorcycle accident. Since the patient has regained consciousness, the nurse has been prioritizing assessments related to the possibility of increased intracranial pressure (ICP). Assessment for early signs of increased ICP should focus most closely on which of the following parameters? Pain level Vital signs Level of consciousness (LOC) Muscle tone

Level of consciousness (LOC)

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

Mannitol

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? Observe for any signs of behavioral changes. Follow up with regular physician is encouraged. A light meal may be eaten if desired. Acetaminophen may be administered for aches.

Observe for any signs of behavioral changes.

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? Giving him a barbiturate Performing a lumbar puncture Placing him on mechanical ventilation Elevating the head of his bed

Performing a lumbar puncture

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? Risk for falls Decreased intracranial adaptive capacity Risk for aspiration Risk for impaired skin integrity

Risk for aspiration

A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client? Self-care Skin care Safety Activity

Safety

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

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

A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because shivering in hypothermia can increase ICP. hypothermia can cause death. hypothermia is indicative of malaria. hypothermia is indicative of severe meningitis.

shivering in hypothermia can increase ICP.

The nurse is caring for a male client who is scheduled for a neurologic examination that uses a radiopaque dye. Before the test, the nurse assesses the allergy history of the client and find the client is allergic to seafood. What does the nurse relate the allergy to seafood as? An allergy to radiation exposure An allergy to antihistamines An allergy to morphine An allergy to iodine

An allergy to iodine

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 pH 7.2; PaO2 72 mm Hg; HCO3 20 mEq/L 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

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