Wk 9 practice test

62, The nurse is caring for a client who has had intracranial surgery and is being discharged home. What instructions would the nurse give the client besides instructions on the medication?

. Expect sensory changes, such as hearing a clicking sound, around the bone flap.

32. A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following?

Anticoagulant therapy

21. Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel?

Assist with bowel training by placing the client on the bedside commode

76. A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAS) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply.

Balloon angioplasty of the carotid artery followed by stent placement Carotid endarterectomy

104. The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first?

Call a Code STROKE

39. Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? Select all that apply.

Cluster activities of care

103. When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms?

Perform stretching exercises and frequent position change.

77. The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?

Test the drainage for presence of glucose

59. The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report?

The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6.

52. The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

The client has cerebral spinal fluid (CSF) leaking from the ear.

28. The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client?

The client is able to focus and stay on task for 10 minutes

71. The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders?

The first thoracic vertebrae

5. The home health nurse is caring for a 28-yearold client with a T1o SCI who says, "I can't do anything. Why am I so worthless?" Which statement by the nurse would be the most therapeutic?

This must be very hard for you. You're feeling worthless?"

6. The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first?

Turn the client to the side to allow the secretions to drain from the mouth

54. A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client?

Use caution while driving or performing hazardous activities.

47. A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?

administer a stool softener bid

55. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

an oral anticoagulant medication

20. The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other?

awaken the client every two (2) hours

85. When caring for a client who has had intracranial surgery, what is the most important parameter to monitor?

body temperature

11. The nurse is caring for a client with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used?

cervical collar

91. While the nurse is making initial rounds after coming on shift, a client thrashes about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?

cluster

79. A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?

schedule for a STAT CT scan of the head

36. The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

traction with weights and pulleys

26. Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)?

55-year-old African American male

10. The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?

Assess for bladder distention

75. The nurse arrives at the site of a one-car motorvehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next?

Assess the client's airway

64. The nurse is caring for a client with a spinal cord injury leaving paralysis. When planning care related to the musculoskeletal system, which considerations are important? Select all that apply.

Contractures Bone demineralization Spasticity Limited range of motion

43. The nurse is working on a neurosurgical unit. Which of the following nursing interventions are included in the plan of care following spinal surgery? Select all that apply.

Dressing assessment Coughing and deep breathing Monitor vital signs EIntake and output Neurovascular assessment of the lower extremity

48. The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?

E Herniation occurs through the foramen magnum.

93. The male client is admitted to the emergency department following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the emergency department nurse implement in the first five (5) minutes? Select all that apply.

Ensure the client has a patent peripheral venous catheter in place Perform a Glasgow Coma Scale assessment

29. The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.

Ensure the pulse oximeter reading is higher than 93%. Administer mild sedatives Administer stool softeners daily

49. The nurse identifies the concept of intracranial regulation disturbance in a client diagnosed with Parkinson's Disease. Which priority intervention should the nurse implement?

Keep the bed low and call light in reach

17. A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility?

Keep the client hydrated.

107. A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply.

Left-sided hemiplegia Neglect of objects and people on the left side Tendency to distractibility

65. A client is admitted with MRI reveals an infarct The nurse understands these symptoms to be suggestive of which weakness, expressive aphasia, and right hemianopia. The brain of the following findings?

Lett-sided cerebrovascular accident (CVA)/

80. The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority?

Maintain an adequate airway

30. A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?

Nausea

12. The concept of intracranial regulation is identified for a client diagnosed with a brain tumor. Which intervention should the nurse include in the client's plan of care?

Place the client on seizure precautions

23. The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.

Position the client to prevent shoulder adduction. Encourage the client to move the affected side

37. The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative

Refer the client to an occupational therapist for evaluation.

family member of the client arrives and is providing details of the client's medical history. 105. A client has sustained a head injury and is unconscious in the emergency room. A Which information is of most concern to the nurse?

The client's medications include warfarin

problem with intracranial regulation. The client's GCS one (1) hour ago was scored 97. The nurse is performing a Glascow Coma Scale (GCS) assessment on a client with a at 10. Which data indicates the client is improving?

The current GSC rating is 12.

42. The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm?

The stimulation can increase intracranial pressure (ICP) or trigger a seizure.

108. The client newly diagnosed with Parkinson's Disease (PD) asks the nurse, "Why can't I control these tremors?" Which is the nurse's best response?

The tremors are caused by a lack of the chemical dopamine in the brain; medication may help.

106. The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department?

a weak pulse, shallow respirations, and cool pale skin

99. The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply.

red wine exposure to flashing light menstruation

35. The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

7 The client's vital signs are temperature, 100.9 °F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.

15. A mother brings her 6-year-old child to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?

A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injunry to the brain.

63. A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client?

Impaired Swallowing

89. The nurse is caring for clients on the rehabilitation unit. Which clients should the nurse assess first after receiving the change of shift report?

The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs

16. The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?

complete a neurological assessment

58. A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

paresthesia

72. The nurse suspects that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? Select all that apply.

poikilothermia bladder distension no perspiration below the level of the injury

25. The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply.

Administer intravenous corticosteroids Monitor the pulse oximetry reading Encourage coughing and deep breathing

81. The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement?

Administer low-dose subcutaneous anticoagulants.

27. The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test?

Are you uncomfortable in closed spaces?"

98. The 80-year-old male client on an Alzheimer's unit is agitated and asking the nurse to get his father to come and see him. Which is the nurse's best response?

Ask the client to talk about his father with the nurse

90. A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?

Avoid heavy lifting.

13. A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

Brain CT scan or MRI

84. A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of cell transplantation therapy. Which early outcome of treatment is anticipated?

Cell transplantation therapy allows the replacement of nerve cells that are damaged.

82. The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

Conception is not impaired; the birth process is determined with the physician.

ischemic attack (TIA). Which assessment finding is most 18. An elderly client, who has fallen several times at home. is admitted for possible transient significant in determining care for this client?

Drooling from side of mouth

51. A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client?

Grade V on the Hunt-Hess Scale

56. The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/leaking of cerebral spinal fluid (CSF)?

Halo sign/

control the headaches and minimize the number of attacks he is having. What instructions 38. A client diagnosed with migraine headaches asks the nurse what he can do to help should the nurse give this client?

Identify and avoid factors that precipitate or intensify an attack.

101. A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA?

Impaired muscle coordination

22. The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?

Instruct the client to report reddened or irritated skin areas

4. The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead." Which data support that the client is brain dead?

No eye activity is observed when the cold caloric test is performed

9. In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock?

No reflex activity below the waist

24. The nurse is caring for a client who was discovering unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled, Which instructions have been compiled for the spouse?

Observe for any signs of behavioral changes.

45. A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken?

Perform a vision field assessment.

60. The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?

Pulse and blood pressure

33. The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving?

Purposeless movement in response to painful stimuli.

14. The 34-year-old male client with an SCl is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement?

Refer the client to the state rehabilitation commission.

88. The 28-year-old client is on the rehabilitation unit post spinal cord injury at level T10. Which collaborative team members should participate with the nurse at the case conference? Select all that apply.

Registered dietitian (RD Social Worker (SW). Physical therapist (PT). Rehabilitation physician

7. A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches?

Relaxes muscles

Which nursing assessment finding is most indicative of a hemorrhagic stroke?

Sudden onset of breathing alterations

92. The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?

Sympathetic nervous system

1. A client who has experienced an initial transient ischemic attack (TIA) states: "Im glad it wasn't anything serious." Which is the best nursing response to this státement?

TIA is a warning sign. Let's talk about lowering your risks."

41. Which diagnostic evaluation tool Would the nurse use to assess the client's cognitive functioning? Select all that apply.

The St. Louis University Mental Status (SLUMS) scale The Mini-Mental Status Examination (MMSE) scale

2. The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?

The assistant places a hand under the client's right axilla to move up in bed.

69. The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized câre?

The client who played soccer in college

87. Which priority goal would the nurse identify for a client diagnosed with Parkinson's Disease (PD)?

The client will be able to maintain mobility and swallow without aspiration

83. The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first?

The client with a basilar fracture,

102. The client with a cerebral aneurysm asks the nurse. "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm?

Your physician wants to evaluate the location and condition of the aneurysm."

78. The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered? Select all that apply.

antibiotics anticunvulsants analgesics

44. The nurse and physician of impact to the skull and edema on the opposite side. The client is sleeping but can be are viewing a brain scan, which indicates bleeding at the point aroused. The client has no memory of actident The nurse provides all details to the next shift and is most accurate to report which type of injury?

contrecoup injury

46. The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?

epidural hematoma

57. The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae with bone from which location?

iliac crest

50. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

indicate to blood pressure of 220/120 mmHg

8. The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question?

intravenous osmotic diuretic

53. The nurse is caring for a client admitted with a stroke, Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?

ischemic

68. The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

neurologic examination

100. A middle-aged client has scheduled a sick visit to the physician's office, stating symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and identified potential causes of the pain. Which area of the drawing would the nurse emphasize?

nucleus pulposus

61. The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?

obtain a rubber mat to place under the dinner plate

74. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document?

paralysis of the right side af the body and ataxia

73. The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?

powerlessness

70. The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious stating, "What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain." The nurse is most correct to turn the teaching to which surgical procedure?

spinal fusion

67. Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

subdural

86. A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?

use this to prevent migraines.

34. The nurse is evaluating the transmission of a report from a paramedic unit to the and face and Battle's sign. What clinical picture would the nurse anticipate? emergency room. The medic reports that a client is unconscious with edema of the head

Edema to the head with bruising of the mastoid process

40. The intensive care nurse is caring for a client with a T1 SCI, When the nurse elevates the head of the bed 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2°F, P 98, R 24, and BP 84/40. Which action should the nurse implement?

Lower the head of the bed immediately

66. A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action?

Migraines often coincide with menstrual cycle.

95. A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Monitoring is needed as rapid neurologic deterioration may occur.

31. The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included the plan of care?

Position the client wth the head of the bed elevated at intervals

19. A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of tissue plasminogen activator (TPA) in a client with CVA requires which of the following? Select all that apply.

Presence of an ischemic stroke Administer within 3 hours of onset of symptoms.

96. The nurse is caring for a client following intracranial surgery. In the plan of care, the nurse states to remove antiembolism stockings. What would the nurse do to accurately complete this intervention?

Remove the antiembolism stockings briefly every 8 hours.

109. The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first?

Stabilize the client's cervical spine