H & I Exam 3
A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The healthcare provider calls and asks for a report on the client's condition. Based on the documentation below, how would the nurse respond? 0800: ICP 20 1000: ICP 20 1300 ICP: 20 "The client's ICP remains elevated." "The client's ICP has decreased to lower than normal limits." "The client's ICP is within normal limits." "The client's ICP was elevated but now has returned to normal."
"The client's ICP remains elevated."
A 6-year-old patient weighing 54lbs is getting IV phenytoin slow infusion over 20 minutes for ongoing seizures. The order is for 18mg/kg/dose. How much phenytoin does the nurse expect to infuse?
441
You're assessing a patient's Glasgow Coma Scale at the bedside. What is the patient's score based on these findings: when you arrive at the patient's bedside, the patient's eyes are closed and don't open when spoken to. The nurse applies a peripheral painful stimulus, and the patient's eyes open. When asked questions, the patient groans and makes moan noises. In addition, the patient can't obey a motor command. Therefore, when you apply a central stimulus, the patient flexes to withdraw from the stimulus. Enter your calculation below.
8
What does the temporal lobe do?
Hearing
What does the cerebellum do?
Balance and coordination
What does the brain stem do?
Controls HR & RR
During an NIHSS test, a client with an acute head injury cannot accurately identify the sensation felt when the nurse touches the intact skin with a cotton ball or paper clip. The nurse is aware that the deficit reflects injury to which brain area?
Parietal lobe
What does the parietal lobe do?
Sensory and touch
What does the frontal lobe do?
Speech, memory and movement
A patient who recently had a stroke is home after one month of rehabilitation. The home care nurse is concerned when the patient says (select all that apply) a. "I just don't want to do anything anymore." b. "My daughter visits twice a day and helps me." c. "I just can't sleep at night. I wake up every hour." d. "I understand that my atrial fibrillation caused my stroke." e. "I have no problem going up the stairs. Why is everyone so worried?"
a. "I just don't want to do anything anymore." c. "I just can't sleep at night. I wake up every hour." e. "I have no problem going up the stairs. Why is everyone so worried?"
A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? a. "We will be sure not to leave hot liquids unattended." b. "I guess our children need to understand what the word hot means." c. "We will be sure that the children stay in their rooms when we work in the kitchen." d. "We will install a safety gate as soon as we get home so the children cannot get into the kitchen."
a. "We will be sure not to leave hot liquids unattended."
A student nurse is working with a child in foster care. The child was removed from the home due to abuse. The child is crying for the parents and the student is confused. What information does the registered nurse provide? a. Children will grieve the loss of parents, even if they were abusive b. The child needs therapy from a qualified therapist. c. Play therapy will alleviate this behavior. d. The parents may not have been the abusers.
a. Children will grieve the loss of parents, even if they were abusive
What does cranial nerve 9 (IX) do? a. Glossopharyngeal - sensory - taste and sensation b. Vagus - sensory - parasympathetic - motor - GI mobility, decreased hear rate, sweating, taste, swallowing, speech c. Accessory - motor - shrugging, head turning d. Hypoglossal - motor - tongue movements
a. Glossopharyngeal - sensory - taste and sensation
The nurse is preparing to administer mannitol as ordered for a client with cerebral edema and increased intracranial pressure. The nurse is aware that mannitol should be administered to this client via which route? a. Intravenously b. Intramuscular c. Intraosseously d. Orally
a. Intravenously
The nurse is performing an initial assessment on a newborn. On assessment, which finding could be indicative of a congenital defect? a. Low-set ears b. Vernix caseosa c. A 5-cm anterior fontanel d. A heart rate of 130 beats per minute
a. Low-set ears
Which test would provide the best initial diagnostic information for a patient who presents to the emergency department with a potential stroke? a. Noncontrast head CT b. Cerebral angiography c. Transcranial doppler ultrasonography d. Intraarterial digital subtraction angiography
a. Noncontrast head CT
What does cranial nerve 1 (I) do? a. Olfactory - sensory - smell b. Optic - sensory - vision c. Oculomotor - motor - eye movement, eyelid elevation, pupil constriction, lens accommodation d. Trochlear - motor - eye movement, eyes down + out, depression, abduction, inward rotation
a. Olfactory - sensory - smell
Which pathology is caused by a partially occluding clot and is preceded by stroke-like symptoms that usually resolve in under an hour and is not identifiable with diagnostic imaging? a. Trans Ischemic Attack (TIA) b. Thrombotic CVA c. Hemorrhagic CVA d. Embolic CVA
a. Trans Ischemic Attack (TIA)
What does cranial nerve 5 (V) do? a. Trigeminal - sensory- facial sensation, tongue sensation - motor - mastication, biting and chewing b. Abducens - motor - eye movement, abducts c. Facial - sensory - taste, saliva, tear secretion - motor - facial expression d. Vestibulocochlear - sensory - hearing and balance
a. Trigeminal - sensory- facial sensation, tongue sensation - motor - mastication, biting and chewing
During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment of a. airway patency. b. presence of a neck injury. c. neurologic status with the Glasgow Coma Scale. d. cerebrospinal fluid leakage from the ears or nose.
a. airway patency.
A patient suspected of having a brain tumor has memory deficits, visual changes, weakness of right upper and lower extremities, and personality changes. The nurse determines that the tumor is likely located in the a. frontal lobe. b. parietal lobe. c. occipital lobe. d. temporal lobe.
a. frontal lobe.
The nurse is assessing a client for a possible brainstem herniation. Which findings assist in confirming this diagnosis? Select all that apply. a. respiratory rate decreased from 14 to 10 breaths per minute and irregular b. blood pressure increased from 118/70 to 140/82 mmHg c. urine output decreased from 45 to 30 mL/hour d. body temperature decreased from 97.8°F (36.5°C) to 96.9°F (36.1°C) e. heart rate increased from 80 to 120 beats per minute
a. respiratory rate decreased from 14 to 10 breaths per minute and irregular b. blood pressure increased from 118/70 to 140/82 mmHg
The nurse assigned to telephone triage returns a call from a parent whose teenager experienced a hard tackle last night. The parent reports, "He seemed dazed after it happened and the coach had him sit out the rest of the game, but he's fine now." What is the most appropriate instruction for the nurse to give? a. "Take him immediately to the emergency department." b. "He can't return to play until he has been evaluated by a health care provider." c. "If he seems fine now and has had no other symptoms, it probably was not a concussion." d. "Watch him closely and call us back if you see any changes."
b. "He can't return to play until he has been evaluated by a health care provider."
The nurse has instructed the family of a client with a recent stroke (brain attack) and subsequent hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? a. "We need to place objects in his impaired field of vision." b. "We need to remind him to turn his head to scan the lost visual field." c. "We need to approach him from the impaired field of vision." d. "We need to discourage him from wearing eyeglasses."
b. "We need to remind him to turn his head to scan the lost visual field."
Which patient has the highest risk for having a stroke? a. A 45-year-old Native American with obesity b. A 65-year-old Black man with hypertension c. A 35-year-old Asian American woman who smokes d. A 32-year-old White woman taking oral contraceptives
b. A 65-year-old Black man with hypertension
What does cranial nerve 6 (VI) do? a. Trigeminal - sensory- facial sensation, tongue sensation - motor - mastication, biting and chewing b. Abducens - motor - eye movement, abducts c. Facial - sensory - taste, saliva, tear secretion - motor - facial expression d. Vestibulocochlear - sensory - hearing and balance
b. Abducens - motor - eye movement, abducts
When planning activities for a child diagnosed with autism, the nurse should give priority to which consideration? a. Encouraging social interactions b. Assessing all activities for safety risks c. Focus upon providing verbal stimulation d. Providing detailed instructions to ensure success
b. Assessing all activities for safety risks
The nurse is caring for a client who is in the chronic phase of stroke and has right-sided hemiparesis. The nurse identifies that the patient is unable to feed themselves. Which is the appropriate nursing intervention? a. Provide a variety of foods on the meal tray to stimulate the client's appetite. b. Assist the client to eat with the left hand to build strength. c. Inform the client that a feeding tube will be placed if progress is not made. d. Provide a pureed diet that is easy for the client to swallow.
b. Assist the client to eat with the left hand to build strength.
A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include? a. Belief that the current surroundings are a racetrack. b. GCS score was "11" one hour ago c. Recent vitals = BP 120/80, HR 82 d. Reported allergy to penicillin and vancomycin
b. GCS score was "11" one hour ago
A home health care nurse is working with a child whose parents seem to be quite rigid in their rules and expectations and seem very distrustful of the nurse. What action by the nurse is most appropriate? a. Ask the parents why they don't trust outsiders. b. Interview the parents separately. c. Monitor the child for signs of abuse. d. Assess the parents for substance abuse.
b. Interview the parents separately.
Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel and a compound fracture of the right tibia and fibula and multiple lacerations and contusions. What is the priority nursing goal for this client? a. Reduce the client's anxiety. b. Maintain adequate oxygenation. c. Decrease chest pain. d. Maintain adequate circulating volume.
b. Maintain adequate oxygenation.
What does cranial nerve 2 (II) do? a. Olfactory - sensory - smell b. Optic - sensory - vision c. Oculomotor - motor - eye movement, eyelid elevation, pupil constriction, lens accommodation d. Trochlear - motor - eye movement, eyes down + out, depression, abduction, inward rotation
b. Optic - sensory - vision
The school nurse observes an unkempt child dressed in inappropriate clothing who repeatedly asks for food. About which problem is the nurse concerned? a. Physical abuse b. Physical neglect c. Emotional abuse d. Sexual abuse
b. Physical neglect
What does cranial nerve 10 (X) do? a. Glossopharyngeal - sensory - taste and sensation b. Vagus - sensory - parasympathetic - motor - GI mobility, decreased hear rate, sweating, taste, swallowing, speech c. Accessory - motor - shrugging, head turning d. Hypoglossal - motor - tongue movements
b. Vagus - sensory - parasympathetic - motor - GI mobility, decreased hear rate, sweating, taste, swallowing, speech
A nursing measure that can reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain. b. controlling fever with prescribed drugs and cooling techniques. c. maintaining strict bed rest with the head of the bed slightly elevated. d. keeping the room dark and quiet to minimize environmental stimulation.
b. controlling fever with prescribed drugs and cooling techniques.
Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter. b. disrupting the blood-brain barrier. c. leaking molecules from the intracellular fluid to the capillaries. d. altering the osmotic gradient flow into the intravascular component.
b. disrupting the blood-brain barrier.
A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position.
b. elevate the head of the bed to 30 degrees.
Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. helping the patient to stand to void. c. keeping a urinal in place at all times. d. catheterizing the patient every 4 hours.
b. helping the patient to stand to void.
For a patient who is suspected of having a stroke, the most important piece of information that the nurse would obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.
b. time at which stroke symptoms first appeared.
A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? a. Difficulty speaking or writing name b. Has slurred speech c. Has trouble swallowing secretions d. The patient has decreased reading comprehension
d. The patient has decreased reading comprehension
What does cranial nerve 11 (XI) do? a. Glossopharyngeal - sensory - taste and sensation b. Vagus - sensory - parasympathetic - motor - GI mobility, decreased hear rate, sweating, taste, swallowing, speech c. Accessory - motor - shrugging, head turning d. Hypoglossal - motor - tongue movements
c. Accessory - motor - shrugging, head turning
Which is the priority goal of the treatment plan when providing care to a patient who has just experienced a stroke? a. Adequate urine output b. Oral hypoglycemic to maintain blood sugar between 120 and 150 mg/dL c. Blood pressure management d. Monitor swallowing function
c. Blood pressure management
What does cranial nerve 7 (VII) do? a. Trigeminal - sensory- facial sensation, tongue sensation - motor - mastication, biting and chewing b. Abducens - motor - eye movement, abducts c. Facial - sensory - taste, saliva, tear secretion - motor - facial expression d. Vestibulocochlear - sensory - hearing and balance
c. Facial - sensory - taste, saliva, tear secretion - motor - facial expression
A patient after a stroke has difficulty finding words and weakness in his right arm. What area of the brain is most likely involved? a. Brainstem b. Vertebral artery c. Left middle cerebral artery d. Right middle cerebral artery
c. Left middle cerebral artery
The home care nurse is visiting a male client who is recovering at home after suffering a cerebral vascular accident 2 weeks ago. The client's wife states that the client has difficulty feeding himself. Which would be the initial nursing action? a. Make the patient NPO and call the Speech Therapist. b. Instruct the wife in the use of a feeding syringe to feed the client. c. Observe the client feeding himself. d. Observe the wife feeding the client.
c. Observe the client feeding himself.
What does cranial nerve 3 (III) do? a. Olfactory - sensory - smell b. Optic - sensory - vision c. Oculomotor - motor - eye movement, eyelid elevation, pupil constriction, lens accommodation d. Trochlear - motor - eye movement, eyes down + out, depression, abduction, inward rotation
c. Oculomotor - motor - eye movement, eyelid elevation, pupil constriction, lens accommodation
The nurse on the clinical unit is assigned to 4 patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. A patient with an acute stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0 to 10 scale d. Patient 2 days postoperative after a craniotomy for a brain tumor who has had continued vomiting
c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0 to 10 scale
A patient arrives at the emergency department with slurred speech, right facial droop, and right arm weakness. Which of these actions by the healthcare provider is the priority? a. Call the speech pathologist to the emergency department b. Prepare to administer a thrombolytic medication c. Prepare the patient for a computerized tomography (CT) scan of the head d. Transfer the patient to the neurological care unit
c. Prepare the patient for a computerized tomography (CT) scan of the head
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. a. The patient is withdrawn b. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance. c. The client has lost the ability to move the right arm but is able to walk independently. d. The client has weakness on the right side of the face and tongue. e. The patient is compulsive f. The client has weakness on the right side of the body. g. The client has complete bilateral paralysis of the arms and legs.
c. The client has lost the ability to move the right arm but is able to walk independently. d. The client has weakness on the right side of the face and tongue. f. The client has weakness on the right side of the body. ???
Management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control inappropriate behavior. b. using diversion techniques to keep the patient stimulated and motivated. c. assisting and supporting the family in understanding any changes in behavior. d. limiting self-care activities until the patient has regained maximum physical functioning. e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.
c. assisting and supporting the family in understanding any changes in behavior. e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.
The nurse is alert to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery. b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.
c. develops decreased level of consciousness and a headache within 48 hours of a head injury.
A patient having TIAs is scheduled for a carotid endarterectomy. The nurse explains that the purpose of this procedure is to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.
c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow.
What does cranial nerve 4 (IV) do? a. Olfactory - sensory - smell b. Optic - sensory - vision c. Oculomotor - motor - eye movement, eyelid elevation, pupil constriction, lens accommodation d. Trochlear - motor - eye movement, eyes down + out, depression, abduction, inward rotation
d. Trochlear - motor - eye movement, eyes down + out, depression, abduction, inward rotation
What does cranial nerve 8 (VIII) do? a. Trigeminal - sensory- facial sensation, tongue sensation - motor - mastication, biting and chewing b. Abducens - motor - eye movement, abducts c. Facial - sensory - taste, saliva, tear secretion - motor - facial expression d. Vestibulocochlear - sensory - hearing and balance
d. Vestibulocochlear - sensory - hearing and balance
The nurse in the pediatric unit is admitting a 2½-year-old child. Which stage in Erikson's psychosocial stages of development should the nurse plan care around? a. Trust versus Mistrust b. Initiative versus Guilt c. Industry versus Inferiority d. Autonomy versus Shame and Doubt
d. Autonomy versus Shame and Doubt
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? a. Fluid is clear and tests negative for glucose. b. Fluid is grossly bloody in appearance and has a pH of 6. c. Fluid clumps together on the dressing and has a pH of 7. d. Fluid separates into concentric rings and tests positive for glucose.
d. Fluid separates into concentric rings and tests positive for glucose.
What does cranial nerve 12 (XII) do? a. Glossopharyngeal - sensory - taste and sensation b. Vagus - sensory - parasympathetic - motor - GI mobility, decreased hear rate, sweating, taste, swallowing, speech c. Accessory - motor - shrugging, head turning d. Hypoglossal - motor - tongue movements
d. Hypoglossal - motor - tongue movements
The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? a. Allow the newborn to establish own sleep-rest pattern. b. Maintain the newborn in a brightly lighted area of the nursery. c. Encourage frequent handling of the newborn by staff and parents. d. Monitor the newborn's response to feedings and weight gain pattern.
d. Monitor the newborn's response to feedings and weight gain pattern.
A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance among brain tissue, blood, and cerebrospinal fluid.
d. a normal balance among brain tissue, blood, and cerebrospinal fluid.
The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. O2 content of the blood. b. amount of cardiac output. c. level of CO2 in the blood. d. degree of collateral circulation.
d. degree of collateral circulation.
Information provided by the patient that would help distinguish a hemorrhagic stroke from a thrombotic stroke includes a. sensory changes. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.
d. sudden onset of severe headache.
If it is determined that a patient has experienced a simple febrile seizure the next course of action is: a. Obtain outpatient brain MRI without contrast b. Lumbar puncture c. No further imaging d. Provide educational and emotional support e. Both C and D
e. Both C and D
What does the occipital lobe do?
vision and visual perception
