MOD and Neuro Test Prep
The seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmonary artery pressure. Which statement, made by the seasoned nurse, reflects the most pertinent information regarding circulation?
A pulmonary artery pressure provides information about pressure on the left side of the heart."
The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply.
Absence of brainstem reflexes Apnea Coma
Oliguria occurs in the progressive stage of shock because the kidneys decompensate. Which of the following are signs or symptoms that indicate decompensation? Select all that apply.
Acid-base imbalance Decreased capillary permeability and fluid and electrolyte shifts Increased blood urea nitrogen and serum creatinine
the nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.)
Activation of the inflammatory response Hypoperfusion of tissues Must produce energy through anaerobic metabolism
A client with fungal encephalitis receiving IV amphotericin B reports fever, chills, and body aches. What action by the nurse is appropriate?
Administer diphenhydramine and acetaminophen per orders.
9. The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient?
0 to 10 mm Hg
When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor?
Body temperature
Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply.
Eating Breathing Transferring to a wheelchair Writing
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?
Herniation
The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply.
Hypertension Diaphoresis Nasal congestion
A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply.
Increased paCO² levels Reports of chest pain Loss in consciousness Ecchymoses and petechiae
The statements presented here match nursing interventions with nursing diagnoses. Which statements are appropriate for a client who has suffered a head injury? Select all that apply.
Ineffective airway clearance: Apply suction as indicated Disturbed sleep pattern: Provide back rubs to the client Interrupted family process: Encourage the family to join a support group
A patient has expressive speaking aphasia after having a stroke. Which portion of the brain does the nurse know has been affected?
Inferior posterior frontal areas
Which of the following antiseizure medication has been found to be effective for post-stroke pain?
Lamotrigine (Lamictal)
Which of the following is a clinical manifestation of pupillary changes that indicate increasing ICP?
Pupils are showing progressive dilation.
The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply.
Young age Male gender Substance abuse
A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain?
codeine
An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the client is at increased risk for what complication of his injury?
hematoma
The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord?
second lumbar vertebrae
A frontal lobe brain abscess produces which manifestation?
seizures
The nurse anticipates that an immunosuppressed client is at greatest risk for which type of shock?
septic
A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family?
sweating
Damage to which area of the brain results in receptive aphasia?
temporal lobe
The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurse's best response?
"Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease."
When beta-2 adrenergic receptors are stimulated which of the following occur?
Bronchioles relax
Which neurotransmitter inhibits pain transmission
Enkephalin
A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?
I use this to prevent migraines
The statements presented here match nursing interventions with nursing diagnoses. Which statements are true for a client with a stroke? Select all that apply.
Impaired swallowing: Provide a pureed diet. Disturbed sensory perception: Stand on the client's unaffected side. Impaired verbal communication: Repeat words and instructions.
Which statements reflect the nursing management of a client with receptive aphasia?
Speak slowly and clearly to assist the client in forming the sounds
When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal?
Treat the oxygenation needs of the heart muscle
The nurse is providing information about spinal cord injury (SCI) prevention to a community group of young adults. The nurse mentions that all of the following are predominant risk factors for SCI except?
being an athlete
Which of the following is the most common side effect of recombinant human activated protein C (rhAPC)?
bleeding
The nurse is providing education to a group of young people about the dangers of tattoos and body piercings. Which of the following would the nurse describe as a possible result of a tongue piercing?
brain abscess
Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion?
contusion
The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?
15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days
A potential complication of a hemorrhagic stroke is interference with the ability of the arachnoid villi to absorb CSF. Therefore, fluid in the ventricles increase beyond the amount that is usually absorbed daily, which is:
350 to 375 mL
The nurse is caring for a client admitted to the emergency department with hypovolemic shock. What most appropriate ratio of IV replacement fluids does the nurse anticipate?
3:1
A nurse is performing glucose checks for a client in the progressive stage of shock. What glucose range would the nurse expect to see for the best outcome with the client?
< 180 mg/dl
The nurse is volunteering for a Red Cross blood drive and is taking the history of potential donors. Which volunteer would the nurse know will not be allowed to donate blood?
A donor who was in college in England for 1 year
The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.)
A heart rate >100 bpm Crackles Lethargy and mental confusion
The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply.
Burns Dehydration
Neurological level of spinal cord injury refers to which of the following?
The lowest level at which sensory and motor function is normal
Which are possible long-term complications of spinal cord injury? Select all that apply.
autonomic dysreflexia respiratory infection
A client at the scene of an MVA seems somewhat anxious and has clammy skin. The client's BP has dropped to 90 mm Hg. What stage of shock is this client most likely experiencing?
decompensation stage
Clinical characteristics of neurogenic shock are noted by which type of stimulation?
parasympathetic
For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:
promote carbon dioxide elimination
A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time?
propofol (Diprivan)
A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply.
respiratory distress difficulty swallowing
A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?
vasodilation
The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client?
vector bites
The nurse caring for a client diagnosed with Guillain-Barré syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurse's communication with the client should reflect the possibility of what sign or symptom of the disease?
vocal paralysis
1. A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?
Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.
An adult client has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this patient. What aspect of his care should be prioritized by the home health nurse?
Assisting the client and family to identify and mobilize community resources
The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of?
Autonomic dysreflexia
Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of a muscular body area?
CT
Which assessment finding is most important in determining nursing care for a client with bacterial meningitis. SATA
Cloudy cerebral spinal fluid Purpura of the hands and feet
A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease?
Elevated protein levels in the CSF
Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis?
Ensure access to language board establish a voiding time schedule encourage the client to walk with feet wide apart
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?
Flat, except for logrolling as needed
The greatest risk of seizures for clients with brain tumors occurs in those who have tumors in which regions of the brain? Select all that apply.
Frontal Parietal Temporal
A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intraveneously. The nurse is careful to assess which of the following related to intake of nutrients?
Gag reflex and bowel sounds
During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?
Gingival hyperplasia
A client with a cervical disc herniation in the acute phase reports of numbness and tingling in the arms. What are the priority interventions for the nurse to perform? Select all that apply
Have the client wear a cervical collar daily Provide NSAID therapy
The nurse is performing an initial assessment on a client admitted with a possible brain abscess. Which of the following would the nurse most likely find?
Headache that is worse in the morning
The ICU nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring?
Heart and respiratory rates are elevated
13. The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following?
Heart failure
Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply.
Hemiparesis Decreased reactivity of the pupils Bradycardia Coma
A nurse is assisting with the assessment of a client with suspected brain abscess. Which of the following findings would be consistent with such an abscess in the frontal lobe of the brain? Select all that apply.
Hemiparesis Seizures Expressive aphasia
In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply.
Hypotension Venous pooling Tachypnea Hypothermia
A client with hypertension comes to the outpatient department for a routine checkup. Because hypertension is a risk factor for cerebral hemorrhage, the nurse questions the client closely about warning signs and symptoms of hemorrhage. Which complaint is a possible indicator of cerebral hemorrhage in this client?
Tinnitus
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
The nurse is preparing the client for a diagnostic test to evaluate blood flow within intracranial blood vessels. For which test is the nurse preparing the client?
Transcranial Doppler
Which of the following diagnostics are beneficial to detect intracranial stenosis?
Transcranial Doppler (TCD)
the nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. what diagnostic procedures might be included in this client's admission orders?
Transcranial Doppler Flow Study Cerebral angiography MRI
A client is unstable and receiving dopamine to increase blood pressure. Which of the following are interventions that the nurse administering dopamine would employ? Select all that apply.
Use an intravenous controller or pump. Verify dosage and pump settings with another RN. Measure urine output every hour.
The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client?
Using the incentive spirometer as prescribed
Clinical manifestations of neurogenic shock include which of the following? Select all that apply.
Venous pooling in the extremities Bradycardia Warm skin
11. The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the priority nursing action?
administer acetaminophen per orders
A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to the legs will illicit severe pain. The client is describing which type of pain?
allodynia
A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care?
client maintains mechanical ventilation with minimal mucus accumulation
The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as
coma
A nurse practitioner is presenting health information about strokes at a clinic. She mentions that there are five categories of strokes based on their origin. Which of the following is the category that has the highest incidence of strokes (30%)?
cryptogenic
A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to:
decrease the potential for brain damage
the nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor?
dexamethasone
A nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels?
distributive
A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply
dobutamine dopamine epinephrine
During the performance of the Romberg test, the nurse observes that the client sways slightly. What is the nurse's most appropriate action?
document successful completion of the assessment
A client with a neurologic deficit is feeling frustrated because it is very difficult to pronounce words since having a stroke. The client is struggling with:
dysarthria.
A client with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this client?
eeg
10. Which activity should be avoided in clients with increased intracranial pressure (ICP)?
enemas
Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)?
epidural
Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery?
epidural
A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with right-sided hemiplegia?
expressive aphasia, defects in the right visual fields, problems with abstract thinking
Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order:
famotidine (Pepcid).
A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?
fever and change in urine clarity
A client is brought into the ED with extensive traumatic injuries. The paramedic reports that the client has "shock." What are the etiologies of shock? Select all that apply.
heart fails as effective pump blood volume decreases peripheral vascular dilation
The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage?
hyperthermia
12. A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:
increase the frequency of the catheterizations.
upper motor neuron lesions cause
little to no muscle atrophy
When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure?
myocardial depression
A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?
nausea
A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock?
neurogenic
A nurse is caring for a client in cardiogenic shock. Which vasopressor agents may be used in the treatment of the client? Select all that apply.
norepinephrine vasopressin phenylephrine
A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply.
Administer antipyretics as prescribed Perform frequent neurologic assessments Monitor pain levels and administer analgesics
A client is suspected to have bacterial meningitis. What is the priority nursing intervention?
Administer prescribed antibiotics
The nurse is administering the IV antiviral medication ganciclovir (Cytovene) to the patient with HSV-1 encephalitis. What is the best way for the nurse to administer the medication to avoid crystallization of the medication in the urine?
Administer via slow IV over 1 hour.
A patient has had a large ischemic stroke and is hospitalized in the neurologic intensive care unit. What interventions will be provided for this patient to decrease intracranial pressure? Select all that apply.
Administering mannitol Maintaining the partial pressure of carbon dioxide (PaCO2) within a range of 30 to 35 mm Hg Elevating the head of the bed 30 degrees
Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply.
Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care
A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of distributive shock should the nurses identify? Select all that apply.
Anaphylactic Septic Neurogenic
The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?
Arterial blood gas (ABG) findings
A client is scheduled for computed tomography (CT) scanning of the abdomen and reports an allergy to iodine. The best action of the nurse is to
Ask the client "How does your allergy manifest itself?"
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
A client is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the client's mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by referring to what laboratory findings? Select all that apply.
Blood urea nitrogen (BUN) level Urine specific gravity Creatinine level
A nurse is caring for a client diagnosed with Guillain-Barré syndrome. The client states, "It's getting harder to take a deep breath." Which action by the nurse is most appropriate?
Call the physician and prepare for intubation.
The nurse is caring for as 78-year-old client with extensive cardiovascular disease. Which type of shock is the client most likely to develop?
Cardiogenic shock
A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?
Cerebellar abscess
Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following is cause of a secondary injury associated with brain injury? Select all that apply.
Cerebral edema Ischemia Infection Seizures Hyperthermia
The causes of acquired seizures include what? SATA
Cerebrovascular disease metabolic and toxic conditions brain tumor drug and alcohol withdrawal
The nurse is caring for a client who is postoperative from surgery for a brain tumor resection. The client has a visitor at the bedside who lowers the head of the bed below 30 degrees. The nurse assesses the client has decreased level of consciousness. What actions should the nurse take? Select all that apply.
Check the client's blood pressure Assess the client for headache Assess for presence of visual changes
A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first?
Check the client's indwelling urinary catheter for kinks to ensure patency.
Which of the following terms is used to describe rapid, jerky, involuntary, purposeless movements of the extremities?
Chorea
A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as
Compensatory
A client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client?
Control the shivering.
The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body?
Correct response: Production of antidiuretic hormone and corticosteroid hormones
A college student goes to the infirmary with a fever, headache, and a stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? Select all that apply.
Correct response: Administration of rifampin (Rifadin) Administration of ciprofloxacin hydrochloride (Cipro) Administration of ceftriaxone sodium (Rocephin)
A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?
Decompensation
Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply.
Decreased glucose Increased protein Increased white blood cells
A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is
Dextran
The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply.
Drop in systolic blood pressure of ≥40 mm Hg from baselines Serum lactate >4 mmol/L Mean arterial pressure (MAP) of ˂65 mm Hg
A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation?
Epidural hematoma
A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?
Even, unlabored respirations
The nurse is providing a health promotion session on the risk factors for various health conditions. When discussing brain tumors, the nurse should include in the session which known risk factors for brain tumors? Select all that apply.
Exposure to certain chemicals Having ionizing radiation
Which of the following cranial nerves is responsible for salivation, tearing, taste, and sensation in the ear?
Facial
Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage?
First 2 to 12 hours
Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage?
First 2 weeks
A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action?
Immediate craniotomy
The nurse is caring for a client with a brain tumor who is experiencing symptoms due to compression and infiltration of normal tissue. The pathophysiologic changes that result can cause what manifestations? Select all that apply
Increased ICP Focal neurologic signs Altered pituitary function
An 83-year-old woman suffers a stroke at home and is hospitalized for treatment and management. Which of the following diagnostic procedures would be best to visualize the extent of damage?
MRA magnetic resonance angiography
The nurse is caring for a client with a central venous line in place for the treatment of shock. Which nursing interventions are essential for the nurse to complete in order to reduce the risk of infection? Select all that apply.
Maintain sterile technique when changing the central venous line dressing. Always perform hand hygiene before manipulating or accessing the line ports. Apply clean gloves before accessing the line port.
The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply.
Making nursing assessments Setting priorities for nursing interventions Anticipating needs and complications Initiating rehabilitation
The community health nurse is preparing to conduct a home visit to a client in the community who was recently discharged from hospital after treatment of a metastic brain lesion. What should the community health nurse plan to include within the time alloted for the home visit? Select all that apply.
Mental status examination Skin integrity Mobility Use of pain medication
A client diagnosed with a brain tumor is exhibiting focal symptoms. Which assessment findings are the nurse likely to note? Select all that apply.
Muscle weakness Sensory loss Aphasia Visual changes
Cardiogenic shock is most commonly seen in which patient population?
Myocardial infarction
During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.
National Institutes of Health Stroke Scale (NIHSS) score LOC at time of admission Age
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?
Neurologic examination
A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention?
Nimodipine PO
Which vasodilator medication is used in the treatment of shock?
Nitroglycerin
A patient diagnosed with meningitis would be expected to exhibit which of the following clinical manifestations? Select all that apply.
Nuchal rigidity Positive Kernig's sign Positive Brudzinski's sign Photophobia
A nurse begins an assessment interview of a patient with a brain tumor. The patient describes her headaches. The nurse expects to hear specific terms that describe her symptoms. Which of the following best describe the symptoms of her headache? Select all that apply.
Occurs most frequently in the early morning Is unrelenting Is made worse with coughing and sudden movement May improve with vomiting
There is a high risk for ineffective coping in a client with a recent spinal cord injury. Which nursing interventions will assist the client with this process? Select all that apply.
Offer encouragement as the client makes progress. Involve the client actively in self care.
A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply.
Orthostatic hypotension Autonomic dysreflexia DVT
A client with diabetes is in the emergency department because of vomiting, diarrhea, and weight loss of 8 pounds over 2 days. Vital signs taken by the triage nurse indicate the client is in hypovolemic shock. Place the nurse's steps in the correct order.
Place the client in the modified Trendelenburg position. Initiate an intravenous (IV) site and prescribed IV fluids. Assess the capillary blood glucose level. Collect a stool specimen for culture.
Which diagnostic test is used for early diagnosis of HSV-1 encephalitis?
Polymerase chain reaction (PCR)
Which of the following is standard test for early diagnosis of herpes simplex virus (HSV)-1 encephalitis?
Polymerase chain reaction (PCR)
After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? Select all that apply.
Poor abstract reasoning Decreased attention span Short- and long-term memory loss
The client in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a postlumbar puncture headache, what is the nurse's most appropriate action?
Position the client prone
A client with a history of a brain tumor is undergoing diagnostic testing to evaluate whether current symptoms are the result of the tumor or scar tissue. The nurse would prepare the client for which test?
Positron emission tomography (PET)
The ED is notified that a 6 year old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy?
Preserving brain homeostasis
A client with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This client's nursing care should involve which of the following?
Protection of the affected limb from injury
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
The nurse is caring for a client with metastatic brain cancer. The client will be recieving pallative treatment. The nurse should anticipate what type of medical management will be included in the client's care? Select all that apply.
Radiosurgery Craniotomy with debulking Radiation
As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.
Recent intracranial pathology Current anticoagulation therapy Symptom onset greater than 3 hours prior to admission
A client is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the client's LOC is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding?
Recognize that this may represent the peak of postsurgical cerebral edema
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 Menstruation Exposure to flashing light
Which of the following are the immediate complications of spinal cord injury?
Respiratory arrest Spinal shock
Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply.
Respiratory irregularities Slow bounding pulse Widened pulse pressure
Which type of shock is caused by an infection?
Septic
You are assessing a 6-year-old girl in the Emergency Department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child?
She is having an allergic reaction and going into anaphylactic shock.
The nurse is aware that, when assessing a patient for symptoms of a brain tumor, the symptom most frequently found is:
Simple to generalized seizures
Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as
Sodium nitroprusside
A client has meningitis and cultures are being done to determine the cause. Which of the following is most likely to be identified as the causative factor?
Streptococcus pneumoniae
A college student is admitted to the emergency room to be evaluated for aseptic meningitis. The nurse knows that the most serious infecting organism (34% mortality rate) is:
Streptococcus pneumoniae
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
Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, is manifested by which of the following?
Tachycardia
The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?
The client grasps the affected arm at the wrist and raises it.
A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply.
The client who is in the first 15 minutes of receiving 1 unit of PRBCs The 55 year-old client with spina bifida The client who reports an allergy to peanuts that causes throat swelling
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
The client will remain free of injury if a seizure does occur.
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
A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock?
The client with testicular cancer who is receiving intravenous chemotherapy
A client receives alteplase (t-PA). It is most important for the nurse to intervene when
The client's Glasgow Coma Score changes from 15 to 13.
The Monro-Kellie hypothesis refers to which of the following?
The dynamic equilibrium of cranial contents
The nurse is completing the physical assessment of a patient suspected of a neurologic disorder. The patient reports to the nurse that he has recently suffered a head trauma. In such a case, which of the following precautions should the nurse take for the patient? Select all that apply.
The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling.
The nurse in a rural nursing outpost will be receiving a client in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. What principle should guide the nurse's administration of intravenous fluid?
Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency
In which specific instances should the nurse assess the client's cranial nerves? Select all that apply.
When level of consciousness is decreased with brain stem pathology in the presence of peripheral nervous system disease
When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data?
When, if any, was your last narcotic use?
A client diagnosed with Bell palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles?
Whistling
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."
Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter?
ineffective cerebral tissue perfusion
The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?
levophed
A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find:
loss of motor power and sensation in the upper extremities.
The nurse in the ICU is caring for a 47-year-old, obese male client who is in shock following a motor vehicle accident. What would be the main challenge in meeting this client's elevated energy requirements during prolonged rehabilitation?
loss of skeletal muscle
A nurse is evaluating a client's drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure?
low urine output
Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in the
lungs
Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in which organ?
lungs
The nurse is caring for a client after lumbar puncture. The client reports a severe headache. Which actions should the nurse complete? Select all that apply.
maintain the client on bed rest administer fluids to the client administer analgesic medication
The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. What appropriate interventions should the nurse take? Select all that apply.
obtain a urine specimen for culture administer pantoprazole IV daily monitor urine output every hour
The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings?
oliguria and serum hyponatremia
6. After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question?
performing a lumbar puncture
1. A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse?
place the patient in a sitting position
A patient is treated for a neurologic dysfunction affecting facial expressions. The affected cranial nerve originates in the:
pons
Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident?
prevention of joint contractures
A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as
progressive
The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply.
vomiting, sudden, severe headache seizures
