Ch 16: Neurologic Clinical Assessment and Diagnostic Procedures

17. The patient is ordered a CT scan with contrast. Which question should the nurse ask the conscious patient before the procedure? A. "Are you allergic to penicillin?" B. "Are you allergic to iodine-based dye?" C. "Are you allergic to latex?" D. "Are you allergic to eggs?"

B. "Are you allergic to iodine-based dye?" 𝘕𝘦𝘶𝘳𝘰𝘭𝘰𝘨𝘪𝘤 𝘋𝘪𝘢𝘨𝘯𝘰𝘴𝘵𝘪𝘤 𝘚𝘵𝘶𝘥𝘪𝘦𝘴, 𝘛𝘢𝘣𝘭𝘦 16.4 (295).

2. A patient with a serious head injury has been admitted. The nurse knows that certain neurologic findings can indicate the prognosis for the patient. Which finding indicates the most serious prognosis? A. Abnormal flexion B. Abnormal extension C. Localization D. Withdrawal

B. Abnormal extension ...𝘢𝘣𝘯𝘰𝘳𝘮𝘢𝘭 𝘧𝘭𝘦𝘹𝘪𝘰𝘯 𝘩𝘢𝘴 𝘢 𝘭𝘦𝘴𝘴 𝘴𝘦𝘳𝘪𝘰𝘶𝘴 𝘱𝘳𝘰𝘨𝘯𝘰𝘴𝘪𝘴 𝘵𝘩𝘢𝘯 𝘦𝘹𝘵𝘦𝘯𝘴𝘪𝘰𝘯 𝘰𝘳 𝘥𝘦𝘤𝘦𝘳𝘦𝘣𝘳𝘢𝘵𝘦 𝘱𝘰𝘴𝘵𝘶𝘳𝘪𝘯𝘨 (𝘉𝘰𝘹 16.4)(290).

3. The nurse knows that change in pupil size is a significant neurologic finding particularly in the patient with a head injury. How much of a size difference between the two pupils is still considered normal? A. 1 mm B. 1.5 mm C. 2 mm D. 2.5 mm

A. 1 mm 𝘈 𝘥𝘪𝘴𝘤𝘳𝘦𝘱𝘢𝘯𝘤𝘺 𝘶𝘱 𝘵𝘰 1 𝘮𝘮 𝘣𝘦𝘵𝘸𝘦𝘦𝘯 𝘵𝘩𝘦 𝘵𝘸𝘰 𝘱𝘶𝘱𝘪𝘭𝘴 𝘪𝘴 𝘯𝘰𝘳𝘮𝘢𝘭; 𝘪𝘵 𝘪𝘴 𝘤𝘢𝘭𝘭𝘦𝘥 𝘢𝘯𝘪𝘴𝘰𝘤𝘰𝘳𝘪𝘢 𝘢𝘯𝘥 𝘰𝘤𝘤𝘶𝘳𝘴 𝘪𝘯 16% 𝘵𝘰 17% 𝘰𝘧 𝘩𝘶𝘮𝘢𝘯𝘴 (291).

21. The patient was admitted with a head injury and an intracranial pressure (ICP) monitoring device was placed. The nurse knows to notify the practitioner if what type of wave start to appear on the monitor? A. A waves B. B wave C. C waves D. D waves

A. A waves 𝘈𝘭𝘴𝘰 𝘤𝘢𝘭𝘭𝘦𝘥 𝘱𝘭𝘢𝘵𝘦𝘢𝘶 𝘸𝘢𝘷𝘦𝘴 𝘣𝘦𝘤𝘢𝘶𝘴𝘦 𝘰𝘧 𝘵𝘩𝘦𝘪𝘳 𝘥𝘪𝘴𝘵𝘪𝘯𝘤𝘵𝘪𝘷𝘦 𝘴𝘩𝘢𝘱𝘦, 𝘈-𝘸𝘢𝘷𝘦𝘴 𝘢𝘳𝘦 𝘵𝘩𝘦 𝘮𝘰𝘴𝘵 𝘤𝘭𝘪𝘯𝘪𝘤𝘢𝘭𝘭𝘺 𝘴𝘪𝘨𝘯𝘪𝘧𝘪𝘤𝘢𝘯𝘵 𝘰𝘧 𝘵𝘩𝘦 𝘵𝘩𝘳𝘦𝘦 𝘵𝘺𝘱𝘦𝘴 (302). ...𝘤𝘰𝘯𝘴𝘪𝘥𝘦𝘳𝘦𝘥 𝘴𝘪𝘨𝘯𝘪𝘧𝘪𝘤𝘢𝘯𝘵 𝘣𝘦𝘤𝘢𝘶𝘴𝘦 𝘰𝘧 𝘵𝘩𝘦 𝘳𝘦𝘥𝘶𝘤𝘦𝘥 𝘊𝘗𝘗 𝘢𝘴𝘴𝘰𝘤𝘪𝘢𝘵𝘦𝘥 𝘸𝘪𝘵𝘩 𝘐𝘊𝘗, 𝘪𝘯 𝘵𝘩𝘦 𝘳𝘢𝘯𝘨𝘦 𝘰𝘧 50 𝘵𝘰 100 𝘮𝘮 𝘏𝘨

11. The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. What must the nurse verify before performing the test? A. Absence of cervical injury B. Depth and rate of respiration C. Patient's ability to swallow D. Patient's ability to follow a verbal command

A. Absence of cervical injury 𝘐𝘧 𝘵𝘩𝘦 𝘱𝘢𝘵𝘪𝘦𝘯𝘵 𝘪𝘴 𝘶𝘯𝘤𝘰𝘯𝘴𝘤𝘪𝘰𝘶𝘴 𝘢𝘴 𝘢 𝘳𝘦𝘴𝘶𝘭𝘵 𝘰𝘧 𝘵𝘳𝘢𝘶𝘮𝘢, 𝘵𝘩𝘦 𝘯𝘶𝘳𝘴𝘦 𝘮𝘶𝘴𝘵 𝘢𝘴𝘤𝘦𝘳𝘵𝘢𝘪𝘯 𝘵𝘩𝘦 𝘢𝘣𝘴𝘦𝘯𝘤𝘦 𝘰𝘧 𝘤𝘦𝘳𝘷𝘪𝘤𝘢𝘭 𝘪𝘯𝘫𝘶𝘳𝘺 𝘣𝘦𝘧𝘰𝘳𝘦 𝘱𝘦𝘳𝘧𝘰𝘳𝘮𝘪𝘯𝘨 𝘵𝘩𝘪𝘴 𝘦𝘹𝘢𝘮𝘪𝘯𝘢𝘵𝘪𝘰𝘯 (291). 𝘖𝘤𝘶𝘭𝘰𝘤𝘦𝘱𝘩𝘢𝘭𝘪𝘤: 𝘋𝘰𝘭𝘭'𝘴 𝘦𝘺𝘦 𝘳𝘦𝘧𝘭𝘦𝘹, 𝘢𝘣𝘯𝘰𝘳𝘮𝘢𝘭 𝘰𝘳 𝘢𝘣𝘴𝘦𝘯𝘵 = 𝘣𝘳𝘢𝘪𝘯𝘴𝘵𝘦𝘮 𝘪𝘯𝘫𝘶𝘳𝘺

16. The nurse is caring for a severely head injured comatose patient who is dying. The practitioner asks to be notified when the patient starts to exhibit signs of Cushing reflex. The nurse would call the practitioner when the patient starts to show which signs? A. Bradycardia, systolic hypertension, and widening pulse pressure B. Tachycardia, systolic hypotension, and tachypnea C. Headache, nuchal rigidity, and hyperthermia D. Bradycardia, aphasia, and visual field disturbances

A. Bradycardia, systolic hypertension, and widening pulse pressure 𝘊𝘶𝘴𝘩𝘪𝘯𝘨 𝘵𝘳𝘪𝘢𝘥 𝘪𝘴 𝘢 𝘴𝘦𝘵 𝘰𝘧 𝘵𝘩𝘳𝘦𝘦 𝘤𝘭𝘪𝘯𝘪𝘤𝘢𝘭 𝘮𝘢𝘯𝘪𝘧𝘦𝘴𝘵𝘢𝘵𝘪𝘰𝘯𝘴 1. 𝘴𝘺𝘴𝘵𝘰𝘭𝘪𝘤 𝘩𝘺𝘱𝘦𝘳𝘵𝘦𝘯𝘴𝘪𝘰𝘯 𝘸𝘪𝘵𝘩 𝘢 𝘸𝘪𝘥𝘦𝘯𝘪𝘯𝘨 𝘱𝘶𝘭𝘴𝘦 𝘱𝘳𝘦𝘴𝘴𝘶𝘳𝘦, 2. 𝘣𝘳𝘢𝘥𝘺𝘤𝘢𝘳𝘥𝘪𝘢, 𝘢𝘯𝘥 3. 𝘣𝘳𝘢𝘥𝘺𝘱𝘯𝘦𝘢 ...𝘢 𝘭𝘢𝘵𝘦 𝘧𝘪𝘯𝘥𝘪𝘯𝘨 𝘵𝘩𝘢𝘵 𝘮𝘢𝘺 𝘣𝘦 𝘢𝘣𝘴𝘦𝘯𝘵 𝘪𝘯 𝘱𝘢𝘵𝘪𝘦𝘯𝘵𝘴 𝘸𝘪𝘵𝘩 𝘴𝘦𝘷𝘦𝘳𝘦 𝘯𝘦𝘶𝘳𝘰𝘭𝘰𝘨𝘪𝘤 𝘥𝘦𝘵𝘦𝘳𝘪𝘰𝘳𝘢𝘵𝘪𝘰𝘯 (294).

18. The nurse is caring for a patient who has just had a cerebral angiogram. Which intervention should be part of the nursing management plan? A. Ensuring that the patient is adequately hydrated B. Maintaining the patient on an NPO status C. Administering antibiotics to the patient D. Keeping the patient flat in bed for 24 hours

A. Ensuring that the patient is adequately hydrated 𝘈𝘧𝘵𝘦𝘳 𝘵𝘩𝘦 𝘵𝘦𝘴𝘵: 𝘌𝘯𝘴𝘶𝘳𝘦 𝘩𝘺𝘥𝘳𝘢𝘵𝘪𝘰𝘯 𝘱𝘰𝘴𝘵𝘱𝘳𝘰𝘤𝘦𝘥𝘶𝘳𝘦 (𝘤𝘰𝘯𝘵𝘳𝘢𝘴𝘵 𝘮𝘦𝘥𝘪𝘶𝘮 𝘶𝘴𝘦𝘥), 𝘛𝘢𝘣𝘭𝘦 16.4 (295).

23. What sites can be used for monitoring ICP? (Select all that apply.) A. Intraventricular space B. Epidural space C. Jugular veins D. Subdural space E. Parenchyma

A. Intraventricular space B. Epidural space D. Subdural space E. Parenchyma 𝘐𝘯𝘵𝘳𝘢𝘤𝘳𝘢𝘯𝘪𝘢𝘭 𝘗𝘳𝘦𝘴𝘴𝘶𝘳𝘦 𝘔𝘰𝘯𝘪𝘵𝘰𝘳𝘪𝘯𝘨 𝘚𝘪𝘵𝘦𝘴- 𝘍𝘪𝘨𝘶𝘳𝘦 16.7 (301).

19. The nursing management plan for a patient undergoing an oil-based contrast myelogram should include intervention? A. Maintain the patient flat in bed for 4 to 8 hours. B. Observe the puncture sight every 15 minutes for 2 hours for signs of bleeding. C. Keep the patient's head elevated 30 to 45 degrees for 8 hours. D. Administer a sedative to keep the patient from moving around.

A. Maintain the patient flat in bed for 4 to 8 hours. 𝘔𝘺𝘦𝘭𝘰𝘨𝘳𝘢𝘱𝘩𝘺- 𝘐𝘧 𝘥𝘰𝘯𝘦 𝘸𝘪𝘵𝘩 𝘰𝘪𝘭-𝘣𝘢𝘴𝘦𝘥 𝘪𝘰𝘱𝘩𝘦𝘯𝘥𝘺𝘭𝘢𝘵𝘦 (𝘗𝘢𝘯𝘵𝘰𝘱𝘢𝘲𝘶𝘦), 𝘱𝘢𝘵𝘪𝘦𝘯𝘵 𝘮𝘶𝘴𝘵 𝘭𝘪𝘦 𝘧𝘭𝘢𝘵 𝘧𝘰𝘳 4-8 𝘩𝘰𝘶𝘳𝘴 𝘢𝘧𝘵𝘦𝘳 𝘴𝘵𝘶𝘥𝘺, 𝘛𝘢𝘣𝘭𝘦 16.4 (295).

22. A critical care patient is diagnosed with massive head trauma. The patient is receiving brain tissue oxygen pressure (PbtO2) monitoring. The nurse recognized that the goal of this treatment is to maintain PbtO2: A. greater than 20 mm Hg. B. less than 15 mm Hg. C. between 15 and 20 mm Hg. D. between 10 and 20 mm Hg.

A. greater than 20 mm Hg. 𝘕𝘰𝘳𝘮𝘢𝘭 𝘗𝘣𝘵𝘖2 𝘪𝘴 23 𝘵𝘰 35 𝘮𝘮 𝘏𝘨.7 𝘈 𝘗𝘣𝘵𝘖2 𝘵𝘩𝘳𝘦𝘴𝘩𝘰𝘭𝘥 𝘰𝘧 𝘭𝘦𝘴𝘴 𝘵𝘩𝘢𝘯 20 𝘮𝘮 𝘏𝘨 𝘳𝘦𝘱𝘳𝘦𝘴𝘦𝘯𝘵𝘴 𝘤𝘰𝘮𝘱𝘳𝘰𝘮𝘪𝘴𝘦𝘥 𝘣𝘳𝘢𝘪𝘯 𝘰𝘹𝘺𝘨𝘦𝘯 (303).

24. A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner performed a lumbar puncture. Which result is an abnormal finding? (Select all that apply.) A. Fluid is clear and colorless B. Glucose of 20 mg/dL C. Protein of 20 mg/dL D. Bloody fluid in first sample only E. Pressure of 250 mm H2O

B. Glucose of 20 mg/dL E. Pressure of 250 mm H2O 𝘎𝘭𝘶𝘤𝘰𝘴𝘦= 50-75 𝘮𝘨/𝘥𝘓 𝘰𝘳 60%-70% 𝘰𝘧 𝘣𝘭𝘰𝘰𝘥 𝘨𝘭𝘶𝘤𝘰𝘴𝘦 𝘗𝘳𝘦𝘴𝘴𝘶𝘳𝘦= 60-200 𝘮𝘮𝘏2𝘖 -𝘛𝘢𝘣𝘭𝘦 16.3 (295).

6. The nurse is admitting a neurologically impaired patient. The patient's family is present. How comprehensive should the initial history be? A. It should be limited to the chief complaint and personal habits. B. It should be all-inclusive, including events preceding hospitalization. C. It should be confined to current medications and family history. D. It should be restricted to only information that the patient can provide.

B. It should be all-inclusive, including events preceding hospitalization. ...𝘯𝘦𝘦𝘥 𝘵𝘰 𝘰𝘣𝘵𝘢𝘪𝘯 𝘢 𝘤𝘰𝘮𝘱𝘳𝘦𝘩𝘦𝘯𝘴𝘪𝘷𝘦 𝘩𝘪𝘴𝘵𝘰𝘳𝘺 𝘰𝘧 𝘦𝘷𝘦𝘯𝘵𝘴 𝘱𝘳𝘦𝘤𝘦𝘥𝘪𝘯𝘨 𝘩𝘰𝘴𝘱𝘪𝘵𝘢𝘭𝘪𝘻𝘢𝘵𝘪𝘰𝘯 (288).

10. The nurse is precepting a nursing student. The student asks about testing of extraocular eye movements. What should the nurse tell the student? A. It tests the pupillary response to light. B. It tests function of the three cranial nerves. C. It tests the ability of the eyes to accommodate to a closer moving object. D. It tests the oculocephalic reflex.

B. It tests function of the three cranial nerves. 𝘐𝘯 𝘢 𝘤𝘰𝘯𝘴𝘤𝘪𝘰𝘶𝘴 𝘱𝘵, 𝘵𝘩𝘦 𝘧𝘶𝘯𝘤𝘵𝘪𝘰𝘯 𝘰𝘧 𝘵𝘩𝘦 3 𝘤𝘳𝘢𝘯𝘪𝘢𝘭 𝘯𝘦𝘳𝘷𝘦𝘴 𝘰𝘧 𝘵𝘩𝘦 𝘦𝘺𝘦 ... 𝘤𝘢𝘯 𝘣𝘦 𝘢𝘴𝘴𝘦𝘴𝘴𝘦𝘥 𝘣𝘺 𝘢𝘴𝘬𝘪𝘯𝘨 𝘵𝘩𝘦 𝘱𝘢𝘵𝘪𝘦𝘯𝘵 𝘵𝘰 𝘧𝘰𝘭𝘭𝘰𝘸 𝘢 𝘧𝘪𝘯𝘨𝘦𝘳 𝘵𝘩𝘳𝘰𝘶𝘨𝘩 𝘵𝘩𝘦 𝘧𝘶𝘭𝘭 𝘳𝘢𝘯𝘨𝘦 𝘰𝘧 𝘦𝘺𝘦 𝘮𝘰𝘵𝘪𝘰𝘯. 𝘐𝘧 𝘵𝘩𝘦 𝘦𝘺𝘦𝘴 𝘮𝘰𝘷𝘦 𝘵𝘰𝘨𝘦𝘵𝘩𝘦𝘳 𝘪𝘯𝘵𝘰 𝘢𝘭𝘭 𝘴𝘪𝘹 𝘧𝘪𝘦𝘭𝘥𝘴, 𝘦𝘹𝘵𝘳𝘢𝘰𝘤𝘶𝘭𝘢𝘳 𝘮𝘰𝘷𝘦𝘮𝘦𝘯𝘵𝘴 𝘢𝘳𝘦 𝘪𝘯𝘵𝘢𝘤𝘵 (291).

12. The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. Which findings indicate that the patient has an intact oculocephalic reflex? A. Patient's eyes move in the same direction as the patient's head when turned. B. Patient's eyes move in the opposite direction as the patient's head when turned. C. Patient's eyes move in opposite directions from each other when the patient's head is turned. D. Patient's eyes move up and down and then back and forth when the patient's head is turned.

B. Patient's eyes move in the opposite direction as the patient's head when turned. 𝘍𝘪𝘨𝘶𝘳𝘦 16.4 (292).

15. The nurse is caring for a severely head injured comatose patient who is dying. The nurse knows the patient has entered the late stages of intracranial hypertension when the nurse observes which signs? A. Pupils are equal and reactive B. Widening pulse pressure C. Eupnea D. Decreased intracranial pressure

B. Widening pulse pressure 𝘈𝘵𝘵𝘦𝘯𝘵𝘪𝘰𝘯 𝘮𝘶𝘴𝘵 𝘢𝘭𝘴𝘰 𝘣𝘦 𝘱𝘢𝘪𝘥 𝘵𝘰 𝘵𝘩𝘦 𝘱𝘶𝘭𝘴𝘦 𝘱𝘳𝘦𝘴𝘴𝘶𝘳𝘦, 𝘣𝘦𝘤𝘢𝘶𝘴𝘦 𝘸𝘪𝘥𝘦𝘯𝘪𝘯𝘨 𝘰𝘧 𝘵𝘩𝘪𝘴 𝘷𝘢𝘭𝘶𝘦 𝘮𝘢𝘺 𝘰𝘤𝘤𝘶𝘳 𝘪𝘯 𝘵𝘩𝘦 𝘭𝘢𝘵𝘦 𝘴𝘵𝘢𝘨𝘦𝘴 𝘰𝘧 𝘪𝘯𝘵𝘳𝘢𝘤𝘳𝘢𝘯𝘪𝘢𝘭 𝘩𝘺𝘱𝘦𝘳𝘵𝘦𝘯𝘴𝘪𝘰𝘯 (294).

20. The nurse is caring for a patient with an intracranial pressure monitoring device that provides access to CSF for sampling. Which type of device does the patient have? A. Subarachnoid bolt B. Epidural catheter C. Intraventricular catheter D. Fiberoptic catheter

C. Intraventricular catheter 𝘛𝘩𝘦 𝘷𝘦𝘯𝘵𝘳𝘪𝘤𝘶𝘭𝘢𝘳 𝘤𝘢𝘵𝘩𝘦𝘵𝘦𝘳 𝘸𝘪𝘵𝘩 𝘦𝘹𝘵𝘦𝘳𝘯𝘢𝘭 𝘴𝘵𝘳𝘢𝘪𝘯 𝘨𝘢𝘶𝘨𝘦 𝘵𝘳𝘢𝘯𝘴𝘥𝘶𝘤𝘦𝘳 𝘢𝘭𝘭𝘰𝘸𝘴 𝘧𝘰𝘳 𝘢𝘤𝘤𝘶𝘳𝘢𝘵𝘦 𝘢𝘯𝘥 𝘳𝘦𝘭𝘪𝘢𝘣𝘭𝘦 𝘐𝘊𝘗 𝘸𝘢𝘷𝘦𝘧𝘰𝘳𝘮 𝘢𝘯𝘥 𝘮𝘦𝘢𝘴𝘶𝘳𝘦𝘮𝘦𝘯𝘵 𝘢𝘴 𝘸𝘦𝘭𝘭 𝘢𝘴 𝘊𝘚𝘍 𝘥𝘳𝘢𝘪𝘯𝘢𝘨𝘦 (301).

4. A patient is admitted immediately after a craniotomy. The patient has no history of eye surgery. When assessing the size and shape of the patient's pupils, the nurse observes the patient's left pupil is oval. What does this finding indicate? A. Cortical dysfunction B. Intracranial hypertension C. Oculomotor nerve damage D. Opioid overdose

C. Oculomotor nerve damage ...𝘢𝘯 𝘪𝘳𝘳𝘦𝘨𝘶𝘭𝘢𝘳𝘭𝘺 𝘴𝘩𝘢𝘱𝘦𝘥 𝘰𝘳 𝘰𝘷𝘢𝘭 𝘱𝘶𝘱𝘪𝘭 𝘮𝘢𝘺 𝘣𝘦 𝘰𝘣𝘴𝘦𝘳𝘷𝘦𝘥 𝘪𝘯 𝘱𝘢𝘵𝘪𝘦𝘯𝘵𝘴 𝘸𝘩𝘰 𝘩𝘢𝘷𝘦 𝘶𝘯𝘥𝘦𝘳𝘨𝘰𝘯𝘦 𝘦𝘺𝘦 𝘴𝘶𝘳𝘨𝘦𝘳𝘺. 𝘐𝘯𝘪𝘵𝘪𝘢𝘭 𝘴𝘵𝘢𝘨𝘦𝘴 𝘰𝘧 𝘊𝘕 𝘐𝘐𝘐 𝘤𝘰𝘮𝘱𝘳𝘦𝘴𝘴𝘪𝘰𝘯 𝘧𝘳𝘰𝘮 𝘦𝘭𝘦𝘷𝘢𝘵𝘦𝘥 𝘐𝘊𝘗 𝘤𝘢𝘯 𝘤𝘢𝘶𝘴𝘦 𝘵𝘩𝘦 𝘱𝘶𝘱𝘪𝘭 𝘵𝘰 𝘩𝘢𝘷𝘦 𝘢𝘯 𝘰𝘷𝘢𝘭 𝘴𝘩𝘢𝘱𝘦 (291).

1. The nurse is caring for a patient with a closed head injury with a Glasgow Coma Scale (GCS) score of 6. What does this score indicate about the patient's neurologic status? A. Patient is in vegetative state. B. Patient is a paraplegic. C. Patient is in a coma. D. Patient is able to obey commands.

C. Patient is in a coma. 𝘈 𝘴𝘤𝘰𝘳𝘦 𝘰𝘧 7 𝘰𝘳 𝘭𝘦𝘴𝘴 𝘰𝘯 𝘵𝘩𝘦 𝘎𝘊𝘚 𝘶𝘴𝘶𝘢𝘭𝘭𝘺 𝘪𝘯𝘥𝘪𝘤𝘢𝘵𝘦𝘴 𝘤𝘰𝘮𝘢 (289).

8. The nurse is caring for a critically injured patient who can only be aroused by vigorous external stimuli. Which category should the nurse use to document the patient's level of consciousness? A. Lethargic B. Obtunded C. Stuporous D. Comatose

C. Stuporous 𝘊𝘢𝘵𝘦𝘨𝘰𝘳𝘪𝘦𝘴 𝘰𝘧 𝘊𝘰𝘯𝘴𝘤𝘪𝘰𝘶𝘴𝘯𝘦𝘴𝘴-𝘉𝘰𝘹 16.2 (288).

7. The nurse is teaching a nursing student about the importance of assessing the patient's level of conscious (LOC). Which statement indicates the nursing student understood the information? A. "The LOC is the most prognostic indicator of the patient's neurologic outcome." B. "The LOC limited to the Glasgow Coma Scale making it the quickest part of the assessment." C. "The LOC is the easiest part of the neurologic exam and thus is generally performed first." D. "In most situations, the LOC deteriorates before any other neurologic changes are observed."

D. "In most situations, the LOC deteriorates before any other neurologic changes are observed." ...𝘢 𝘱𝘢𝘵𝘪𝘦𝘯𝘵'𝘴 𝘭𝘦𝘷𝘦𝘭 𝘰𝘧 𝘤𝘰𝘯𝘴𝘤𝘪𝘰𝘶𝘴𝘯𝘦𝘴𝘴 𝘥𝘦𝘵𝘦𝘳𝘪𝘰𝘳𝘢𝘵𝘦𝘴 𝘣𝘦𝘧𝘰𝘳𝘦 𝘢𝘯𝘺 𝘰𝘵𝘩𝘦𝘳 𝘯𝘦𝘶𝘳𝘰𝘭𝘰𝘨𝘪𝘤 𝘤𝘩𝘢𝘯𝘨𝘦𝘴 𝘢𝘳𝘦 𝘯𝘰𝘵𝘪𝘤𝘦𝘥 (288).

13. The nurse is precepting a new graduate nurse. The new graduate asks about testing the oculovestibular reflex. What should the nurse tell the new graduate? A. "The test should not be performed on an unconscious patient because of the risk of aspiration." B. "An abnormal response is manifested by conjugate, slow, tonic nystagmus, deviating toward the irrigated ear." C. "This test should be included in the nursing neurologic examination of a patient with a head injury." D. "This test is performed by the practitioner and one of the final clinical assessments of brainstem function."

D. "This test is performed by the practitioner and one of the final clinical assessments of brainstem function." 𝘛𝘩𝘦 𝘰𝘤𝘶𝘭𝘰𝘷𝘦𝘴𝘵𝘪𝘣𝘶𝘭𝘢𝘳 𝘳𝘦𝘧𝘭𝘦𝘹 𝘪𝘴 𝘱𝘦𝘳𝘧𝘰𝘳𝘮𝘦𝘥 𝘣𝘺 𝘢 𝘱𝘩𝘺𝘴𝘪𝘤𝘪𝘢𝘯, 𝘰𝘧𝘵𝘦𝘯 𝘢𝘴 𝘰𝘯𝘦 𝘰𝘧 𝘵𝘩𝘦 𝘧𝘪𝘯𝘢𝘭 𝘤𝘭𝘪𝘯𝘪𝘤𝘢𝘭 𝘢𝘴𝘴𝘦𝘴𝘴𝘮𝘦𝘯𝘵𝘴 𝘰𝘧 𝘣𝘳𝘢𝘪𝘯𝘴𝘵𝘦𝘮 𝘧𝘶𝘯𝘤𝘵𝘪𝘰𝘯 (292).

5. A patient is admitted with an anoxic brain injury. The nurse notes abnormal extension of both extremities to noxious stimuli. This finding indicates dysfunction in which area of the central nervous system? A. Cerebral cortex B. Thalamus C. Cerebellum D. Brainstem

D. Brainstem 𝘈𝘣𝘯𝘰𝘳𝘮𝘢𝘭 𝘦𝘹𝘵𝘦𝘯𝘴𝘪𝘰𝘯 𝘰𝘤𝘤𝘶𝘳𝘴 𝘸𝘪𝘵𝘩 𝘭𝘦𝘴𝘪𝘰𝘯𝘴 𝘪𝘯 𝘵𝘩𝘦 𝘢𝘳𝘦𝘢 𝘰𝘧 𝘵𝘩𝘦 𝘣𝘳𝘢𝘪𝘯𝘴𝘵𝘦𝘮 (290).

14. The nurse is caring for a patient with a head injury and observes a rhythmic increase and decrease in the rate and depth of respiration followed by brief periods of apnea. What should the nurse document under breathing pattern? A. Central neurogenic hyperventilation B. Apneustic breathing C. Ataxic respirations D. Cheyne-Stokes respirations

D. Cheyne-Stokes respirations 𝘜𝘴𝘶𝘢𝘭𝘭𝘺 𝘴𝘦𝘦𝘯 𝘸𝘪𝘵𝘩 𝘣𝘪𝘭𝘢𝘵𝘦𝘳𝘢𝘭 𝘥𝘦𝘦𝘱 𝘤𝘦𝘳𝘦𝘣𝘳𝘢𝘭 𝘭𝘦𝘴𝘪𝘰𝘯𝘴 𝘰𝘳 𝘴𝘰𝘮𝘦 𝘤𝘦𝘳𝘦𝘣𝘦𝘭𝘭𝘢𝘳 𝘭𝘦𝘴𝘪𝘰𝘯𝘴; 𝘛𝘢𝘣𝘭𝘦 16.2 (294).

9. The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious patient. During the procedure, the patient reaches over with his left hand and tries to remove the noxious stimuli. How would the nurse document this response? A. Decorticate posturing B. Decerebrate posturing C. Withdrawal D. Localization

D. Localization 𝘓𝘰𝘤𝘢𝘭𝘪𝘻𝘢𝘵𝘪𝘰𝘯 𝘖𝘤𝘤𝘶𝘳𝘴 𝘸𝘩𝘦𝘯 𝘵𝘩𝘦 𝘦𝘹𝘵𝘳𝘦𝘮𝘪𝘵𝘺 𝘰𝘱𝘱𝘰𝘴𝘪𝘵𝘦 𝘵𝘩𝘦 𝘦𝘹𝘵𝘳𝘦𝘮𝘪𝘵𝘺 𝘳𝘦𝘤𝘦𝘪𝘷𝘪𝘯𝘨 𝘱𝘢𝘪𝘯 𝘤𝘳𝘰𝘴𝘴𝘦𝘴 𝘮𝘪𝘥𝘭𝘪𝘯𝘦 𝘰𝘧 𝘣𝘰𝘥𝘺 𝘪𝘯 𝘢𝘯 𝘢𝘵𝘵𝘦𝘮𝘱𝘵 𝘵𝘰 𝘳𝘦𝘮𝘰𝘷𝘦 𝘵𝘩𝘦 𝘯𝘰𝘹𝘪𝘰𝘶𝘴 𝘴𝘵𝘪𝘮𝘶𝘭𝘶𝘴 𝘧𝘳𝘰𝘮 𝘵𝘩𝘦 𝘢𝘧𝘧𝘦𝘤𝘵𝘦𝘥 𝘭𝘪𝘮𝘣- (𝘉𝘰𝘹 16.4) (290).