MedSurg II: Exam 1

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

Body Temperature *Because of the possibility of infection*

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find?

Hypotension Venous pooling Tachypnea Hypothermia

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate?

Respiratory irregularities Slow bounding pulse Widened pulse pressure

Which of the following terms is used to describe rapid, jerky, involuntary, purposeless movements of the extremities? a. Chorea b. Bradykinesia c. Spondylosis d. Dyskinesia

a. Chorea

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do? a. Maintain a diet for the client that is high in protein, vitamins, and calories. b. Avoid range of motion exercises for the client because of spasms. c. Keep accurate intake and output. d. Watch closely for signs of urinary tract infection.

a. Maintain a diet for the client that is high in protein, vitamins, and calories.

Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of a muscular body area? a. computed tomography (CT) b. magnetic resonance imaging (MRI) c. positron emission tomography (PET) d. single-photon emission computed tomography (SPECT)

a. computed tomography (CT)

Which anatomic part supplies cerebrospinal fluid to the subarachnoid space and down the spinal cord on the dorsal surface? a.Third ventricle b.Fourth ventricle c.Lateral ventricle d.Arachnoid villus

b. Fourth ventricle

Which neurotransmitter inhibits pain transmission? a. Acetylcholine b. Serotonin c. Enkephalin d. Dopamine

c. Enkephalin

A patient is treated for a neurologic dysfunction affecting facial expressions. The affected cranial nerve originates in the: a. cerebral hemisphere. b. midbrain. c. pons. d. medulla.

c. pons

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? a. Epidural b. Subdural c. Intracerebral d. Cerebral

a.Subdural

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? a. Symptoms will evolve over a period of 1 week. b. Monitoring is needed as rapid neurologic deterioration may occur. c. The crash cart with defibrillator is kept nearby. d. Bleeding continues into the intracerebral area.

b. Monitoring is needed as rapid neurologic deterioration may occur. Epidural Hematoma: brief loss of consciousness, lucid interval, increasing agitation, rapid dterioration

A potential complication of a hemorrhagic stroke is interference with the ability of the arachnoid villi to absorb CSF. Therefore, fluid in the ventricles increase beyond the amount that is usually absorbed daily, which is: a. 150 to 200 mL. b. 200 to 250 mL. c. 275 to 325 mL. d. 350 to 375 mL.

d. 350 to 375 mL.

Which of the following cranial nerves is responsible for salivation, tearing, taste, and sensation in the ear? a. Vestibulocochlear b. Oculomotor c. Facial d. Trigeminal

c. Facial

The cerebral circulation receives approximately what percentage of the cardiac output? a. 15% b. 10% c. 25% d. 20%

a. 15%

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order: a. naloxone (Narcan). b. famotidine (Pepcid). c. nitroglycerin (Nitro-Bid). d. atracurium (Tracrium).

b. famotidine (Pepcid)

A comatose client is being cared for by a critical care nurse who documents that the client responds only to very painful stimuli by fragmentary, delayed reflex withdrawal. The nurse knows that reflexes in the body are centered where? a. In the pons b. In the medulla oblongata c. In the spinal cord d. In the midbrain

c. In the spinal cord

The brain stem holds the medulla oblongata. What is the function of the medulla oblongata? a. transmits sensory impulses from the brain to the spinal cord b. controls striated muscle activity in blood vessel walls c. controls parasympathetic nerve impulses in the pons d. transmits motor impulses from the brain to the spinal cord

d. transmits motor impulses from the brain to the spinal cord

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad?

Bradycardia Hypertension Bradypnea