UNIT 4 Evolve Questions

Damage to which cranial nerve may lead to decreased olfactory acuity? A. 1 B. 10 C. 5 D. 8

A

During an annual physical assessment, a client reports not being able to smell coffee and most foods. Which cranial nerve function would the nurse assess? A. 1 B. 2 C. 10 D. 7

A

In which position would the nurse place a client w/ a spinal cord injury experiencing autonomic dysreflexia? A. high fowler B. left side-lying C. right side-lying D. flat on the back

A

When performing an assessment, the nurse identifies that the client has a dilated R pupil. Which cranial nerve is likely to be involved? A. 3 B. 4 C. 2 D. 7

A

A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which area of paralysis would the nurse expect to find upon assessment? SELECT ALL THAT APPLY A. left leg B. Left arm C. right leg D. right arm E. left side of face

A, B, E

Which early sign of increased ICP would the nurse monitor in a client who sustained a head injury while playing soccer? A. nausea B. lethargy C. sunset eyes D. hyperthermia

B (change in lOC is the first signs of increased ICP) - sunset eyes and hyperthermia are late signs

Which assessment would the nurse perform specific to the safe administration of IV mannitol? A. body weight daily B. urine output hourly C. VS every 2 hours D. LOC every 8 hours

B (mannitol is an osmotic diuretic)

Which functions will the nurse assess when caring for a client w/ a head injury that involves the medulla? SELECT ALL THAT APPLY A. balance B. breathing C. HR D. fat metabolism E. temp regulation

B, C

Which assessment would the nurse include for a client w/ spine injuries who wears a body jacket brace? SELECT ALL THAT APPLY A. inspection of pin sites B. development of cast syndrome C. signs of compartment sysndrome D. auscultation for bowel sounds E. skin over the thoracic bony prominences

B, D, E

Which cranial nerves assist w/ both sensoty and motor function? SELECT ALL THAT APPLY A. optic B. facial C. trochlear D. accessory E. trigeminal

B, E

A client who recently experienced a brain attack (CVA) and has limited mobility reports constipation. Which is most important for the nurse to determine when collecting info about the constipation? A. presence of distention B. amount of high-fiber food consumed C. length of time this problem has existed D. extent of discomfort when attempting to defecate

C (find out last BM)

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. Which condition is indicated w/ this result? A. CF B. phenylketonuria C. down syndrome D. neural tube defect

D

Which priority intervention would the nurse perform immediately for a client w/ a spinal cord injury? A. monitor the urinary output B. assess for other injuries C. infuse LR solution D. immobilize and stabilize the cervical spine

D

Which clinical manifestation helps distinguish a myelomeningocele from a meningocele? A. enlarged head B. sac over the lumbar area C. affected lower extremities D. infection of the spinal fluid

C

Which clinical manifestation would the nurse expect to identify in a client experiencing spinal shock immediately after sustaining a functional transection of the spinal cord at C7-C8? SELECT ALL THAT APPLY A. spasticity B. incontinence C. flaccid paralysis D. respiratory failure E. lack of reflexes below the injury

C, E

A client w/ a head injury has a CT scan that shows a subdural hematoma. How would the nurse interpret this finding? A. blood within the brain tissue B. blood in the subarachnoid space C. blood between the dura and the skull D. blood between the dura mater and the arachnoid layer

D

The nurse performing a neuro assessment of an adolescent w/ a seizure disorder. Which action would the nurse take to test cranial nerve 11? A. by checking gag reflex B. by asking the adolescent to swallow C. by stroking the planter surface of the foot D. by telling the adolescent to shrug the shoulders

D

Which physiological response is the likely cause of a client developing hydrocephalus 2 weeks after cranial surgery for a ruptured cerebral aneurysm? A. vasospasm of adjacent cerebral arteries B. ischemic changes in the Broca speech center C. increased production of CSF D. blocked absorption of fluid from arachnoid space

D

Which education would the nurse provide the parent of a preschool child w/ a spinal cord injury about foods to avoid during prolonged bed rest to prevent complications w/ immobility? A. fish B. fruit C. beef D. cheese

D (will cause kidney stones)

Which test would the nurse expect to be prescribed for a client who is suspected to have an intracranial aneurysm? A. diffusion imaging B. MRI C. magnetic resonance angiography D. magnetic resonance spectroscopy

C

In which part of the brain would the nurse suspect the tumor is located when caring for a client admitted to the hospital w/ a suspected brain tumor w/ loss of equilibrium and coordination? A. cerebellum B. parietal lobe C. basal ganglia D. occipital lobe

A

Which care plan would the nurse implement for a 1 month old infant w/ hydrocephalus scheduled to have surgery for the insertion of a ventriculoperitoneal shunt? A. maintaining a satisfactory comfort level to limit crying B. applying bandages to the infant's head to protect it from injury C. establishing a fixed feeding schedule to ensure appropriate hydration D. providing play objects to maintain age-appropriate stimulation for the child

A (preventing crying will avoid sudden increases in ICP)

When assessing a client w/ a diagnosed "brain attack," the nurse evaluated the baseline VS of HR of 78 and a BP of 120/80. Which changes in the baseline VS indicate an increasing ICP? A. HR 50, BP 140/60 B. HR 56, BP 130/110 C. HR 60, BP 126/96 D. HR 120, BP 80/60

A (widened pulse pressure and decreased HR)

A client has inflammation of the facial nerve, causing facial paralysis on 1 side. Which diagnosis from the medical record is consistent with this finding? A. botulism B. bell palsy C. trigeminal neuralgia D. guillain-barre syndrome

B

A young adult client who has permanent paralysis secondary to a spinal cord injury says, "I wish God would end my suffering and take me." Which response would the nurse use? A. "you shouldn't give up hope; things can change" B. "being incapacitated is difficult for you" C. "Would you like to speak to a religious advisor?" D. "have you talked to your family about your feelings?"

B

For an unconscious child admitted to the PICU w/ a closed head injury, which action would the nurse establish as a primary goal for this child? A. prevent unnecessary trauma to the vital organs B. limit stimuli that increase ICP C. establish access routes for infusion of meds D. enhance health team's management of the illness

B

How would the nurse explain the cause of caput succedaneum in a newborn to the new mother? A. overlap of fetal bones as they pass thru the maternal birth canal B. swelling of the soft tissue of the scalp as a result of pressure during labor C. hemorrhage of ruptured blood vessels that does not cross the suture lines D. accumulation of fluid resulting from partial blockage of CSF drainage

B

Which clinical finding would the nurse recognize as a sign of neuro injury when assessing a 7-month-old injured in an automobile collision? A. babinski reflex B. persistent vomiting C. HR of 110 D. temp of 99.6

B

A toddler w/ a repaired myelomeningocele has urinary incontinence and some flaccidity of the lower extremities. Which education would the nurse provide the parent? A. an ileal bladder will be necessary once the child is of school age B. an indwelling catheter offers the best hope for bladder management C. the child will probably require a program of intermittent straight catheritization D. the child will have to wear diapers for many years b/c bladder training is a slow process

C

Which finding for a client w/ a head injury indicates increasing ICP? A. polyuria B. tachypnea C. increased restlessness D. intermittent tachycardia

C (indicates a lack of O2 to the brainstem, RR is decreased, HR will be slow and bounding)

Which equiptement would the nurse need to obtain to assess the client's vagus nerve (10)? A. tuning fork B. ophthalmoscope C. tongue depressor D. cotton ball

C (soft palate symmetry and gag reflex)

Which clinical indicator is commonly present in the assessment of a client w/ a ruptured cerebral aneurysm? A. tonic-clonic seizures B. decerebrate posturing C. narrowed pulse pressure D. sudden, sever headache

D

Which is the priority nursing intervention for a client admitted to the hospital w/ a cerebrovascular accident? A. changing position every 2 hours B. keeping a serial record of the pulse C. performing ROM exercises D. monitoring for increased ICP

D

Which mechanism of injury might be the reason for a suspected spinal cord injury w/ a direct injury to the vertebral column from a gunshot after a mass shooting? A. hyperflexion B. hyperextention C. excessive rotation D. penetrating trauma

D

Which parent education would the nurse provide the parents of an infant recently diagnosed w/ communicating hydrocephalus? A. "too much spinal fluid is being produced within the spaces (ventricles) of the brain" B. "the flow of spinal fluid thru the brain cells does not empty effectively into the spinal cord" C. "the spinal fluid is preserved from being adequately absorbed by a blockage in the spaces (ventricles) of the brain" D. "there is part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately"

D

Which action is the priority for a client who is admitted to the hospital w/ a severe head injury? A. maintain ventilation B. prevent contractures C. preserve skin integrity D. monitor BP

A

Which assessment finding in a child being monitored for a closed head injury would require the nurse to notify the HCP? A. vomiting B. pupils measuring 3 mm C. RR of 24 D. systolic BP falling below 110

A

Which clinical manifestation indicates a client who sustained head and chest injuries from a motor vehicle accident, responded to medical treatments, and is ready for transfer to a critical care unit? A. stabilized VS and complaints of pain B. pale and alert; remains restless C. increasing temp and apprehension D. fluctuating VS and drowsy, but easily roused

A

Which explanation would the nurse provide family members who ask the meaning of their loved one's diagnosis of "paraplegia" after experiencing a spinal cord injury? A. the client's LE are paralyzed B. the client's UP are paralyzed C. one side of the client's body is paralyzed D. both UE and LE are paralyzed

A

Which intervention would the nurse perform first for the client admitted w/ a closed head injury and increased ICP? A. place the head and neck in neutral alignment B. obtain a prescription for 100 mg of pentobarbital IV C. administer 1 g mannitol IV as prescribed D. increase the ventilator's RR to 20

A

Which position would the nurse use for an infant after the insertion of a ventriculoperitoneal shunt for hydrocephalus? A. supine on the unaffected side B. side-lying on the affected side C. head elevated at 45 degrees on the affected side D. head elevated at 90 degrees on the unaffected side

A

Which potential complication may occur early in the recovery period when providing care for a client w/ paraplegia secondary to a spinal cord injury? A. impairment of bladder control B. inadequacy of nutritional intake C. insufficient quadriceps setting D. unskillful use of aids for ambulation

A

Which part of the brain controls the respiratory patterns of a child? A. medulla B. cerebellum C. hypothalamus D. cerebral cortex

A - cerebellum controls skeletal muscles -hypothalamus links the nervous system to the endocrine system and functions as a relay station between the cerebral cortex and lower autonomic centers

Which condition would the nurse suspect when assessing a client who was admitted w/ a head injury and is unable to understand written or verbal speech? A. aphasia B. dysarthria C. borborygmia D. dysphagia

A -dysarthria = difficulty speaking

Which assessment is the priority after checking airway for a client w/ a cervical spinal cord injury? A. LOC B. sensory perception in all extremities C. presence and location of diaphoresis D. VS and O2 assessment

A (LOC as part of GCS)

Which clinical assessment would the nurse perform to evaluate the effectiveness of a shunt for an infant w/ hydrocephalus? A. palpating the anterior fontanel B. determining the frequency of voiding C. assessing the child for periorbital edema D. assessing the symmetry of the Moro reflex

A (a bulging fontanel is the most significant sign of increased ICP in an infant)

3 days after admission to the hospital for a brain attack (CVA), a client has a NG tube inserted and is receiving continuous tube feedings. Which action would the nurse take to evaluate whether the feeding is being absorbed? A. aspirate for residual volume B. evaluate the intake in relation to the output C. instill air into the client's stomach while auscultating D. compare the client's body weight w/ the baseline data

A (a gastric residual of more than 200 mL or as specified by the PCP will alert the nurse that the feeding is not being absorbed)

Which exercise would the nurse teach a client who has a spinal cord injury at the T4 level and wants to use a wheelchair? A. push-ups to strengthen arm muscles B. leg lifts to prevent hip contractures C. balancing exercises to promote equilibrium D. quadriceps-setting exercises to maintain muscle tone

A (arm strength is necessary for transfers and activities of daily living and for use of crutches or a wheelchair)

Which condition causes impaired speech coordination? A. cranial nerve lesion B. occipital lobe lesion C. parietal cortex lesion D. limbic lobe lesion

A (cranial nerves are responsible for speech coordination) - parietal cortex lesions interfere w/ spacial and body positioning perception - limbic lesions could interfere w/ emotions, learning, and memory

Which explanation would the nurse provide to the client about transient ischemic attacks (TIAs)? A. temporary episodes of neurologic dysfunction B. intermittent attacks caused by multiple small clots C. ischemic attacks that result in progressive neuro deterioration D. exacerbations of neuro dysfunction alternating w/ remissions

A (narrowing of arteries supplying the brain causes temporary neuro deficits that last for a short period)

Which nursing action would be a priority for a client w/ a spinal cord injury who has development sudden autonomic dysreflexia? A. place in a sitting position B. give nifedipine as prescribed C. examine for symptoms of pressure injuries D. monitor BP every 10-15 minutes

A (naturally decreases BP)

For which client condition would the nurse stabilize the cervical spine as the priority nursing intervention? SELECT ALL THAT APPLY A. flail chest B. head injuries C. facial chemical burn D. renal colic pain E. blunt abd pain

A, B, C (all pts with face, head or neck injuries, pt may have respiratory distress)

Which clinical indicators would the nurse consider evidence of increasing ICP? SELECT ALL THAT APPLY A. vomiting B. irritability C. hypotension D. increased RR E. decreased LOC

A, B, E

Of which cranial nerve does the nurse assess the function when asking the client to shrug their shoulders and to turn their head against passive resistance? A. nerve 2 B. nerve 11 C. nerve 6 D. nerve 7

B

The nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehab will be effective for this client? A. arrangements will be made by the client and the client's family B. the plan is formulated and implemented early in the client's care C. the rehab is minimal and short-term, because the client will return to former activities D. arrangements will be made for long-term care, because the client is no longer capable of self-care

B

When performing an assessment of a client's trigeminal nerve function, how would the nurse identify function of this nerve? A. observing pupil constriction B. identifying corneal sensation C. determining the ability to smell D. determining the ability to shrug the shoulders

B

Which info would the nurse include when explaining the cause of transient ischemic attacks (TIAs) to a client? A. genetic valvular heart disease B. atherosclerotic plaques within arteries C. developmental defects in arterial walls D. emboli ascending from the lower extremities

B

Which structure is likely damaged in a client w/ a head injury whose temp rapidly increases to 102.2? A. thalamus B. hypothalamus C. temporal lobe D. globus pallidus

B

While providing care for a client who sustained a severe head injury in an accident, the nurse observes the client is constantly passing urine and dehydrated. Which condition would the nurse suspect as the cause of the client's condition? A. decreased secretion of aldosterone B. decreased secretion of ADH C. decreased secretion of PTH D. decreased secretion of ANP

B

Which client condition requires a medium priority of care according to the National Institutes of Health Stroke Scale (NIHSS) score? A. visual score of 3 B. facial palsy score of 1 C. LOC score of 0 D. motor and drift of each extremity score of 4

B -visual score of 3 may be blind = high priority - LOC score of 0 = stable - motor and drift of each extremity score of 4 = no movement and requires an emergent priority

A client who sustained a head injury reports to the nurse that food always tastes unappealingly bland even tho the food has been prepared to be flavorful. Which area of the brain would the nurse suspect to be affected in the client? A. frontal lobe B. parietal lobe C. occipital lobe D. temoral lobe

B -parietal lobe= taste, spacial perception, and understanding of sensory inputs - frontal lobe= voluntary eye movement, access to current sensory data, affective response to a situation, ability to develop long-term goals, and ability to reason and concentrate - occipital lobe= vision - temporal lobe= hearing

A child loses consciousness a few days after a traumatic head injury that resulted in a subdural hematoma. While assessing extraocular movements, the nurse notes the child is displaying the oculocephalic reflex. Which conclusive response to the presence of the oculocephalic reflex is an unconscious child would the nurse have? A. unusual B. expected C. suppressed D. hyperactive

B (this reflex indicates the functional integrity of the brainstem in unconscious individuals)

Whihc components would the nurse encourage the parent to increase in the diet of a 4 year old child w/ spina bifida who spends many hours in a wheelchair? SELECT ALL THAT APPLY A. fat B. fiber C. protein D. calories E. carbs

B, C (fiber to prevent constipation, protein for muscle mass and to prevent pressure ulcers)

A client is admitted to the hospital after sustaining a head injury. Which assessment finding indicates increased ICP? A. rise in RR B. narrowing of pulse pressure C. decrease in the LOC D. increase in the diastolic BP

C

A client whose spinal cord was severed in an accident 1 month ago asks the nurse what is causing the severe leg spasms. Which response would the nurse make? A. "you have developed thrombophlebitis, which causes pain" B. "motor function is returning now that the edema is subsiding" C. "spinal shock has subsided, and you reflexes are hyperactive" D. "the nerves are regenerating, and your motor function is returning"

C

The implementation of which maneuver would benefit a motor vehicle accident client who is chocking and may have a spinal cord injury? A. vagal B. valsalva C. jaw-thrust D. oculocephalic

C

Which client finding are consistent w/ a recent complete transection of the spinal cord? A. impaired voluntary movements, paralysis on 1 side B. loss of pain sensation, weakness of all extremities C. muscle tone and contractility absent, paralysis of all extremities D. difficulty in swallowing, paralysis of eye muscles

C

Which mechanism of action is responsible for the therapeutic effects of mannitol prescribed for a client w/ a head injury? A. decreasing the production of CSF B. limiting the metabolic requirements of the brain C. drawing fluid from brain cells into the bloodstream D. preventing uncontrolled electrical discharges in the brain

C

Which radiologic study is used to obtain three-dimensional brain images? A. electromyography B. cerebral angiography C. CT D. transcranial doppler

C

Which rationale explains why fluid intake would be increased for a client who has quadriparesis from a spinal cord injury/ A. to prevent dehydration B. to maintain electrolyte balance C. to prevent a UTI D. to limit an increase in temp

C

Which response would the nurse give when a client w/ syncope from a vagal response asks why it is important to avoid bearing down during bowel movement? A. "straining can decrease blood flow to you brain b/c it is filling hemorrhoids" B. "trouble moving your bowels is stressing your heart and may lead to a heart attack" C. "bearing down stimulates a nerve response that decreases you HR and BP" D. "difficulty w/ a bowel movement means you are dehydrated, which causes low BP"

C

Which possible cause would the nurse suspect in a client w/ a head injury who has a fixed, dilated R pupil, responds only to painful stimuli, and exhibits flexion (decorticate) posturing? A. meningeal irritation B. subdural hemorrhage C. cerebral compression D. medullary compression

C - medullary compression results in alterations in VS

Which action would the nurse take when a client who sustained a closed head injury being monitored for increased ICP and the results of ABGs include PCO2 of 33? A. suction the client's orophrynx B. encourage the client to slow the breathing rate C. continue to monitor the signs of increased ICP D. notify the HCP that the client needs more oxygen

C (a lower than expected PCO2 actually will benefit the pt because it reduces ICP by preventing vasodilation)

Which complication would the nurse monitor in a client who sustained a transection of the spinal cord, but no other injuries? A. hemorrhage B. hypovolemic shock C. GI atony D. autonomic hyperreflexia

D

Which description of myelomeningocele is accurate? A. it is a fusion failure of the vertebral arches w/o herniation of cord or meninges B. there is a defect in the base of the skull thru which the brain and meninges have herniated C. a membrane-covered sac of meninges, filled w/ spinal fluid, is protruding thru a defect in the spine D. a saclike cyst of meninges, containing a portion of spinal cord and fluid, is protruding thru a defect in the spine

D

Which instruction would the nurse give the client when assessing for damage to the glossopharyngeal and vagus nerve? A. smile B. shrug C. smell D. swallow

D

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the ED to a neuro trauma unit? A. notifying the receiving unit of the transfer B. having the client's records ready for the transfer C. verifying that the family has been notified of the transfer D. validating availability of a bag-valve-mask during the transfer

D

Which nursing intervention would the nurse implement for an infant during the first 24 hours after surgery to place a ventriculoperitoneal shunt for hydrocephalus? A. placing in the high fowlers position B. administering the prescribed sedative C. positioning on the same side as the shunt D. monitoring for increasing ICP

D

Which intervention would the nurse perform first for a client w/ a spinal cord injury who is experiencing autonomic dysreflexia? A. assess for the cause B. place the client in sitting position C. check the client for fecal impaction D. give an alpha blocker prophylactically

B

When a client is admitted to the ED w/ a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? SELECT ALL THAT APPLY A. bradycardia B. hypotension C. spastic paralysis D. urinary retention E. increased pulse pressure

A, B, D (deceased pulse pressure)

The nurse identifies which anti-coagulant meds as safe to administer during pregnancy for tx of thrombophlebitis? SELECT ALL THAT APPLY A. heparin B. warfarin C. enoxaparin D. clopidogrel E. acetylsalicylic acid

A, C (warfarin crosses the placental barrier)

A nurse is assessing a newborn w/ myelomeningocele. Which clinical finding prompt the nurse to suspect hydrocephalus? SELECT ALL THAT APPLY A. bulging fontanels B. high-pitched crying C. apgar score of less than 5 D. a defect in the lumbosacral area E. head circumference 2 cm greater than the chest circumference

A, B, D

Which problem would the nurse rank as high priority when planning care for a group of clients? SELECT ALL THAT APPLY A. knowledge deficit r/t new meds prescribed B. complaints of chest pain following ambulation in the hallway C. decreased levels of consciousness after an automobile accident D. coughing and performing deep-breathing exercises after a surgical procedure E. respiratory depression after narcotic pain medication administration

B, C, E

Which cranial nerve would the nurse assess further if the client cannot close the right eye? A. 10 B. 4 C. 2 D. 7

D (controls the eye blink)

Which nursing action is essential when a client experiences hemianopsia as the result of a L ischemic stroke? A. place objects within the visual field B. teach passive ROM exercises C. instill artificial teardrops into the affected eye D. reduce time client is positioned on the L side

A (hemianopsia is loss of vision in half of eyes, in this situation the R visual field of each eye)

Which complication would the nurse anticipate when planning care for a client who is admitted w/ a crushing injury to a spinal cord at the level of phrenic nerve origin? A. prolonged coma B. v-fib C. diaphragmatic paralysis D. vagus nerve dysfunction

C

The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve 7. Which condition would the nurse observe upon assessment? A. inhibition of tear production B. inhibition of peripheral vision C. inhibition of eye movement D. inhibition of pupil constriction

A

When the nurse is developing educational programs for parents of younger school-age children to promote safety, which info would the nurse include that would be appropriate for this age group? A. use a helmet when bike riding B. place locks on cabinets C. refrain from alcohol use D. install front-facing car seats

A

Which action would be implemented when the nurse finds a victim under the wreckage of a collapsed building and the individual os conscious, supine, breathing satisfactory, and reports experiencing back pain and an inability to move the legs? A. leave the individual lying on the back w/ instructions not to move, and seek additional help B. roll the individual onto the abdomen, place a pad under the head, and cover w/ any material available C. gently raise the individual to a sitting position to determine whether the pain either diminishes or increases in intensity D. gently lift the individual onto a flat piece of lumber and, using any available transportation, rush to the closest medical institution

A

Which assessment finding strongly indicates cerebral injury and warrants further evaluation of an 8-month-old client? A. significant head lag B. posterior fontanel closure C. short neck w/ skinfolds between the head and shoulders D. the head held to one side w/ the chin pointing toward the opposite side

A

Which assessment findings alert the nurse that the client who has a spinal cord injury is developing autonomic hyperrflexia (autonomic dysreflexia)? A. HTN and bradycardia B. flaccid paralysis and numbness C. absence of sweating and pyrexia D. escalating tachycardia and shock

A

Which class of medication would a nurse expect to be prescribed to prevent the development of cerebral edema after craniotomy to remove a brain tumor? A. glucocorticoids B. anti-cholinergics C. anti-convulsants D. anti-HTN

A

Which client is suspected to have sustained injury to cranial nerve 3? A. drooping eyelids B. nearsightedness C. cross-eyed D. protruding eyes

A

Which intervention is a priority when caring for a child who sustained a head injury 12 hours earlier? A. assessing the LOC every hour B. promoting rest by fostering a quiet environment C. asking about the circumstances that led to the injury D. administering the prescribed opioid for complaints of a headache

A (evidence of subdural hemorrhage may take hours or days to develop)

Which intervention would the nurse provide the parents of an infant w/ myelomeningocele to facilitate the parent-child relationship during the pre-op period? A. encouraging the parents to stroke their infant B. allowing the parents to hold their infant in their arms C. referring the parents to the spina bifida association of america D. teaching the parents to use special techniques when feeding the infant

A (infant can't be held)

A client who has severe back pain is found to have a vertebral compression fracture. Which cause of fracture would the nurse consider when planning interventions? A. collapse of the vertebral bodies B. demineralization of the spinal cord C. wear and tear of the spinous processes D. bulging of the spinal cord from the vertebra

A (osteoporotic vertebrae collapse under the weight of the upper body or by improper or rapid turning, reaching, or lifting)

Which action would the nurse take when a young man who sustained a spinal cord injury at the cervical level expresses concern about future sexual function? A. explain to the client that he will likely be able to have reflex penile erections B. reassure the client that he will be able to have sexual intercouse and reproduce C. arrange for the client to be informed by the HCP that sexual performance is unlikely D. discourage the client from forming sexual relationships because little pleasure will be possible

A (the reflex arc for sexual activity is intact; the control of ejaculation is not)

Which action would the nurse include in the plan of ace for a client who had an ischemic stroke caused by a-fib and has been placed on anti-coagulantion therapy to prevent further strokes from occurring? SLECT ALL THAT APPLY A. wearing a medical alert bracelet B. initiating bleeding precautions C. refraining from estrogen therapy D. obtaining routine prothrombin times E. notify PCP of anticoagulation

A, B, C, D, E

Which safety topic would the nurse include when providing info to parents of an 8-year-old regarding bicycle safety? SELECT ALL THAT APPLY A. helmet use B. hand signals C. crossing signs D. reflective lights E. close-toed shoes

A, B, C, D, E

Which assessment finding indicates that a client has had a stroke? SELECT ALL THAT APPLY A. lopsided smile B. unilateral vision C. incoherent speech D. unable to raise right arm E. symptoms started 2 hours ago

A, B, C, D, E (acronym FAST= facial drooping, arm weakness, speech difficulties, time) - unilateral vision loss can also signify stroke

Which assessments would the nurse include in a focused assessment for a client who has sustained a head injury? SELECT ALL THAT APPLY A. HR B. Carotid pulse strength C. inspection of the oral cavity D. deep tendon reflexes E. pulse pressure F. LOC

A, C, E, F (slowed HR, increased pulse pressure, altered LOC, bleeding in oral cavity)

Which parent teaching would the nurse provide about signs of shunt failure in a 4 month old infant w/ a ventriculoperitoneal shunt? SELECT ALL THAT APPLY A. vomiting B. dehydration C. sunken eyeballs D. distended fontanels E. abdominal distention

A, D (vomiting and bulging fontanels are signs of increased ICP)

Which education would the nurse provide the parent of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus? A. the prognosis is excellent, and the valve is permanent B. the shunt may need to be replaced as the child grows older C. if any brain damage has occurred, it is irreversible even after the first year of life D. hydrocephalus usually is self-limiting by 2 years of age, and then the shunt is removed

B (shunts are updated, with the length of tubing increased as the child grows)

The nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Which statement explains the nurse's rationale? A. deep tendon reflexes has been lost B. there is partial transection of the cord C. there is damage above the 6th thoracic vertebra D. flaccid paralysis of the lower extremities has occurred

C

When providing care for a client w/ a traumatic brain injury and increased intracranial pressure, which HCP prescription would the nurse question? A. continue anti-convulsants B. teach isometric exercises C. continue osmotic diuretics D. keep HOB at 30 degrees

B (increase basal metabolic rate and intracranial pressure)

Which intervention would the nurse plan for a client who has a head injury and a diminished corneal reflex in the left eye? A. irrigating the eye routinely B. instilling artificial tears frequently C. checking the corneal reflex hourly D. taping the eyelids open during the day

B (prevents drying of the cornea)

What is the purpose of placing a child in cervical traction after sustaining a fractured cervical vertebra? A. hyperextending the neck maintains an open airway B. flexing the head prevents stretching of the neck muscles C. immobilizing the area minimizes injury to the spinal cord D. aligning the body allows for CSF to encircle the spinal cord

C

When using the GCS, which consideration would the nurse make when evaluating a 3 year old child w/ a head injury? A. can they state name and address B. are they able to clearly state the time and place C. they may not respond to strangers asking questions D. they should be assessed without the parents present

C

The nurse in the ED is caring for a 9-year-old child w/ a suspected spinal cord injury sustained while falling off a bicycle. Which initial action should the nurse take? A. placing the child's head on a pillow for support B. immobilizing the child's spine to limit additional injury C. logrolling the child to check for lacerations on the back D. moving the child onto a firm stretcher for transport to the radiology department

B

Which eye movement is controlled by cranial nerve 6? A. levator B. lateral rectus C. medial rectus D. superior oblique

B

Which parent education about skin care would the nurse provide to the parents of an infant w/ spina bifida? A. diapers should be changed at least every 4 hours B. frequent diaper changes w/ cleansing are needed C. medicated ointment should be applied 6 times a day D. powder may be used in the perineal area when it becomes wet

B

Which possible complication would the nurse monitor for when a client develops a venous thrombosis in the left calf? A. embolic stroke B. PE C. MI D. ischemia of the L foot

B

Which rationale explains why the nurse would monitor a client who has a spinal cord injury at the T2 level for signs of autonomic hyperrflexia (autonomic dysrflexia)? A. the injury results in loss of the reflex arc B. the injury is above the 6th thoracic vertebra C. there has been a partial transection of the cord D. there is a flaccid paralysis of the lower extremities

B

Which action would the nurse include when preparing a toddler with the diagnosis of hydrocephalus for a CT scan? A. shaving the head B. administering the prescribed sedative C. starting the prescribed IV infusion D. giving the child a simple explanation of the procedure

B (a toddler may not be able to follow directions and may be scared of the equipment so sedatives are usually prescribed)

Which action would the nurse be responsible for during a lumbar puncture procedure for an 18-month-old toddler? A. coaching the parent to hold the child in their arms B. keeping the child immobilized w/ restraints C. collecting the aspirated drainage in a culture tube D. maintaining the continuous flow of local anesthetic

B (child needs to be in restraints, no continuous anesthesia needed)

Which early sign of impending hydrocephalus would the nurse monitor for in an infant who has had surgery for repair of a myelomeningocele? A. frequent crying B. bulging fontanels C. change in VS D. difficulty w/ feeding

B (frequent crying may be a typical patterns for the neonate; it does nor, in and of itself, indicate changes in ICP)

Which early clinical manifestation of meningeal irritation would the nurse assess in a client w/ head trauma? A. sunset eyes B. kernig sign C. planter reflex D. homans sign

B (inability to completely extend the legs--classic sign of meningeal irritation)

The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for hydrocephalus are taught about post-op positioning that helps prevent pressure on the valve site. Which statement indicates that they understand the teaching? A. "we'll place her in the position that seems comfortable" B. "the flat left side-lying position is the safest position for our baby" C. "we should place her on her back w/ a small support under the neck" D. "the right side-lying position w/ the head supported is the best position"

B (side lying on the unaffected side helps prevent pressure against the valve)

Which nursing intervention would the nurse perform immediately for the client w/ a head injury and a GCS score of 9? A. intubate the client B. stabilize the cervical spine C. administer O2 via a nonrebreather mask D. control external bleeding w/ a sterile pressure dressing

B (will maintain the airway, O2 after stabilized cervical spine)

Which aspect would the nurse assess to determine whether intracranial pressure is increased around the medulla? SELECT ALL THAT APPLY A. taste B. breathing C. HR D. fluid balance E. voluntary movement

B, C -parietal cerebral lobe --> taste sensations -somatomotor area of the cerebral cortex --> voluntary movements

When monitoring a client for hyponatremia, which assessment findings would the nurse consider significant? SELECT ALL THAT APPLY A. thirst B. seizures C. erythema D. confusion E. constipation

B, D

Which info would be included when teaching the parent of a newborn about automobile infant restraint systems? SELECT ALL THAT APPLY A. use a forward-facing infant car seat B. secure the infant seat so that it faces the rear C. position the seat between the driver's and passenger's seats in the front seat D. follow the manufacturer's directions to secure the infant seat in the back seat E. be sure to follow weight guidelines set forth in the manufacture's instructions

B, D, E

Which action would the nurse take for a client who underwent cerebral angiography? SELECT ALL THAT APPLY A. wipe off the gel applied before the test B. maintain pressure dressing for 2 hours C. remove the electrodes gently and thoroughly D. obtain VS and complete neuro checks E. check dressing for bleeding and swelling around the site

B, D, E - gel and electrodes for EEG

During a lumbar puncture procedure for confirming of bacterial meningitis, the nurse notes that the infant's spinal fluid is cloudy. The nurse recalls this info indicates which result? A. healthy spinal fluid B. increased glucose level C. increased WBC count D. rising number of RBCs

C

During the immediate post injury period, which action is the priority focus of nursing care for a client w/ a spinal cord injury? A. inhibiting UTI B. preventing contractures and atrophy C. avoiding flexion or hyperextension of the spine D. preparing the client for vocational rehab

C

In which position would the nurse place a client who sustained a back injury? A. lateral position w/ a pillow between the knees B. any position that reduces pain and is comfortable C. supine position while not allowing the spine to flex D. sitting position w/ a pillow placed in the small of the back

C

The nurse explains to the pregnant client that the serum alpha-fetoprotein test screens for which condition? A. trisomy 21 B. turner syndrome C. open neural tube defects D. chromosomal aberrations

C

Which intervention would the nurse implement immediately for an alert and oriented client who arrived at the ED after a head injury that occurred while playing basketball? A. assess full ROM to determine extent of injuries B. call for immediate head CT C. immobilize the client's head and neck D. open the airway w/ the head-tilt chin-lift maneuver

C

Which intervention would the nurse include in the plan of care after the closure of a newborn's myelomeningocele? A. limiting leg movement B. decreasing environmental stimuli C. measuring head circumference daily D. monitoring for serous drainage from the nares

C

Which nursing action would have the highest priority when the nurse is moving a client w/ a neck and spinal cord injury during the assessment process? A. removing the cervical spine collar B. monitoring for autonomic dysreflexia C. implementing the logrolling technique D. administering the prescribed pain meds

C

Which preventative would the nurse anticipate will be prescribed daily to avoid straining due to constipation for a client who has had a recent brain attack (cerebrovascular accident/stroke)? A. stimulant laxatives such as bisacodyl B. tap-water enemas C. stool softener D. saline laxatives such as magnesium citrate

C

the nurse in an ED is assessing a young child w/ a head injury. The child is accompanied by a parent. Which observation would prompt the nurse to assess the child for abuse? A. the child has mongolian spots on the back B. the child belongs to a single-parent family C. the child has received care for injuries twice earlier D. the child and parent narrate the same story about the injury

C

A client who sustained injury reports bland taste of food. upon examination, the nurse finds that there is loss of taste perception from the anterior 2/3 region of the tongue. Which origin of the brain is associated w/ the involved nerve? A. medulla B. midbrain C. inferior pons D. cerebrum

C - medulla= glossopharyngeal, vagus, accessory, and hypoglossal nerves - midbrain= optic and oculomotor nerve - cerebrum= olfactory nerve

2 weeks after sustaining a spinal cord injury, a client begins vomiting thick, coffee-ground material and appears restless and apprehensive. Which is the most important initial nursing action? A. change the client's diet to bland B. obtain a stool specimen for occult blood C. prepare for insertion of a NG tube D. monitor recent lab reports for HGB levels

C (NG tube will keep the stomach depressed)

Which of these clients in the ED would the nurse see first? A. a client w/ a head injury B. a client w/ a fractured femur C. a client w/ v-fib D. a client w/ a penetrating abd wound

C (can cause irreversible brain damage and then death in minutes)

Which action would the nurse take for a client who sustained a head injury from a fall off a ladder and has a clear fluid leaking from the left ear? A. position the client turned on the right side B. irrigate the ear canal with a syringe of saline C. test the ear drainage with glucose reagent strip D. pack sterile cotton in the external canal of the L ear

C (could be CSF)

Damage to which nerve explains why a client recovering from a head injury is unable to move the tongue? A. facial B. trigeminal C. hypoglossal D. glossopharyngeal

C (cranial nerve 12)

An infant has noncommunicating hydrocephalus, and a ventriculoperitoneal shunt is inserted. Which nursing intervention would the nurse implement for the infant during the initial post-op period? A. change the dressing when soiled B. offer the infant fluids to increase fluid intake C. place the infant flat w/ the head of the unaffected side D. encourage the parents to hold their infant to help prevent crying

C (dressing changed by HCP)

The nurse is assessing a client who has a head injury. Which movement of the client's arm after the nurse applies nail bed pressure would cause the most concern? A. flexing B. localizing C. extending D. withdrawing

C (greater cerebral injury leads to less purposeful movement)

Which intervention would be a priority for the nurse to include in the plan of care for a client w/ a gunshot wound who has severe hemiplegia associated w/ abnormal body posturing and fixed and dilated pupils? A. monitoring skin integrity B. monitoring bowel patterns C. monitoring RR D. monitoring nutritional status

C (hemorrhagic shock , clients who sustained a stroke ate vulnerable to airway obstruction which result in respiratory problems)

The client with which National Institutes of Health Stroke Scale (NIHSS) score would the receive priority nursing care first? A. 0 for dysarthria B. 1 for limb ataxia C. 3 for facial palsy D. 0 for LOC

C (high score = bad)

2 days after birth a neonate's head circumference is 16 inches (41 cm) and the chest circumference is 13 inches (33 cm). Which condition is the nurse concerned about based on these measurements? A. microcephaly B. narrow chest C. enlarged head D. expected head size

C (may indicate hydrocephalus)

Which assessment finding is associated with cranial nerve dysfunction after carotid endarterectomy? A. labored breathing B. edema of the neck C. difficulty in swallowing D. alteration in BP

C (nerves 9 and 10)

Which finding would the nurse expect when assessing a client who has a vertebral fracture at the T1 level? A. difficulty breathing B. inability to move the lower arms C. normal biceps reflexes in the arms D. loss of pain sensation in the hands

C (nerves for arm innervation are at C4)

Which condition would the nurse suspect in an ED client w/ C8 tetraplegia, BP 80/40, HR 48 bpm, RR 18? A. autonomic dysreflexia B. hemorrhagic shock C. neurogenic shock D. PE

C (s/s of neurogenic chock are hypotension, bradycardia, warm/dry skin) - HTN, bradycardia, flushing, nd sweating w/ autonomic dysreflexia

Which clinical manifestation would the nurse identify as an indicator suggesting a client has urinary retention and overflow after sustaining a CVA? SELECT ALL THAT APPLY A. edema B. polyuria C. frequent voiding D. suprapublic distention E. continual incontinence

C, D (with retention the total amount of urine produced is unaffected)

Which intervention would the nurse anticipate as the priority focus of care after the ED received a client who was a passenger in an automobile collision, w/ rhinorrhea and bleeding from the ear and a suspected basilar head injury? A. PT B. psychosocial support C. nutritional management D. anti-microbial administration

D (preventing infection is the initial priority)

Which behavior would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain? SELECT ALL THAT APPLY A. impaired judgement B. spatial-perceptual deficits C. slow performance and caution D. impaired speech/language aphasias E. tendency to deny or minimize problems F. awareness of deficits w/ depression and anxiety

C, D, F

After a head injury, client reports hearing ringing noises. Which area would the nurse assess further? A. frontal lobe B. occipital lobe C. 6th cranial nerve (abducens) D. 8th cranial nerve (vestibulocochlear)

D

The parents of a toddler w/ a R ventriculoperitoneal (VP) shunt for the tx of hydrocephalus are taught about post-op positioning. The nurse concludes that they understand the teaching when they state that they will place the toddler in which position? A. in the position that provides the most comfort B. on the back w/ a small support beneath the neck C. on the abdomen w/ the head turned to the left side D. flat on the left side w/ the head and back supported

D

Which health problem history would increase an older adult's r/f experiencing a cerebrovascular accident (CVA)? A. glaucoma B. hypothyroidism C. continuous nervousness, stress D. transient ischemia attacks (TIAs)

D

Which response would alert the nurse that a client w/ a spinal cord injury is developing autonomic dysreflexia? A. flaccid paralysis and numbness B. absence of sweating and pyrexia C. escalating tachycardia and shock D. paroxysmal HTN and bradycardia

D

Which tx would the nurse be referring to when explaining to a client w/ trigeminal neuralgia that tx is effective on a temporary (6 to 18 month) basis? A. weekly IV injections of cobra venom B. a lidocaine injection at the ventral root of the 11th spinal nerve C. microvascular decompression of the blood vessels at the nerve root D. an alcohol injection at the peripheral branch of the 5th cranial nerve

D

A client who sustained head injuries is admitted to the hospital. During assessment of cranial nerves, the nurse notices that the client lost the perception of taste, especially in the anterior portion of the tongue. Which cranial nerve might have been injured in this client? A. nerve 10 B. nerve 9 C. nerve 12 D. nerve 7

D (7 deals with the anterior two-thirds of the tongue) -12 deals with improper movements of the tongue

Which position would the nurse select for an infant w/ hydrocephalus? A. on either side and supine B. supine and transdelenburg C. prone, w/ the legs elevated about 30 degrees D. supine, w/ the head elevated about 45 degrees

D (HOB should be elevated because gravity minimizes ICP)

Which problem is the nurse trying to prevent by encouraging a client w/ a spinal cord injury to increase oral fluid intake? A. dehydration B. skin breakdown C. electrolyte imbalances D. UTI

D (clients in the early stages of spinal cord damage experience an atomic bladder which leads to UTI)

When the nurse tries to bathe a young client w/ a spinal cord injury who has an incontinence episode the client says, "Leave me alone. Having you care for me is worse than lying in this mess." Which response is the best? A. "do you want me to get someone else to change you?" B. "you shouldn't be embarrassed; this is part of my job" C. "i'll be back in a little while; why don't you rest until then?" D. "during the bath, i'll start teaching you about bowel training"

D (delaying care can lead to skin breakdown and infection)

Which assessment would the nurse perform to monitor for a major complication in an infant after surgery to correct a myelomeningocele? A. daily weights B. fluid output every 8 hours C. BP every 12 hours D. daily head circumference measurements

D (hydrocephalus is a major complication of myelomeningocele)

Which part of the brain would the nurse suspect is injured in a client w/ a head injury whose temp assessments do not correspond w/ the client's condition? A. pons B. medulla C. thalamus D. hypothalamus

D (hypothalamus controls temp) -pons controls LOC -thalamus controls motor and sensory functions

An infant born w/ hydrocephalus will be discharged after insertion of a ventriculoperitoneal shunt. Which common complication would the nurse instruct the parents to report if it occurs at home? A. visibility of the sclerae above the irises B. violent involuntary muscle contractions C. excessive fluid accumulation in the abd D. fever accompanied by decreased responsiveness

D (infection)

Which short-term goal would a nurse develop when planning care for a client 1 week after the client experienced a spinal cord injury at the T3 level? A. "the client will understand limitations" B. "the client will consider lifestyle changes" C. "the client will perform independent ambulation" D. "the client will carry out personal hygiene activities"

D (other options are longer-term goals)

Which intervention and rationale would the nurse plan for a client admitted to the hospital w/ a right-sided cerebrovascular accident (CVA)? A. apply elastic stockings to prevent flaccid leg muscles B. use a bed cradle to prevent dorsiflexion of the feet C. implement ROM exercises to prevent muscle atrophy D. use a hand roll and support the left arm on a pillow to prevent contractures

D (passive ROM prevent contractures not muscle atrophy, it can also cause increased ICP)

A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects to react to which clinical manifestation? A. v-fib and decreased perfusion B. dysfunction of the vagus nerve w/ hiccups C. retention of sensation but paralysis of the lower extremities D. respiratory paralysis and cessation of diaphragmatic contractions

D (phrenic nerve works with the diaphragm)

Which part of the brain contains the "central switchboard" of the central nervous system (CNS)? A. cerebrum B. brainstem C. cerebellum D. diencephalon

D (the thalamus is considered to be the major rely station or "central switchboard" for the CNS)

Which education would the nurse provide the parent of a preschool-aged child regarding injury prevention? A. "preschool-aged children are more prone to falls than toddlers" B. "preschool-aged children are at r/f injury b/c of their poor gross motor skills" C. "preschool-aged children are less likely to follow rules, which increases the r/f injury" D. "preschool-aged children are at r/f head injuries from riding a tricycle or balance bike"

D (use helmets)

For which reason would a lumbar puncture (LP) be performed on a client? SELECT ALL THAT APPLY A. confirming spinal cord injuries B. assessing sensory nerve probelms C. measuring blood flow in many areas D. reading CSF pressure E. injecting contrast medium for diagnostic study

D, E

Which condition poses an increased r/f injury for an adolescent? SELECT ALL THAT APPLY A. poisoning B. abduction (stealing child) C. home accidents D. substance abuse E. motor vehicle accidents

D, E - poisoning and abduction for toddlers and preschoolers - home accidents for toddlers