ms.p practice questions came from this head trauma /icp set
14. Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? 1. Insert an indwelling urinary catheter to straight drainage 2. Schedule intermittent catheterization every 2 to 4 hours 3. Perform a straight catheterization every 8 hours while awake 4. Perform Crede's maneuver to the lower abdomen before the client voids.
14. Answer: 2. Schedule intermittent catheterization every 2 to 4 hours Intermittent catheterization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours.
15. A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? 1. Laceration of the middle meningeal artery 2. Rupture of the carotid artery 3. Thromboembolism from a carotid artery 4. Venous bleeding from the arachnoid space
15. Answer: 1. Laceration of the middle meningeal artery Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery.
16. A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? 1. Position the client flat in bed 2. Check the fluid for dextrose with a dipstick 3. Suction the nose to maintain airway patency 4. Insert nasal and ear packing with sterile gauze
16. Answer: 2. Check the fluid for dextrose with a dipstick Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose.
17. When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? 1. An interval when the client's speech is garbled 2. An interval when the client is alert but can't recall recent events 3. An interval when the client is oriented but then becomes somnolent 4. An interval when the client has a "warning" symptom, such as an odor or visual disturbance.
17. Answer: 3. An interval when the client is oriented but then becomes somnolent A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness.
18. Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? 1. A client with a brain injury 2. A client with a herniated nucleus pulposus 3. A client with a high cervical spine injury 4. A client with a stroke
18. Answer: 3. A client with a high cervical spine injury Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren't prone to dysreflexia.
19. Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? 1. Absence of pain sensation in chest 2. Spasticity 3. Spontaneous respirations 4. Urinary continence
19. Answer: 2. Spasticity Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury.
20. A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? 1. Headache 2. Lumbar spinal cord injury 3. Neurogenic shock 4. Noxious stimuli
20. Answer: 4. Noxious stimuli Noxious stimuli, such as a full bladder, fecal impaction, or a decubitus ulcer, may cause autonomic dysreflexia.
21. During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? 1. Elevate the client's legs 2. Put the client flat in bed 3. Put the client in the Trendelenburg's position 4. Put the client in the high-Fowler's position
21. Answer: 4. Put the client in the high-Fowler's position Putting the client in the high-Fowler's position will decrease cerebral blood flow, decreasing hypertension.
22. A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? 1. Autonomic dysreflexia 2. Hypervolemia 3. Neurogenic shock 4. Sepsis
22. Answer: 3. Neurogenic shock Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock.
23. A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? 1. Absent corneal reflex 2. Decerebrate posturing 3. Movement of only the right or left half of the body 4. The need for mechanical ventilation
23. Answer: 4. The need for mechanical ventilation The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time.
24. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? 1. Decreased urine output or oliguria 2. Hypertension and bradycardia 3. Respiratory depression 4. Symptoms of shock
24. Answer: 2. Hypertension and bradycardia Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect.
7. A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? 1. Assess full ROM to determine extent of injuries 2. Call for an immediate chest x-ray 3. Immobilize the client's head and neck 4. Open the airway with the head-tilt-chin-lift maneuver
7. Answer: 3. Immobilize the client's head and neck All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. The airway doesn't need to be opened since the client appears alert and not in respiratory distress.
44. A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? 1. Widening pulse pressure 2. Decrease in the pulse rate 3. Dilated, fixed pupil 4. Decrease in LOC
Answer: 4. Decrease in LOC A decrease in the client's LOC is an early indicator of deterioration of the client's neurological status. Changes in LOC, such as restlessness and irritability, may be subtle.
32. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. 1. Elevate the HOB to 90 degrees 2. Loosen constrictive clothing 3. Use a fan to reduce diaphoresis 4. Assess for bladder distention and bowel impaction 5. Administer antihypertensive medication 6. Place the client in a supine position with legs elevated
Answer: 1, 2, 4, 5. The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered.
4. When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? 1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). 2. Emergent; the client is poorly oxygenated. 3. Normal 4. Significant; the client has alveolar hypoventilation.
Answer: 1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels.
33. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: 1. Desmopressin (DDAVP, Stimate) 2. Dexamethasone (Decadron) 3. Ethacrynic acid (Edecrin) 4. Mannitol (Osmitrol)
Answer: 1. Desmopressin (DDAVP, stimate) A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin.
27. Which neurotransmitter is responsible for may of the functions of the frontal lobe? 1. Dopamine 2. GABA 3. Histamine 4. Norepinephrine
Answer: 1. Dopamine The frontal lobe primarily functions to regulate thinking, planning, and affect. Dopamine is known to circulate widely throughout this lobe, which is why it's such an important neurotransmitter in schizophrenia.
3. A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? 1. Evaluate urine specific gravity 2. Anticipate treatment for renal failure 3. Provide emollients to the skin to prevent breakdown 4. Slow down the IV fluids and notify the physician
Answer: 1. Evaluate urine specific gravity Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce the anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration.
30. After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? 1. Quadriplegia with gross arm movement and diaphragmatic breathing 2. Quadriplegia and loss of respiratory function 3. Paraplegia with intercostal muscle loss 4. Loss of bowel and bladder control
Answer: 1. Quadriplegia with gross arm movement and diaphragmatic breathing A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing.
1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? 1. Reposition the client to avoid neck flexion 2. Administer 1 g Mannitol IV as ordered 3. Increase the ventilator's respiratory rate to 20 breaths/minute 4. Administer 100 mg of pentobarbital IV as ordered.
Answer: 1. Reposition the client to avoid neck flexion The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP.
42. Which of the following respiratory patterns indicate increasing ICP in the brain stem? 1. Slow, irregular respirations 2. Rapid, shallow respirations 3. Asymmetric chest expansion 4. Nasal flaring
Answer: 1. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns.
41. A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? 1. Unequal pupil size 2. Decreasing systolic blood pressure 3. Tachycardia 4. Decreasing body temperature
Answer: 1. Unequal pupil size Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve.
40. A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, list in order of priority, the nurse's actions (Number 1 being the first priority and number 5 being the last priority). 1. Check for bladder distention 2. Raise the head of the bed 3. Contact the physician 4. Loosen tight clothing on the client 5. Administer an antihypertensive medication
Answer: 2, 4, 1, 3, 5. Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and remove the noxious stimulus. The nurse should loosen any tight clothing and then check for bladder distention. If the client has a foley catheter, the nurse should check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact if necessary. The physician is contacted especially if these actions do not relieve the signs and symptoms. Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.
50. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? 1. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. 2. Administer phenytoin (Dilantin) 200 mg PO daily. 3. Teach patient about the need for good oral hygiene. 4. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.
Answer: 2. Administer phenytoin (Dilantin) 200 mg PO daily. Administration of medications is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize.
47. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? 1. Count the rate to be sure the ventilations are deep enough to be sufficient 2. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. 3. Call the physician to adjust the ventilator settings. 4. Check deep tendon reflexes to determine the best motor response
Answer: 2. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. Checking deep tendon reflexes is one part of the GCS analysis.
48. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? 1. Keeping the client flat on one side or the other 2. Elevating the head of the bed to 30 degrees 3. Log rolling or turning as a unit when turning 4. Keeping the head in neutral position
Answer: 2. Elevating the head of the bed to 30 degrees Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brainstem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite of the incision, if not contraindicated by the ICP; is used for supratentorial craniotomies.
5. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? 1. Bloody drainage from the ears 2. Frequent swallowing 3. Guaiac-positive stools 4. Hematuria
Answer: 2. Frequent swallowing Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx.
35. The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: 1. A flattened abdomen 2. Hematest positive nasogastric tube drainage 3. Hyperactive bowel sounds 4. A history of diarrhea
Answer: 2. Hematest positive nasogastric tube drainage Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool.
36. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? 1. Strict adherence to a bowel retraining program 2. Limiting bladder catheterization to once every 12 hours 3. Keeping the linen wrinkle-free under the client 4. Preventing unnecessary pressure on the lower limbs
Answer: 2. Limiting bladder catheterization to once every 12 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing.
2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Rapid Dilantin administration can cause cardiac arrhythmias. 3. Dilantin should be mixed in dextrose in water before administration. 4. Dilantin should be administered through an IV catheter in the client's hand.
Answer: 2. Rapid Dilantin administration can cause cardiac arrhythmias. Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias.
13. A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? 1. To hasten wound healing 2. To immobilize the cervical spine 3. To prevent autonomic dysreflexia 4. To hold bony fragments of the skull together
Answer: 2. To immobilize the cervical spine Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished.
45. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? 1. Place her in a jacket restraint 2. Wrap her hands in soft "mitten" restraints 3. Tuck her arms and hands under the draw sheet 4. Apply a wrist restraint to each arm
Answer: 2. Wrap her hands in soft "mitten" restraints It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation.
26. An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? 1. "Watch him for keyhole pupil the next 24 hours." 2. "Expect profuse vomiting for 24 hours after the injury." 3. "Wake him every hour and assess his orientation to person, time, and place." 4. "Notify the physician immediately if he has a headache."
Answer: 3. "Wake him every hour and assess his orientation to person, time, and place." Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are frequently assessed for 24 hours.
28. The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? 1. Extent of intracranial bleeding 2. Sites of brain injury 3. Activity of the brain 4. Percent of functional brain tissue
Answer: 3. Activity of the brain An EEG measures the electrical activity of the brain
31. A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? 1. By inserting a nasopharyngeal airway 2. By inserting a oropharyngeal airway 3. By performing a jaw-thrust maneuver 4. By performing the head-tilt, chin-lift maneuver
Answer: 3. By performing a jaw-thrust maneuver If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway.
43. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? 1. Give the client a warming blanket 2. Administer low-dose barbiturate 3. Encourage the client to hyperventilate 4. Restrict fluids
Answer: 3. Encourage the client to hyperventilate Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg.
29. A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? 1. Subdural hematoma 2. Subarachnoid hemorrhage 3. Epidural hematoma 4. Contusion
Answer: 3. Epidural hematoma An epidural hematoma occurs when blood collects between the skull and the dura mater.
39. The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? 1. Positive reflexes 2. Hyperreflexia 3. Inability to elicit a Babinski's reflex 4. Reflex emptying of the bladder
Answer: 3. Inability to elicit a Babinski's reflex Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex.
11. A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? 1. Acetazolamide (Diamox) 2. Furosemide (Lasix) 3. Methylprednisolone (Solu-Medrol) 4. Sodium bicarbonate
Answer: 3. Methylprednisolone (Solu-Medrol) High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance.
37. The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? 1. Monitoring vital signs before and during position changes 2. Using vasopressor medications as prescribed 3. Moving the client quickly as one unit 4. Applying Teds or compression stockings.
Answer: 3. Moving the client quickly as one unit Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound.
10. While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? 1. Autonomic dysreflexia 2. Hemorrhagic shock 3. Neurogenic shock 4. Pulmonary embolism
Answer: 3. Neurogenic shock Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion.
9. A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? 1. Bladder distension 2. Neurological deficit 3. Pulse ox readings 4. The client's feelings about the injury
Answer: 3. Pulse ox readings After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary.
25. A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? 1. "Clean the meatus from back to front." 2. "Measure the quantity of urine." 3. "Gently rotate the catheter during removal." 4. "Clean the meatus with soap and water."
Answer: 4. "Clean the meatus with soap and water." Intermittent catheterization may be performed chronically with clean technique, using soap and water to clean the urinary meatus.
46. Which of the following describes decerebrate posturing? 1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers 2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet 3. Supination of arms, dorsiflexion of feet 4. Back arched; rigid extension of all four extremities.
Answer: 4. Back arched; rigid extension of all four extremities. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by the arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet.
34. The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: 1. Skull fracture 2. Concussion 3. Subdural hematoma 4. Epidural hematoma
Answer: 4. Epidural hematoma The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly.
38. The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: 1. Keeping the client on a stretcher 2. Logrolling the client on a firm mattress 3. Logrolling the client on a soft mattress 4. Placing the client on a Stryker frame
Answer: 4. Placing the client on a Stryker frame Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.
12. A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? 1. Place the client flat in bed 2. Assess patency of the indwelling urinary catheter 3. Give one SL nitroglycerin tablet 4. Raise the head of the bed immediately to 90 degrees
Answer: 4. Raise the head of the bed immediately to 90 degrees Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer.
8. A client with a C6 spinal injury would most likely have which of the following symptoms? 1. Aphasia 2. Hemiparesis 3. Paraplegia 4. Tetraplegia
Answer: 4. Tetraplegia Tetraplegia occurs as a result of cervical spine injuries.
6. After a hypophysectomy, vasopressin is given IM for which of the following reasons? 1. To treat growth failure 2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH) 3. To reduce cerebral edema and lower intracranial pressure 4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.
Answer: 4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary. After hypophysectomy or removal of the pituitary gland, the body can't synthesize ADH.
49. A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply. 1. Decerebrate posturing 2. Dilated nonreactive pupils 3. Deep tendon reflexes 4. Absent corneal reflex
Answers: 2, 3, 4. A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not be seen.
