NU351 Unit 5
An unconscious patient with a traumatic head injury has a blood pressure of 130/76 mm Hg and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.
74
A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome? A. Short-term memory B. Muscle coordination C. Glasgow Coma Scale D. Pupil reaction to light
A
A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate? A. Ask questions that the patient can answer with "yes" or "no." B. Develop a list of words that the patient can read and practice reciting. C. Have the patient practice her facial and tongue exercises with a mirror. D. Prevent embarrassing the patient by answering for her if she does not respond.
A
A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now reporting a headache. Which prescribed intervention should the nurse implement first? A. Administer IV 5% hypertonic saline. B. Draw blood for arterial blood gases (ABGs). C. Send patient for computed tomography (CT). D. Administer acetaminophen (Tylenol) 650 mg.
A
A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? A. Apply intermittent pneumatic compression stockings. B. Assist to dangle on edge of bed and assess for dizziness. C. Encourage patient to cough and deep breathe every 4 hours. D. Insert an oropharyngeal airway to prevent airway obstruction.
A
A patient has a tumor in the cerebellum. What goal should the nurse use to focus the plan of care? A. Prevent falls. B. Stabilize mood. C. Avoid aspiration. D. Improve memory.
A
A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first? A. Check oxygen saturation. B. Palpate the head for injuries. C. Assess pupil reaction to light. D. Verify Glasgow Coma Scale (GCS) score.
A
A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? A. Encourage family members to remain at the bedside. B. Apply soft restraints to protect the patient from injury. C. Keep the room well-lighted to improve patient orientation. D. Minimize contact with the patient to decrease sensory input.
A
A patient with possible viral meningitis is admitted to the nursing unit after a lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? A. Restrict oral fluids to 1000 mL/day. B. Elevate the head of the bed 20 degrees. C. Administer ceftriaxone 1 g IV every 12 hours. D. Give ibuprofen 400 mg every 6 hours as needed for headache.
A
Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mmHg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? A. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min B. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min C. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respirations 28 breaths/min D. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min
A
After receiving change-of-shift report on the following four patients, which patient should the nurse see first? A. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed B. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) C. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled D. A 40-yr-old patient who had a transient ischemic attack yesterday and has a dose of aspirin due
A
During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe? a. 1 b. 2 c. 3 d. 4
A
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? A. Risk for aspiration B. Impaired skin integrity C. Impaired physical mobility D. Disturbed sensory perception
A
The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions? A. Pale yellow urine output of 1200 mL over the past 2 hours. B. Ventriculostomy drained 40 mL of fluid in the past 2 hours. C. Intracranial pressure spikes to 16 mm Hg when patient is turned. D. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
A
When admitting an acutely confused patient with a head injury, which action should the nurse take? A. Ask family members about the patient's health history. B. Ask leading questions to assist in obtaining health data. C. Wait until the patient is better oriented to ask questions. D. Obtain only the physiologic neurologic assessment data.
A
Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? A. A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis B. A 35-yr-old patient with intracranial pressure (ICP) monitoring after a head injury C. A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day D. A 55-yr-old patient who is receiving hyperventilation therapy for increased ICP
A
A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? A. Have the patient gently blow the nose. B. Check the drainage for glucose content. C. Teach the patient that rhinorrhea is expected after a head injury. D. Obtain a specimen of the fluid to send for culture and sensitivity.
B
A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans? A. The patient is anxious about the test results. B. The patient reports a previous allergy to shellfish. C. The patient has back pain when lying flat for more than 4 hours. D. The patient drank apple juice 4 hours before the scheduled procedure.
B
A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? A. Take the patient's blood pressure. B. Check the respiratory rate and effort. C. Assess the Glasgow Coma Scale score. D. Send the patient for a computed tomography (CT) scan.
B
A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? A. Document the BP and ICP in the patient's record. B. Report the BP and ICP to the health care provider. C. Elevate the head of the patient's bed to 60 degrees. D. Continue to monitor the patient's vital signs and ICP.
B
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the patient? a. tPA b. Aspirin c. Warfarin d. Nimodipine
B
A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take? A. Administer IV furosemide (Lasix). B. Prepare the patient for craniotomy. C. Initiate high-dose barbiturate therapy. D. Type and crossmatch for blood transfusion.
B
A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How should the nurse record the patient's Glasgow Coma Scale score? a. 9. b. 11. c. 13. d. 15.
B
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? A. "The diseased portion of the artery is replaced with a synthetic graft." B. "The obstructing plaque is surgically removed from inside an artery in the neck." C. "A wire is threaded through an artery in the leg to the clots in the carotid artery, and clots are removed." D. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon flattens the plaque."
B
After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? A. Document the increase in intracranial pressure. B. Ensure that the patient's neck is in neutral position. C. Notify the health care provider about the change in pressure. D. Increase the rate of the prescribed propofol (Diprivan) infusion.
B
After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider? A. Pulse of 102 beats/min B. Temperature of 101.6° F C. Intracranial pressure of 15 mm Hg D. Mean arterial pressure of 90 mm Hg
B
An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider should the nurse question? A. Obtain x-rays of the skull and spine. B. Prepare the patient for lumbar puncture. C. Send for computed tomography (CT) scan. D. Perform neurologic checks every 15 minutes.
B
Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation? A. "This type of monitoring system is complex, and it is managed by skilled staff." B. "The monitoring system helps show whether blood flow to the brain is adequate." C. "The ventriculostomy monitoring system helps check for changes in cerebral perfusion pressure." D. "This monitoring system has many benefits, including the ability to drain cerebrospinal fluid."
B
Several patients have been hospitalized for diagnosis of neurologic problems. Which patient should the nurse assess first? A. A patient with a transient ischemic attack (TIA) returning from carotid duplex studies B. A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram C. A patient with a seizure disorder who has just completed an electroencephalogram (EEG) D. A patient prepared for a lumbar puncture whose health care provider is waiting for assistance
B
Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? A. Limit fluid intake to 1200 mL daily to reduce urine volume. B. Assist the patient onto the bedside commode every 2 hours. C. Perform intermittent catheterization after each voiding to check for residual urine. D. Use an external "condom" catheter to protect the skin and prevent embarrassment.
B
The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? A. Keep the head of the bed elevated. B. Insert nasogastric tube to low suction. C. Turn patient side to side every 2 hours. D. Apply cold packs intermittently to face.
B
The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? A. The pulse rate is 102 beats/min. B. The patient has difficulty speaking. C. The blood pressure is 144/86 mm Hg. D. There are fine crackles at the lung bases.
B
The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective? A. Emphasize the importance of hand washing before meals. B. Encourage immunization for adolescents and college freshmen. C. Tell adolescents and young adults to avoid crowds in the winter. D. Support serving healthy nutritional options in the college cafeteria.
B
What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel (Plavix)? A. Monitor and record the blood pressure daily. B. Call the health care provider if stools are tarry. C. Clopidogrel will dissolve clots in the cerebral arteries. D. Clopidogrel will reduce cerebral artery plaque formation.
B
When assessing a patient who has a right frontal lobe tumor, what finding should the nurse expect? A. Expressive aphasia B. Impaired judgment C. Right-sided weakness D. Difficulty swallowing
B
Which action should the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)? A. Assist to stand and ambulate. B. Withhold oral fluids and food. C. Insert an oropharyngeal airway. D. Apply artificial tears every hour.
B
Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? A. Coordinate the transfer of the patient to the operating room. B. Provide discharge instructions about monitoring neurologic status. C. Arrange to admit the patient to the neurologic unit for observation. D. Transport the patient to radiology for magnetic resonance imaging (MRI).
B
Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? A. Teach about prophylactic antibiotics after exposure to encephalitis. B. Encourage the use of effective insect repellent during mosquito season. C. Remind patients that most cases of viral encephalitis can be cared for at home. D. Arrange to screen school-age children for West Nile virus during the school year.
B
Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider? A. Specific gravity of 1.007 B. Protein of 65 mg/dL (0.65 g/L) C. Glucose of 45 mg/dL (1.7 mmol/L) D. White blood cell (WBC) count of 4 cells/L
B
Which equipment should the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction? A. Sharp pin B. Tuning fork C. Reflex hammer D. Calibrated compass
B
Which finding should the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? A. Spasticity B. Flaccidity C. Impaired sensation D. Hyperactive reflexes
B
Which information about a 76-yr-old patient should the nurse identify as uncharacteristic of normal aging? A. Triceps reflex response graded at 1/5 B. Unintended weight loss of 15 pounds C. Patient report of chronic difficulty in falling asleep D. 10 mm Hg orthostatic drop in systolic blood pressure
B
Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider? A. The patient reports having a stiff neck. B. The patient's blood pressure (BP) is 90/50 mm Hg. C. The patient reports a severe and unrelenting headache. D. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
B
Which of the following should the nurse consider the priority nursing assessment for a patient being admitted with a brainstem infarction? A. Pupil reaction B. Respiratory rate C. Reflex reaction time D. Level of consciousness
B
Which problem should the nurse expect for a patient who has a positive Romberg test result? a. Pain b. Falls c. Aphasia d. Confusion
B
Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for related functional deficits? A. "Do you have any difficulty in hearing?" B. "Are you experiencing vision problems?" C. "Are you having any trouble with your balance?" D. "Have you developed any weakness on one side?"
B
Which statement by a patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? A. "I will return if I feel dizzy or nauseated." B. "I am going to drive home and go right to bed." C. "I do not even remember being in an accident today." D. "I can take acetaminophen (Tylenol) for my headache."
B
While admitting a 42-yr-old patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? A. The patient reports a severe dull headache. B. The patient takes warfarin (Coumadin) daily. C. The patient's blood pressure is 162/94 mm Hg. D. The patient is unable to remember the accident.
B
Which assessments should the nurse make to monitor a patient's cerebellar function? (Select all that apply.) A. Test for graphesthesia. B. Observe arm swing with gait. C. Perform the finger-to-nose test. D. Assess heat and cold sensation. E. Measure strength against resistance.
B, C
Which nursing actions should be included in the plan of care for a patient after cerebral angiography? (Select all that apply.) A. Monitor for photophobia. B. Observe for bleeding at the puncture site. C. Keep patient NPO until gag reflex returns. D. Check pulse and blood pressure frequently. E. Assess orientation to person, place, and time.
B, D, E
A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? A. Provide a wide variety of food choices. B. Provide oral care before and after meals. C. Assist the patient to eat with the right hand. D. Teach the patient the "chin-tuck" technique.
C
A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question? A. Keep head of bed elevated at least 30 degrees. B. Infuse normal saline intravenously at 75 mL/hr. C. Start a labetalol drip to keep BP less than 140/90 mm Hg. D. Begin tissue plasminogen activator (tPA) intravenously per protocol.
C
A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.
C
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? A. Document that the patient refused the aspirin. B. Tell the patient that the aspirin is used to prevent a fever. C. Explain that the aspirin is ordered to decrease stroke risk. D. Call the health care provider to clarify the medication order.
C
A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? A. Encourage coughing and deep breathing. B. Position the patient with knees and hips flexed. C. Keep the head of the bed elevated to 30 degrees. D. Cluster nursing interventions to provide rest periods.
C
A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take? A. Order a varied pureed diet. B. Assess the patient's appetite C. Assist the patient into a chair. D. Offer the patient a sip of juice.
C
A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to the unlicensed assistive personnel (UAP) who regularly works in the intensive care unit? A. Document intracranial pressure every hour B. Turn and reposition the patient every 2 hours. C. Check capillary blood glucose level every 6 hours. D. Monitor cerebrospinal fluid color and volume hourly.
C
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? A. Complete blood count (CBC) B. Chest radiograph (chest x-ray) C. Computed tomography (CT) scan D. 12-Lead electrocardiogram (ECG)
C
An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment. What action is best for the nurse to take? A. Call the family's pastor or spiritual advisor to take them to the chapel. B. Ask the family to stay in the waiting room until the assessment is completed. C. Allow the family to stay with the patient and briefly explain all procedures to them. D. Refer the family members to the hospital counseling service to deal with their anxiety.
C
During change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. What finding should the nurse anticipate? A. Dysphasia B. Confusion C. Visual deficits D. Poor judgment
C
During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. What should the nurse suspect as a likely cause of these findings? A. Cerebellar injury B. A brainstem lesion C. Frontal lobe damage D. A temporal lobe lesion
C
How should the nurse assess the patient's trigeminal and facial nerve function (CNs V and VII)? A. Check for unilateral eyelid droop. B. Shine a light into the patient's pupil. C. Touch a cotton wisp strand to the cornea. D. Have the patient read a magazine or book.
C
The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further teaching about neurologic assessment? A. Tests for light touch before testing for pain. B. Has the patient close the eyes during testing. C. Asks the patient if the instrument feels sharp. D. Uses an irregular pattern to test for intact touch.
C
The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? A. The staff nurse assesses neurologic status every hour. B. The staff nurse elevates the head of the bed to 30 degrees. C. The staff nurse suctions the patient routinely every 2 hours. D. The staff nurse administers an analgesic before turning the patient.
C
The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on patient information shown in the accompanying figure, which action should the nurse take? A. Teach about preventing hypoglycemia. B. Begin processes to obtain a wheelchair. C. Provide support to the spouse caregiver. D. Remind the patient to take prescribed medications.
C
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? A. Blood pressure B. Oxygen saturation C. Intracranial pressure D. Hemoglobin and hematocrit
C
The nurse is caring for a patient who has a head injury and fractured right arm. Which assessment information requires rapid action by the nurse? A. The patient reports a headache. B. The apical pulse is slightly irregular. C. The patient is more difficult to arouse. D. The blood pressure increases to 140/62 mm Hg.
C
The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? A. Assess the patient's gag and cough reflexes. B. Determine when the stroke symptoms began. C. Administer the prescribed short-acting insulin. D. Infuse the prescribed IV metoprolol (Lopressor).
C
What concern should the nurse anticipate for a patient who had a right hemisphere stroke? A. Right-sided hemiplegia B. Speech-language deficits C. Denial of deficits and impulsiveness D. Depression and distress about disability
C
What should the nurse include in a focused assessment of a patient's left posterior temporal lobe functions? A. Sensation on the left side of the body B. Reasoning and problem-solving ability C. Ability to understand written and oral language D. Voluntary movements on the right side of the body
C
What topic should the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, and dysarthria with no residual effects? A. Cerebral aneurysm clipping B. Heparin intravenous infusion C. Oral low-dose aspirin therapy D. Tissue plasminogen activator (tPA)
C
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response? A. Flexion withdrawal B. Localization of pain C. Decorticate posturing D. Decerebrate posturing
C
Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? A. Intracranial pressure of 15 mm Hg B. Cerebrospinal fluid (CSF) drainage of 25 mL/hr C. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg D. Cardiac monitor shows sinus tachycardia at 120 beats/min
C
Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke? A. Apply an eye patch to the right eye. B. Approach the patient from the right side. C. Place needed objects on the patient's left side. D. Teach the patient that the left visual deficit will resolve.
C
Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? A. The patient is 25 pounds above the ideal weight. B. The patient drinks a glass of red wine with dinner daily. C. The patient's usual blood pressure (BP) is 170/94 mm Hg. D. The patient works at a desk and relaxes by watching television.
C
A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.
C, D, A, B
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient? A. Surgical endarterectomy B. Transluminal angioplasty C. Intravenous heparin drip administration D. Tissue plasminogen activator (tPa) infusion
D
A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect? A. Impulsive behavior B. Right-sided neglect C. Hyperactive left-sided tendon reflexes D. Difficulty comprehending instructions
D
A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first? A. Administer ceftizoxime (Cefizox) 1 g IV. B. Give acetaminophen (Tylenol) 650 mg PO. C. Use a cooling blanket to lower temperature. D. Swab the nasopharyngeal mucosa for cultures.
D
A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? A. The patient received a regular diet tray. B. Staff turned off the lights in the patient's room. C. The bedrails on both sides of the bed are elevated. D. Staff have entered the patient's room without a mask.
D
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? A. The patient's speech is difficult to understand. B. The patient's blood pressure (BP) is 144/90 mm Hg. C. The patient takes a diuretic because of a history of hypertension. D. The patient has atrial fibrillation and takes warfarin (Coumadin).
D
A patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond? A. Use a calm voice to ask the patient to stop the crying behavior. B. Explain to the family that depression is normal following a stroke. C. Have the family members leave the patient alone for a few minutes. D. Teach the family that emotional outbursts are common after strokes.
D
A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure? A. Enforce NPO status for 4 hours. B. Transfer the patient to radiology. C. Administer a sedative medication. D. Help the patient to a lateral position.
D
After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has weakness, impaired physical mobility, and a decreased level of consciousness. Which nursing action will be included in the plan of care? A. Cluster nursing activities to allow longer rest periods. B. Turn and reposition the patient side to side every 2 hours. C. Position the bed flat and log roll to reposition the patient. D. Perform range-of-motion (ROM) exercises every 4 hours.
D
After the emergency department nurse has received a status report on the following patients with head injuries, which patient should the nurse assess first? A. A 20-yr-old patient whose cranial x-ray shows a linear skull fracture B. A 30-yr-old patient who lost consciousness for 10 seconds after a fall C. A 40-yr-old patient who has an initial Glasgow Coma Scale score of 13 D. A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light
D
The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider? A. Report of severe headache B. Large contusion behind left ear C. Bilateral periorbital ecchymosis D. Temperature of 101.4° F (38.6° C)
D
When assessing an adult who has bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention? A. The patient exhibits nuchal rigidity. B. The patient has a positive Kernig's sign. C. The patient's temperature is 101° F (38.3° C). D. The patient's blood pressure is 88/42 mm Hg.
D
Which test should the nurse anticipate discussing with a patient who has a possible seizure disorder? A. Cerebral angiography B. Evoked potential studies C. Electromyography (EMG) D. Electroencephalography (EEG)
D