MedSurge T3 questions

The male client is being discharged from the ED after sustaining a minor head injury. Which statement indicates the wife understands the discharge teaching?

"I will bring my husband back to the emergency room if he starts vomiting"

You're educating a patient about treatment options for Guillain-Barré Syndrome. Which statement by the patient requires you to re-educate the patient about treatment?

"Plasmapheresis or immunoglobin therapies are treatment options available for this syndrome but are most effective when given within 4 weeks of the onset of symptoms."

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."

"The obstructing plaque is surgically removed from an artery in the neck." In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is replaced" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure.

The HCP has discussed a carotid endarterectomy w. the client who has experienced 2 transient ischemic attacks (TIAs). The client tells the nurse, "I really don't understand why I need the procedure, and I don't want to have it." Which scientific rationale would support the nurse's response?

"This surgery is indicated for clients with symptoms of a TIA due to carotid artery stenosis."

TEXTBOOK (9th Ed.)

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REGISTERED NURSE RN - GB

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TEXT BOOK (7th ed.)

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The client diagnosed with lung cancer has developed metastasis to the brain. Which problem would be the priority for this client? 1. Anticipatory grieving 2. impaired gas exchange 3. altered nutrition status 4. alteration in comfort

1. Anticipatory grieving

The nurse is preparing the client diagnosed w. head injury for a MRI. Which intervention should the nurse implement? SELECT ALL. 1. Ask the pt if they are claustrophobic 2. Have the client sign a procedural permit 3. Determine if the client is allergic to shellfish 4. Check if the pt has any prosthetic devices 5. Ask the client to empty his bladder

1. Ask the pt if they are claustrophobic 4. Check if the pt has any prosthetic devices 5. Ask the client to empty his bladder

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1. Confusion 2. Bradycardia 3. Sluggish pupils 4. A widened pulse pressure

1. Confusion

The nurse is preparing for a lumbar puncture for the client diagnosed with R/O meningitis. Which interventions should the nurse implement? SELECT all. 1. Determine if the client has an allergy to iodine 2. do not let the client urinate 2 hours before the procedure. 3. place the client in a prone position w. the face turned to the side 4. instruct the client to take slow deep breaths during the procedure 5. label the specimen & send to the the laboratory for cultures

1. Determine if the client has an allergy to iodine 4. instruct the client to take slow deep breaths during the procedure 5. label the specimen & send to the the laboratory for cultures

594. After an automobile collision a client who is unconscious is exhibiting decerebrate posturing is brought to the emergency department. When assessing this client, the nurse expects to observe:

1. Hyperextension of both the upper and lower extremities

606. A client who had an infratentorial craniotomy is admitted to the intensive care unit after discharge from the postanesthesia care unit. Frequent assessments reveal that the client's intracranial pressure is increasing. The nurse should first: 1. Notify the surgeon 2. Elevate the head of the bed 3. Reduce the flow rate of IV fluid 4. Administer the next dose of osmotic diuretic early

1. Notify the surgeon

632. A client has carotid atherosclerotic plaques, and a right carotid endarterectomy is performed. Two hours after surgery the client demonstrates progressive hypotension. The nurse should: 1. Notify the surgeon 2. Increase the IV flow rate 3. Raise the head of the bed 4. Put the client in a slight Trendelenburg position

1. Notify the surgeon

During the evening shift, you note that the patient is having difficulty mobilizing secretions.Which interventions should be implemented for this problem? (Select all that apply.) 1. Oropharyngeal suctioning as needed 2. Coughing and deep breathing 3. Oxygen at 2 L per nasal cannula 4. Chest physiotherapy 5. Plasmapheresis

1. Oropharyngeal suctioning as needed 2. Coughing and deep breathing 4. Chest physiotherapy

589. A nurse is caring for a client with Guillain-Barré syndrome. For what essential care related to rehabilitation should the nurse prepare the client?

1. Physical therapy

609. After 3 months of rehabilitation after a craniotomy, a female client is still having motor speech difficulties. To promote the client's use of speech the nurse should: 1. Support her efforts to communicate 2. Correct verbal mistakes immediately 3. Use simple words with short sentences 4. Explain why she is having difficulty speaking

1. Support her efforts to communicate

631. A client has a history of progressive carotid and cerebral atherosclerosis and transient ischemic attacks (TIAs). The nurse explains to the client that TIAs are: 1. Temporary episodes of neurological dysfunction 2. Intermittent attacks caused by multiple small clots 3. Ischemic attacks that result in progressive neurological deterioration 4. Exacerbations of neurological dysfunction alternating with remissions

1. Temporary episodes of neurological dysfunction

600. A young adult who is unconscious after an accident is brought to the emergency department. The client's pupils are equal and responsive to light. As part of the neurological assessment, the nurse applies a painful stimulus to the client's left lower leg. An expected response in a healthy adult is: 1. Withdrawing the leg 2. Making no movement 3. Plantar flexing the left foot 4. Flexing the upper extremities

1. Withdrawing the leg

The male client diagnosed with a brain tumor who is receiving hospice care is admitted to the hospital & provides the nurse w. a copy of his living will, stating he does not want any heroic measures. Which action should the nurse implement FIRST? 1. check the chart to make sure there is a DNR order 2. inform the HCP that the client has a living will 3. Place a copy of the living will in the front of the client's chart 4. Request the hospital chaplains to come & talk to the client

1. check the chart to make sure there is a DNR order

The nurse is caring for clients on a medical surgical unit. Which client should be assessed FIRST? 1. the client diagnosed w. epilepsy who reports over the intercom having an aura 2. The client with an L-1 SC injury who is complaining of shortness of breath while exercising 3. The client diagnosed with Parkinson disease who is being discharged today 4. The client diagnosed with a CVA who has resolving left hemiparesis

1. the client diagnosed w. epilepsy who reports over the intercom having an aura

634. A client is admitted to the hospital with weakness in the right extremities, a slight speech problem, and vital signs that are within expected limits. The practitioner suspects that the client has sustained a brain attack (CVA). During the first 24 hours the nurse gives priority to: 1. Checking the client's temperature 2. Evaluating the client's motor status 3. Monitoring the client's blood pressure 4. Obtaining the client's urine for a urinalysis

2. Evaluating the client's motor status

The nurse performs an initial assessment on an old client. Which of the assessment findings would the nurse expect to be the result of normal physiologic aging? SELECT ALL. 1. Confusion 2. Hearing loss 3. Decerebrate positioning 4. Slurred speech 5. Constipation 6. Urinary incontinence

2. Hearing loss 5. Constipation

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1. Clustering nursing activités 2. Hyperoxygenating before suctioning 3. Maintaining 20 degree flexion of the knees 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed at 30 degrees elevation

2. Hyperoxygenating before suctioning 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed at 30 degrees elevation

627. A client is admitted to the emergency department after sustaining a spinal cord injury above the T6 level. Which response is most important for the nurse to monitor when concerned about spinal shock? 1. Tachycardia 2. Hypoventilation 3. Bladder distention 4. Elevated blood pressure

2. Hypoventilation

588. During the neurological assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, the nurse expects that the client will manifest:

2. Increased muscular weakness

592. When performing a neurological check on a client with a head injury, the nurse identifies a diminished corneal reflex in the left eye. Appropriate nursing care for a client with an absent corneal reflex includes:

2. Instilling artificial tears frequently

639. A female client manifests right-sided hemianopsia as a result of a brain attack (CVA). The nurse should: 1. Correct the client's misuse of equipment 2. Instruct the client to scan her surroundings 3. Teach the client to look at the position of her left extremities 4. Provide the client with tactile stimulation to the affected extremities

2. Instruct the client to scan her surroundings

608. A client has surgery for the creation of burr holes after sustaining head trauma from a fall and is at risk for developing an infection. An early clinical manifestation of meningeal irritation for which the nurse assesses the client is: 1. Sunset eyes 2. Kernig's sign 3. Plantar reflex 4. Homans' sign

2. Kernig's sign

635. A client having a brain attack (CVA) is brought to the emergency department. The vital signs are P, 78; R, 16; and BP, 120/80. The change in this client's vital signs that indicates increasing intracranial pressure (ICP) requiring notification of the practitioner is: 1. P, 120; R, 16; BP, 80/60 2. P, 50; R, 22; BP, 140/60 3. P, 60; R, 18; BP, 126/96 4. P, 56; R, 20; BP, 130/110

2. P, 50; R, 22; BP, 140/60

587. A nurse is caring for a client newly diagnosed with Guillain-Barré syndrome. Which procedure should the nurse expect the practitioner to discuss as a potential treatment option?

2. Plasmapheresis

626. A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to prepare for this activity? 1. Leg lifts to prevent hip contractures 2. Push-ups to strengthen arm muscles 3. Balancing exercises to promote equilibrium 4. Quadriceps-setting exercises to maintain muscle tone

2. Push-ups to strengthen arm muscles

The client diagnosed with septic meningitis is admitted to the medical floor at 1200. Which HCP's order would the nurse implement FIRST? 1. Administer IV ABX 2. Start the client's IV line 3. Provide a quiet, calm dark room 4. initiate seizure precautions

2. Start the client's IV line

605. When caring for an unconscious client with increasing intracranial pressure, the nursing intervention that is contraindicated is: 1. Lubricating the skin with baby oil 2. Suctioning the oropharynx routinely 3. Elevating the head of the bed 20 degrees 4. Cleansing the eyes every 4 hours with normal saline

2. Suctioning the oropharynx routinely

601. A client had spinal anesthesia for surgery. On the second day after surgery the client complains of a headache. The nurse should: 1. Begin an early ambulation program 2. Supply the client with several containers of juice 3. Remove any elastic antiembolism stockings being worn 4. Assist the client to sit at the bedside with the feet dangling

2. Supply the client with several containers of juice (Encouraging fluids will hydrate the pt & contribute to the restoration of CFS/cushions the brain)

The nurse has received the morning shift report. Which client should the nurse assess first? 1. The client who is complaining of a headache at a 3 on scale of 1 to 10. 2. The client has an apical pulse of 56 & a BP of 210/116 3. The client who is reporting not having a bowel movement for 3 days 4. The client who is angry because the call light has not been answered for 1 hr

2. The client has an apical pulse of 56 & a BP of 210/116

623. A client who sustained a spinal cord injury at the T2 level should be assessed for signs of autonomic hyperreflexia because: 1. The injury results in loss of the reflex arc 2. The injury is above the sixth thoracic vertebra 3. There has been a partial transection of the cord 4. There is a flaccid paralysis of the lower extremities

2. The injury is above the sixth thoracic vertebra

The client is being admitted w. rule-out brain tumor. Which signs/symptoms support the diagnosis of a brain tumor? 1. Widening pulse pressure, HTN, bradycardia 2. headache, vomiting, diplopia 3. hypotension, tachycardia, tachypnea 4. abrupt loss of motor fxn, diarrhea, changes in taste

2. headache, vomiting, diplopia

The ICU nurse is caring for a pt following an infratentorial craniotomy. Which interventions should the nurse implement? SELECT ALL. 1. keep the HOB elevated at 30 degrees 2. keep a humidifier in the clients room 3. don't put anything in the patient's mouth 4. clear liquid diet 5. Assess the respiratory status every hr

2. keep a humidifier in the clients room 4. clear liquid diet 5. Assess the respiratory status every hr

The charge nurse has received laboratory data for clients. Which situation requires the charge nurses intervention FIRST? 1. brain tumor w. ABGs pH 7.36, PaO2 95, PaCO2 38, HCO3 24 2. postop craniotomy w. serum sodium: 153 mEq/L 3. septic meningitis w. WBC 12000 4. epilepsy w. serum phenytoin 15 mcg/mL

2. postop craniotomy w. serum sodium: 153 mEq/L

630. On the first postoperative evening after a lumbar laminectomy, a male client tells the nurse that his feet are as numb as they were before the operation. What is the nurse's best response?

3. "Continue to let me know how you feel. It often takes time before this feeling subsides."

640. The husband of a client with expressive aphasia as a result of a brain attack (CVA) asks whether his wife's speech will ever return. What is the best response by the nurse?

3. "It is hard to say how much improvement will occur."

Which pt would the nurse identify as being least at risk for experiencing a CVA? 1. 55 y.o. AA male who is obese 2. 73 y.o. Japanese female who has essential HTN 3. 67 y.o. caucasian male whose cholesterol level is below 200 4. 39 y.o. female who is taking oral contraceptives

3. 67 y.o. caucasian male whose cholesterol level is below 200

The RN, LPN, and UAP are caring for clients on a neuro unit. Which task would be the most appropriate for the nurse assign/delegate? 1. Instruct the LPN to complete the client's admission assessment 2. Request the UAP to change the central line dressing 3. Assign the LPN to administer routine medications 4. Tell the UAP to complete the Glasgow Coma Scale

3. Assign the LPN to administer routine medications

595. A client is admitted to the hospital after sustaining a head injury. The most reliable sign that this client is experiencing an increase in intracranial pressure is a slowly:

3. Decreasing level of consciousness

The 88 y.o. pt is admitted to the ED w. numbness & weakness of the left arm & slurred speech. The CT scan was negative for bleeding. Which nursing action is a priority? 1. Prepare to admin tPA 2. Discuss the precipitating factors that caused the symptoms 3. Determine the exact time the symptoms occurred 4. notify the speech pathologist for an emergency consult

3. Determine the exact time the symptoms occurred

633. After a carotid endarterectomy, the client is monitored for the complication of cranial nerve dysfunction. To monitor for this complication, the nurse assesses the client for: 1. Labored breathing 2. Edema of the neck 3. Difficulty in swallowing 4. Alteration in blood pressure

3. Difficulty in swallowing

The spouse of a patient brought to the ED states that 6 hours ago her husband began having difficulty finding words. The patient has since become progressively worse. He has right hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position and has been incontinent of urine.What is the priority nursing intervention for this patient at this time? 1. Provide perineal care 2. Assess for gag reflex 3. Elevate the head of bed 4. Perform a linen and gown change

3. Elevate the head of bed

607. A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex. Postoperatively, the position that is most appropriate for this client is: 1. Semi-Fowler's with knee gatch elevated 2. Flat on one side with the neck maintained in alignment with a small pillow 3. Head of the bed elevated 30 to 45 degrees with the neck in neutral alignment 4. Head of the bed elevated 20 degrees with the head turned to the operative side

3. Head of the bed elevated 30 to 45 degrees with the neck in neutral alignment

603. In what position should a nurse plan to maintain a client who has experienced a subarachnoid hemorrhage? 1. In the supine position 2. On the unaffected side 3. In bed with the head of the bed elevated 4. With sandbags on either side of the head

3. In bed with the head of the bed elevated

599. A client w. severe head injury is being monitored by the nurse for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure? 1. Polyuria 2. Tachypnea 3. Increased restlessness 4. Intermittent tachycardia

3. Increased restlessness

596. During the immediate post-trauma period after injury to the frontal lobe of the brain, the nurse places a client in the:

3. Low Fowler's position

622. A client sustains a vertebral fracture at the T1 level as a result of diving into shallow water. On admission to the emergency department a detailed neurological assessment is performed. Which clinical finding should the nurse expect to identify? 1. Difficulty breathing 2. Inability to move the lower arms 3. Normal biceps reflexes in the arms 4. Loss of pain sensation in the hands

3. Normal biceps reflexes in the arms

629. A client whose vertebral column at the level of T6 and T7 was completely crushed and whose left leg was traumatically amputated above the knee is admitted to the ICU. When performing an assessment the nurse expects to find that the client is experiencing: 1. Difficulty breathing 2. Discomfort in the residual limb 3. Pain at the level of compression 4. Spastic paralysis of the extremities

3. Pain at the level of compression

636. On the evening before discharge from the hospital, a client has a hypertensive crisis and a brain attack (CVA). Initially the nurse should place the client in a:

3. Side-lying position

The charge nurse in the medsurg dept is making rounds at 0700. Which client should the nurse see first? 1. the client diagnosed w. brain tumor who is complaining of a headache 2. The client diagnosed w. meningitis who is complaining of a stick neck 3. The client diagnosed w. diabetes who is reporting seeing spots in the eyes 4. The client diagnosed w. low back pain who has radiating pain down the left leg

3. The client diagnosed w. diabetes who is reporting seeing spots in the eyes (RETINAL DETACHMENT)

602. A 26-year-old client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The nurse concludes that neurological deficits, which may be present immediately after a subarachnoid hemorrhage, primarily are caused by: 1. Blood loss 2. Tissue death 3. Vascular spasms 4. Electrolyte imbalance

3. Vascular spasms

The nurse is preparing to administer dexamethasone IV push to a client with an acute spinal cord injury. Which interventions should the nurse implement? Rank in order 1. Administer the medications over 2 mins 2. dilute the med w. normal saline 3. check the client's med administration w. MAR 4. Check the client's ID band 5. clamp the IV tubing distal to the port

3. check the client's med administration w. MAR 2. dilute the med w. normal saline 4. Check the client's ID band 5. clamp the IV tubing distal to the port 1. Administer the medications over 2 mins

The nurse asks the UAP to help admit the client diagnosed w. bacterial meningitis. Which nursing task is the priority? 1. Taking the client's vital signs 2. obtain the client's height & weight 3. prep the room for respiratory isolation 4. pull the drapes and make sure the room is dim

3. prep the room for respiratory isolation

598. A client who sustained a severe head injury in a diving accident remains unconscious. In addition, the nurse observes bleeding from the left ear and rhinorrhea. The nurse concludes that drainage from the ear and nose indicates a: 1. Contusion 2. Concussion 3. Nose fracture 4. Basilar fracture

4. Basilar fracture

597. A nurse in the emergency department prepares a checklist before transferring an unconscious client with a head injury to the neurological trauma unit. Which nursing action is the priority? 1. Notifying the receiving unit of the transfer 2. Having the client's records ready for the transfer 3. Verifying that the family has been notified of the transfer 4. Checking that a bag-valve mask is available during the transfer

4. Checking that a bag-valve mask is available during the transfer

641. When assisting the family to help a member with expressive aphasia regain as much speech function as possible, the nurse instructs them to:

4. Encourage the client to speak while being patient with each attempt

637. Initially after a brain attack (CVA), a client's pupils are equal and reactive to light. Later the nurse assesses that the right pupil is reacting more slowly than the left and the systolic blood pressure is beginning to increase. The nurse concludes that these signs are suggestive of: 1. Spinal shock 2. Hypovolemic shock 3. Transtentorial herniation 4. Increasing intracranial pressure

4. Increasing intracranial pressure

638. What should the nurse do to prevent a client, who had a brain attack (CVA) 2 days ago, from developing plantar flexion? 1. Place a pillow under the thighs 2. Elevate the knee gatch of the bed 3. Encourage active range of motion 4. Maintain the feet at right angles to the legs

4. Maintain the feet at right angles to the legs

604. After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. To ensure adequate cerebral blood flow the nurse should: 1. Clear the ear of draining fluid 2. Discontinue anticonvulsant therapy 3. Elevate the head of the bed thirty degrees 4. Monitor serum carbon dioxide levels routinely

4. Monitor serum carbon dioxide levels routinely

624. The nurse determines that a client with a spinal cord injury is developing autonomic hyperreflexia when the client has: 1. Flaccid paralysis and numbness 2. Absence of sweating and pyrexia 3. Escalating tachycardia and shock 4. Paroxysmal hypertension and bradycardia

4. Paroxysmal hypertension and bradycardia

642. A client, employed as a carpenter, has difficulty holding tools because of carpal tunnel syndrome. Because the client must continue to work, the issue of most concern is: 1. Anxiety 2. Persistent pain 3. Low self-esteem 4. Potential for injury

4. Potential for injury

625. During the first week after a spinal cord injury at the T3 level, a male client and the nurse identify a short-term goal. An appropriate short-term goal for this client is, "The client will: 1. understand limitations." 2. consider lifestyle changes." 3. perform independent ambulation." 4. carry out personal hygiene activities."

4. carry out personal hygiene activities."

The nurse is caring for a patient with a diagnosis of Bell's palsy. The nurse understands that for a patient with Bell's palsy the symptoms are the most severe during which time period after beginning?

48 hrs after onset

593. The nurse uses the Glasgow Coma Scale to assess a client with a head injury that resulted from a snowboarding accident. The nurse identifies that the client is in a coma when the Glasgow Coma Scale score is:

6

The nurse performs discharge teaching for a 34-year-old male patient with a T2 spinal cord injury resulting from a construction accident. Which statement, if made by the patient to the nurse, indicates that teaching about recognition and management of autonomic dysreflexia is successful? A. "I will perform self-catheterization at least six times per day." B. "A reflex erection may cause an unsafe drop in blood pressure." C. "If I develop a severe headache, I will lie down for 15 to 20 minutes." D. "I can avoid this problem by taking medications to prevent leg spasms."

A. "I will perform self-catheterization at least six times per day."

You're teaching a group of nursing students about Guillain-Barré Syndrome and how it can affect the autonomic nervous system. Which signs and symptoms verbalized by the students demonstrate they understood the autonomic involvement of this syndrome? SELECT ALL. A. Altered body temperature regulation B. Inability to move facial muscles C. Cardiac dysrhythmias D. Orthostatic hypotension E. Bladder distension

A. Altered body temperature regulation C. Cardiac dysrhythmias D. Orthostatic hypotension E. Bladder distension

A patient with Guillain-Barré Syndrome has a feeding tube for nutrition. Before starting the scheduled feeding, it is essential the nurse? SELECT ALL. A. Assesses for bowel sounds B. Keeps the head of bed less than 30' degrees C. Checks for gastric residual D. Weighs the patient

A. Assesses for bowel sounds C. Checks for gastric residual

The nurse is teaching a client about taking a new prescription for pyridostigmine. Which statements by the nurse indicate correct info about this drug? SELECT ALL. A. Avoid opioids & other sedating drugs when taking this medication B. Report increased mucous secretions & sweating immediately to the primary HCP C. Take the prescribed meds after meals to increase intestinal absorption D. Avoid taking ABX, especially neomycin while on this medication E. Maintain the exact same dose of this medication every day

A. Avoid opioids & other sedating drugs when taking this medication B. Report increased mucous secretions & sweating immediately to the primary HCP D. Avoid taking ABX, especially neomycin while on this medication

The nurse is caring for a client diagnosed with Guillain-Barre syndrome. Which assessment findings require nursing action? SELECT ALL. A. BP 80/42 B. RR 24 C. Shallow breathing pattern D. Peripheral oxygen saturation of 85% E. Diminished breath sounds in all lung fields

A. BP 80/42 C. Shallow breathing pattern D. Peripheral oxygen saturation (SpO2) of 85% E. Diminished breath sounds in all lung fields

The nurse is teaching a client about what to expect during a cerenbral angiographic exam. Which statement by the client indicates a need for further teaching? A. I can't have this test b.c I am allergic to shellfish B. My head will be strapped in place so I don't move C. I'll have to keep my leg very still after the procedure D. I'll have a temporary dressing on my groin

A. I can't have this test b.c I am allergic to shellfish

The nurse provides health teaching for a client beginning glatiramer acetate therapy. Which statement by the client indicates a need for additional teaching? A. I'll take this drug w. food every morning B. I'll look for signs ok skin rxn at the injection site C. I'll stay away from kids who have colds D. I'll avoid large crowds so I don't get sick

A. I'll take this drug w. food every morning

The nurse is teaching a client about self-management measures to help prevent low back pain. Which teaching should be included? SELECT ALL. A. Losing weight can decrease strain on your back B. Avoid twisting at your waist C. Exercise on a regular basis, including walking D. Don't bend at your waist when lifting a heavy object E. Eat foods high in calcium & vitamin D to prevent bone loss

A. Losing weight can decrease strain on your back B. Avoid twisting at your waist C. Exercise on a regular basis, including walking D. Don't bend at your waist when lifting a heavy object E. Eat foods high in calcium & vitamin D to prevent bone loss

You're assessing a patient's health history for risk factors associated with developing Guillain-Barré Syndrome. SELECT ALL RF. A. Recent upper respiratory infection B. Patient's age: 3 years old C. Positive stool culture Campylobacter Jejuni D. Hyperthermia E. Epstein-Barr F. Diabetes G. Myasthenia Gravis

A. Recent upper respiratory infection C. Positive stool culture Campylobacter Jejuni E. Epstein-Barr Risk factors for developing GB Syndrome include: experiencing upper respiratory infection, GI infection (especially from Campylobacter Jejuni), Epstein-Barr infection, HIV/AIDS, vaccination (flu or swine flu

An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg, and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.

ANS: 74 Calculate the CPP: (CPP = MAP - ICP). MAP = DBP + 1/3 ([SBP] - [DBP]). The MAP is 94. The CPP is 74.

An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Refer the family members to the hospital counseling service to deal with their anxiety. d. Call the family's pastor or spiritual advisor to take them to the chapel while care is given.

Allow the family to stay with the patient and briefly explain all procedures to them.

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

Apply intermittent pneumatic compression stockings. The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

The nurse is caring for a client w. chronic confusion who often yells and screams when touched. Which nursing intervention is most appropriate when caring for this client?

Approach the pt so the nurse can be seen clearly

The nurse is caring for pt's on a rehab unit. Which nursing task would be most appropriate for the nurse to delegate to the UAP?

Ask the UAP to hold the urinal while the client performs the Crede manuever

A 22-year-old female with paraplegia after a spinal cord injury tells the home care nurse that bowel incontinence occurs two or three times each day. Which action by the nurse is most appropriate? a. take magnesium citrate every morning w. breakfast b. teach the patient to gradually increase intake of high fiber foods c. Assess bowel movements for frequency, consistency, and volume d. instruct the patient to avoid all caffeinated and carbonated beverages

Assess bowel movements for frequency, consistency, and volume

The nurse is caring for a pt with septic meningitis. The UAP reports T 101.6 F, P 128, RR 32, BP 96/46. Which action should the nurse implement FIRST? 1. Notify MD 2. Assess client immediately 3. Prep to administer acetaminophen 4. check the chart for the culture & sensitivity report

Assess the client immediately

18 y/o client is admitted to the medical floor w. a diagnosed meningitis. Which priority intervention should the nurse assess?

Assess the neurological status

The nurse is assessing a pt who opens both eyes when spoke to, obeys commands, and seems confused during conversation. Which Glasgow Coma Scale will the nurse document?

B. 14

Which statements about stroke prevention indicate a client's understanding of health teaching by the nurse? SELECT ALL. A. I will take aspirin every day B. I have decided to stop smoking C. I will try to walk at least 30 mins most days of the week D. I need to cut down a lot on my drinking E. I'm going to decrease salt in my diet

B. I have decided to stop smoking C. I will try to walk at least 30 mins most days of the week D. I need to cut down a lot on my drinking E. I'm going to decrease salt in my diet

Your patient is back from having a lumbar puncture. SELECT ALL the correct nursing interventions for this patient? A. Place the patient in lateral recumbent position. B. Keep the patient flat. C. Remind the patient to refrain from eating or drinking for 4 hours. D. Encourage the patient to consume liquids regularly.

B. Keep the patient flat. D. Encourage the patient to consume liquids regularly.

During a client's neuro assessment, the nurse finds the that client continues to be drowsy, BUT IS EASILY AWAKENED. How does the nurse document this client's level of consciousness? A. stuporous B. Lethargic C. Comatose D. Alert

B. Lethargic

A 25 year-old presents to the ER with unexplained paralysis from the hips downward. The patient explains that a few days ago her feet were feeling weird and she had trouble walking and now she is unable to move her lower extremities. The patient reports suffering an illness about 2 weeks ago, but has no other health history. The physician suspects Guillain-Barré Syndrome and orders some diagnostic tests. Which finding below during your assessment requires immediate nursing action? A. The patient reports a headache. B. The patient has a weak cough. C. The patient has absent reflexes in the lower extremities. D. The patient reports paresthesia in the upper extremities.

B. The patient has a weak cough.

The nurse is caring for a pt treated w. alteplase following a stroke. Which assessment finding is the highest priority for the nurse? A. BP 144/90 B. epistaxis C. client ate only half of the last meal D. Client continues to be drowsy

B. epistaxis

The patient's lumbar puncture results are back. Which finding below correlates with Guillain-Barré Syndrome?

B. high protein with normal white blood cells

A client was admitted this morning with an incomplete spinal cord injury and is placed in a halo fixer vest after surgery. Which assessment finding will the nurse report immediately to the HCP?

BP of 88/42

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 154/68, pulse 56, respirations 12 b. Blood pressure 134/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

Blood pressure 154/68, pulse 56, respirations 12 Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

Which symptom is the earliest indicator of increased intracranial pressure? A. Increased pupil size B. Elevated blood pressure C. Agitation and confusion D. Nausea and vomiting

C. Agitation and confusion

Which tests below can be ordered to help the physician diagnose Guillain-Barré Syndrome? SELECT ALL. A. Edrophonium Test B. Sweat Test C. Lumbar puncture D. Electromyography E. Nerve Conduction Studies

C. Lumbar puncture D. Electromyography E. Nerve Conduction Studies

You're about to send a patient for a lumbar puncture to help rule out Guillain-Barré Syndrome. Before sending the patient you will have the patient? A. Clean the back with antiseptic B. Drink contrast dye C. Void D. Wash their hair

C. Void

A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? a. Document intracranial pressure every hour. b. Turn and reposition the patient every 2 hours. c. Check capillary blood glucose level every 6 hours. d. Monitor cerebrospinal fluid color and volume hourly.

Check capillary blood glucose level every 6 hours

A 68-year-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a. Check oxygen saturation. b. Assess pupil reaction to light. c. Verify Glasgow Coma Scale (GCS) score. d. Palpate the head for hematoma or bony irregularities.

Check oxygen saturation.

When providing discharge teaching to a client after a lumbar laminectomy, the nurse teaches him or her to call the surgeon immediately for which potential complication?

Clear drainage from the incision site

A client who sustained a recent cervical spinal cord injury reports feeling flushed. The clients BP is 180/100. What is the nurse's best action at this time? A. Perform a bladder assessment B. Insert an indwelling urinary catheter C. Turn on a fan to cool the pt D. Place the pt in a sitting position

D. Place the pt in a sitting position

During nursing report you learn that the patient you will be caring for has Guillain-Barré Syndrome. As the nurse you know that this disease tends to present with:

D. signs and symptoms that are symmetrical and ascending that start in the lower extremities

The ED nurse is entering the room of a pt who was at baseball game and was hit in the head by a bat. Which intervention should the nurse implement FIRST?

Determine the client's reaction to the door opening

The male client w. a C-6 SC injury tells the home health nurse he has had a severe pounding headache for the last 2 hours. Which intervention should the clinic nurse implement?

Determine when and how much the client last urinated

A family member asks the nurse about whether there would be any long-term psychological effects from a client's mild traumatic brain injury. What is the nurse's best response?

Each person's reaction to brain injury is different

The nurse is caring for a 53 yr old woman with new onset of migraine headaches with photophobia. What is a priority nursing intervention?

Education of cardiovascular and stroke signs and symptoms

A client returns from the the PACU after a craniotomy for removal of a right frontal lobe tumor. How will the nurse position the client after surgery?

Elevate the HOB to at least 30 degrees to promote venous drainage

The nurse is planning care for the client experiencing dysphagia secondary to a CVA. Which intervention should be included in the plan of care?

Evaluate the client during mealtime.

The 22 y.o. w. a severe head injury is admitted to the critical care unit. Some of the client's friends come to the nurse's station requesting info. Which action would be most appropriate by the nurse?

Explain that no info can be shared with the friends

The male client is scheduled for gamma knife stereotactic surgery for a brain tumor. Which preoperative instruction should the nurse discuss with the client?

Explain there are no activity limitations after this procedure

The client diagnosed with CVA has hemiparesis. Which problem would be the priority for the client?

High risk for injury

Which statement by a client about preventing stroke indicates a need for further teaching by the nurse?

I only smoke cigars, which is better than smoking cigarettes

The nurse is admitting a client diagnosed w. meningococcal meningitis and notes lesions over the face and extremities. Which priority intervention should the nurse implement?

Initiate IV ABX stat

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a. Blood pressure b. Oxygen saturation c. Intracranial pressure d. Hemoglobin and hematocrit

Intracranial pressure

A client returns from the PACU after a surgical removal of a brainstem tumor. In what position will the nurse place the client at this time?

Keep the client flat in bed or up to 10 degrees and reposition from side to side

The client with a T-1 SC injury complains of lightheadedness and dizziness when the HOB is elevated. The pt's BP is 84/40. Which action should the nurse implement FIRST?

Lower the clients HOB immediately

The nurse is caring for a client with a C-6 SC injury in the neuro ICU. Which nursing intervention should be implemented?

Maintain the client's ice saline infusion

What nursing intervention should be implemented in the care of a patient who is experiencing increased ICP? a. Monitor fluid and electrolyte status carefully b. Position the patient in a high fowlers position c. administer vasoconstrictors to maintain cerebral perfusion d. Maintain physical restraints to prevent episodes of agitation

Monitor fluid and electrolyte status carefully Rationale: b is wrong because it should be 30 degrees/semi fowlers

The client diagnosed with a brain tumor is prescribed IV dexamethasone, a steroid. Which intervention should the nurse implement when administering this medication?

Monitor the pt's glucose level

The ICU nurse is caring for a client diagnosed with a TBI who is exhibiting decorticate posturing. 3 hrs later the client has flaccid posturing. Which action should the nurse implement FIRST?

Notify MD ASAP

A nurse is caring for a client who has a hard cervical collar for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary HCP?

Painful pressure injury under the collar

The nurse is assessing the client experiencing a left-sided CVA. Which clinical manifestations would the nurse expect the client to exhibit?

Paralysis of the right side of the body & aphasia

The client is diagnosed with a frontal lobe brain tumor. Which sign/symptom would the nurse expect the client to exhibit? 1. Ataxia 2. Decreased visual acuity 3. Scanning speech 4. Personality changes

Personality changes

The nurse is caring for a client with expressive (Broca's) aphasia. Which nursing intervention is appropriate for communicating with the client?

Provide picture to help the client communicate

The 25-year old pt with a SC injury is sharing with the nurse that he is worried about how his family will be able to survive financially until he can go back to work. Which intervention should the nurse implement?

Refer the client to a social worker about applying for disability

A client is admitted to the critical care unit w. possible Guillain-Barre syndrome. Which assessment is the most important for this client?

Respiratory system assessment

The nurse is caring for a client with trigeminal neuralgia. Which patient problem is the priority for the nurse?

Severe facial pain

The pt diagnosed w. a right-sided CVA is admitted to the rehab unit. Which intervention should be included in the nursing care plan?

Small pillow under pt's left shoulder

During a client's neurologic assessment, the nurse finds that he is arousable only if his trapezius muscle is pinched. How will the nurse document this client's level of consciousness? A. "Stuporous" B. "Lethargic" C. "Comatose" D. "Drowsy"

Stuporous

An alert & oriented client is admitted to the E.D. w. a moderate head injury. Which assessment finding will the nurse report immediately to the HCP?

Sudden drowsiness

The nurse is preparing a teaching plan for a client with migraine headaches who is receiving propranolol for migraine headaches. What health teaching by the nurse is important for the client?

Take this drug as prescribed every day, even when feeling well, to prevent a migraine

The pt is diagnosed w. a pituitary tumor & is scheduled for a transsphenoidal hypophysectomy. Which postoperative instruction is important to discuss with the client?

Tell the client not to blow their nose for 2 weeks after surgery

The UAP and nurse are caring for a pt with right-sided paralysis secondary to a CVA. Which action by the UAP requires the nurse to intervene?

The UAP leaves a urinal full of urine at the client's bedside

The nurse & a UAP are caring for a pt with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The UAP places the gait belt under the client's axilla prior to ambulating 2. The UAP places the client on the abdomen with the client's head to the side 3. The UAP uses a lift sheet when moving the client up in bed 4. the UAP praises the client for attempting to perform ADLs independently

The UAP places the gait belt under the client's axilla prior to ambulating

The nurse is caring for a female pt who sustained a closed head injury 8 days ago due to a motor vehicle accident. Which signs/symptoms would alert the nurse to a complication of the head injury?

The client complains of increased thirst & increased urine output.

The nurse is caring for a pt who has a C-6 vertebral fracture & is using Crutchfield tongs with 2-lbs weights. Which data would the nurse expect the pt to exhibit?

The client has 2+ DTR in the lower extremities

The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery?

The client has a urinary output of 250 ml over the last 24 hours

The client w. brain tumor was admitted to the ICU w. decorticate posturing. Which indicates the client's condition is improving?

The client has purposeful movement with painful stimuli

The nurse is admitting a client diagnosed w. meningitis who has AIDS. Which sign/symptom would the nurse expect the client to exhibit?

The client may be asymptomatic

The rehab nurse is caring for the client w. closed head injury. Which cognitive goal would the be most appropriate for this client?

The client will be able to stay on task for 15 mins

The nurse is developing a plan of care for a client diagnosed with septic meningitis. Which client goal would be the most appropriate for the client problem of "altered thermoregulation"?

The client will be afebrile for 48 hours before discharge

The nurse on the rehab unit is caring for the following client's with SC injuries. Which client should the nurse assess first after receiving the change-of-shift report?

The client with C-6 SC injury who has a warm, reddened edematous gastrocnemius muscle

The ICU nurse is caring for a pt diagnosed with a closed head injury. Which data would warrant immediate intervention?

The client's glasgow coma scale goes from 13 to 7

The client with increased ICP is receiving mannitol, an osmotic diuretic. Which intervention should the nurse implement?

Use a filter needle when administering the medication

After learning about rehabilitation for his spinal cord tumor, which statement shows the patient understands what rehab is and can do for him?

With rehabilitation, I will be able to function at my highest level of wellness

A patient with a suspected traumatic brain injury has bloody nasal drainage. What observations should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak?

a halo sign on the nasal drip pad (yellowish ring will encircle the blood)

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects

a normal balance between brain tissue, blood, & CSF

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? a. A 45-year-old receiving IV antibiotics for meningococcal meningitis b. A 25-year-old admitted with a skull fracture and craniotomy the previous day c. A 55-year-old who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy d. A 35-year-old with ICP monitoring after a head injury last week

a. A 45-year-old receiving IV antibiotics for meningococcal meningitis An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The postcraniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a. Administer IV 5% hypertonic saline. b. Draw blood for arterial blood gases (ABGs). c. Send patient for computed tomography (CT). d. Administer acetaminophen (Tylenol) 650 mg orally.

a. Administer IV 5% hypertonic saline.

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input

a. Encourage family members to remain at the bedside.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Short-term memory b. Muscle coordination c. Glasgow Coma Scale d. Pupil reaction to light

a. Short-term memory Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.

A 19-year-old man is admitted to the emergency department with a C6 spinal cord injury after a motorcycle crash. What is the priority of care for him? a. maintain airway and provide O2 b. immobilize neck with sandbags and tape c. administed IV immunoglobulin d. give methylprednisolone sodium succinate

a. maintain airways and provide O2

A 19-yea-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Clear fluid is draining from the patient's nose. What action by the nurse is most appropriate?

apply a loose gauze pad under the patients nose

Which statement by a 40-year-old patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go to bed." c. "I do not even remember being in an accident." d. "I can take acetaminophen (Tylenol) for my headache."

b. "I am going to drive home and go to bed."

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best? a. "This type of monitoring system is complex and it is managed by skilled staff." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

b. "The monitoring system helps show whether blood flow to the brain is adequate." Short and simple explanations should be given initially to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members' anxiety.

46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

b. 11. The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

b. Assist the patient onto the bedside commode every 2 hours.

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

b. Check the drainage for glucose content.

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Ensure that the patient's neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.

b. Ensure that the patient's neck is in neutral position.

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours d. Apply cold packs intermittently to face.

b. Insert nasogastric tube to low suction. Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.

Which finding for a patient who has a head injury should the nurse report immediately to the health care provider? a. Intracranial pressure is 16 mm Hg when patient is turned. b. Pale yellow urine output is 1200 mL over the last 2 hours. c. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg. d. Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours.

b. Pale yellow urine output is 1200 mL over the last 2 hours.

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Prepare the patient for craniotomy. c. Initiate high-dose barbiturate therapy. d. Type and crossmatch for blood transfusion.

b. Prepare the patient for craniotomy. The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI). d. Arrange to admit the patient to the neurologic unit for 24 hours of observation.

b. Provide discharge instructions about monitoring neurologic status.

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP.

b. Report the BP and ICP to the health care provider. Calculate the cerebral perfusion pressure (CPP): (CPP = mean arterial pressure [MAP] - ICP). MAP = DBP + 1/3 (systolic blood pressure [SBP] - diastolic blood pressure [DBP]). Therefore the (MAP) is 70 and the CPP is 56 mm Hg, which is below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Elevate the head of the bed 20 degrees. b. Restrict oral fluids to 1000 mL daily. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

b. Restrict oral fluids to 1000 mL daily. The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis.

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? a. Pulse 102 beats/min b. Temperature 101.6° F c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

b. Temperature 101.6° F Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

b. The patient has difficulty speaking.

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

b. The patient's blood pressure (BP) is 90/50 mm Hg. To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

a 68 year old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver to assist the patient with bowel evacuation? Select all. a. drink more milk b. eat 20-30 g of fiber each day c. use oral laxatives every day d. drink 1800 to 2800 ml of water or juice e. establish bowel evacuation time at bedtime

b. eat 20-30 g of fiber each day d. drink 1800 to 2800 ml of water or juice

The nurse is providing care for a patient who has been admitted to the hospital with a head injury and who requires regular neurologic and vital sign assessment. Which assessments will be components of the patient's score on the GCS? SELECT ALL. a. judgment b. eye opening c. best verbal response d. best motor response e. abstract reasoning f. cranial nerve function

b. eye opening c. best verbal response d. best motor response

The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. the patient smokes a pack of cigs daily b. pt's bp is chronically btwn 150/80 and 170/90 mm Hg c. the patient works at a desk and relaxes by watching TV d. the patient is 11.3 kg above the ideal weight

b. pt's blood pressure is chronically between 150/80 and 170/90 mm Hg

The client has sustained a traumatic brain injury secondary to a motor vehicle collision. Which signs/symptoms would the ED nurse expect the client to exhibit?

blurred vision, nausea, right-sided hemiparesis

The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which change in vital signs would the nurse interpret as a manifestation of increased ICP? a. tachypnea b. bradycardia c. hypotension d. narrowing pulse pressure

bradycardia

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? a. bradycardia b. HTN c. neurogenic spasticity d. bounding pedal pulses

bradycardia

A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain computed tomography (CT) scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient. a. Obtain computed tomography (CT) scan without contrast. b. Infuse tissue plasminogen activator (tPA). The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

c. Administer the prescribed short-acting insulin.

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score.

c. Check the respiratory rate and effort. The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? a. Encourage adolescents and young adults to avoid crowds in the winter. b. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Emphasize the importance of hand washing to prevent the spread of infection.

c. Immunize adolescents and college freshman against Neisseria meningitides.

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing. b. Position the patient with knees and hips flexed. c. Keep the head of the bed elevated to 30 degrees. d. Cluster nursing interventions to provide rest periods.

c. Keep the head of the bed elevated to 30 degrees.

the nurse on the clinical unit is assigned 4 patients. Which patient should she assess first? a. patient w. skull fracture whose nose is bleeding b. older patient w. stroke who is confused & whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale d. Patient who had a craniotomy for a brain tumor who is now 3 days post op & has had continued vomiting

c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse? a. The apical pulse is slightly irregular. b. The patient complains of a headache. c. The patient is more difficult to arouse. d. The blood pressure (BP) increases to 140/62 mm Hg.

c. The patient is more difficult to arouse.

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. A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse assesses neurologic status every hour. b. The staff nurse elevates the head of the bed to 30 degrees. c. The staff nurse suctions the patient routinely every 2 hours. d. The staff nurse administers an analgesic before turning the patient.

c. The staff nurse suctions the patient routinely every 2 hours.

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

c. decorticate posturing.

A patient with a C7 spinal cord injury undergoing rehab tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call physician b. check the patient's temp c. take the patient's blood pressure d. elevate the head of the bed to 90 degrees

c. take the patient's blood pressure

a 68-year-old man w. suspected bacterial meningitis has just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first? a. codeine b. phenytoin c. ceftriaxone d. acetaminophen

ceftriaxone

Your patient being treated for a head injury needs to be suctioned. You notice his ICP has risen from 11 to 17. What do you do first? a. suction the patient b. lower HOB c. check for neck alignment d. Notify the neurosurgeon

check for neck alignment

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13 c. A 40-year-old patient who lost consciousness for a few seconds after a fall d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.

A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Administer tissue plasminogen activator (tPA) per protocol. d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.

d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg. Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

d. Risk for aspiration related to inability to protect airway

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order for collaborative intervention should the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.

d. Swab the nasopharyngeal mucosa for cultures. Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider? a. Complaint of severe headache b. Large contusion behind left ear c. Bilateral periorbital ecchymosis d. Temperature of 101.4° F (38.6° C)

d. Temperature of 101.4° F (38.6° C) Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

d. The patient has atrial fibrillation and takes warfarin (Coumadin).

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient exhibits nuchal rigidity. b. The patient has a positive Kernig's sign. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 88/42 mm Hg.

d. The patient's blood pressure is 88/42 mm Hg. Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The lights in the patient's room are turned off and the blinds are shut. d. Unlicensed assistive personnel enter the patient's room without a mask.

d. Unlicensed assistive personnel enter the patient's room without a mask. Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

When initiating oral feedings for a patient with a stroke, the nurse determines that the patient has an intact gag reflex and then does which of the following actions? a. offers the patient a sip of juice b. orders pureed diet c. assesses the patient's appetite d. assists the patient into a chair

d. assists the patient into a chair

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority? a. risk for impairment of tissue integrity caused by paralysis b. altered patterns of urinary elimination caused by tetraplegia c. altered family and individual coping caused by the extent of trauma d. ineffective airway clearance caused by high cervical spinal cord injury

d. ineffective airway clearance caused by high cervical spinal cord injury

A patient with right-sided weakness that started 1 hr ago is admitted to the emergency department and the following diagnostic tests are ordered. Which order should the nurse act on first? a. Chest radiograph b. electrocardiogram c. CBC d. non contrast computed tomography scan

d. non contrast computed tomography scan (CT)

After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. cluster nursing activities to allow longer rest periods. b. turn and reposition the patient side to side every 2 hours. c. position the bed flat and log roll to reposition the patient. d. perform range-of-motion (ROM) exercises every 4 hours.

d. perform range-of-motion (ROM) exercises every 4 hours ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

d. teach the family that emotional outbursts are common after strokes.

The nurse is alerted to a possible acute subdural hematoma in the pt who

develops decreased level of consciousness and a headache within 48 hours of a head injury

A nurse plans care for the patient with increased ICP with the knowledge that the best way to position is to

elevate the HOB to 30 degrees

A 25-year-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuna use. What is the nurses priority during rehab?

encourage him to verbalize his feelings rationale: prevent self harm

A college student came to the university health clinic and was diagnosed with bacterial meningitis and admitted to a local hospital. Which intervention should the university health clinic nurse implement?

ensure dormitory roommates receive chemoprophylaxis using rifampin

Which clinical manifestation would the nurse assess in the client with a T-12 SC injury who is experiencing spinal shock?

flaccid paralysis below the waist

What health history question will give the nurse the most information when evaluating a patient for Guillain Barre Syndrome?

have you had a respiratory virus in the past 2 wks

Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? a. headache and rising BP b. irregular respirations and shortness of breath c. decreased LOC or hallucinations d. abdominal distention and absence of bowel sounds

headache and rising blood pressure

The rehab nurse caring for the young client with a T-12 SC injury is developing the nursing care plan. Which priority intervention should the nurse implement?

insert a rectal stimulant at the same time every morning

A patient is admitted to the ICU with a C7 spinal cord injury & diagnosed with Brown-Sequard Syndrome. On physical examination, the nurse would most likely find

ipsilateral motor loss & contralateral sensory loss BELOW C7

Which classification of stroke is the most common, representing approximately 80% of all strokes?

ischemic stroke

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's BP is 84/50, pulse 38, & remains orally intubated. The nurse determines that this pathophysiological response is caused by

loss of sympathetic nervous system innervation resulting in peripheral vasodilation

For a 65 year old woman who has lived with a T1 spinal cord injury for 20 years, which of the following health teaching instructions should the nurse emphasize? a. a mammogram needed every year b. bladder function tends to improve with age c. heart disease is not common in persons with spinal cord injury d. as a person ages the need to change body position is less important

mammogram is needed every year

A client with a history of seizures is placed on seizure precautions. What emergency equipment will the nurse provide at the bedside? Select all. 1. tongue blade 2. O2 setup 3. NG tube 4. Suction setup 5. artificial oral airway

o2 setup, suction, artificial oral airway

The male client with a brain tumor having a closed MRI scan in 1 hr. The client tells the radiology nurse, "I don't like small enclosed spaces." Which action should the nurse implement?

obtain an order for anti-anxiety medication

During admission of a patient with a severe head injury to the ED the nurse places the highest priority on assessment for

patency of airway

A patient with a spinal cord injury at C5-C6 reports sudden severe headache. The patient is flushed. VS include a BP of 190/100 mmHg and HR of 52 bpm. What is the priority nursing intervention?

place the patient in a sitting position

The nurse is assessing the client diagnosed with bacterial meningitis. In addition to the nuchal rigidity, which clinical manifestations would the nurse assess?

positive brudzinski sign & photophobia

The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation?

resistance to flexion of the neck

What information is key to differentiating a hemorrhagic stroke from a thrombotic stroke

severe headache

The nurse is caring for a patient admitted with a spinal cord injury following a vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? a. spinal shock b. central cord syndrome c. anterior cord syndrome d. Brown-Sequard syndrome

spinal shock

Which type of precautions should the nurse implement for the client diagnosed w. aseptic (viral) meningitis?

standard precautions

A client receiving IV sodium heparin after a dose of rtPA begins to have severe epistaxis. What is the nurse's first action?

stop the infusion immediately

Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia? a. urinary catherization b. admin of benzo's c. suctioning upper airway d. placement of the patient in trendelenburg

urinary catherization

The nurse is preparing to administer sinemet to a client whose highest BP is 88/50 while lying in bed. What is the nurse's priority action at this time?

withhold the drug until contacting the HCP