Test 3 class quizes
A nursing student asks the nurse to describe decerebrate posturing. In order to answer, the nurse must know that decerebrate posturing includes what? 1) Withdrawal in response to pain. 2) Flexion of the upper extremities. 3) Extension of all the extremities. 4) Presence of Babinski and gag reflexes.
extension of all extermities
Placement of a nasogastric tube (NG) is contraindicated during emergency care when the patient has a possible Inhalation injury. Head or facial trauma. Intra-abdominal bleeding. Cervical spine fracture.
head traum
A patient with a head injury is to receive dexamethasone (Decadron) 3.5 mg IV stat. The vial contains 8mg/2ml. How much Decadron does the nurse administer? Question 2 options: 1) 0.43 ml 2) 0.88 ml 3) 7.0 ml 4) 8.75 ml
.88 ml
What is the most important and reliable index of a patient's neurological status? Question 19 options: 1) Vital signs. 2) Pupillary reaction. 3) Motor activity and posturing. 4) Response to external stimuli.
4
A nurse is teaching a class about intracranial pressure and includes what information that best explains autoregulation of cerebral blood flow? Question 11 options: 1) Intraabdominal and intrathroracic pressures are the priniciple factors that influence cerebral blood flow. 2) Blood vessels in the brain constrict decreasing blood flow in response to respiratory and metabolic acidosis. 3) This mechanism keeps intracranial blood flow constant by dilating or constricting vessels in the brain. 4) Cerebral blood flow is the difference between mean arterial pressure and intracranial pressure.
This mechanism keeps intracranial blood flow constant by dilating or constricting vessels in the brain.
A nurse is caring for a patient with a head injury who begins to have flow of cerebrospinal fluid from his nose. What causes this? Question 3 options: 1) Trauma to sinuses related to forces that caused the head injury. 2) Swelling and inflammation of the nasal tissues from edema. 3) Nasopharyngeal and meningeal infection that complicates head trauma. 4) Battle's sign and raccoon eyes that appear 24 hours post trauma.
Trauma to sinuses related to forces that caused the head injury.
A client was in an automobile accident and sustained a head injury. A diagnosis of increasing ICP was made. Which of the following is the most appropriate nursing intervention for the care of this client? Question 20 options: 1) Turn the client carefully at least every 2 hours. 2) Keep the head of the bed elevated 45 degrees. 3) Teach vigorous coughing techniques. 4) Encourage plenty of liquids by mouth.
Turn the client carefully at least every 2 hours.
A client is admitted with a diagnosis of epidural hematoma. The family asks why the client became unresponsive so quickly after the fall. The nurse's response is based on the awareness that epidural bleeding 1) is usually arterial. 2) is most often venous. 3) usually results in hemorrhagic shock. 4) causes global neuronal dysfunction.
is usually arterial.
Generally, the first priority that should be addressed in an emergency situation involving a child with suspected trauma injuries is: 1) movement of the injured child which, if done improperly, may lead to serious, permanent injury or death. 2) personal safety, because the victim cannot be helped if the rescuer is injured. 3) observation of the scene for possible clues about the mechanism of injury to the child. 4) control of bleeding by applying direct pressure to the wound site.
personal safety, because the victim cannot be helped if the rescuer is injured
A nurse caring for an unconscious client with head trauma identifies the nursing diagnosis of "Risk for aspiration". Which of the following interventions would be most appropriate for this diagnosis? 1) Place the client in a supine position. 2) Position the patient on the side. 3) Provide a soft diet with liquids. 4) Suction the patient while offering fluids.
position patient on the side
The nurse is caring for a patient who had surgery to remove a blood clot in the left occipital area of the brain. The nurse notices clear drainage on the sheets under the client's right ear. The nurse should 1) change the sheets to prevent moisture contributing to skin breakdown. 2) inspect the surgical dressing for blood. 3) elevate the head of the bed to reduce increased intracranial pressure. 4) test the drainage for presence of glucose.
test the drainage for presence of glucose
Trauma patients who sustain fractures of the ribs are at high risk for: 1) head trauma 2) damage to pleura and lungs 3) kidney lacerations 4) sacral spinal injuries.
2
A nursing student asks the nurse to describe decerebrate posturing. In order to answer, the nurse must know that decerebrate posturing includes what? Question 23 options: 1) Withdrawal in response to pain. 2) Flexion of the upper extremities. 3) Extension of all the extremities. 4) Presence of Babinski and gag reflexes.
Extension of all extermities
A nurse is caring for a patient who has a decerebrate response to stimulation. This type of response is demonstrated by what? 1) Withdrawal from pain. 2) Drawing arms toward the core of the body. 3) Extension of all extremities. 4) Rhythmic flexion/extension of extremities.
Extension of all extremities.
The nurse recognizes that a lumbar puncture is contraindicated in which neurologic disorder? 1) Head injury. 2) Meningitis. 3) Multiple sclerosis. 4) Encephalitis
Head injury
Which of the following is the best position for a patient with increased intracranial pressure and no spinal injury? 1) Head of bed raised 30 degrees. 2) Supine with neck straight. 3) Head flexed on two pillows. 4) Prone with head to the side.
Head of the bed raised to 30 degrees
The nurse is caring for a patient with severe head trauma after a car accident. Which of the following are very serious signs that often precede death? Question 13 options: 1) Sluggish and unequal pupils 2) Combativeness and confusion 3) Hyperactive and irritable deep tendon reflexes 4) Cycles of hyperventilation and apnea
cycles of hyperventilation and apnea
An infant is admitted with a head injury. A nurse notes which of the following clinical manifestations signifying increased intracranial pressure in an infant? Question 8 options: 1) A high-pitched cry. 2) A sunken fontanel. 3) Diplopia, blurred vision. 4) Tachycardia.
High pitched cry Other signs of increased icp bulging fontanel, separation of cranial sutures, irritability, restlessness, increased sleeping, high pitched cry, poor feeding, setting sun sign, distended scalp vein
A 27 year old female with quadriplegia for two weeks experiences leg spasms. She says to the nurse, "Look, nurse! I can move! I'll walk again!" What is the best response? 1) "I see the movement. What do you think that means?" 2) "Oh, yes! I bet you will!" 3) "Oh, no. That is just reflex movement." 4) "We'll have to have the doctor evaluate this."
1
A nurse is testing a patient for the oculocephalic reflex. Which of the following indicates a normal response of this reflex? Question 18 options: 1) The eyes turn to the left when the head is rotated to the right. 2) Both pupils constrict when a light is presented to the right eye. 3) The eyes turn to the left as the left ear canal is irrigated. 4) The eyes turn upward as the neck is extended backward.
1
What is the chemotherapeutic classification of Cis-platin? 1) Platinum drug 2) Antineoplastic antibiotic 3) Antimetabolite 4) Hormonal agent
1
Which of the following are included in the primary survey assessment of a patient with a life-threatening problem (check all that apply)? 1) Airway with cervical spine stabilization 2) Disability 3) A full set of vital signs 4) Breathing
1, 2, 4 Full set of vital signs is included in secondary assessment
A 44-year-old woman has advanced multiple sclerosis (MS). She has a very weak cough and dysphagia. To prevent respiratory complications in the patient, which nursing intervention is appropriate? 1) Sit her upright with her head flexed toward the sternum when eating. 2) Administer supplemental oxygen when she attempts to cough and clear her lungs. 3) Offer bronchodilators to her before she eats. 4) Give her opportunities to talk about her anxiety related to breathing and eating.
1. Be sure that you know MS is and why respiratory problems are an issue here. Your general knowledge about care of patients with respiratory difficulties, though, should help you answer this question. Maintaining a patent airway is always first priority.
A client is scheduled for a craniotomy because of a brain tumor. What is the most important nursing intervention before surgery? 1) Discuss advance directives. 2) Assess and establish a neurological baseline. 3) Find out where the tumor is located. 4) Obtain a complete history and physical.
2
A client with cancer is receiving chemotherapy. A nurse caring for her would expect her to experience which of the following genitourinary infections? 1) Herpetic 2) Streptococcal 3) Escherichia coli 4) Viral
3
A nurse is caring for a patient with head trauma in the emergency department. During the assessment the nurse determines that her Glasgow Coma Scale score is 9. This means that the patient is Question 19 options: 1) comatose. 2) unstable, but score is within normal limits. 3) in need of emergency care. 4) in normal neurological condition.
3
A nurse, who is caring for a patient with a head injury, says in report that the patient is in respiratory alkalosis because of increased intracranial pressure. Which set of blood gases indicates this to be true? 1) pH 7.31; pCO2 50; HCO3 21 2) pH 7.45; pCO2 37; HCO3 24 3) pH 7.49; pCO2 31; HCO3 22 4) pH 7.58; pCO2 45; HCO3 32
3
During physical assessment of a patient with Guillain-Barre (GB)syndrome, which manifestation would the nurse most likely find? 1) Decreased level of consciousness. 2) Progressive muscle weakness starting in the head and upper extremities. 3) Pupillary abnormalities. 4) Numbness and tingling pain.
4
Which drug is sometimes given as "rescue therapy" to patients who have received methotrexate for treatment of cancer? 1) Nitrogen mustard 2) Allopurinol (Zyloprim) 3) Ifosfamide (Ifex) 4) Folinic acid (Leucovorin)
4
A 67-year-old woman is seen in the clinic with Parkinson's disease. Which of the following most likely would be present on physical examination? 1) Slow, shuffling gait. 2) Rigidity when she experiences passive range of motion. 3) Postural instability. 4) All of the above.
4 Hide Feedback Be sure you are familiar with Parkinson's disease, signs, symptoms, complications, treatment. Watch out for "all of the above" type choices and remember that in order for "all of the above" to be correct, ALL the other answers must be correct. Consider each choice carefully. Don't get caught in assuming that "D" is always the right answer in this type of question.
Which of the following patients is most appropriate for the intensive care unit charge nurse to assign to an RN who has floated from a medical unit? Question 6 options: 1) A 23-year-old patient who had a skull fracture and craniotomy the previous day. 2) A 30-year-old patient who has an ICP monitor in place after a head injury a week ago. 3) A 44-year-old patient who is comatose after a head injury 3 weeks ago. 4) A 61-year-old patient who has increased ICP and is receiving osmotic diuretic therapy.
A 44-year-old patient who is comatose after a head injury 3 weeks ago.
The correct sequence for the primary assessment of the pediatric trauma patient is: Airway, breathing, circulation, cervical spine protection, neurological, remove clothes Neurological, airway, cervical spine protection, breathing, circulation, remove clothes. Airway, cervical spine protection, breathing, circulation, neurological, remove clothes. Remove clothes and keep warm, neurological, airway, breathing, circulation.
Airway, cervical spine protection, breathing, circulation, neurological, remove clothes.
During an intubation attempt, the child's heart rate drops to 40 beats/minute. Which intervention is indicated? Ask the physician to stop the intubation attempt and perform bag-mask-ventilation. Start chest compressions and ask to physician to continue with intubation attempts. Apply cricoid pressure and establish IV access. Inform the physician of the heart rate and ask him/her to intubate faster.
Ask the physician to stop the intubation attempt and perform bag-mask-ventilation
A nurse is caring for a patient with a head injury and knows that the most reliable clinical manifestation of a patient's neurological status is what? 1) Presence or absence of vomiting. 2) Pupillary reaction. 3) Motor activity and posturing. 4) Behavior.
Behavior
A patient's wife asked the nurse what diagnostic test will be used to obtain the most accurate information regarding her husband's head injury. The best response is what? Question 17 options: 1) Complete skull and spine x-rays. 2) Myelogram. 3) Electroencephalogram (EEG). 4) Computed tomography (CT) scan.
CT ATI: Head injury Diagnostic procedures Cervical spine XRay CT or MRI
The nurse is caring for a child with severe increased intracranial pressure from a head injury. Which intervention is the most useful in controlling intracranial pressure in this child? Question 13 options: 1) Elevate head of the bed 30 degrees while keeping the head and neck midline. 2) Wake the child every 30 minutes while providing extra sensory stimulation. 3) Measure intake and output carefully while encouraging extra fluid intake. 4) Suction the respiratory tract frequently while promoting expectoration.
Elevate head of the bed 30 degrees while keeping the head and neck midline.
A patient has just been diagnosed as having Hodgkin's lymphoma. Which statement about the disease would be most accurate to convey to the family? 1) Ataxia, visual defects, and headaches are common presenting symptoms 2) Hodgkin's lymphoma is characterized by painless enlargement of lymphnodes 3) Peak age of incidence is between 5 - 9 years old 4) Bone marrow transplant is the most effective medical treatment for this type of cancer
Hodgkin's lymphoma is characterized by painless enlargement of lymphnodes
A nursing student notices that a patient has an intracranial pressure (ICP) monitoring device and asks the nurse questions about ICP. Which statement by the nurse is a correct one to give the student about ICP? Question 8 options: 1) Normal ICP as measured by a pressure monitor is 25-30mm Hg. 2) ICP is determined by blood flow, cerebrospinal fluid and brain tissue. 3) Cerebral perfusion pressure is equal to ICP plus pulse pressure. 4) Pressure in the cranium is monitored only during procedures.
ICP is determined by blood flow, cerebrospinal fluid and brain tissue.
A patient with an epidural hematoma is evaluated in the ED. The nurse caring for her knows that an epidural hematoma is best described with which statement? Question 17 options: 1) Initial unconsciousness followed by a lucid period, then drowsiness and coma. 2) Brief disruption in the level of consciousness, then return to normal. 3) Often chronic with symptoms occurring up to several weeks after injury. 4) Transient collection of blood or fluid between the dura mater and arachnoid spaces.
Initial unconsciousness followed by a lucid period, then drowsiness and coma.
A patient has had a hemorrhage into the brain resulting in neurologic deficits. A nurse caring for this patient recognizes that these deficits are most likely the result of what? Question 10 options: 1) Irritation of brain tissue by blood. 2) Intracerebral hematoma. 3) Subdural hematoma. 4) Subarachnoid hemorrhage.
Intracerebral hematoma.
Which nursing action is used to prevent hypercapnia and hypoxia in patients with increased intracranial pressure? Question 16 options: 1) Encourage the patient to breathe into a paper bag twice daily. 2) Consolidate all nursing care activities into a cluster. 3) Promote patient coughing as frequently as possible. 4) Limit suctioning to no more than ten seconds in duration.
Limit suctioning to no more than ten seconds in duration
Which is the most appropriate nursing intervention when caring for an unconscious patient with increased intracranial pressure? 1) Change the patient's position frequently to minimize the development of pneumonia. 2) Administer narcotics and sedatives to provide comfort and pain relief. 3) Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. 4) Administer solid foods to promote nutrition when chewing motions have returned.
Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.
A nurse caring for a patient with a head injury notes that the patient has impaired vision or functional blindness. Based on these findings, the nurse realizes that which part of the brain is most likely injured? 1) Medulla 2) Cerebellum 3) Frontal lobes 4) Occipital lobe
Occipital lobe
If a patient has a fracture of the anterior skull fossa, which cranial nerves are most likely to be damaged as well? 1) Olfactory 2) Acoustic 3) Vagus 4) Hypoglossal
Olfactory
A client with a severe head injury is placed on mechanical ventilation and hyperventilation is maintained. What is the best explanation of this therapy? 1) Increases oxygen to the brain. 2) Increases cerebral blood volume. 3) Promotes vasoconstriction to decrease cerebral blood flow. 4) Dilates cerebral blood vessels to increase cerebral blood flow.
Promotes vasoconstriction to decrease cerebral blood flow
A nurse is caring for a patient with a head injury and notices that he begins to have a seizure. Which action should the nurse take first? Question 6 options: 1) Attempt to restrain the patient. 2) Insert a tongue blade into the patient's mouth. 3) Protect the patient from injuring himself on bedrails. 4) Leave the patient to get anticonvulsant medication.
Protect the patient from injuring himself on bedrails.
Question 15 (1 point) A nurse is caring for a patient with severe head trauma on the day after his injury. He is comatose. He also begins to have decreased urine output with a specific gravity of 1.031. He has a serum sodium level of 129 mEq/L and a hematocrit of 34%. The nurse will do what initially? Question 15 options: 1) Suspect that the patient is experiencing diabetes insipidus and expect to transfuse him with whole blood. 2) Continue to monitor the patient and chart the above findings as expected in a patient with a head injury. 3) Recognize that the patient is probably experiencing syndrome of inappropriate ADH and notify the physician. 4) Irrigate his foley catheter and ensure his intravenous line is patent before increasing his fluid rate.
Recognize that the patient is probably experiencing syndrome of inappropriate ADH and notify the physician.
A 50-year-old woman was in a car accident in which she sustained a blow to her head and neck. She is very drowsy. Approximately 5 minutes after her arrival to ER, she begins vomiting. The most appropriate nursing intervention at the time is what? Question 12 options: 1) Suction her mouth and throat immediately. 2) Turn her head to the side and give her an emesis basin. 3) Place a nasogastric tube to prevent aspiration 4) Administer antiemetics as ordered.
Suction her mouth and throat immediately.
The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? The staff nurse 1) suctions the endotracheal tube every 10 minutes. 2) assesses neurologic status every hour. 3) elevates the head of the bed to 30 degrees. 4) administers an analgesic before turning the patient.
Suctioning q 10 min
Four patients from a motor vehicle accident arrive at the emergency department at the same time. Which should receive care first, based on the seriousness of their head injuries? 1) A 4-year-old with a concussion. 2) A 45-year-old with a compound skull fracture. 3) A 37-year-old with a comminuted occipital fracture 4) A 75-year-old with linear fracture of the frontal bone.
The 45 year old with a compound fracture
A patient is being discharged from the ED with a concussion. What is the most critical discharge instruction for the nurse to include for this patient? 1) Bring the patient to the follow-up appointment with the neurologist in the morning. 2) Wake the patient up every 2 hours to observe level of consciousness for the next 24 hours. 3) Provide small feedings of soft foods and fluids at least every 3-4 hours throughout the night. 4) Be sure someone helps the patient get up to the bathroom for at least 3 days after the injury.
Wake the patient up every 2 hours to observe level of consciousness for the next 24 hours.
When the patient is admitted to the emergency room, the mnemonic SAMPLE helps the nurse to remember to gather information about (check all that apply): 1) Medications taken by the patient 2) Allergies of the patient 3) Last menstrual period 4) Last food that was eaten by the patient
all of them SAMPLE refers to this: S = symptoms/symptoms A = allergies M = medication history P = past health history which includes preexisting medical conditions, previous hospitalizations/surgeries, smoking history, recent use of drugs/alcohol, tetanus immunization, last menstrual period L = last meal E = events/environment preceding illness or injury
A client is admitted to the hospital following a fall from a building and is unconscious. The nurse observes bloody drainage from the client's nose. Which of the following interventions will assist indetermining the presence of cerebrospinal fluid (CSF) in the drainage? 1) Obtaining a culture of the drainage using sterile swabs and sending it to the laboratory. 2) Allowing the drainage to drip on a sterile gauze and observing for a halo or ring around the blood. 3) Suctioning the nose gently with a bulb syringe to obtain a specimen which is sent to the laboratory. 4) Inserting sterile nasal packing into the nares and after 24 hours checking the packing for glucose.
allowing the drainage to drip on a steril gauze and observing for a halo or ring around blood
Which intervention is most important to include in developing a plan of care for a patient with a C5 spinal cord injury who is immobilized in traction? 1) Encourage intake of orange or pineapple juice with every meal. 2) Provide high-calorie, high-protein snacks such as milk shakes, puddings, and custards. 3) Assess lower extremities every eight hours for redness and swelling. 4) Provide sensory stimulation of the affected body parts with massage and cold compresses.
assess lower extermities every 8 hours for redness and swelling
A patient experiences granulocytopenia as a side effect of chemotherapy. At the time of discharge, which information is most important to give the patient regarding this side effect? 1) Take aspirin for a temperature above 100.8 degrees F 2) Increase high-protein food in the diet 3) Practice energy conservation techniques 4) Avoid crowds
avoid crowds
A nurse working with victims of head injury recognizes that which of the following head injuries is the least severe? Question 9 options: 1) Brainstem contusion 2) Cerebral contusion 3) Concussion 4) Cerebral laceration
concussion
A patient is admitted to the ED with a skull fracture and X-rays are ordered. The nurse realizes that which of the following types of skull fractures is the most difficult to detect on X-ray? Question 20 options: 1) Compound 2) Depressed 3) Comminuted 4) Basilar
basilar
A nurse is assessing a patient in the ICU who has periorbital ecchymosis and Battle's sign. With these manifestations, what type ofhead in jury would the nurse expect? Question 1 options: 1) Epidural hematoma 2) Subarachnoid hemorrhage 3) Basilar skull fracture 4) Brain tissue laceration
basilar skull fracture
A nurse caring for a patient with a severe head injury recognizes that when a patient suffers from herniation of the brain, the: 1) meninges become dehydrated and shrink. 2) brain swells and causes the skull to fracture. 3) brain is forced through the foramen magnum. 4) spinal cord is compressed by the brain.
brain is forced through the foramen magnum.
A student asks the nurse about other disease processes that cause cerebral edema besides head injury. The nurse's response includes what? 1) Diabetes mellitus 2) Cerebrovascular accident 3) Deep vein thrombosis in the leg 4) Hypotension
cerebrovascular accident
The nurse knows that the most sensitive and reliable indicator of increased intracranial pressure in a patient is what? 1) Pupillary changes. 2) Changes in ability to respond to questions. 3) Respiratory pattern alterations. 4) Decrease in muscle strength.
changes in ability to respond to questions
The school nurse assesses a 7-year-old male after he fell on his head from a swing and is concerned about increased intracranial pressure (IICP). Which is the most reliable indicator of IICP in a child? Question 2 options: 1) Drop in blood pressure. 2) Changes in sensorium. 3) Nausea and vomiting. 4) Tachycardia
changes in sensorium
A 24-year-old patient is hospitalized with a basilar skull fracture. He complains of nasal drainage. Which is the initial nursing action? Question 11 options: 1) Instruct him to carefully blow his nose. 2) Check the drainage for glucose. 3) Notify the physician immediately. 4) Obtain a culture of the drainage.
check for glucose
A nurse is teaching a class of students about head injury risks. The nurse mentions that which patient is at the highest risk for a chronic subdural hematoma? A patient Question 10 options: 1) who is the victim of child abuse. 2) sustaining a compound skull fracture. 3) who received a gunshot wound to the head. 4) with a history of severe mental illness.
child abuse
A nurse realizes that which of the following is the most severe type of skull fracture? Question 21 options: 1) Linear 2) Comminuted 3) Compound 4) Closed
compound
When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as Question 7 options: 1) decorticate posturing. 2) decerebrate posturing. 3) purposeful reaction to pain. 4) seizure activity response.
decorticate posturing.
A nurse is teaching a class about increased intracranial pressure. A participant asks "How does the brain compensate for elevated intracranial pressure?" The nurse answers that there is 1) an increase in oxygen concentration in brain tissue. 2) a decrease in blood flow to the brain. 3) an increase in circulation of cerebrospinal fluid. 4) an immediate loss of consciousness
decrease in blood flow to the brain
The nurse is caring for a patient with a head injury. The patient's latest blood gases show an increase in PC02. In planning care for the patient, the nurse anticipates that hyperventilation will be required. Which best explains the rationale for hyperventilation? 1) Increases the diameter of the cerebral blood vessels. 2) Prevents respiratory arrest. 3) Decreases cerebral blood flow. 4) Reduces respiratory and metabolic alkalosis.
decreases cerebral blood flow
A nurse who is caring for a patient with head trauma knows that preventing hyperthermia will have what effect on the brain? 1) Decreasing metabolism of cerebral tissues. 2) Preventing cerebrovascular hypoxia 3) Diminishing the volume of cerebrospinal fluid. 4) Constricting arteries in the brain.
decreasing metabolism of the cerebral tissue
The nurse is evaluating the status of a 75-year-old man with a possible head injury. Which behavior would be of most concern to the nurse? 1) Difficulty remembering and describing recent events. 2) Short attention span when listening to instructions. 3) Short delay in response when answering questions. 4) Trouble with dividing and multiplying large numbers.
difficulty remembering recent events
A nurse is caring for a patient who has a decerebrate response to stimulation. This type of response is demonstrated by what? Question 15 options: 1) Withdrawal from pain. 2) Drawing arms toward the core of the body. 3) Extension of all extremities. 4) Rhythmic flexion/extension of extremities.
drawing arms towards the core
A patient is admitted with right pupil dilation, weakness of arms and legs on the left and decreased level of consciousness. His family said he suffered a head injury 10 days ago but was released from the hospital and has been fine since then. These signs and symptoms are most characteristic of what type of injury? Question 2 options: 1) Concussion 2) Cerebral laceration 3) Epidural hematoma 4) Subdural hematoma
epidural hematoma
The leading cause of death in children from multiple trauma is due to injuries of the ___traffic accidents___
head, spinal cord
A client is at risk for autonomic dysreflexia. The nurse should instruct the client and family to report what? 1) Dizziness and wheezing. 2) Circumoral pallor and tingling around the lips. 3) Rash and itching on the face or neck. 4) Headache and sweating.
headache and sweating
A nurse caring for a patient with a head injury recognizes that which condition contributes directly to increased metabolism in the brain? 1) Hyperthermia 2) Fluid and electrolyte imbalance 3) Acute renal failure 4) Immobilization
hyperthermia
A nurse gives a dose of mannitol to a patient with increased intracranial pressure. What is the most reliable indication that the mannitol is effective for this patient? Question 14 options: 1) Intracranial pressure decreases from 32 to 24 mm Hg. 2) Urine output increases by 300 ml in one hour. 3) Blood glucose level rises to 120 mg% 4) Cerebral perfusion pressure decreases to 50 mm Hg.
icp goes from 32 to 24
A nurse is teaching a class about cerebrovascular blood flow. The nurse should include what information about the effect of hypercapnea on cerebrovascular status? Hypercapnea Question 22 options: 1) increases the diameter of blood vessels in the brain 2) decreases cerebrovascular blood supply 3) increases the pH of brain tissues 4) causes carbon monoxide to attach to cerebral hemoglobin
incrases the diameter of blood vessels in the brain
A nurse is caring for a patient who has been diagnosed with a subdural hematoma. Which of the following is a characteristic of this problem? Question 7 options: 1) Momentary unconsciousness followed by a brief lucid period. 2) Increased intracranial pressure usually a result of venous bleeding. 3) Transient disruption of neural activity by a blow to the head. 4) Bleeding occurring between the skull and dura mater.
increased intracranial pressure usually a result of venous bleeding. PPT says dura mater and archnoid mater
Question 3 (1 point) Saved A patient with a stroke has a mean arterial pressure (MAP) of 60 mm Hg and an intracranial pressure (ICP) of 40 mm Hg. Given this data, which nursing diagnosis would be highest priority? Question 3 options: 1) Ineffective cerebral tissue perfusion. 2) Alteration in comfort level. 3) Increased intracranial adaptive capacity. 4) Risk for disuse syndrome.
ineffective cerebral tissue perfusion
The nurse is checking orders for a patient just admitted to the ED with a head injury. Which order should the nurse question? 1) Keep Sp02 at 90% or higher. 2) Insert an NG tube. 3) Elevate head of bed. 4) Start IV with saline to keep open.
inserting an NG tube
The physician prescribes a drug that is given with Methotrexate to decrease its toxic effects. Which drug is this? 1) Prednisone 2) Cytoxan 3) Leukovorin 4) Vincristine
leukovorin Hide Feedback Methotrexate is an antimetabolite that prevents cells from using folic acid which they need to replicate. Leucovorin (folinic acid) helps decrease the toxic effects of this drug and enhances the recovery of normal cells. It is actually an antidote for methotrexate toxicity and so it is given in the event of an overdose. Usually the person receiving methotrexate is not given multivitamins that contain folic acid. Prednisone is a hormone that is given to inhibit synthesis of protein and depress the immune system. It does not affect methotrexate. Cytoxan is an alkylating agent and damages DNA. It does not affect methotrexate. Vincristine is a plant alkaloid and does not affect methotrexate.
A nurse is caring for a patient with the following drugs. The nurse knows that which drug is an osmotic diuretic used to control increased intracranial pressure? Question 18 options: 1) Furosemide (Lasix) 2) Bumetanide (Bumex) 3) Mannitol 4) Aldactone
mannitol
A nurse is measuring cerebral perfusion pressure and recognizes that this is a function of which of the following? Question 16 options: 1) Mean arterial pressure minus the intracranial pressure. 2) Systolic blood pressure minus diastolic pressure 3) Pulse rate times stroke volume times intracranial pressure 4) Intracranial pressure plus the systolic pressure
map-icp
The nurse is caring for an unconscious child with increased intracranial pressure. Which of the following is a nursing intervention to reduce intracranial pressure? Question 5 options: 1) Suction the child frequently. 2) Assess pupils every 15 minutes. 3) Turn head side to side every hour. 4) Minimize environmental noise.
minimize enviornmental noises
Myasthenia gravis is primarily a disease in which there is faulty 1) central nervous system conduction. 2) myoneural conduction. 3) upper motor neuron transmission. 4) epinephrine and norepinephrine production.
myoneural conduction
Which of the following is NOT one of the seven warning signs of cancer in an adult? 1) Change in bowel or bladder habits 2) Lesion that does not heal 3) Hypertension 4) Nagging cough or hoarseness
nagging cough or hoarseness
The nurse is closely monitoring a man who is unconscious after a fall and notices that he suddenly has a fixed and dilated pupil. The nurse should interpret this as which of the following? 1) Eye trauma. 2) Neurosurgical emergency. 3) Severe brainstem damage. 4) Indication of brain death.
neurolosurgical emergency
A nurse is caring for a young child with a head injury and a bolt method intracranial pressure monitoring device. The nurse recognizes that the waveform on the monitoring device is not normal. What should the nurse do? Adjust the pressure monitor to be sure it is properly placed. Notify the neurosurgeon immediately about the abnormal waveform. Peel back the dressing at the bolt site to visualize placement. Change the bolt dressing to be sure it is not wet with drainage.
notify the doctor about the abnormal wave form
A nurse caring for a patient with increased intracranial pressure notes abnormal constriction of his pupils. This occurs because which of the following is damaged? Question 4 options: 1) Frontal lobe 2) Cranial nerve III (Oculomotor nerve) 3) Medulla oblongata 4) Cranial nerve VII (Facial nerve)
oculomotor nerve
Which of the following types of drugs are most often used to control increased intracranial pressure? Question 4 options: 1) Osmotic diuretics 2) Pituitary hormones 3) ACE inhibitors 4) Anti-seizure drugs
osmotic diuretics
The nurse is reviewing the blood gases of a patient with a head injuryand increased intracranial pressure. Which set of arterial blood gaseswould be worrisome to the nurse at this time? 1) pH 7.31; pCO2 49 mm Hg; HCO3 24 mEq 2) pH 7.35; pCO2 39 mm Hg; HCO3 25 mEq 3) pH 7.45; pCO2 35 mm Hg; HCO3 28 mEq 4) pH 7.47; pCO2 31 mm Hg; HCO3 21 mEq
pH 7.31; pCO2 49 mm Hg; HCO3 24 mEq
A nurse is caring for a patient with possible increased intracranial pressure (IICP). Which of the following is the most likely indicator of IICP? Question 25 options: 1) Decreased diastolic blood pressure. 2) Absence of Babinski reflex. 3) Projectile vomiting. 4) Cerebral spinal fluid (CSF) otorrhea.
projectile vomiting
Which of the following prescriptions are included in a primary survey immediately following admission of a client suffering from trauma? Choose all that apply. Provision of a patent airway. Replacement of blood volume as needed. Repair of specific injuries (i.e. maxillofacial). Control of hemorrhage. Assessment of central nervous system. Administration of pain medication.
provision of patent airway replacement of blood volume as needed control of hemorrhage assessment of central nervous system
Mannitol is ordered for the client with increasing intracranial pressure. The nurse caring for him recognizes that the purpose of this drug is to do what? Question 12 options: 1) Help retain fluid and sodium by diuresis to increase cerebral blood flow. 2) Constrict vessels through osmosis in the cerebrovascular circulatory system. 3) Pull fluid from interstitial spaces of the brain by osmosis into the blood. 4) Cause dehydration of brain cells from potassium loss and osmotic diuresis.
pulls fluids from interstital spaces of brain by osmosis into the blood
A patient is hospitalized with a basilar skull fracture. The nurse notes clear drainage coming from his nose. What is the most appropriate nursing action at this time? Question 9 options: 1) Suction the nares gently to remove drainage. 2) Raise the head of the bed immediately. 3) Examine the sinuses for inflammation. 4) Obtain a culture of the drainage.
raise the head of the bed asap
A nurse is performing a neurological assessment on a child whose level ofconsciousness is variable and who has a cervical neck injury. Which of the following is the most essential in this assessment? Question 5 options: 1) Corneal reflex. 2) Reactivity of pupils. 3) Doll's eyes maneuver. 4) Oculovestibular response.
reactivity of the pupils
Which of the following Glasgow Coma Scale scores indicates to the nurse that the client's neurologic function is most severely impaired? Question 24 options: 1) Score of 15 2) Score of 11 3) Score of 7 4) Score of 3
score of a 3
A patient is admitted with right pupil dilation, weakness of arms and legs on the left and decreased level of consciousness. His family said he suffered a head injury 10 days ago but was released from the hospital and has been fine since then. These signs and symptoms are most characteristic of what type of injury? 1) Concussion 2) Cerebral laceration 3) Epidural hematoma 4) Subdural hematoma
subdural hematoma
A patient is just admitted with a concussion. Which of the following is the best description of a concussion? Question 5 options: 1) Petechial hemorrhages on skin at site of injury. 2) Visible bruising and tearing of cerebral tissue. 3) Sudden transient disturbance of neural function. 4) Injury on the side of the brain opposite the site of trauma.
sudden transient disturbance
Which of the following is the major cause of death in children with acute leukemia? 1) HF due to leukemic cells infiltrating the myocardium 2) Central nervous system involvement 3) Hemorrhage due to thrombocytopenia 4) Various types of infection
various types of infections
