NEURO ATI BOOK

A nurse is caring for a client who experienced a traumatic head injury and has an intraventicular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the pt for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension

B. Infection: the nurse should monitor a pt who has a ventriculostomy for infection, which is a complication. The nurse should use strict asepsis to avoid this life-threatening condition, which can result in meningitis. Incorrect: complication for pt with increased ICP A. Headache C. Aphasia D. Hypertension

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Crede's method D. Indwelling urinary cath

A. Condom catheter: noninvasive; the bladder will empty on its own due to the pt having an upper motor neuron injury, which is manifested by a spastic bladder.

A nurse in the critical care unit is completing an admission assessment of a pt who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? SA A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A. Headache B. Dilated pupils D. Decorticate posturing

A nurse is planning care for a client who has meningitis and is at risk for ICP. Which of the following actions should the nurse plan to take? SA A. Implement seizure precautions B. Perform neurological checks four times a day C. Admin morphine for the report of neck and generalized pain D. Turn off room lights and television E. Monitor for impaired extraocular movements F. Encourage the client to cough frequently

A. Implement seizure precautions; ICP = seizure D. Turn off room lights and television; to decrease neuro stimulation = ICP E. Monitor for impaired extraocular movements = ICP Incorrect: B. Perform neurological checks four times a day; q 2 hours C. Admin morphine for the report of neck and generalized pain; avoid opioids F. Encourage the client to cough frequently; avoid = ICP

A nurse is assessing for the presence of Brudzinski's sign in a pt who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? SA A. Place pt in supine position. B. Flex pt's hip and knee. C. Place hands behind the pt's neck. D. Bend pt's head toward chest. E. Straighten the pt's flexed leg at the knee.

A. Place pt in supine position -- brudzinski C. Place hand behind the pt's neck toward the chest. D. Bend pt's head toward chest. Incorrect: B. flex pt's hip and knee for kernicks E. Straighten the pt's flexed leg at the knee.

A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the pt should the nurse report to the provider? SA A. "I think I might be pregnant" B. "I take warfarin." C."I am taking antihypertensive meds." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning."

A. pregnant -contrast dye can be harmful for fetus. B. Warfarin - r/o potential risk for bleeding following angiography D. shrimp - shellfish -> potential allergic reaction E. I ate a light breakfast this morning -> bc pt should remain NPO for 4 - 6 hr before the procedure. Incorrect: C. "I am taking antihypertensive meds."

A nurse is caring for a pt who was recently admitted to the ER following a head-on motor vehicle crash. The pt is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized B. Insert NG tube C. Monitor pulse and BP frequently D. Establish IV access and start fluid replacement

A. pt at greatest risk for permanent damage to the spinal cord if a cervical injury does exist; keep the neck immobile until damage to the cervical spine can be r/o.

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? SA A. Monitor for bradycardia B. Provide an emesis basin at the bedside C. Admin antipyretic meds D. Perform skin assessment E. Keep HOB flat

B. Provide an emesis basin at the bedside C. Admin antipyretic meds D. Perform skin assessment Incorrect A. Monitor for bradycardia; monitor for tachy E. Keep HOB flat; HOB at 30 degrees to promote venous drainage from the head and prevent increased ICP

A nurse is planning care for a pt who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The pt has no muscle control of lower limbs, bowel, or bladder. Which of the following should the nurse highest priority? A. Prevention of further damage of the spinal cord B. Prevention of contractures of the lower extremities. C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the pt in the wheelchair

A. the greatest risk to the pt during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention the nurse should take is to prevent further damage to the spinal cord by administration of corticosteroids, minimizing movement of the pt until spinal stabilization is accomplished thru either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.

A nurse is caring for a pt who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include BP 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? A. Notify the provider B. Sit the pt upright in bed C. Check the urinary catheter for blockages D. Admin antihypertensives meds

B. Sit the pt upright in bed; pt at greatest risk for developing stroke so need to lower the bp

A nurse is caring for a pt who has a closed-head injury with ICP readings ranging from 16 - 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the pt's ICP? SA A. Suction the endotracheal tube frequently B. Decrease the noise level in the pt's room C. Elevate the pt's head on two pillows D. Admin a stool softener E. Keep the pt well hydrated

B. Decrease the noise level in the pt's room D. Admin a stool softener

A nurse is assessing a client for changes in the LOC using the GCS. The pt opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C.E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8

B. E3 + V4 + M4 = 11 Rationale: moderate head injury. E3 = opening eyes secondary to voice stimulation V4 = verbal conversation that is incoherent and disoriented M4 = motor response as a general withdrawal to pain.

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

B. Hyponatremia; powerful osmotic diuretic can cause electros imbalance such as this

A nurse is assessing a pt who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics B. Implement droplet precautions C. Initiate IV access D. Decrease bright lights

B. Implement droplet precautions

A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics B. Implement droplet precautions C. Initiate IV access D. Decrease bright lights

B. Implement droplet precautions; to prevent the spread to others

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following info should the nurse include in the teaching? A. "Do not was your hair the morning of the procedure." B. "Try to stay awake most of the night prior to the procedure." C. "The procedure will take approx 15 mins" D. "You will need to lie flat for 4 hours after the procedure."

B. The nurse should teach the pt to remain awake most of the night to provide cranial stress and increases the possibility of abnormal electrical activity.

A nurse is caring for a pt who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow coma scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

C. Oxygen saturation; ABC -- assessment of o2 sat is the priority; brain tissue can only survive for 3 mins before permanent damage occurs

A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A. The vaccine is indicated to reduce the risk of resp infections B. The vaccine is administered in a series of four doses C. The vaccine is recommended for adolescents before starting college D. The vaccine is initially given at 2 months of age

C. The vaccine is recommended for adolescents before starting college Incorrect: A. The vaccine is indicated to reduce the risk of resp infections; yes but also for CNS infection B. The vaccine is administered in a series of four doses; HIB C. The vaccine is recommended for adolescents before starting college D. The vaccine is initially given at 2 months of age; HIB

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? SA A. Use the glasgow coma scale when assessing the client B. Assist the pt to a supine position C. Admin an opioid med D. Encourage the client to increase fluid intake E. Instruct the pt to perform deep breathing and coughing exercises.

Correct: B. Assist the pt to a supine position --> can relieve headache following lumbar puncture C. Admin an opioid med for headache D. Encourage the client to increase fluid intake to maintain a positive fluid balance --> relieve headache post procedure Incorrect: A. glasgow coma scale is used to assess a pt's LOC & is not ness. after lumbar puncture E. Coughing increases ICP, which can result in pt's headache.

A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following types of prescribed meds should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H1 antagonists D. Muscle relaxants

D. Muscle relaxants; clarify the need of this med bc the pt will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

A nurse is caring for a pt who has C4 spinal cord injury. The nurse should recognize the pt is at greatest risk for which of the following complications. A. Neurogenic shock B. Paralytic ileus C. Stress Ulcer D. Respiratory compromise

D. Respiratory compromise secondary to involvement of phrenic nerve. Incorrect: the nurse should monitor, but not priority at this time.