EXAM 4 CH 16 WEEK 10

6. The nurse is admitting a neurologically impaired patient. The patient's family is present. How comprehensive should the initial history be? A. It should be limited to the chief complaint and personal habits. B. It should be all-inclusive, including events preceding hospitalization. C. It should be confined to current medications and family history. D. It should be restricted to only information that the patient can provide.

B. It should be all-inclusive, including events preceding hospitalization.

11. The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. What must the nurse verify before performing the test? A. Absence of cervical injury B. Depth and rate of respiration C. Patient's ability to swallow D. Patient's ability to follow a verbal command

A. Absence of cervical injury

17. The patient is ordered a CT scan with contrast. Which question should the nurse ask the conscious patient before the procedure? A. "Are you allergic to penicillin?" B. "Are you allergic to iodine-based dye?" C. "Are you allergic to latex?" D. "Are you allergic to eggs?"

B. "Are you allergic to iodine-based dye?"

2. A patient with a serious head injury has been admitted. The nurse knows that certain neurologic findings can indicate the prognosis for the patient. Which finding indicates the most serious prognosis? A. Abnormal flexion B. Abnormal extension C. Localization D. Withdrawal

B. Abnormal extension

10. The nurse is precepting a nursing student. The student asks about testing of extraocular eye movements. What should the nurse tell the student? A. It tests the pupillary response to light. B. It tests function of the three cranial nerves. C. It tests the ability of the eyes to accommodate to a closer moving object. D. It tests the oculocephalic reflex.

B. It tests function of the three cranial nerves.

14. The nurse is caring for a patient with a head injury and observes a rhythmic increase and decrease in the rate and depth of respiration followed by brief periods of apnea. What should the nurse document under breathing pattern? A. Central neurogenic hyperventilation B. Apneustic breathing C. Ataxic respirations D. Cheyne-Stokes respirations

D. Cheyne-Stokes respirations

5. A patient is admitted with an anoxic brain injury. The nurse notes abnormal extension of both extremities to noxious stimuli. This finding indicates dysfunction in which area of the central nervous system? A. Cerebral cortex B. Thalamus C. Cerebellum D. Brainstem

D. Brainstem

3. The nurse knows that change in pupil size is a significant neurologic finding particularly in the patient with a head injury. How much of a size difference between the two pupils is still considered normal? A. 1 mm B. 1.5 mm C. 2 mm D. 2.5 mm

A. 1 mm

21. The patient was admitted with a head injury and an intracranial pressure (ICP) monitoring device was placed. The nurse knows to notify the practitioner if what type of wave start to appear on the monitor? A. A waves B. B wave C. C waves D. D waves

A. A waves

16. The nurse is caring for a severely head injured comatose patient who is dying. The practitioner asks to be notified when the patient starts to exhibit signs of Cushing reflex. The nurse would call the practitioner when the patient starts to show which signs? A. Bradycardia, systolic hypertension, and widening pulse pressure B. Tachycardia, systolic hypotension, and tachypnea C. Headache, nuchal rigidity, and hyperthermia D. Bradycardia, aphasia, and visual field disturbances

A. Bradycardia, systolic hypertension, and widening pulse pressure

18. The nurse is caring for a patient who has just had a cerebral angiogram. Which intervention should be part of the nursing management plan? A. Ensuring that the patient is adequately hydrated B. Maintaining the patient on an NPO status C. Administering antibiotics to the patient D. Keeping the patient flat in bed for 24 hours

A. Ensuring that the patient is adequately hydrated

23. What sites can be used for monitoring ICP? (Select all that apply.) A. Intraventricular space B. Epidural space C. Jugular veins D. Subdural space E. Parenchyma

A. Intraventricular space B. Epidural space D. Subdural space E. Parenchyma

19. The nursing management plan for a patient undergoing an oil-based contrast myelogram should include intervention? A. Maintain the patient flat in bed for 4 to 8 hours. B. Observe the puncture sight every 15 minutes for 2 hours for signs of bleeding. C. Keep the patient's head elevated 30 to 45 degrees for 8 hours. D. Administer a sedative to keep the patient from moving around.

A. Maintain the patient flat in bed for 4 to 8 hours.

22. A critical care patient is diagnosed with massive head trauma. The patient is receiving brain tissue oxygen pressure (PbtO2) monitoring. The nurse recognized that the goal of this treatment is to maintain PbtO2: A. greater than 20 mm Hg. B. less than 15 mm Hg. C. between 15 and 20 mm Hg. D. between 10 and 20 mm Hg.

A. greater than 20 mm Hg.

24. A patient has been admitted with acute confusion and other focal neurologic signs. The practitioner performed a lumbar puncture. Which result is an abnormal finding? (Select all that apply.) A. Fluid is clear and colorless B. Glucose of 20 mg/dL C. Protein of 20 mg/dL D. Bloody fluid in first sample only E. Pressure of 250 mm H2O

B. Glucose of 20 mg/dL E. Pressure of 250 mm H2O Cerebrospinal fluid is normally a clear, colorless, odorless solution that contains 50 to 75 mg/dL of glucose, 5 to 25 mg/dL of protein, and no red blood cells. Blood in the first sample is indicative of a traumatic spinal tap and is not considered abnormal.

12. The nurse is caring for a patient who has sustained a traumatic head injury. The practitioner has asked the nurse to test the patient's oculocephalic reflex. Which findings indicate that the patient has an intact oculocephalic reflex? A. Patient's eyes move in the same direction as the patient's head when turned. B. Patient's eyes move in the opposite direction as the patient's head when turned. C. Patient's eyes move in opposite directions from each other when the patient's he

B. Patient's eyes move in the opposite direction as the patient's head when turned.

15. The nurse is caring for a severely head injured comatose patient who is dying. The nurse knows the patient has entered the late stages of intracranial hypertension when the nurse observes which signs? A. Pupils are equal and reactive B. Widening pulse pressure C. Eupnea D. Decreased intracranial pressure

B. Widening pulse pressure

20. The nurse is caring for a patient with an intracranial pressure monitoring device that provides access to CSF for sampling. Which type of device does the patient have? A. Subarachnoid bolt B. Epidural catheter C. Intraventricular catheter D. Fiberoptic catheter

C. Intraventricular catheter

4. A patient is admitted immediately after a craniotomy. The patient has no history of eye surgery. When assessing the size and shape of the patient's pupils, the nurse observes the patient's left pupil is oval. What does this finding indicate? A. Cortical dysfunction B. Intracranial hypertension C. Oculomotor nerve damage D. Opioid overdose

C. Oculomotor nerve damage

1. The nurse is caring for a patient with a closed head injury with a Glasgow Coma Scale (GCS) score of 6. What does this score indicate about the patient's neurologic status? A. Patient is in vegetative state. B. Patient is a paraplegic. C. Patient is in a coma. D. Patient is able to obey commands.

C. Patient is in a coma.

8. The nurse is caring for a critically injured patient who can only be aroused by vigorous external stimuli. Which category should the nurse use to document the patient's level of consciousness? A. Lethargic B. Obtunded C. Stuporous D. Comatose

C. Stuporous

7. The nurse is teaching a nursing student about the importance of assessing the patient's level of conscious LOC). Which statement indicates the nursing student understood the information? A. "The LOC is the most prognostic indicator of the patient's neurologic outcome." B. "The LOC limited to the Glasgow Coma Scale making it the quickest part of the assessment." C. "The LOC is the easiest part of the neurologic exam and thus is generally performed first." D. "In most situatio

D. "In most situations, the LOC deteriorates before any other neurologic changes are observed."

13. The nurse is precepting a new graduate nurse. The new graduate asks about testing the oculovestibular reflex. What should the nurse tell the new graduate? A. "The test should not be performed on an unconscious patient because of the risk of aspiration." B. "An abnormal response is manifested by conjugate, slow, tonic nystagmus, deviating toward the irrigated ear." C. "This test should be included in the nursing neurologic examination of a patient with a head injury." D. "This t

D. "This test is performed by the practitioner and one of the final clinical assessments of brainstem function."

9. The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious patient. During the procedure, the patient reaches over with his left hand and tries to remove the noxious stimuli. How would the nurse document this response? A. Decorticate posturing B. Decerebrate posturing C. Withdrawal D. Localization

D. Localization