Neuro Test

Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100

A. A patient with a complete spinal injury at the C5 dermatome level

In an unconscious patient, eye movements are tested by the oculocephalic response, Which statements regarding the testing of this reflex are true? (Select all that apply) a. Dolls eyes absent indicate a disruption in normal brainstem processing b. Dolls eyes present indicate brainstem activity c. Eye movement in the opposite direction as the head when turned indicates an intact reflex d. Eye movement in the same direction as the head when turned indicates an intact reflex e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex f. Presence of cervical injuries is a contraindication to assessment of this reflex

A. Dolls eyes absent indicate a disruption in normal brainstem processing B. Dolls eyes present indicate brainstem activity C. Eye movement in the opposite direction as the head when turned indicates an intact reflex E. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex F. Presence of cervical injuries is a contraindication to the assessment of this reflex

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patients plan of care? (Select all that apply) a. Make frequent neurological assessments b. Maintain CO2 level at 50 mmHg c. Maintain MAP less than 130 mmHg d. Prepare for thrombolytic administration e. Restrain affected limb to prevent injury

A. Make frequent neurological assessments C. Maintain MAP less than 130 mmHg

The nurse receives a patient from the emergency department following a closed head injury. After insertion of a ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60, heart rate 52, respiratory 24, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mmHg. Which physician order should the nurse institute first? a. Mannitol 1g IV b. Portable chest x-ray c. Seizure precautions d. Acef 1g IV

A. Mannitol 1g IV

The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mmHg, heart rate 55, respiratory rate 10, oxygen saturation (SpO2) 94% on oxygen at 3L per NC. What is the priority nursing action? a. Monitor the patients airway patency b.Elevate the head of the patients bed c. Increase supplemental oxygen delivery d. Support bony prominences with padding

A. Monitor the patients airway patency

The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment finding by the nurse include blood pressure 100/50, heart rate 58, respiratory rate 30, and temperature of 100.5. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in the patients plan of care? a. frequent neurological assessments b. side to side position changes c. range of motion exercises d. frequent oropharyngeal suctioning

A. frequent neurological assessments

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 heart rate 115, respiratory rate 28, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L.min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mmHg. After reviewing the physician orders, which order is of the highest priority? a. Lasix 20mg IV push as needed b. 500mL albumin intravenous infusion c. Decadron 10mg IV push d. Dilantin 50mg IV push

B. 500ml albumin intravenous infusion

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90, heart rate 60, respirations 24, and 50ml of urine via indwelling urinary catheter for the past 4hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache b. Assess for a kinked urinary catheter and assess for bowel impaction c. Encourage the patient to take slow, deep breaths d. Notify the physician of the patients blood pressure

B. Assess for a kinked urinary catheter and assess for bowel impaction

The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine (Cardene) infusion. Baseline blood pressure assessed by the nurse is 170/100. Five minutes after beginning the infusion at 5mg/hour, the nurse assesses the patients blood pressure to be 160/90. What is the best action by the nurse? a. Stop the infusion for 5 minutes b. Increase the dose by 2.5 mg/hr c. Notify the physician of the BP d. Begin weaning the infusion

B. Increase the dose by 2.5mg/hr

The nurse admits a patient to the emergency department (ED) with a suspected cervical spin injury. What is the priority nursing action? a. Keep the neck in the hyperextended position b. Maintain proper head and neck alignment c. Prepare for immediate endotracheal intubation d. Remove cervical collar upon arrival to the ED

B. Maintain proper head and neck alignment

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a. Maintain body temperature b. Monitor blood pressure c. Pad all bony prominences d. Use proper hand washing

B. Monitor blood pressure

The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The physician order 30mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4mg/kg/min for 23 hours. What is the total 24 hour dose for the 70kg patient? a. 2478 mg b. 5000 mg c. 10794 mg d. 12750 mg

C. 10794 mg

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure of 95/50, heart rate 110, respiratory rate 20, oxygen saturation SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5. Which physician order should the nurse institute first? a. Blood cultures (2 specimens) for temperature > 101 b. Acetaminophen (Tylenol) 650mg per rectum c. 500 mL albumin infusion IV d. Decadron 20mg IV push every 4 hours

C. 500ml albumin infusion IV

A patient with a head injury has an intracranial pressure (ICP) of 18 mmHg. Her blood pressure is 144/90, and her mean arterial pressure (MAP) is 108 mmHg. What is the cerebral perfusion pressure (CPP)? a. 54 mmHg b. 72 mmHg c. 90 mmHg d. 126 mmHg

C. 90 mmHg

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mmHg and a CPP of 85 mmHg. What is the best interpretation by the nurse? a. Both pressures are high b. Both pressures are low c. ICP is high; CPP is normal d. ICP is high; CPP is low

C. ICP is high; CPP is normal

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mmHg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO2 of 60 mmHg is normal)

C. Increased cerebral blood volume due to vessel dilation

While caring for a patient with a basilar skill fracture, the nurse assesses clear drainage from the patients left Paris. What is the best nursing action? a. Have the patient blow the nose until clear b. Insert bilateral cotton nasal packing c. Place a nasal drip pad under the nose d. Suction the left nares until the drainage clears

C. Place a nasal drip pad under the nose

The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply) a. Use of a heparin flush solution b. Manually flushing the device prn c. Recording ICP as a mean value d. Use of a pressurized flush system e. Zero referencing the transducer system

C. Recording ICP as a mean value E. ero referencing the transducer system

The nurse is caring for a patient who has diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing b. The patient is exhibiting flexion posturing c. The patient is exhibiting purposefully movements d. The patient is withdrawing to stimulation

C. The patient is exhibiting purposefully movements

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38 PaCO2 55 mmHg HCO3 22 mEq/L PaO2 85 mmHg b. pH 7.38 PaCO2 40 mmHg HCO3 24 mEq/L PaO2 70 mmHg c. pH 7.38 PaCO2 35 mmHg HCO3 24mEq/L PaO2 85 mmHg d. pH 7.38 PaCO2 28 mmHg HCO3 26 mEq/L PaO2 65 mmHg

C. pH 7.38 PaCO2 35 mmHg HCO3 24 mEq/L PaO2 85 mmHg

After receiving the hand off report from the day shift change nurse, which patient should the evening charge nurse assess first? a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a. GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure (ICP) of 20 mmHg and an oral temperature of 104

D. A patient with an ICP of 20 mmHg and an oral temperature of 104

The nurse is caring for a patient with an ICP of 18 mmHG and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a. ICP of 10 mmHg b. CPP of 70 mmHg c. GCS score of 5 d. CVP of 2 mmHg

D. CVP of 2 mmHg

The nurse admits a patient to the emergency department with new onset of blurred speech and right-sided weakness. What is the primary nursing action? a. Assess for the presence of a headache b. Assess the patients general orientation c. Determine the patients drug allergies d. Determine the time of symptom onset

D. Determine the time of symptom onset

The nurse is caring for a patient who was hit not he head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action? a. Stimulate the patient hourly b. Continue to monitor the patient c. Elevate the head of the bed d. Notify the physical immediately

D. Notify the physician immediately

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mmHG. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning b. Elevate the patients head of the bed to 30 degrees c. Apply bilateral heel protectors after repositioning d. Provide rest periods between nursing interventions

D. Provide rest periods between nursing interventions

The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left are. What is the most appropriate nursing action? a. Insert bilateral ear plugs b. Monitor airway patency c. Maintain neutral head position d. Apply a small nasal drip pad

D. apply a small nasal drip pad

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mmHg, heart rate 60, respirations 18, and temperature of 102. To reduce the risk of increased intracranial pressure (ICP0 in this patient, what is (are) the priority nursing action(s)? a. Ensure adequate periods of rest between nursing interventions b. Insert an oral airway and monitor respiratory rate and depth c. Maintain neutral head alignment and avoid extreme hip flwxion d. Reduce ambient room temperature and administer antipyretics

d. Reduce ambient room temperature and administer antipyretics