study for 6

10. The nurse is admitting a patient to the same day clinic following a myelogram. A water based contrast was used. The nurse would plan which of the following activity restrictions for the patient? A. Bedrest for 6-8 hrs., with HOB elevated 15-30 degrees B. Bedrest for 2-4 hrs., with HOB elevated 15-30 degrees C. Bedrest for 6-8 hrs., with HOB flat D. Bedrest for 2-4 hrs., with HOB flat

A

12. The nurse is positioning a patient with increased ICP. Which of the following positions would the nurse avoid? A. Head turned to the side B. Head midline C. Neck in neutral position D. HOB elevated to 30-45 degrees

A

13. The patient is recovering from a head injury is arousable and participating in care. The nurse determines that the patient understands measures to prevent elevations in ICP if the nurse observed the patient doing which of the following activities? A. Exhaling during repositioning B. Isometric exercises C. Blowing nose D. Coughing vigorously

A

15. The patient with a head injury has begun urinating copious amounts of dilute urine through the Foley catheter. The patient's urine output for the previous shift was 3000 mL. The nurse implements a new MD order to administer: A. Desmopressin (DDAVP) B. Dexamethasone (Decadron) C. Ethacrynic acid (Edecrin) D. Mannitol (Osmitrol)

A

17. The nurse is evaluating that status of the patient who had a craniotomy 3 days ago. The nurse would suspect the patient is developing meningitis as a complication of the surgery if the patient exhibits: A. A positive Brudzinski's sign B. A negative Kernig's sign C. Absence of nuchal rigidity A GCS score of 15

A

22. The nurse is caring for the patient who has suffered a spinal cord injury. The nurse further assesses the patient for other signs of autonomic dysreflexia if the patient experiences: A. Severe throbbing headache B. Pallor of the face and neck C. Sudden tachycardia D. Severe and sudden hypotension

A

7. The patient is having a lumbar puncture performed. The nurse would place to place the patient in which position for the procedure? A. Side lying, with legs pulled up and head bent down to chest B. Side lying with pillow under hip C. Prone, in slight Trendelenburg's position D. Prone, with pillow under abdomen

A

The patient has an impairment of cranial nerve II. Specific to this impairment the nurse would plan to do which of the following to ensure patient safety? A. Provide a clear path for ambulation without obstacles B. Test the temperature of the shower water C. Speak loudly to the patient D. Check the temperature of the food on the dietary tray

A

11. The nurse is caring for a patient with increased ICP. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

B

14. The patient has clear fluid leaking from his nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid : A. Clumps together into concentric rings and has a pH of 7 B. Separates into concentric rings and tests positive foe glucose C. Is grossly bloody in appearance and has a pH of 6 Is clear and tests negative for glucose

B

20. The nurse is caring for a patient who suffered from a spinal cord injury 48 hrs ago. The nurse monitors for GI complications by assessing for: A. A flattened abdomen B. Hematest positive NG tube drainage C. Hyperactive bowel sounds D. A history of diarrhea

B

21. A nursing student develops a plan of care for a patient with paraplegia who has a Risk for injury related to spasticity of the leg muscles. The nurse reads the plan and would speak to the student about which incorrect intervention? A. Removing potentially harmful objects near the spastic limbs B. Performing ROM to the affected limbs C. Use of padded restraints to immobilize the limb D. Use of PRN orders for muscle relaxants such as Baclofen

B

24. The patient 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? A. Strict adherence to bowel retraining program B. Limiting bladder catherization to once every 12 hrs C. Keeping linen wrinkle-free under the patient D. Preventing unnecessary pressure on the lower limbs

B

28. The nurse is assessing the patient who is experiencing seizure activity. The nurse understands that it is unnecessary to determine information about which of the following items as part of routine assessment of seizures? A. Duration of seizures B. What the patient ate 2 hrs preceding the seizure activity C. Seizure progression and type of movements Changes in pupil size or eye deviation

B

4. The nurse is testing the coordinated functioning of CN III, IV, and VI. To do this correctly, the nurse would test the: A. Corneal reflex B. 6 cardinal fields of gaze C. Pupil response to light D. Pupil response to light and accommodation

B

25. The nurse is planning care for the patient in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of injury? A. Monitoring VS before and during position changes B. Using vasopressor medications as prescribed C. Moving the patient quickly as one unit D. Applying TED hose or SCDs

C

27. The nurse is evaluating the neurological signs of the male patient in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock is present? A. Positive reflexes B. Hyperreflexia C. Inability to elicit a Babinski's reflex D. Reflex emptying of the bladder

C

3. The nurse is planning to test the function of the trigeminal nerve (CN V). The nurse would gather which of the following items to perform the test? A. Flashlight, pupil size chart or millimeter ruler B. Tuning fork and audiometer C. Safety pin, hot and cold water in test tubes, cotton wisp Snellen's chart, ophthalmoscope

C

9. The nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious patient. Cold water is injected into the left auditory canal. The patient exhibits eye movement toward the left followed by rapid nystagmus toward the right. The nurse understands that this indicates the patient has: A. A cerebral lesion B. A temporal lesion C. An intact brainstem D. Brain death

C

16. The nurse is caring for the patient in the ER following a head injury. The patient momentarily lost consciousness at the time of the injury and then regained it. The patient now has lost consciousness again. The nurse takes quick action knowing this is compatible with: A. Skull fracture B. Concussion C. Subdural hematoma D. Epidural hematoma

D

18. The patient with a cervical spine injury has cervical tongs applied in the ER. The nurse would avoid which of the following when planning care of this patient? A. Use of a Roto-rest bed B. Assessment of the integrity of the weights and pulleys C. Comparing the amount of ordered traction with the amount in use D.Removing the weights to reposition the patient

D

19. The nurse has completed discharge instructions for the patient with application of a Halo device. The nurse determines that the patient needs further instructions if the patient stated to: A. Use caution because the device alters balance B. Wash the skin daily under the lamb's wool liner of the vest C. Use a straw for drinking D. Drive only during the daytime

D

2. The patient has a neurological deficit involving the limbic system. Specific to this type of deficit the nurse would document which of the following information related to the patient's behavior? A. Demonstrates inability to add or subtract, does not know the president B. Cannot recall what was eaten for breakfast today C. Is disoriented to person, place and time D. Affect is flat, with periods of emotional lability

D

23. The family of a patient with a spinal cord injury rushes to the nurse's station saying the patient needs immediate help. On entering the room, the nurse notes that the patient is diaphoretic, with a flushed face and neck and complains of a severe headache. The pulse rate is 40 BPM, BP is 230/100 mmHg. The nurse acts quickly, knowing that the patient is experiencing: A. Spinal shock B. Malignant hypertension C. Pulmonary embolism D. Autonomic dysreflexia

D

26. The nurse is caring for a patient admitted with spinal cord injury. The nurse minimizes the risk of compounding injury most effectively by: A. Keeping the patient on the stretcher B. Logrolling the patient on a firm mattress C. Logrolling the patient on a soft mattress D. Placing the patient on a Stryker frame

D

5. The nurse is assessing the motor function of an unconscious patient. The nurse would plan to use which of the following to test the patient's peripheral response to pain? A. Sternal rub B. Pressure on the orbital rim C. Squeezing of the sternocleidomastoid muscle D. Nail bed pressure

D

6. The patient admitted with a neurological problem indicates to the nurse that MRI may be done. The nurse interprets that the patient may be ineligible for this procedure based on the patient's history of: A. Hypertension B. COPD C. Heart failure D. Prosthetic valve replacement

D

8. The patient has just undergone a CT scan with contrast. The nurse would evaluate that the patient understands post-procedure care if the patient verbalizes to: A. Eat lightly for the remainder of the day B. Rest quietly for the remainder of the day C. Hold medications for at least 4 hours D. Increase fluid intake for the day

D