Head Injury Questions

An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed?Select all that apply. 1. Immobilize the neck using rolled towels or a cervical collar. 2. The patient will be placed in a supine position 3. The patient will be placed on a ventilator. 4. The head of the bed will be elevated. 5. The patient's head will be secured with a belt or tape secured to the stretcher.

1. Immobilize the neck using rolled towels or a cervical collar. 2. The patient will be placed in a supine position 5. The patient's head will be secured with a belt or tape secured to the stretcher.

The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided? 1. Reposition the patient every two hours. 2. Position the patient with the head elevated 30 degrees. 3. Suction the airway every two hours per standing orders. 4. Provide continuous oxygen as ordered.

3. Suction the airway every two hours per standing orders.

A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and get an order for radiologic evaluation. 3. Prepare the patient for surgery, as her condition is worsening. 4. Explain to the patient that this could be a common, temporary problem.

4. Explain to the patient that this could be a common, temporary problem.

A patient with a suspected closed head injury has bloody nasal drainage. You suspect that this patient has a cerebrospinal fluid (CSF) leak when observing which of the following? A. A halo sign on the nasal drip pad B. Decreased blood pressure and urinary output C. A positive reading for glucose on a Test-tape strip D. Clear nasal drainage along with the bloody discharge

A. A halo sign on the nasal drip pad

You are providing care for a patient who has been admitted to the hospital with a head injury who requires regular neurologic vital signs. Which assessments are components of the patient's score on the Glasgow Coma Scale (select all that apply)? A. Eye opening B. Abstract reasoning C. Best verbal response D. Best motor response E. Cranial nerve function

A. Eye opening C. Best verbal response D. Best motor response

You are caring for a patient admitted with a subdural hematoma after a motor vehicle accident. Which change in vital signs would you interpret as a manifestation of increased intracranial pressure? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure

B. Bradycardia

You are alerted 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 decreasing LOC 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 LOC.

C. develops decreasing LOC and a headache within 48 hours of a head injury.

A patient being monitored has an ICP pressure of 12 mm Hg. You understand 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 between brain tissue, blood, and cerebrospinal fluid.

D. a normal balance between brain tissue, blood, and cerebrospinal fluid.

A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? a. Laceration of the middle meningeal artery b. Rupture of the carotid artery c. Thromboembolism from a carotid artery d. Venous bleeding from the arachnoid space

a. Laceration of the middle meningeal artery

A patient with a traumatic brain injury is in need of fluid replacement therapy to maintain a systole blood pressure of at least 90 mm Hg. The nurse realizes that the best fluid replacement for this patient would be: a. Normal saline b. D5W c. D5 1/2 0.9% NS d. 0.45% NS

a. Normal saline

During an assessment of a patient's motor status with the Glasgow Coma scale, the patient assumes a posture of abnormal flexion. The nurse would document this finding as: a. 5 b. 4 c. 3 d. 2

c. 3

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first? a. Administer acetaminophen (Tylenol) 650 mg orally. b. Administer 5% hypertonic saline intravenously. c. Draw blood for arterial blood gases (ABGs). d. Send patient to radiology for computed tomography (CT) of the head.

c. Draw blood for arterial blood gases (ABGs).

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? a. Frontal b. Occipital c. Parietal d. Temporal

c. Parietal

The neurologic functions that are affected by a stroke are primarily related to a. the amount of tissue area involved b. the rapidity of onset of symptoms c. the brain area perfused by the affected artery d. the presence or absence of collateral circulation

c. the brain area perfused by the affected artery

Problems with memory and learning would relate to which of the following lobes? a. Frontal b. Occipital c. Parietal d. Temporal

d. Temporal

A patient is recovering following a carotid endarterectomy. The blood pressure has risen this morning to 168/60. The nurse should do which of the following? 1. Recheck the blood pressure and make sure the correct size cuff was used. Then compare the trend of blood pressure readings and call the physician now. 2. Recheck the blood pressure every hour and report this change to the physician when he or she makes rounds the next time. 3. Record the blood pressure and find out who took this reading. Have that staff member demonstrate his or her blood pressure procedure and offer tips to obtain more accurate readings. 4. Check the standing orders and see if there is a medication ordered p.r.n. for lowering blood pressure. If so, administer it and document the action.

1. Recheck the blood pressure and make sure the correct size cuff was used. Then compare the trend of blood pressure readings and call the physician now.

A lumbar puncture (LP) is done on a patient to rule out a spinal cord tumor. The cerebrospinal fluid (CSF) is xanthochromic, has increased protein, no cells, and clots immediately. What syndrome do these findings describe? 1. Glasgow's syndrome 2. Froin's syndrome 3. cord tumor syndrome 4. reflex syndrome

2. Froin's syndrome

A patient has manifestations of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition?Select all that apply. 1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor 4. diarrhea 5. fecal impaction

2. kinked catheter tubing 5. fecal impaction

A patient with a spinal cord injury was given IV Decadron (dexamethasone) after arriving in the emergency department. The patient also has a history of hypoglycemia. During the hospital stay, the nurse would expect to see which of the following? 1. increased episodes of hypoglycemia 2. possible episodes of hyperglycemia 3. no change in the patient's glycemic parameters 4. both hyper- and hypoglycemic episodes

2. possible episodes of hyperglycemia

The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia

2. spinal shock

While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following? 1. hypoxia 2. bradycardia 3. elevated blood pressure 4. tachycardia

3. elevated blood pressure

Of the following, which groups are the most at risk for bacterial meningitis?Select all that apply. 1. older adults 2. pregnant women 3. military recruits 4. college students 5. low-income

3. military recruits 4. college students

The nurse realizes that the goal of surgery for a patient with a secondary metastatic spinal cord tumor is 1. complete removal of the tumor and affected spinal cord tissue. 2. eradication of the tumor with excision and drainage. 3. tumor excision to reduce cord compression. 4. exploration to visualize the tumor and obtain a biopsy.

3. tumor excision to reduce cord compression.

Which of the following nursing actions is appropriate for preventing skin breakdown in a patient who has recently undergone a laminectomy? 1. Provide the patient with an air mattress. 2. Place pillows under patient to help patient turn. 3. Teach the patient to grasp the side rail to turn. 4. Use the log roll to turn the patient to the side.

4. Use the log roll to turn the patient to the side.

The nurse is teaching regarding risk factors for stroke (CVA). The greatest risk factor is which of the following? 1. diabetes 2. heart disease 3. renal insufficiency 4. hypertension

4. hypertension

A patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which of the following? 1. impending brain death 2. decreasing intracranial pressure 3. stabilization of the patient's condition 4. increased intracranial pressure

4. increased intracranial pressure

A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation? 1. hemiplegia 2. paresthesia 3. paraplegia 4. quadriplegia

4. quadriplegia

Which nursing action should be implemented in the care of a patient who is experiencing increased ICP? A. Monitor fluid and electrolyte status astutely. B. Position the patient in a high-Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.

A. Monitor fluid and electrolyte status astutely.

The patient has rhinorrhea after a head injury. What action should you take? A. Pack the nares with sterile gauze B. A loose collection pad may be placed under the nose. C. Suction the drainage with an inline suction catheter. D. Obtain a sample for culture.

B. A loose collection pad may be placed under the nose.

A patient with increased ICP is being monitored in the intensive care unit (ICU) with a fiberoptic catheter. Which order is a priority for you? A. Perform hourly neurologic checks. B. Take a complete set of vital signs. C. Administer the prescribed mannitol (Osmitrol). D. Give an H2-receptor blocker.

C. Administer the prescribed mannitol (Osmitrol).

A patient with increased ICP has mannitol (Osmitrol) prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects? A. Urine output increases from 30 mL to 50 mL/hour. B. Blood pressure remains less than 150/90 mm Hg. C. The LOC improves. D. No crackles are auscultated in the lung fields.

C. The LOC improves.

Which option indicates a sign of Cushing's triad, an indication of increased intracranial pressure (ICP)? A. Heart rate increases from 90 to 110 beats/minute B. Kussmaul respirations C. Temperature over 100.4° F (38° C) D. Heart rate decreases from 75 to 55 beats/minute

D. Heart rate decreases from 75 to 55 beats/minute

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

a. "The obstructing plaque is surgically removed from an artery in the neck."

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is: a. 52 mm Hg b. 88 mm Hg c. 48 mm Hg d. 68 mm Hg

a. 52 mm Hg

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: a. A positive Brudzinski's sign b. A negative Kernig's sign c. Absence of nuchal rigidity d. A Glascow Coma Scale score of 15

a. A positive Brudzinski's sign

When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). b. Emergent; the client is poorly oxygenated. c. Normal d. Significant; the client has alveolar hypoventilation.

a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a a. CT scan b. lumbar puncture c. cerebral arteriogram d. positron emission tomography (PET)

a. CT scan

A client who was in a motor vehicle accident a few days ago is now complaining of progressive weakness in his arms and upper body while the functioning of his lower limbs is unchanged. Which of the following might this client be experiencing? a. Central cord syndrome b. Whiplash syndrome c. Anterior cord syndrome d. Brown-Sequard syndrome

a. Central cord syndrome

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? a. Evaluate urine specific gravity b. Anticipate treatment for renal failure c. Provide emollients to the skin to prevent breakdown d. Slow down the IV fluids and notify the physician

a. Evaluate urine specific gravity

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation (DIC)? a. Hemorrhagic skin rash b. Edema c. Cyanosis d. Dyspnea on exertion

a. Hemorrhagic skin rash

the client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as high risk for immobility complications. Which intervention would be included in the plan of care? a. Position the client with the head of the bed elevated at intervals. b. Performed active range of motion exercises every 4 hours. c. Turn the client every shift and massage bony prominences. d. Explain all procedures to the client before performing them.

a. Position the client with the head of the bed elevated at intervals.

the clients diagnosed with a gunshot wound to the head assumes decorticate pOsturing when the nurse applies painful stimuli. Which assessment data obtained 3 hours later would indicate the client is improving? a. Purposeless movement in response to painful stimuli. b. flaccid paralysis in all four extremities. c. Decerebrate posturing when painful stimuli are applied. d. Pupils that are 6 millimeters in size and nonreactive to painful stimuli.

a. Purposeless movement in response to painful stimuli.

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a. Urine output increases b. Pupils are 8 mm and nonreactive c. Systolic blood pressure remains at 150 mm Hg d. BUN and creatinine levels return to normal

a. Urine output increases

A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is a. aseptic technique to prevent infection b. constant monitoring of ICP waveforms c. removal of CSF to maintain normal ICP d. sampling CSF to determine abnormalities

a. aseptic technique to prevent infection

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is a. avoiding positioning the patient with neck and hip flexion b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg c. clustering nursing activities to provide periods of uninterrupted rest d. routine suctioning to prevent accumulation of respiratory secretions

a. avoiding positioning the patient with neck and hip flexion

the client diagnosed with a mild concussion is being discharged from the emergency department. which discharge instruction should the nurse teach the clients significant other? a. awake the client every 2 hours b. monitor for increased ICP c. observe frequently for hypervigillance. d. offer the client food every 3-4 hours.

a. awake the client every 2 hours

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first a. check the patient's gag reflex b. order a soft diet for the patient c. raise the head of the bed to sitting position d. evaluate the patient's ability to swallow small sips of ice water

a. check the patient's gag reflex

When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. decorticate posturing. b. decerebrate posturing. c. localization of pain. d. flexion withdrawal.

a. decorticate posturing.

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply) a. fever b. oriented to name only c. narrowing pulse pressure d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus

a. fever b. oriented to name only d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus

A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate for the nurse to include in patient and family teaching? Select all that apply. a. how to use a sign board b. transfer techniques c. information about impulse control d. time adjustment to complete activities e. safety precautions for transferring

a. how to use a sign board b. transfer techniques e. safety precautions for transferring

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds

a. hypertension

The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracrainal hypertension? a. hypoventilation b. elevating the head of the bed c. hypernatremia d. quiet darkened environnent

a. hypoventilation

A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the nurse should a. place objects on the right side within the patient's field of vision b. approach the patient from the left side to encourage the patient to turn the head c. place objects on the patient's left side to assess the patient's ability to compensate d. patch the affected eye to encourage the patient to turn the head to scan the environment

a. place objects on the right side within the patient's field of vision

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score as a. 6 b. 7 c. 9 d. 11

b. 7

the nurse is caring for a client diagnosed with epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. a. Maintain the head of the bed at 60 degrees. b. Administer stool softeners daily. c. Ensure that pulse oximeter reading is higher than 93 percent. d. Perform deep Nasal suction every 2 hours. e. Administer mild sedative.

b. Administer stool softeners daily. c. Ensure that pulse oximeter reading is higher than 93 percent. e. Administer mild sedative.

the client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order with the nurse question? a. A subcutaneous anti coagulant. b. An intravenous osmotic diuretics. c. An oral anticonvulsant. d. An oral proton pump inhibitor.

b. An intravenous osmotic diuretics.

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? a. Try to calm the patient and make the environment soothing. b. Assess for a full bladder. c. Notify the healthcare provider. d. Prepare the patient for diagnostic radiography.

b. Assess for a full bladder.

A patient is admitted with a subacute subdural hematoma. The nurse realizes this patient will most likely be treated with: a. Emergency craniotomy. b. Elective draining of the hematoma. c. Burr holes to remove the hematoma. d. Removal of the affected cranial lobe.

b. Elective draining of the hematoma.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? a. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. b. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. c. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. d. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

b. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? a. Vomiting continues b. Intracranial pressure (ICP) is increased c. The client needs mechanical ventilation d. Blood is anticipated in the cerebralspinal fluid (CSF)

b. Intracranial pressure (ICP) is increased

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? a. Absence of pain sensation in chest b. Spasticity c. Spontaneous respirations d. Urinary continence

b. Spasticity

the 29-year-old client that was employed as a forklift operator sustains a traumatic brain injury secondary to a motor vehicle accident. The client is being discharged from the rehabilitation unit after 3 months and has cognitive deficits. Which goal would be more realistic for this client? a. The client will return to work within 6 months. b. The client is able to focus and stay on task for 10 minutes. c. The client will be able to dress self without assistance. d. The client will regain power and bladder control.

b. The client is able to focus and stay on task for 10 minutes.

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse? a. The blood pressure increases from 120/54 to 136/62. b. The patient is more difficult to arouse. c. The patient complains of a headache at pain level 5 of a 10-point scale. d. The patient's apical pulse is slightly irregular.

b. The patient is more difficult to arouse.

the resident in a long term care facility Fell during the previous shift and has a laceration in the occiptal area that has been closed with steri strips. Which signs or symptoms would warrant transferring the resident to the emergency department? a. 4 cm of bright red drainage on the dressing b. a weak pulse, shallow respirations, and cool pale skin c. pupils that are equal, react to light, and accommodate d. complaints of a headache that's resolved with medication

b. a weak pulse, shallow respirations, and cool pale skin

The client with an old C6 spinal cord injury complains of suddenly being too warm, with nasal congestion and a very red face. What is your next assessment? a. temperature b. blood pressure c. input and output for previous 8 hours d. bowel for impaction

b. blood pressure

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

b. decreased pulse, irregular respiration, increased pulse pressure

A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates a. high blood flow to the brain. b. normal intracranial pressure (ICP). c. impaired brain blood flow. d. adequate cerebral perfusion.

b. normal intracranial pressure (ICP).

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include a. hyperventilation therapy b. surgical clipping of the aneurysm c. administration of hyperosmotic agents d. administration of thrombolytic therapy

b. surgical clipping of the aneurysm

To promote communication during rehabilitation of the patient with aphasia, an appropriate nursing intervention is to a. use gestures, pictures, and music to stimulate patient responses b. talk about activities of daily living (ADLs) that are familiar to the patient c. structure statements so that patient does not have to respond verbally d. use flashcards with simple words and pictures to promote language recall

b. talk about activities of daily living (ADLs) that are familiar to the patient

A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse a. examines the tympanic membrane for a tear b. tests the fluid for a halo sign on a white dressing c. tests the fluid with a glucose identifying strip or stick d. collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis

b. tests the fluid for a halo sign on a white dressing

Which of the following is the best treatment for acute ischemic stroke? a. heparin b. LMWH c. Alteplase d. Eptifibatie e. Warfarin

c. Alteplase

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: a. A cerebral lesion b. A temporal lesion c. An intact brainstem d. Brain death

c. An intact brainstem

When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? a. An interval when the client's speech is garbled b. An interval when the client is alert but can't recall recent events c. An interval when the client is oriented but then becomes somnolent d. An interval when the client has a "warning" symptom, such as an odor or visual disturbance.

c. An interval when the client is oriented but then becomes somnolent

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30

c. Blood pressure 156/60, pulse 60, respirations 14

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? a. Complete set of vital signs b. Palpation and auscultation of the abdomen c. Brief neurologic assessment d. Initiation of pulse oximetry

c. Brief neurologic assessment

A school nurse is called after a student falls down a flight of stairs. The student is breathing, but unconsciousness. After calling the ambulance, which is the most appropriate action by the nurse? a. Protect the patient's neck and head from any movement. b. Place the patient on his side to prevent aspiration. c. Immobilize the neck,,securing the head. d. Try to rouse the patient by gently shaking his shoulders.

c. Immobilize the neck,,securing the head.

A client with a spinal cord injury is exhibiting poikilothermia. Which of the following would be appropriate to include in this client's plan of care? a. Provide good perineal care. b. Pass nasogastric tube to decompress stomach. c. Keep client warm with extra blankets. d. Stimulate the anal-rectal reflex.

c. Keep client warm with extra blankets.

A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate? a. Document and continue to monitor the parameters. b. Elevate the head of the patient's bed. c. Notify the health care provider about the assessments. d. Check the patient's pupillary response to light.

c. Notify the health care provider about the assessments.

A patient hospitalized with a known AV malformation begins to complain of a headache and becomes disorientated. Which is the most appropriate action by the nurse? a. Recommend to the family members that they start to look for a long-term care facility. b. Prepare to give aspirin or a "clot buster." c. Prepare the patient for surgery. d. Document the changes and monitor closely.

c. Prepare the patient for surgery.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a. Prevent respiratory alkalosis. b. Lower arterial pH. c. Promote carbon dioxide elimination. d. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

c. Promote carbon dioxide elimination.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? a. Bradycardia b. Large amounts of very dilute urine c. Restlessness and confusion d. Widened pulse pressure

c. Restlessness and confusion

the client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? a. Notify the health-care provider immediately. b. Prepare to administer an antihistamine. c. Test the drainage for presence of glucose. d. Place 2x2 Gauze under the nose to collect drainage.

c. Test the drainage for presence of glucose.

The nurse is caring for the following clients. Which client what the nurse assess first after receiving the shift report? a. The 22 year old male client diagnosed with a concussion who is complaining someone is waking him up every 2 hours. b. The 36 year old female client admitted with complaints of left sided weakness who is scheduled for an MRI scan. c. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. d. The 62-year-old client diagnosed with CVA who has expressive aphasia.

c. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6.

A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis? a. The client reports pain in the affected leg b. A large hematoma is visible in the affected extremity c. The affected extremity is shortened, adducted, and extremely rotated d. The affected extremity is edematous

c. The affected extremity is shortened, adducted, and extremely rotated

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

c. The patient reports that symptoms began with a severe headache.

the client has sustained a severe closed head injury and the neurosurgeon is determining if the client is brain dead. Which data support That the client is brain dead? a. The clients head is turned to the right, the eyes turn to the righT. b. the EEG has identifiable waveforms. c. There is no Eye activity when the cold caloric test is performed. d the client assumes decorticate posturing when painful stimuli are applied.

c. There is no Eye activity when the cold caloric test is performed.

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? a. To reduce intraocular pressure b. To prevent acute tubular necrosis c. To promote osmotic diuresis to decrease ICP d. To draw water into the vascular system to increase blood pressure

c. To promote osmotic diuresis to decrease ICP

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is a. vomiting. b. headache. c. change in level of consciousness (LOC). d. sluggish pupil response to light.

c. change in level of consciousness (LOC).

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of a. furosemide (Lasix) b. lovastatin (Mevacor) c. daily low dose aspirin d. nimodipine (Nimotop)

c. daily low dose aspirin

A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to a. ignore undesirable behaviors manifested by the patient b. provide directions to the patient verbally in small steps c. distract the patient from inappropriate emotional responses d. supervise all activities before allowing the patient to pursue them independently

c. distract the patient from inappropriate emotional responses

A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery a. is used to restore blood to the brain following an obstruction of a cerebral artery b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery c. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke d. is sued to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation

c. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke

Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should a. monitor oxygen saturation. b. check arterial blood gases (ABGs). c. monitor intracranial pressure (ICP). d. assess patient breath sounds.

c. monitor intracranial pressure (ICP).

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. patient with a skull fracture whose nose is bleeding b. elderly patient with a stroke who is confused and whose daughter is present c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should a. use restraints to protect the patient from injury b. administer CNS depressants to lightly sedate the patient c. perform the exercises less frequently because posturing can increase ICP d. continue the exercises because they are necessary to maintain musculoskeletal function

c. perform the exercises less frequently because posturing can increase ICP

A patient is placed in ventilator support with the diagnosis of botulism and failure to thrive. Which nursing actions would be most appropriate for this patient? Select all that apply. a. maintaining intravenous fluids at KVO (keep vein open) b. assessing bowel sounds once a shift c. referring the patient for a physical therapy consult d. recording the patient's ongoing calorie count e. assessing the patient's urinary output every hour

c. referring the patient for a physical therapy consult d. recording the patient's ongoing calorie count e. assessing the patient's urinary output every hour

A 54-year old man is recovering from a skull fracture with a subacute subdural hematoma. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge or the patient, the nurse explains to the patient and the family that a. continuous improvement in the patient's condition should occur until he has returned to pre trauma status b. the patient's complete recovery may take years, and the family should plan for his long term dependent care c. the patient is likely to have long term emotional and mental changes that may require continued professional help d. role changes in family members will be necessary because the patient will be dependent on his family for care and support

c. the patient is likely to have long term emotional and mental changes that may require continued professional help

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.

c. visual deficits.

A pediatric client is admitted to the neuro ICU with a closed-head injury sustained after falling out of a tree house. The mechanisms of injury this young client most likely sustained would be: a. Acceleration b. Penetrating c. Rotational d. Deceleration

d. Deceleration

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

d. Difficulty comprehending instructions

the client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? a. Assess nurological status. b. Monitor pulse, respiration, and blood pressure. c. Initiate an intravenous access. d. Maintain an adequate airway.

d. Maintain an adequate airway.

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? a. Sternal rub b. Pressure on the orbital rim c. Squeezing the sternocleidomastoid muscle d. Nail bed pressure

d. Nail bed pressure

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? a. Place the client flat in bed b. Assess patency of the indwelling urinary catheter c. Give one SL nitroglycerin tablet d. Raise the head of the bed immediately to 90 degrees

d. Raise the head of the bed immediately to 90 degrees

the nurse is enjoying a day out at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health care provider to respond to the accident. Which intervention should be implemented first? a. Assess the clients loc. b. Organize onlookers to remove the client from the lake. c. Perform a head to toe assessment to determine injuries. d. Stabilize the clients cervical spine.

d. Stabilize the clients cervical spine.

A client with a C4 spinal injury would most likely have which of the following symptoms? a. Aphasia b. Hemiparesis c. Paraplegia d. Tetraplegia

d. Tetraplegia

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a. He didn't arrive within the time frame for that therapy b. Not every is eligible for this drug. Has he had surgery lately? c. You should discuss the treatment of your husband with your doctor d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understand that this pressure reflects a. a severe decrease in cerebral perfusion pressure b. an alteration in the production of CSF c. the loss of autoregulatory control of ICP d. a normal balance between brain tissue, blood, and CSF

d. a normal balance between brain tissue, blood, and CSF

Metabolic and nutritional needs of the patient with increased ICP are best met with a. enteral feedings that are low in sodium b. the simple glucose available in D5W IV solutions c. a fluid restriction that promotes a moderate dehydration d. balanced, essential nutrition in a form that the patient can tolerate

d. balanced, essential nutrition in a form that the patient can tolerate

When assessing the body function of a patient with increased ICP, the nurse should initially assess a. corneal reflex testing b. extremity strength testing c. pupillary reaction to light d. circulatory and respiratory status

d. circulatory and respiratory status

A nursing intervention is indicated for the patient with hemiplegia is a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive ROM of the affected limb with the unaffected limb

d. having the patient perform passive ROM of the affected limb with the unaffected limb

The priority intervention in the emergency department for the patient with a stroke is a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration

d. maintenance of respiratory function with a patent airway and oxygen administration

Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the nurse anticipates that a. the patient will receive life-support measures until the condition stabilizes b. immediate burr holes will be made to rapidly decompress the intracranial activity c. the patient will be treated conservatively with close monitoring for changes in neurologic condition d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium

d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

Which patient is at highest risk for a spinal cord injury? 1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 20-year-old female with a history of substance abuse 3. 50-year-old female with osteoporosis 4. 35-year-old male who coaches a soccer team

1. 18-year-old male with a prior arrest for driving while intoxicated (DWI)

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure

1. autonomic dysreflexia

The nurse recognizes that the most common type of brain attack (CVA) is related to which of the following? 1. ischemia 2. hemorrhage 3. headache 4. vomiting

1. ischemia

When caring for a patient admitted post-stroke (CVA) who has altered consciousness, the nurse should place the patient in which position? 1. side-lying 2. supine 3. prone 4. semi-Fowler's

1. side-lying

Prodromal manifestations prior to an intracranial aneurysm rupture could be recognized by the nurse as which of the following?Select all that apply. 1. visual deficits 2. headache 3. mild nausea 4. dilated pupil 5. stiff neck

1. visual deficits 2. headache 4. dilated pupil

A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication? 1. "I will stop taking this medicine if I notice any bruising." 2. "I will not eat spinach while I'm taking this medicine." 3. "It will be OK for me to eat anything, as long as it is low fat." 4. "I'll check my blood pressure frequently while taking this medication."

2. "I will not eat spinach while I'm taking this medicine."

The nurse understands that when the spinal cord is injured, ischemia results and edema occurs. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week? 1. "Tissue repair does not begin for 72 hours." 2. "The edema extends the level of injury for two cord segments above and below the affected level." 3. "Neurons need time to regenerate so stating the injury early is not predictive of how the patient progresses." 4. "Necrosis of gray and white matter does not occur until days after the injury."

2. "The edema extends the level of injury for two cord segments above and below the affected level."

The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs? 1. "I will have less pain if I use the halo device." 2. "The halo device will allow me to get out of bed." 3. "I am less likely to get an infection with the halo device." 4. "The halo device does not have to stay in place as long."

2. "The halo device will allow me to get out of bed."

The family of a patient who has had a brain attack (CVA) asks if the patient will ever talk again. The nurse should do which of the following? 1. Explain that the patient's speech will return to normal with time. 2. Explain that it is difficult to know how far the patient will progress. 3. Tell the family that nurses cannot discuss such issues. Tell them to ask the physician. 4. Tell the family what they see today is all they can expect.

2. Explain that it is difficult to know how far the patient will progress.

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient?Select all that apply. 1. modifying the traction weights as needed 2. assessing the patient's skin integrity 3. applying the traction upon admission 4. administering pain medication 5. providing passive range of motion

2. assessing the patient's skin integrity 4. administering pain medication 5. providing passive range of motion

The nurse must be alert to complications in the patient who has suffered a ruptured intracranial aneurysm. The nurse should assess the patient for signs of which of the following?Select all that apply. 1. headache 2. hydrocephalus 3. rebleeding 4. vasospasm 5. stiff neck

2. hydrocephalus 3. rebleeding 4. vasospasm

A hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may have had a stroke (CVA). What is the nurse's priority intervention? 1. Move the patient to the critical care unit. 2. Assess blood pressure. 3. Assess the airway and breathing. 4. Observe urinary output.

3. Assess the airway and breathing.

An appropriate food for a patient with a stroke who has mild dysphagia is a. fruit juices b. pureed meat c. scrambled eggs d. fortified milkshakes

c. scrambled eggs

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease