NURS 495: Exam IV: Neuro - NCLEX q's

A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Dilantin should be mixed in dextrose in water before administration. 3. Rapid dilantin administration can cause cardiac arrhythmias. 4. Dilantin should be administered through an IV catheter in the client's hand.

3

A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? 1. Subdural hematoma 2. Epidural hematoma 3. Subarachnoid hemorrhage 4. Contusion

2

A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? 1. Assess full ROM to determine extent of injuries 2. Immobilize the client's head and neck 3. Call for an immediate chest x-ray 4. Open the airway with the head-tilt chin-lift maneuver

2

A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? 1. Check the fluid for dextrose with a dipstick 2. Position the client flat in bed 3. Insert nasal and ear packing with sterile gauze 4. Suction the nose to maintain airway patency

1

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? 1. Methylprednisolone (Solu-Medrol) 2. Acetazolamide (Diamox) 3. Furosemide (Lasix) 4. Sodium bicarbonate

1

A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? 1. Unequal pupil size 2. Decreasing systolic blood pressure 3. Decreasing body temperature 4. Tachycardia

1

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? 1. Neurological deficit 2. Pulse ox readings 3. Bladder distension 4. The client's feelings about the injury

2

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, list in order of priority, the nurse's actions (Number 1 being the first priority and number 5 being the last priority). *A*. Check for bladder distention *B*. Raise the head of the bed *C*. Contact the physician *D*. Loosen tight clothing on the client *E*. Administer an antihypertensive medication. 1. A, B, C, D, E 2. B, D, A, C, E. 3. C, A, D, E, B 4. C, D, A, B, E

2

A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? 1. Diencephalon 2. Midbrain 3. Cortex 4. Medulla

2

The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: 1. A history of diarrhea 2. Hematest positive nasogastric tube drainage 3. Hyperactive bowel sounds 4. A flattened abdomen

2

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? 1. Respiratory depression 2. Symptoms of shock 3. Hypertension and bradycardia 4. Decreased urine output or oliguria

3

Which of the following describes decerebrate posturing? 1. Supination of arms, dorsiflexion of feet 2. Back arched; rigid extension of all four extremities. 3. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet - Given 4. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers

2

A client with a C6 spinal injury would most likely have which of the following symptoms? 1. Tetraplegia 2. Aphasia 3. Paraplegia 4. Hemiparesis

1

A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? 1. Neurogenic shock 2. Autonomic dysreflexia 3. Sepsis 4. Hypervolemia

1

A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? 1. Ineffective breathing pattern 2. Self-care deficit: Dressing/grooming 3. Disturbed sensory perception (tactile) 4. Impaired physical mobility

1

Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? 1. Encourage the client to hyperventilate 2. Give the client a warming blanket 3. Administer low-dose barbiturate 4. Restrict fluids

1

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? 1. Assess patency of the indwelling urinary catheter - Given 2. Place the client flat in bed 3. Give one SL nitroglycerin tablet 4. Raise the head of the bed immediately to 90 degrees

4

A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? 1. Widening pulse pressure 2. Dilated, fixed pupil 3. Decrease in the pulse rate 4. Decrease in LOC

4

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? 1. Strict adherence to a bowel retraining program 2. Preventing unnecessary pressure on the lower limbs 3. Keeping the linen wrinkle-free under the client 4. Limiting bladder catheterization to once every 12 hours

4

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? 1. Urinary continence 2. Spontaneous respirations 3. Absence of pain sensation in chest 4. Spasticity

4

The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: 1. Placing the client on a Stryker frame 2. Logrolling the client on a soft mattress 3. Logrolling the client on a firm mattress 4. Keeping the client on a stretcher

1

The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: 1. Epidural hematoma 2. Subdural hematoma 3. Concussion 4. Skull fracture

1

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? 1. Inability to elicit a Babinski's reflex 2. Positive reflexes 3. Hyperreflexia 4. Reflex emptying of the bladder

1

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? 1. Schedule intermittent catheterization every 2 to 4 hours 2. Insert an indwelling urinary catheter to straight drainage 3. Perform a straight catheterization every 8 hours while awake 4. Perform Crede's maneuver to the lower abdomen before the client voids.

1

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. 1. Loosen constrictive clothing 2. Assess for bladder distention and bowel impaction 3. Elevate the HOB to 90 degrees 4. Use a fan to reduce diaphoresis 5. Administer antihypertensive medication

1,2,3,5

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? 1. Rupture of the carotid artery 2. Laceration of the middle meningeal artery 3. Thromboembolism from a carotid artery 4. Venous bleeding from the arachnoid space

2

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? 1. Administer 100 mg of pentobarbital IV as ordered. 2. Reposition the client to avoid neck flexion 3. Increase the ventilator's respiratory rate to 20 breaths/minute 4. Administer 1 g Mannitol IV as ordered

2

The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? 1. Extent of intracranial bleeding 2. Activity of the brain 3. Percent of functional brain tissue 4. Sites of brain injury

2

A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? 1. Decerebrate posturing 2. Absent corneal reflex 3. The need for mechanical ventilation 4. Movement of only the right or left half of the body

3

A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? 1. Check deep tendon reflexes to determine the best motor response 2. Count the rate to be sure the ventilations are deep enough to be sufficient 3. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. 4. Call the physician to adjust the ventilator settings.

3

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? 1. Anticipate treatment for renal failure 2. Slow down the IV fluids and notify the physician 3. Evaluate urine specific gravity 4. Provide emollients to the skin to prevent breakdown

3

A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? 1. furosemide (Lasix) 2. phenytoin (Dilantin) 3. lidocaine (Xylocaine) 4. mannitol (Osmitrol)

3

A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? 1. By inserting a nasopharyngeal airway 2. By inserting a oropharyngeal airway 3. By performing the head-tilt, chin-lift maneuver 4. By performing a jaw-thrust maneuver

4

During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? 1. Elevate the client's legs 2. Put the client in the Trendelenburg's position 3. Put the client flat in bed 4. Put the client in the high-Fowler's position

4

The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses which of the following? 1. Cerebellar function 2. Intellectual function 3. Sensory function 4. Cerebral function

4

Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? 1. A client with a brain injury 2. A client with a stroke 3. A client with a herniated nucleus pulposus 4. A client with a high cervical spine injury

4

After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? 1. Loss of bowel and bladder control 2. Paraplegia with intercostal muscle loss 3. Quadriplegia with gross arm movement and diaphragmatic breathing 4. Quadriplegia and loss of respiratory function

3

After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? 1. Give him a barbiturate. 2. Place him on mechanical ventilation. 3. Perform a lumbar puncture. 4. Elevate the head of his bed.

3

The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: 1. Dexamethasone (Decadron) 2. Mannitol (Osmitrol) 3. Desmopressin (DDAVP, stimate) 4. Ethacrynic acid (Edecrin)

3

The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? 1. Applying Teds or compression stockings. 2. Monitoring vital signs before and during position changes 3. Moving the client quickly as one unit 4. Using vasopressor medications as prescribed

3

A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: 1. shining a bright light into the pupil. 2. introducing ice water into the external auditory canal. 3. turning the client's head suddenly while holding the eyelids open. 4. touching the cornea with a wisp of cotton.

3

A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? 1. Lumbar spinal cord injury 2. Headache 3. Noxious stimuli 4. Neurogenic shock

3

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? 1. Emergent; the client is poorly oxygenated. 2. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). 3. Normal 4. Significant; the client has alveolar hypoventilation.

2

An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? 1. "Watch him for keyhole pupil the next 24 hours." 2. "Notify the physician immediately if he has a headache." 3. "Expect profuse vomiting for 24 hours after the injury." 4. "Wake him every hour and assess his orientation to person, time, and place."

4

Which of the following respiratory patterns indicate increasing ICP in the brain stem? 1. Rapid, shallow respirations 2. Slow, irregular respirations 3. Asymmetric chest expansion 4. Nasal flaring

2