HCC3- Exam 3 study guide

A nurse is caring for a client who has mild TBI. Which of the following manifestations should the nurse immediately report to the provider?

A change in the GCS score from 13 to 11

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?

A client who sustained a head injury and is having periods of confusion

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

A lucid period followed by an immediate loss of consciousness

A nurse on the ICU is caring for a client who has severe TBI and a CPP of 59 mmHg. Which of the following actions should the nurse take?

Adjust the client's HOB

A nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take?

Administer a saline solution after injection

A nurse is preparing to administer phenytoin 50 mg by intermittent IV bolus to a client who has a seizure disorder. Which of the following actions should the nurse take?

Administer the medication over 1 minute

A nurse is providing teaching to a client who has seizures and a new rx for phenytoin. Which of the following information should the nurse provide?

Alcohol increases the chance of phenytoin toxicity

A nurse in the ED is caring for a client following an MVA in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining form the client's nose. Which of the following interventions should the nurse take?

Allow the drainage to drip onto a sterile gauze pad

A nurse in the ED is caring for a client who has an epidural hematoma following an MVA. Which of the following is an expected finding for this client?

Alternating periods of alertness and unconsciousness

A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?

Apply a protective boot to the right ankle

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Assess the client's airway patency, Remove objects from the client's bed, Place the client in a side-lying position

A nurse is assessing a client who has Parkinson's dz. Which of the following manifestations should the nurse expect?

Bradykinesia

A nurse is assessing an 11 mo old infant. Which of the following manifestations is associated with a CNS infection?

Bulging fontanel

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Call emergency services

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

Check the oximeter

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess CN III?

Checking the pupillary response to light

A nurse is caring for a client who has an ICP reading of 40 mmHg. Which assessment should the nurse recognize as a late sign of ICP? (Select all that apply.)

Confusion, Nonreactive dilated pupils, Slurred speech

A nurse is caring for a client who has sustained a TBI. The nurse should monitor the client for which of the following manifestations of increased ICP?

Decreased LOC

A nurse is caring for a client who has Parkinson's dz and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see?

Decreased tremors

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?

Dilated scalp veins

A nurse is assessing the reflexes of a client who has an unrepaired femur fx and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?

Dorsiflexion of the great toe

A nurse is caring for a client following surgical tx for a supratentorial brain tumor. Which of the following interventions should the nurse take?

Elevate the HOB 30

A nurse is implementing precautions for a client who has a cerebral aneurysm. Which following nursing interventions should the nurse implement?

Encourage exhaling through mouth during defecation

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse take?

Encourage the client to take small bites

A nurse at a rehab center is planning care for a client who had a left hemispheric CVA 3 weeks ago. Which of the following goals should the nurse include in the client's rehab program?

Establish the ability to communicate effectively

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in ICP? (Select all that apply.)

HA, Slurred speech, Pupillary changes, Disorientation

A nurse in an ED is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe HA and vomiting. The client's VS are as follows: BP 198/110 mmHg, pulse 82/min, RR 24/min, temp 100.8F. Which of the following neurologic disorders should the nurse suspect?

Hemorrhagic stroke

A nurse is performing D/C teaching for a client who has seizures and a new RX for phenytoin. Which of the following statements by the client indicates a need for further teaching?

I'll be glad when I can stop taking this medication

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires an intervention by the nurse?

ICP 18 mmHg

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?

Impaired sense of humor

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Inability to recognize his family members

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

Incorporate nonverbal cues in the conversation

A nurse is assessing an infant following a MVA. Which of the following findings should the nurse monitor to identify IICP?

Increased sleeping

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the fx of cranial nerve III?

Instruct the client to look up and down w/o moving his head

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse ID as a manifestation of IICP?

Irritability

A nurse is providing teaching to a client who has a new dx of Parkinson's dz. On which of the following medications should the nurse prepare to instruct the client?

Levodopa/carbidopa

A nurse is assessing a client who was involved in a MVA. Which of the following techniques should the nurse use to test corneal reflexes?

Lightly touch the eyes with a wisp of cotton

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Loosen restrictive clothing, Place a pillow under the client's head

A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take?

Maintain the client on absolute bed rest

A nurse is caring for a client who has a TBI and is exhibiting signs of IICP. Which of the following medications should the nurse plan to administer?

Mannitol 25%

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

Mannitol 25%

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

Minimize environmental stimuli

A nurse is teaching the family of a client who has a new dx of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

Move objects away from the client

A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Notify EMS

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's POC?

Obtain IV access

A nurse is assessing a client who had a craniotomy and has developed SIADH. Which of the following manifestations should the nurse anticipate?

Oliguria

A nurse is caring for a child who is postoperative following ventriculoperitoneal VP shunt placement. In which of the following position should the nurse place the client?

On the unoperated side

A nurse is teaching a client who has a new dx of a-fib. The nurse should instruct the client to monitor for which of the following complications?

PE

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

Perform a Romberg's test

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Place a pillow under the client's head

An acute care nurse receives shift report for a client who has ICP. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Plantar flexion of the legs

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Poor impulse control

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

Position the child laterally

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Position the child side-lying

A nurse is creating a POC for a client who has a hx of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)

Provide a suction set up at the bedside, Elevate the side rails near the head when the client is in bed, Place the bed in the lowest position, Keep an oxygen set up at the bedside

A nurse is assessing a client who has a traumatic head injury to determine motor fx response. Which of the following client responses to painful stimulus is expected?

Pushes the painful stimulus away

A nurse is preparing to administer an osmotic diuretic IV to a client w/ increased ICP. Which of the following should the nurse identify as the purpose of the medication?

Reduce edema of the brain

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?

Reduce stimuli

A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Remind the client to look for food on the left side of the tray

A nurse is caring for a client 4h following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Respiratory status

A nurse is caring for a client who has a TBI. Which of the following findings should the nurse identify as an indication of ICP?

Restlessness

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?

Sensitivity to light

A nurse is caring for a 2 yo child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose.

Shake the container vigorously

A nurse is teaching a client who has a new rx for phenytoin. The nurse should instruct the client to monitor for which of the following effects of this medication?

Skin rash

A nurse in the ED is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125ml/hr. Which of the following is an appropriate nursing action by the nurse?

Slow the rate to 50 ml/hr

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

Small drops of clear fluid in left ear

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?

Speak to the client about one idea at a time

A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

Supplements via NGT

A nurse is assessing a client who sustained a basal skull fx and notes a thin stream of clear drainage coming from the client's rt. Nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose

A nurse is assessing a client who has a rea score of 6 on the GCS. The nurse should expect which of the following outcomes based on this score?

The client needs total nursing care

A nurse is receiving a transfer report for a client who has a head injury. The client has GCS score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on THIS data?

The client opens his eyes when spoken to

A nurse is in a client's room when the client begins to have a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side

A nurse administers desmopressin to a client who has diabetes insipidus. The nurse recognizes that which of the following laboratory findings indicate a therapeutic effect of the medication?

Urine specific gravity 1.015

A nurse is caring for a client who has ICP following a closed-head injury. Which of the following action should the nurse take?

Use log rolling to reposition the client

A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instruction should the nurse include?

When walking, move your left foot forward first