practice qs

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? a) Decerebrate posturing and loss of corneal reflex b) Loss of gag reflex and mental confusion c) Mental confusion and pupillary changes d) Complaints of headache and lack of pupillary response

a

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? a) Cerebral aneurysm b) Cardiogenic emboli c) Large artery thrombosis d) Small artery thrombosis

a

A patient with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient? a) Restricting fluid intake and hydration b) Maintaining adequate hydration c) Administering prescribed antipyretics d) Hyperoxygenation before and after tracheal suctioning

a

Which of the following is the initial diagnostic test for a stroke? a) Noncontrast CT scan b) Transcranial Doppler studies c) ECG d) Carotid Doppler

a

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a) Maintaining the client in a quiet environment b) Positioning the client to prevent airway obstruction c) Keeping the client in one position to decrease bleeding d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess

c

An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following therapeutic effects? a) To increase urine output b) To reduce cellular metabolic demands c) To dehydrate the brain and reduce cerebral edema d) To lower uncontrolled fevers

c

Cerebral edema peaks at which timeframe post intracranial surgery? a) 72 hours b) 12 hours c) 24 hours d) 48 hours

c

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? a) Cerebral aneurysm b) Cardiogenic emboli c) Intracerebral hemorrhage d) Arteriovenous malformation

b

The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? a) Speaking in complete sentences b) Speaking loudly c) Avoiding the use of hand gestures d) Establishing eye contac

d

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." b) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved." d) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."

a

Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Avoiding flexion of the neck with use of a cervical collar b) Extreme hip flexion supported by pillows c) Rotating the neck to the far right with neck support d) Keeping the head flat with use of no pillow

a

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. a) Purpura of hands and feet b) Cloudy cerebral spinal fluid c) Low white blood cell (WBC) count d) Low red blood cell (RBC) count e) Pain and stiffness of the extremities f) Low antidiuretic hormone (ADH) levels

a b

Which interventions are appropriate for a patient with increased ICP? Select all that apply. a) Frequent oral care b) Elevating the head of the bed at 90 degrees c) Administering prescribed antipyretics d) Maintaining aseptic technique with the intraventricular catheter e) Encouraging deep breathing and coughing every 2 hours

a c d

The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate? a) Place patient in the dorsal recumbent position. b) Place patient in supine position with head slightly elevated. c) Place patient in the Trendelenburg position. d) Place patient in prone position with head turned to unaffected side.

b

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care? a) Risk of injury related to decreased LOC b) Ineffective airway clearance related to altered LOC c) Deficient fluid volume related to inability to take fluids by mouth d) Risk for impaired skin integrity related to prolonged immobility

b

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms? a) Hypertension b) Cardiac disease c) Diabetes insipidus d) Impaired cerebral circulation

d

The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern? a) Blood pressure (BP): 128/86 mm Hg b) Neck pain: 3/10 (0 to 10 pain scale) c) Mild neck edema d) Difficulty swallowing

d

A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a) Cerebral aneurysm b) Transient ischemic attack c) Left-sided stroke d) Right-sided stroke

b

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? a) Assess pupils. b) Assess Glasgow Coma Scale. c) Assess for a patent airway. d) Assess vital signs.

c