Med/Surg 3 Exam 2 NCLEX Style Questions Chapters 44, 45, 46, and 47

A client with a spinal cord injury has full head and neck control when the injury is at which level? C5 C2 to C3 C1 C4

C5

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture? basilar simple linear comminuted

basilar

A client with a brain tumor is exhibiting papilledema. When reviewing the client's history, which information would the nurse correlate with this finding? SATA double vision enhanced visual acuity visual field deficit swaying gait aphasia

double vision visual field deficit

Which type of hematoma results from a skull fracture that causes a rupture or laceration to the middle meningeal artery? intracerebral diffuse axonal epidural subdural

epidural

A nurse is reviewing a client's medical record and finds that the client has a spinal cord tumor that involves the vertebral bodies. The nurse identifies this as which type of spinal tumor? metastatic intramedullary extradural intradural-intramedullary

extradural

Which is the most common cause of spinal cord injury (SCI)? falls sports-related injuries acts of violence motor vehicle crashes

motor vehicle crashes

Which term is used to describe edema of the optic nerve? scotoma angioneurotic edema papilledema lymphedema

papilledema

A client with a brain tumor is experiencing changes in cognition that require the nurse to reorient the client frequently. When performing this task, which devices would be appropriate for the nurse to use? SATA picture of the client's family calendar clock common words client's clothing

picture of the client's family calendar clock client's clothing

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction? "I'll check under the liner for blisters and redness." "I can apply powder under the liner to help with sweating." "If a pin becomes detached, I'll notify the surgeon." "I will change the vest liner periodically."

"I can apply powder under the liner to help with sweating."

A posttraumatic seizure classified as "early" occurs within which time frame? more than 7 days following injury 4 hours of injury 1 to 7 days of injury 24 hours of injury

1 to 7 days of injury

Which Glasgow Coma Scale score is indicative of a severe head injury? 11 7 13 9

7

Which signs are considered cardinal signs of brain death? SATA absence of brainstem reflexes no brain waves coma apnea

absence of brainstem reflexes coma apnea

What type of brain injury is characterized by a loss of consciousness associated with stupor and confusion? intracranial hemorrhage diffuse axonal injury contusion concussion

contusion

Which are risk factors for spinal cord injury (SCI)? SATA drug abuse female gender Caucasian ethnicity alcohol use young age

drug abuse alcohol abuse young age

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client vomits. sleeps for short periods of time. reports a headache. reports generalized weakness.

vomits.

Which medication classification should be avoided in the treatment of brain tumors? osmotic diuretics anticonvulsants anticoagulants corticosteroids

anticoagulants

A nurse is assessing a client who has sustained a traumatic brain injury. The client's Glasgow Coma Score is 15. Which assessment would the nurse most likely document? SATA eye opening response: to voice best motor response: obeys command best verbal response: confusion best motor response: localizes pain eye opening response: spontaneous best verbal response: orientated

best motor response: obeys command eye opening response: spontaneous best verbal response: orientated

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale score of 7. This score is generally interpreted as minimally responsive. most responsive. least responsive. coma.

coma

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness? concussion intracranial hemorrhage diffuse axonal injury contusion

contusion

A client being treated for a brain tumor is exhibiting signs of cerebral edema. The nurse anticipates that the practitioner will most likely prescribe which agent? immunotherapy agent anticonvulsant agent corticosteroid diuretic

corticosteroid

The client with a brain tumor may be at an increased risk for aspiration. What does the nurse determine is the most important nursing intervention? evaluation of gag reflex and ability to swallow frequent orientation monitoring vital signs assistance with self-care

evaluation of gag reflex and ability to swallow

What is the most common type of brain neoplasm? neuroma meningioma angioma glioma

glioma

A client is diagnosed with a brain angioma. When teaching the client about the risks associated with this type of brain tumor, the nurse would educate about signs and symptoms associated with which condition? thyroid disorders hearing loss visual loss hemorrhagic stroke

hemorrhagic stroke

The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? SATA hypertension fever nasal congestion tachycardia diaphoresis

hypertension diaphoresis

A nurse is providing care to a client who has been diagnosed with metastatic brain cancer. When developing the client's plan of care, which outcome would the nurse most likely identify? improved quality of life elimination of distressing signs and symptoms reduced incidence of recurrence removal of all or part of the tumor

improved quality of life

The statements presented here match nursing interventions with nursing diagnoses. Which statements are true for a client who has suffered a head injury? SATA disturbed sleep pattern: provide back rubs to the client ineffective cerebral tissue perfusion: maintain cerebral perfusion pressure less than or equal to 50mmHg ineffective airway clearance: apply suction as needed deficient fluid volume: administer 1 L of normal saline daily interrupted family process: encourage the family to join a support group

ineffective airway clearance: apply suction as needed disturbed sleep pattern: provide back rubs to the client interrupted family process: encourage the family to join a support group

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? serum sodium concentration testing urine testing for acetone out of bed to chair three times daily insertion of nasogastric (NG) tube

insertion of nasogastric (NG) tube

What is the only known risk factor for brain tumors? use of hair dye ionizing radiation head trauma cellular telephones

ionizing radiation

After undergoing a surgery for removal of a spinal cord tumor, the client is placed in the side-lying position. The nurse places a pillow between the client's knees to prevent: knee flexion. body misalignment. pressure injury. CSF leakage.

knee flexion.

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? emphasize complete bedrest look for a halo sign look for signs of increased intracranial pressure have the client avoid physical exertion

look for signs of increased intracranial pressure

A nurse is reading a journal about spinal cord tumors and metastasis from other primary sites. The nurse demonstrates understanding of the article when identifying which primary sites as commonly metastasizing to the spinal cord? SATA lung breast prostate gastrointestinal tract bladder

lung breast gastrointestinal tract

A client is diagnosed with a tumor of the temporal lobe. When developing the client's plan of care the nurse would plan interventions to address problems with which areas of functioning? writing memory understanding language reading emotions

memory understanding language emotions

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury? diarrhea placing the client in a sitting position voiding placing a blanket over the client

placing a blanket over the client

A client who is suspected of having a spinal cord tumor is reporting pain. Upon further assessment, the nurse would report that the pain increases in which position? semi-fowlers supine side-lying prone

prone

Corticosteroids are used in the management of brain tumors to prevent extension of the tumor reduce cerebral edema facilitate regeneration of neurons identify precise location of the tumor

reduce cerebral edema

A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be the priority for this client? activity self-care safety skin care

safety

A client diagnosed with a brain tumor is exhibiting focal symptoms. Which assessment findings are the nurse likely to note? SATA sensory loss aphasia vomiting visual changes muscle weakness

sensory loss aphasia visual changes muscle weakness

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? tetraplegia paraplegia spinal shock cardiogenic shock

spinal shock

A client is scheduled for diagnostic testing to evaluate the possibility of a brain tumor. The nurse would anticipate preparing the client for which test? MRI CT scan electroencephalography lumbar puncture

MRI

A client with a history of a brain tumor is undergoing diagnostic testing to evaluate whether current symptoms are the result of the tumor or scar tissue. The nurse would prepare the client for which test? PET MRI cerebral angiography three-dimensional biopsy

PET

The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation? escape of CSF from the client's ear an area of bruising over the mastoid bone a bloodstain surrounded by a yellowish stain on the head dressing escape of CSF from the client's nose

an area of bruising over the mastoid bone

A client is scheduled to receive Gamma Knife therapy. The nurse interprets this as which form of therapy? surgical resection stereotactic radiosurgery open biopsy external beam radiation therapy

stereotactic radiosurgery

A client with a malignant brain tumor comes in to the clinic for a follow-up. During the visit, the client asks the nurse, "why am I so tired all the time?" When responding to the client, which information would the nurse include as possible causes? SATA metastasis stress effects of intracranial pressure tumor treatment being used

stress tumor treatment being used

A client diagnosed with a malignant brain tumor is scheduled to receive chemotherapy intrathecally. When explaining this technique to the client, the nurse would describe the medication as being injected into which area? epidural space implanted port subarachnoid space central vein

subarachnoid space

What condition occurs when blood collects between the dura matter and arachnoid membrane? extradural hematoma epidural hematoma subdural hematoma intracerebral hemorrhage

subdural hematoma

A nurse is providing care for a client recently diagnosed with a brain tumor. When planning the client's care, the nurse anticipates which therapy is providing the best outcome for the client? immunotherapy chemotherapy surgery radiation therapy

surgery

A nurse is providing care to a client diagnosed with a spinal cord tumor. Based on the nurse's understanding about treatment for this type of tumor, the nurse would most likely expect to develop a teaching plan related to which therapy? radiation therapy surgery chemotherapy spinal cord decompression

surgery

Which activities would the client with a T4 spinal cord injury be able to perform independently? SATA transferring to a wheelchair ambulating breathing eating writing

transferring to a wheelchair breathing eating writing

A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician return to the ED if the client demonstrates/reports which complications? SATA sleeps for short periods of time vomiting weakness on one side of the body headache slurred speech

vomiting weakness on one side of the body slurred speech

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? decreased body temperature widened pulse pressure decreased respirations increased pulse

widened pulse pressure