Neurological Disorders

Question 1

The nurse is helping a patient who is recovering from a 2nd to 4th thoracic vertebral injury with transferring from bed to sitting in a chair. Which nursing interventions are indicated to prevent the onset of orthostatic hypotension? (select all that apply)

1. Apply a binder around the patient’s abdomen.
2. Be certain the patient is wearing compression stockings.
3. Swing the patient’s legs to the side of the bed in one swift, smooth movement.
4. Gradually raise the head of the bed.
5. Allow the patient to sit on the side of the bed with feet dangling before moving to a chair.

Answer 1

Correct Answer: 1,2,4,5

Rationale 1: The patient should be wearing an abdominal binder when moving from a lying to a sitting position.

Rationale 2: The patient should be wearing compression hose prior to moving from a lying to a sitting position.

Rationale 3: The patient will likely not tolerate a rapid movement to a sitting position as is indicated by this action.

Rationale 4: Chronic peripheral vasodilation causes orthostatic hypotension, particularly for patients with injuries at T6 or above. Chronic vasodilation in combination with a quick position change results in a loss of consciousness. Therefore, initial attempts to mobilize the patient are done slowly. Gradually raising the head of bed is indicated.

Rationale 5: Allowing the patient to side on the side of the bed with feet dangling until the blood pressure accommodates a sitting position will help prevent orthostatic hypotension.

Question 2

A patient was admitted this morning after sustaining an acute spinal cord injury. This afternoon his neurological assessment shows some deterioration of function. How would the nurse explain this to the patient’s family?

1. “Injured cells release potassium that causes destruction of the covering of nerves in the area injured.”
2. “Decreased blood flow increases the size of the affected area.”
3. “The body’s inflammatory response has caused blood vessels in the area to dilate.”
4. “Injury to nerves impairs the body’s healing responses.”

Answer 2

Correct Answer: 2

Rationale 1: Calcium is released in a spinal cord injury and is responsible for demyelization.

Rationale 2: Blood flow to the spinal cord decreases immediately on injury as a result of hypotension and vasospasm induced thrombosis. Thrombi in the microcirculation impede blood flow. The zone of ischemia can spread if perfusion to the cord is not restored.

Rationale 3: Dilation of vessels would improve blood flow to the region and would not result in deterioration of neurological condition.

Rationale 4: This statement is not true.

Question 3

The nurse, assessing a patient with a Glasgow Coma Score 4, finds the patient’s pupils to be pinpoint and nonreactive to light. The nurse takes into consideration that this finding can be due to which situations? (select all that apply)

1. The patient was given atropine sulfate for bradycardia.
2. The patient has increased blood glucose.
3. The patient may have taken an opioid drug overdose.
4. The patient has sustained compression of the oculomotor nerve.
5. The patient has sustained damage to the pons.

Answer 3

Correct Answer: 3,5

Rationale 1: Recent administration of atropine sulfate leads to dilated pupils.

Rationale 2: Metabolic disorders cause small but reactive pupils.

Rationale 3: Opiod drug overdose will result in pinpoint, nonreactive pupils.

Rationale 4: Compression of the oculomotor nerve causes a unilateral fixed and dilated pupil.

Rationale 5: Damages to the pons will result in fixed and pinpoint pupils.

Question 4

A patient in the intensive care unit has pulled out his peripheral intravenous line twice and continually picks at his abdominal dressing. How should the nurse describe this behavior?

1. As hyperactive dementia
2. As hyperactive delirium
3. As hypoactive delirium
4. As mixed dementia

Answer 4

Correct Answer: 2

Rationale 1: There is no indication that this patient has dementia.

Rationale 2: Hyperactive delirium, also referred to as ICU psychosis, is characterized by agitation, restlessness, and “picking” at monitoring, feeding, or intravenous devices.

Rationale 3: Hypoactive delirium is characterized by lethargy rather than agitation, withdrawal, flat affect, apathy, and decreased responsiveness.

Rationale 4: There is no indication that this patient suffers from dementia.

Question 5

The nurse is providing care to a patient receiving a neuromuscular blocking agent. Which nursing intervention is most important specifically due to this medical intervention?

1. Monitor urine output.
2. Provide eye care.
3. Move the patient as little as possible.
4. Provide mouth care.

Answer 5

Correct Answer: 2

Rationale 1: Urine output should be monitored for all critically ill patients. This monitoring is not specific to patients under neuromuscular block.

Rationale 2: Nursing care of a patient receiving a neuromuscular blocking agent should include prophylactic eye care. The nurse should keep the eyes closed and covered with a soft eye pad and use eye lubricants or artificial tears.

Rationale 3: The patient receiving neuromuscular blockage will be unable to move self. The nurse must intervene with actions to prevent muscle contractures and skin breakdown.

Rationale 4: Mouth care is an essential component of the care of all critically ill patients.

Question 6

A patient is admitted with a possible 2nd cervical vertebra injury. The nurse prepares for which most likely method to manage the patient’s respiratory system?

1. Incentive spirometer every hour while awake.
2. Quad coughing
3. Humidified oxygen via face mask
4. Intubation and mechanical ventilation

Answer 6

Correct Answer: 4

Rationale 1: Incentive spirometer is not the most likely method of managing this patient’s respiratory system.

Rationale 2: Quad coughing is not the most likely method for managing this patient’s respiratory system.

Rationale 3: Humidified oxygen via face mask will not be sufficient to manage this patient’s respiratory system.

Rationale 4: Patients with 1st or 2nd cervical injuries will require mechanical ventilation because of loss of phrenic nerve enervation to the diaphragm.

Question 7

A patient suffered an acute T6 spinal cord injury. Family has been told that the patient will likely be paraplegic. However, this morning the patient has limited use of his arms. How should the nurse explain this change?

1. “There must be a second area of fracture higher in the spine.”
2. “The spinal cord is probably swollen above the area of original injury.”
3. “These changes are due to the low blood pressure he had before he got to the hospital.”
4. “This is a sign that he is dehydrated and will go away as we give him more IV fluids.”

Answer 7

Correct Answer: 2

Rationale 1: It would be premature to suggest that a second area of injury exists.

Rationale 2: In a spinal cord injury, as the cord swells within the bony vertebrae, edema moves up and down the cord. A patient may exhibit symptoms as a result of the edema and not the initial injury. Because edema can extend the level of injury for several cord segments above and below the affected level, the extent of injury may not be determined for several days, until after the cord edema has resolved.

Rationale 3: There is no evidence that this change in neurological status is associated with prehospital hypotension.

Rationale 4: This change is not likely due to hypovolemia.

Question 8

A patient in the intensive care unit with a spinal cord injury is receiving intravenous fluid therapy for hypotension. Which finding would the nurse evaluate as indicating the therapy has had its desired effect?

1. Normal temperature
2. Systolic blood pressure of 85 mm Hg
3. Systolic blood pressure of 120 mm Hg
4. Mean arterial pressure of 88 Hg

Answer 8

Correct Answer: 4

Rationale 1: Temperature is not a good way to assess for therapeutic effect in this intervention.

Rationale 2:

Rationale 3: Systolic pressure of 120 mm Hg may be difficult to obtain without administering so much fluid that the patient develops pulmonary edema.

Rationale 4: Judicious use of intravenous fluids is required when treating hypotension because too much fluid can precipitate pulmonary edema. However, medications might be needed to maintain adequate cardiac output and tissue perfusion. Current guidelines recommend that the mean arterial pressure be maintained 85 to 90 mm Hg for the first 7 days post–spinal cord injury.

Question 9

A patient in the intensive care unit begins to seize. The nurse would anticipate initial management of this seizure to include which intravenous medication?

1. Fosphenytoin
2. Lorazepam
3. Propofol
4. Diazepam

Answer 9

Correct Answer: 2

Rationale 1: Fosphenytoin would be administered if the first line class of drugs was ineffective in controlling the seizure.

Rationale 2: Intravenous benzodiazepines are effective in stopping seizures 65–80% of the time. Lorazepam is the treatment of choice over diazepam because it lasts longer.

Rationale 3: Propofol could be administered if the first and second line drugs are ineffective in controlling the seizure.

Rationale 4: Diazepam is a benzodiazepine that can be administered intravenously; however, it does not last as long as the preferred drug.

Question 10

A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the patient extends his legs and demonstrates extreme plantar flexion. What action should be taken by the nurse?

1. Document the presence of decorticate posturing.
2. Immediately stop the attempt at intravenous insertion and obtain a blood pressure reading.
3. Assess the position of the patient’s arms.
4. Administer intravenous sedation as quickly as possible after access is obtained

Answer 10

Rationale 1: It is not possible to assess decorticate posturing from this scenario.

Rationale 2: It is important to gain IV access for this patient. Posturing to noxious stimuli indicates brain damage. Blood pressure is not pertinent at this time.

Rationale 3: The nurse should assess the position of the patient’s arms to determine if decorticate or decerebrate posturing is present.

Rationale 4: Administering sedation is not indicated at this time as assessment is continuing

Question 11

A nurse is preparing to conduct a neurological assessment on a patient who is not suspected for having neurological impairment. Which tests should the nurse perform? (select all that apply)

1. Observation for level of consciousness
2. Checking pupillary response to light
3. Ability to count by serial 7s
4. Assessing the blood pressure
5. Visual acuity

Answer 11

Correct Answer: 1,2,3,4

Rationale 1: Simple testing for level of consciousness includes observing the patient for response to auditory or tactile stimuli.

Rationale 2: Simple penlight testing for pupillary response to light is a part of the abbreviated neuro check.

Rationale 3: Ability to count by serial 7s is not part of the abbreviated neuro check.

Rationale 4: Vital sign assessment is part of the abbreviated neuro check.

Rationale 5: Visual acuity is not a part of the abbreviated neuro check.

Question 12

It is suspected that a patient admitted with spinal cord injury has severe cord injury. The nurse would prepare the patient for which diagnostic test to determine the extent of this edema?

1. Angiography
2. Somatosensory-evoked potentials
3. CT scan
4. MRI

Answer 12

Correct Answer: 4

Rationale 1: Angiography is useful for patients with complex cervical spine fractures involving subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures.

Rationale 2: Somatosensory-evoked potentials are used to establish a functional prognosis after resolution of spinal cord edema.

Rationale 3: CT scans are not the most sensitive tests for determination of cord edema.

Rationale 4: The MRI has greater sensitivity than a CT scan for diagnosing contusions, hematomas, and edema. The diagnostic test that would be the most helpful for this patient would be the MRI.

Question 13

A patient diagnosed with delirium has a history of adverse reaction to haloperidol. Which medication would the nurse anticipate using instead of haloperidol?

1. Phenytoin
2. Risperidone
3. Morphine
4. Amiodarone

Answer 13

Correct Answer: 2

Rationale 1: Phenytoin is used to manage seizures.

Rationale 2: For patients unable to tolerate haloperidol for delirium, risperidone is an alternative.

Rationale 3: Morphine is prescribed to control pain may cause a worsening of delirium.

Rationale 4: Amiodarone is a cardiac medication.

Question 14

A patient recovering from surgery to stabilize a lumbar spinal cord injury is fitted with a clam shell brace. How would the nurse explain the purpose of this brace?

1. “Wearing this brace will eliminate the need for further surgery.”
2. “You need to wear this device to support your surgical site.”
3. “This brace will maximize your range of motion.”
4. “You need to wear this brace to protect your surgical incision.”

Answer 14

Correct Answer: 2

Rationale 1: It is premature to assure the patient that wearing a brace will eliminate need for further surgery.

Rationale 2: A clam shell brace after surgery to stabilize a lumbar spinal cord injury is prescribed to specifically support the surgical site.

Rationale 3: Stabilization devices do not necessarily maximize the patient’s range of motion but rather limit range of motion.

Rationale 4: The brace is not prescribed for the purpose of protecting the surgical incision.

Question 15

A nurse is about to administer flumazenil to a patient who has experienced oversedation from benzodiazepine use. Before administering this drug the nurse should prepare to manage which patient response?

1. Hypertension
2. Seizure
3. Sudden temperature elevation
4. Bradycardia

Answer 15

Correct Answer: 2

Rationale 1: Hypertension is not the response most likely to occur when flumazenil is administered.

Rationale 2: Seizures and delirium are more likely to occur with sudden discontinuation of benzodiazepines which will occur when flumazenil is administered.

Rationale 3: Sudden temperature elevation does not occur with administration of flumazenil.

Rationale 4: Bradycardia does not occur with administration of flumazenil.

Question 16

A patient in the intensive care unit begins exhibiting seizure activity. What nursing interventions are indicated? (select all that apply)

1. Hold the patient as still as possible to prevent tissue damage.
2. Roll the patient to the side if possible.
3. Place a padded tongue blade in the patient’s mouth.
4. Time the seizure from beginning to end.
5. Call the rapid response team.

Answer 16

Correct Answer: 2,4

Rationale 1: The nurse should remove hard objects if possible and pad objects that cannot or should not be removed. This action will help prevent injury. The nurse should not attempt to hold the patient still.

Rationale 2: Rolling the patient to the side will allow secretions to clear the mouth and will help prevent aspiration.

Rationale 3: No attempt to place anything in the patient’s mouth should be made.

Rationale 4: Length of seizure is important assessment information that can be collected by the nurse.

Rationale 5: The nurse working in the intensive care unit should be adequately prepared to manage a patient having a seizure. There is no need to call for a rapid response team for a simple seizure.

Question 17

A nurse is monitoring a patient who sustained a head injury. The nurse recognizes which finding as the earliest sign of change in neurologic status?

1. The patient cannot remember where he is.
2. The patient’s pupil size is increased.
3. The patient’s blood pressure has increased.
4. The patient exhibits decorticate posturing when stimulated.

Answer 17

Correct Answer: 1

Rationale 1: The level of consciousness is the most important indicator of neurological function in the high-acuity patient.

Rationale 2: Pupillary changes do occur with neurological damage but are not the earliest signs.

Rationale 3: Changes in vital sign can indicate neurological damage, but are not the earliest signs.

Rationale 4: Posturing is an important finding associated with neurologic damage, but is not the earliest sign.

Question 18

An initiative for early identification of critical illness myopathy has been undertaken by the nurses in the intensive care unit. These nurses would be most watchful of this complication in which patients? (select all that apply)

1. Patients with history of type 1 diabetes mellitus
2. Patients with documented presence of renal calculi
3. Patients admitted with the diagnosis of chronic bronchitis
4. Patents sedated with neuromuscular blocking agents
5. Patients who have received high dose corticosteroid therapy

Answer 18

Correct Answer: 4,5

Rationale 1: Elevated glucose levels have been associated with critical illness polyneuropathy.

Rationale 2: Renal calculi are not associated with critical illness myelopathy.

Rationale 3: Chronic bronchitis is not associated with the development of critical illness myopathy.

Rationale 4: Critical illness myelopathy is a spectrum of muscle disorders that present with diffuse weakness, depressed deep tendon reflexes, and mildly elevated creatine kinase levels. It has been associated with neuromuscular blocking agent use.

Rationale 5: Critical illness myopathy is associated with use of high dose corticosteroid therapy.

Question 19

A patient is admitted with a spinal cord injury located at the 4th thoracic vertebral area. When assessing this patient, the nurse will expect to find sensory deficits at which anatomical area?

1. Anterior thigh
2. Nipple line
3. Umbilicus
4. Groin

Answer 19

Rationale 1: Innervation to the anterior thigh is at the 2nd lumbar vertebra.

Rationale 2: The nerve root for the 4th thoracic vertebra is approximately at the level of the nipple line.

Rationale 3: The nerve root for the umbilical region is the 10th thoracic vertebra.

Rationale 4: Innervation to the groin is at the 1st lumbar vertebra

Question 20

From the use of the CAM-ICU assessment tool, a patient is found to have hypoactive delirium. Which nursing intervention is indicated?

1. Use the prn order for morphine to control the patient’s pain.
2. Use wrist restraints to maintain monitoring devices and lines.
3. Restrict visitors to times when the patient’s mentation is clearest.
4. Reorient the patient to the environment as needed.

Answer 20

Correct Answer: 4

Rationale 1: Morphine has been linked to an increase in delirium and should be avoided if it is suspected as being the cause for the patient’s delirium.

Rationale 2: Delirium can be worsened by the use of physical restraints.

Rationale 3: The presence of family and significant others often helps to reassure and reorient the patient. Visitation should be encouraged even during times of decreased mentation.

Rationale 4: One of the causative factors of delirium is change in environment. The nurse should reorient the patient as needed in a calm and reassuring manner.

Question 21

The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain. The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable?

1. There will be an increase in the blood flow to the brain.
2. There is a decrease in the blood–brain barrier.
3. There must be a decrease in another of the intracranial compartments.
4. There will be an increase in the production of cerebrospinal fluid

Answer 21

Correct Answer: 3

Rationale 1: Blood flow to the brain would decrease as more space is taken up by the brain.

Rationale 2: The blood–brain barrier does not increase or decrease in response to changes in the brain.

Rationale 3: The contents of the intracranial vault include the brain, cerebral blood volume, and cerebrospinal fluid. The Monro–Kellie hypothesis states that as the content of one of the intrancranial compartments increases, it is at the expense of the other two. The correct answer is that if there is an increase in the volume of brain tissue, there will need to be a decrease in another of the intracranial compartments.

Rationale 4: An increased amount of cerebrospinal fluid would increase the pressure in the intracranial vault

Question 22

A patient with an intraventricular catheter for the assessment of increased intracranial pressure is demonstrating is demonstrating A waves. The nurse would assess for which other findings? (select all that apply)

1. Decreasing level of consciousness
2. Pupillary changes
3. Posturing
4. Variations in blood pressure
5. Changes in the wave associated with respiration

Answer 22

Correct Answer: 1,2,3

Rationale 1: A waves are clinically significant and typically occur when ICP is elevated. A decreasing level of consciousness may occur with this elevation.

Rationale 2: A waves are clinically significant and typically occur when ICP is elevated. Pupillary changes may occur with this elevation.

Rationale 3: A waves are clinically significant and typically occur when ICP is elevated. Posturing may occur with this elevation.

Rationale 4: C waves occur with variations in blood pressure.

Rationale 5: C waves vary according to respiration.

Question 23

A patient is diagnosed with central cord syndrome. Which assessment finding would the nurse anticipate from this injury?

1. Complete paralysis of lower extremities
2. Loss of bladder and bowel function
3. Motor function intact in upper extremities
4. Variable motor function in lower extremities

Answer 23

Correct Answer: 4

Rationale 1: Complete paralysis of lower extremities does not result from central cord syndrome.

Rationale 2: Patients with central cord injury typically retain some bladder and bowel function.

Rationale 3: The upper extremities will demonstrate spastic paralysis and not an intact upper extremity motor status.

Rationale 4: In central cord syndrome the patient will demonstrate variable motor function of the lower extremities.

Question 24

A nurse is assisting with a patient’s oculocephalic and oculovestibular reflex assessment. How should the nurse prepare for this testing? (select all that apply)

1. Prepare for oculocephalic testing to be done after oculovestibular testing.
2. Ensure that cervical spine injury has been ruled out.
3. Obtain cold water and a syringe
4. Be certain there is no perforation of the tympanic membrane in the side being tested.
5. Tell the patient he will be asked to report any feeling of numbness or vertigo.

Answer 24

Correct Answer: 2,3,4

Rationale 1: Patients with an absent oculocephalic reflex may have a normal oculovestibular reflex, so testing for oculovestibular reflex should follow oculocephalic reflex.

Rationale 2: Oculocephalic testing requires moving the patient’s head from side-to-side, so it should not be performed until the cervical spine is cleared of injury.

Rationale 3: Oculovestibular reflex testing includes injecting cold water into the patient’s ear.

Rationale 4: Since oculovestibular testing includes placing water in the ear, it is contraindicated if there is a perforation or tear in the tympanic membrane.

Rationale 5: Oculovestibular and oculocephalic testing is done on patients with suspected brain stem depression. The patients are not conscious.

Question 25

A patient is diagnosed with damage to the spinothalamic tract of the spinal cord. Which assessment finding would the nurse attribute to this damage?

1. The patient reports an unusual amount of pain.
2. Muscle spasms are occurring in the patient’s right leg.
3. The patient has ataxia.
4. The patient is complaining of vertigo.

Answer 25

Correct Answer: 1

Rationale 1: The spinothalamic tract originates in the spinal cord, crosses over with segments of entry and ascends to the thalamus in the brain. It transmits pain and temperature. The patient with damage to the spinothalamic tract of the spinal cord will manifest an unusual amount of pain.

Rationale 2: The corticospinal tract originates in the brain and crosses over in the brainstem to innervate the opposite side of the body. It transmits motor activity, which would be the cause for the muscle spasms in the patient.

Rationale 3: The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as ataxia.

Rationale 4: The posterior horn contains axons from the peripheral sensory neurons and is responsible for position sense. Damage to this portion of the cord could manifest as vertigo in the patient.

Question 26

The nurse is caring for a patient with a fractured sacrum. The nurse would assess for which changes as a result of this fracture?

1. Altered sympathetic responses
2. Alteration in pain responses
3. Alteration in position sense
4. Altered parasympathetic responses

Answer 26

Correct Answer: 4

Rationale 1: The sympathetic nervous system is located in the gray matter of the first thoracic through the second lumbar section of the cord. The patient does not have an injury to this region.

Rationale 2: Alteration in pain responses would be seen with damage to the spinothalamic tracts.

Rationale 3: Alteration in position sense would be seen with damage to the posterior column tracts.

Rationale 4: The parasympathetic nervous system originates in a group of neurons located in the brainstem and in a group located between the second and fourth sacral segments of the cord. The patient with a fractured sacrum could experience alterations in the parasympathetic responses.

Question 27

A patient is diagnosed with a fracture of anterior and posterior columns of three cervical vertebrae. How would the nurse describe this injury?

1. As life threatening
2. As stable
3. As minor
4. As unstable

Answer 27

Correct Answer: 4

Rationale 1: In itself, this injury is not life threatening. If secondary damage occurs, it could become life threatening.

Rationale 2: This injury is significant and would not be considered stable.

Rationale 3: Damage to two columns of three vertebrae is not a minor injury.

Rationale 4: The spine is conceptualized as having three columns: an anterior column that includes the anterior part of the vertebral body, a middle column that houses the posterior wall of the vertebral body, and a posterior column that includes the vertebral arch. If two or more of these columns are damaged, the injury is considered to be unstable. The patient has an unstable spinal cord injury.

Question 28

A patient is diagnosed with a spinal cord injury located at the 1st and 2nd thoracic vertebra. The nurse will expect to find which deep tendon reflexes affected by this injury? (select all that apply)

1. Supinator
2. Patellar
3. Triceps
4. Biceps
5. Achilles

Answer 28

Rationale 1: The supinator reflex originates at the 6th cervical vertebra, which is above the area injured.

Rationale 2: The patellar reflex originates at the 3rd lumbar vertebra. The patient has an injury at the 1st and 2nd thoracic vertebra, which means reflexes below this region will be affected.

Rationale 3: The triceps reflex originates at the 7th cervical vertebra, which is above the injured area.

Rationale 4: The biceps reflex originates at the 5th cervical vertebra which is above the injured area.

Rationale 5: The Achilles reflex originates at S1. The patient has an injury at the 1st and 2nd thoracic vertebra which means reflexes below this region will be affected.

Question 29

A patient, admitted with the diagnosis of stroke, has left hemiparesis involving the face, arm, and leg. The nurse explains that this stroke most likely involves which artery?

1. Right vertebral
2. Left posterior communicating
3. Left middle cerebral
4. Right middle cerebral

Answer 29

Correct Answer: 4

Rationale 1: The right vertebral area is not the most common site of damage causing a stroke.

Rationale 2: The posterior communicating arteries are part of the circle of Willis, but are not the most common areas involved in stroke.

Rationale 3: The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the left side of the brain controls the right side of the body.

Rationale 4: The middle cerebral arteries supply blood to the lateral surfaces of the frontal, temporal, and parietal lobes. These arteries are often involved in stroke. The motor fibers cross so the right side of the brain controls the left side of the body.

Question 29

A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times. What rationale would the nurse provide for this position?

1. The brain will compress the cerebral veins less in this position.
2. The ventricles of the brain will drain better in this position.
3. This position allows for less pain for the patient.
4. The cerebral spinal veins are valveless and drain by gravity.

Answer 29

Correct Answer: 4

Rationale 1: This statement is not physiologically correct.

Rationale 2: This statement is not physiologically correct.

Rationale 3: There is no reason that pain would be reduced in this position.

Rationale 4: The cerebral spinal veins drain best via gravity, an important characteristic to remember when caring for patients with the risk for increased intracranial pressure as would be present in intracranial surgeries.

Question 29

The nurse is providing care for a patient who sustained a severe head injury. The nurse would intervene to prevent which occurrence that increases cerebral blood flow?

1. Oversedation
2. Hypothermia
3. Fever
4. Paralysis

Answer 29

Correct Answer: 3

Rationale 1: Sedation will decrease cerebral blood flow.

Rationale 2: Hypothermia will decrease cerebral blood flow.

Rationale 3: Fever increases the body’s metabolic rate and will increase cerebral blood flow.

Rationale 4: Paralysis, often initiated chemically, will decrease cerebral blood flow.

Question 29

A patient with a head injury has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 20 mm Hg. Which cerebral perfusion pressure would the nurse document for this patient?

1. 50 mm Hg
2. 90 mm Hg
3. 70/40 mm Hg
4. 40/70 mm Hg

Answer 29

Correct Answer: 1

Rationale 1: The cerebral perfusion pressure is calculated as the mean arterial pressure minus the intracranial pressure. In this patient the cerebral perfusion pressure would be inadequate and intervention is needed.

Rationale 2: This calculation is incorrect for the values given.

Rationale 3: This calculation is incorrect for the values given.

Rationale 4: This calculation is incorrect for the values given.

Question 29

A patient is admitted to the intensive care unit accompanied by a family member who says, “He suddenly started acting funny and couldn’t remember where he was.” The nurse would anticipate that first assessment efforts would focus on which condition?

1. Hypovolemic shock
2. Cerebral infection
3. Ischemic stroke
4. Drug overdose

Answer 29

Correct Answer: 3

Rationale 1: Hypovolemic shock is not the most common cause of changes in mentation in patients admitted to the ICU.

Rationale 2: Cerebral infection is not the most common cause of changes in mentation in patients admitted to the ICU.

Rationale 3: Even though there are many causes of impaired mentation in patients who have not sustained a head injury, ischemic stroke has been found to be the most frequent cause of impaired mentation on admission to the intensive care unit. The patient should be assessed first for an ischemic stroke.

Rationale 4: Drug overdose is not the most common cause of changes in mentation in patients admitted to the ICU.

Question 29

A patient who was in a coma for one week after surgery is unable to tell the nurse where he lives or what he did for a living. The nurse evaluates this condition as suggesting which change resulting from the coma?

1. The patient now has a learning deficit.
2. The patient has instability of emotions.
3. The patient’s cognition is impaired.
4. The patient was near brain death before the coma resolved.

Answer 29

Correct Answer: 3

Rationale 1: The patient should be able to remember basic facts about his life. He would not have to relearn these facts, so this scenario does not indicate that a learning deficit exists.

Rationale 2: There is no indication that the patient has responded emotionally to his change in mental status.

Rationale 3: Inability to remember basic facts indicates that the patient’s cognition is impaired.

Rationale 4: Simple inability to remember facts cannot be construed to mean that patient was near brain death. This might have been the case, but there are not enough facts to support this option.

Question 29

An elderly patient is admitted to the intensive care unit with acute respiratory injury from aspiration. The nurse monitors this patient very carefully to avoid onset of polyneuropathy because the patient has history of which disorder?

1. Hypertension
2. Type 2 diabetes mellitus
3. Urinary urgency
4. Congestive heart failure

Answer 29

Correct Answer: 2

Rationale 1: History of hypertension is not known to increase risk for development of polyneuropathy in critically ill patients.

Rationale 2: It is believed that tight glucose control with intensive insulin therapy can reduce the incidence of critical illness polyneuropathy by 44%. Therefore, the patient with history of type 2 diabetes is at higher risk for developing polyneuropathy when critically ill.

Rationale 3: There is no indication that urinary urgency is associated with increased risk of polyneuropathy in critically ill patients.

Rationale 4: There is no evidence to suggest that history of congestive heart failure increases risk of polyneuropathy in critically ill patients.

Question 29

Upon assessment of a patient in the intensive care unit, the nurse suspects critical illness polyneuropathy is developing. Which finding would support this suspicion?

1. The patient exhibits facial grimacing to painful stimuli but does not withdrawal from the stimuli.
2. There is bilateral absence of deep tendon reflexes.
3. Laboratory results reveal elevation of creatine kinase level.
4. The patient exhibits diffuse weakness.

Answer 29

Correct Answer: 1

Rationale 1: One symptom of critical illness polyneuropathy is the demonstration of a painful stimuli being present, such as facial grimacing, without the ability to withdraw from the stimuli. This is because of a distal loss of pain reception abilities.

Rationale 2: Deep tendon reflexes are preserved in critical illness polyneuropathy.

Rationale 3: There is no laboratory test to diagnose critical illness polyneuropathy. Electrodiagnostic testing is necessary for diagnosis.

Rationale 4: Critical illness polyneuropathy that mainly affects the lower limb nerves. Diffuse weakness is characteristic of critical illness myelopathy.

Question 29

A patient newly admitted to the intensive care unit reports that he has not been sleeping well at home. The nurse would conduct assessment for which preexisting conditions? (select all that apply)

1. Taking a beta blocker
2. Use of a bronchodilator
3. Snoring
4. Hypothyroidism
5. Alcoholism

Answer 29

Correct Answer: 1,2,3,5

Rationale 1: Beta blockers can be implicated in development of insomnia.

Rationale 2: Bronchdilators can be implicated in development of insomnia.

Rationale 3: Snoring is associated with sleep apnea, which can cause insomnia.

Rationale 4: Hyperthyroidism is a more likely cause of insomnia.

Rationale 5: Substance abuse may cause insomnia.

Question 30

A patient comes into the emergency department after being injured in an automobile crash in which a semi-truck hit her car from behind. The nurse will assess this patient for findings associated with which type of injury?

1. Ankylosing spondylitis
2. Axial loading
3. Hyperflexion
4. Hyperextension

Answer 30

Correct Answer: 4

Rationale 1: Ankylosing spondylitis can cause a nontraumatic hyperextension injury.

Rationale 2: Axial loading injury, or compression fracture, is caused by a vertical force along the spinal cord and is seen after diving into shallow water or jumping from tall heights and landing on the feet or buttocks.

Rationale 3: Hyperflexion injury is most often caused by a sudden deceleration of the motion of the head or a head-on collision.

Rationale 4: Hyperextension injuries are caused by a forward and backward motion of the head as seen in rear-end collisions. With this injury, the anterior ligaments are torn and the spinal cord is stretched. A mild form of hyperextension injury is the whiplash injury.

Question 31

What interventions will the nurse include in the plan of care for a patient with a newly applied halo device and vest? (select all that apply)

1. Assess motor and sensory function every shift.
2. Have the patient hold onto the halo struts during turns and repositioning.
3. Keep the pins and traction bars slightly loose to prevent pressure ulcers.
4. Tape a halo vest wrench to the front of the vest.
5. Use a moist cloth to clean the skin under the vest.

Answer 31

Correct Answer: 4,5

Rationale 1: Motor function and sensation should be assessed every 2 to 4 hours.

Rationale 2: Pulling on the struts can disrupt the device integrity and possible result in spinal cord damage. Having the patient hold onto the struts would likely cause stress to the device.

Rationale 3: The pins and traction bars should be firmly attached to provide stabilization.

Rationale 4: A halo vest wrench is to be taped to the front of the vest to be able to remove the vest in the event the patient needs to receive cardiopulmonary resuscitation.

Rationale 5: The vest is not removed for bathing, so a moist cloth is used to clean the skin under the vest.

Question 33

A patient with a head injury is being monitored with an intraventricular catheter. The nurse would design interventions based upon which priority nursing diagnosis (NDX)?

1. Risk for Injury
2. Decreased Intracranial Adaptive Capacity
3. Altered Comfort, Acute Pain
4. Risk for Infection

Answer 33

Correct Answer: 4

Rationale 1: This patient is at risk for injury, but this is not the priority NDX.

Rationale 2: This patient likely has at risk for decreased intracranial adaptive capacity but this is not the priority NDX.

Rationale 3: This patient may have altered comfort due to injury, procedures, or positioning, but this is not the priority NDX.

Rationale 4: The placement of an intraventricular catheter to monitor intracranial pressure places the patient at risk for infection. The nurse must practice meticulous infection control measures while caring for these patients.

Question 34

A patient diagnosed with several fractured vertebra is having surgical stabilization. The nurse would reinforce which information about this surgery?

1. “You will be required to wear a hard cervical collar for several months after the surgery.”
2. “After surgery you will be fitted for a halo device.”
3. “The fusion generally requires insertion of rods to stabilize your spine internally.”
4. “This is the first of a series of surgeries you will require.”

Answer 34

Correct Answer: 3

Rationale 1: A hard cervical collar is a manual fixation device. Whether this device is required and how long it is required is variable and is likely not known prior to surgery.

Rationale 2: The patient may or may not require a halo device.

Rationale 3: Surgery is reserved for patients not sufficiently aligned with manual stabilization. Typically, spinal segments are fused, spinal canal is decompressed, and rods are inserted to stabilize thoracic spinal injuries.

Rationale 4: There is no indication that this patient will require a series of surgeries.

Question 35

A patient was the unrestrained driver of a car that was struck head on by another vehicle. During initial assessment the nurse observes another nurse using supraorbital pressure to assess for response. What nursing intervention is indicated?

1. Hold the patient’s head still so that the test will be valid.
2. Stop the procedure.
3. Ask the nurse to repeat the procedure on the other orbit.
4. Document the response as 1+, 2+, 3+, or 4+.

Answer 35

Correct Answer: 2

Rationale 1: The nurse should not attempt to hold the patient’s head still.

Rationale 2: Since this patient is at high risk for facial fractures, supraorbital pressure should not be used.

Rationale 3: The procedure should not be repeated.

Rationale 4: The nurse should intervene in a different manner.

Question 36

A patient being treated with haloperidol for symptoms of delirium has a blood pressure reading of 190/110 mm Hg. Which nursing action is priority?

1. Encourage the patient to drink at least 240 mL of fluids.
2. Contact the prescriber about an increase in the haloperidol dosage.
3. Place the patient on seizure precautions.
4. Hold the haloperidol dose and collaborate with the prescriber.

Answer 36

Correct Answer: 4

Rationale 1: There is no indication that fluid intake will treat this drug reaction.

Rationale 2: The patient may be experiencing an adverse drug reaction, so increasing the dose is not indicated.

Rationale 3: Seizure is a possibility, but is not the primary nursing action.

Rationale 4: One nursing indication for a patient prescribed haloperidol is to monitor for neuroleptic malignant syndrome especially in those patients who take lithium or who have hypertension. One indicator of neuroleptic malignant syndrome is instability of blood pressure. The nurse should contact the prescriber and discuss discontinuing the drug.

Question 37

A nurse is providing care for a patient with increased intracranial pressure and is monitoring cerebral perfusion pressure. The nurse compares measurements to which critical normal value?

1. 50 mm Hg
2. 70 mm Hg
3. 120 mm Hg
4. 30 mm Hg

Answer 37

Correct Answer: 2

Rationale 1: The CPP critical value is higher than 50 mm Hg.

Rationale 2: In order to ensure adequate cerebral oxygenation, the cerebral perfusion pressure must be maintained at greater than 70 mm Hg.

Rationale 3: CPP of 120 mm Hg is high and will result in a loss of autoregulation. This is not the critical value to which the nurse compares actual measurements.

Rationale 4: A CPP of 30 mm Hg is low and will result in loss of autoregulation. This is not the critical value to which the nurse compares actual measurements.

Question 40

A nurse is monitoring a patient’s Glasgow Coma Scale (GSC). At which point would the nurse document that the patient is comatose?

1. 11
2. 15
3. 7
4. 9

Answer 40

Correct Answer: 3

Rationale 1: A score of 11 indicates some impairment, but does not indicate coma.

Rationale 2: A GCS of 15 is normal.

Rationale 3: A score of 7 or less indicates a significant alteration in the level of consciousness and the development of coma.

Rationale 4: A GCS score of 9 indicates significant neurological changes, but does not indicate coma.

Question 41

The family of a comatose patient asks the nurse if there is any way to know if their loved one will ever “wake up.” The nurse should consider which test when formulating a response to this concern?

1. Evoked potentials
2. CT scan
3. Electroencephalogram
4. Lumbar puncture

Answer 41

Correct Answer: 1

Rationale 1: Evoked potentials are recordings of cerebral electrical impulses generated in response to visual, auditory, or somatosensory stimuli. They are used to assist in the evaluation of the location and extent of brain dysfunction after head injury. Evoked potentials may be useful in predicting coma outcome.

Rationale 2: A CT scan can help diagnose structural changes, but does not help predict outcome of a coma.

Rationale 3: Electroencephalography allows recording of the electrical activity of the brain using electrodes attached to the scalp but is not used to help predict the outcome of a coma.

Rationale 4: Lumbar puncture can help determine cause of coma but does not help predict outcome of coma.

Question 42

Following a stroke a patient is diagnosed with expressive aphasia. What nursing intervention is indicated?

1. Speak slowly and face the patient directly when speaking.
2. Speak at a slightly louder volume.
3. Watch the patient carefully for behavioral clues.
4. Decrease environmental stimuli before attempting to communicate with the patient.

Answer 42

Correct Answer: 3

Rationale 1: The patient with expressive aphasia can understand speech, so this action is not necessary.

Rationale 2: The patient with expressive aphasia can understand speech, so it is not necessary to speak at a louder volume.

Rationale 3: The patient with expressive aphasia cannot write or use language. The nurse should observe for behavioral clues to the patient’s needs.

Rationale 4: The patient with expressive aphasia can understand speech, so decreasing environmental stimuli is not necessary for the purpose of communication.

Question 44

A patient who sustained a traumatic brain injury is being sent for a CT scan. Which nursing statements would help the patient’s spouse understand the rationale for a CT scan rather than an MRI? (select all that apply)

1. “CT scans are easier for patients with head injuries because movement is allowed.”
2. “We can get results from a CT scan quicker than from an MRI.”
3. “MRIs are more costly so the least expensive test is always done first.”
4. “CT scans are noninvasive.”
5. “CT scans show more detail than an MRI.”

Answer 44

Correct Answer: 4

Rationale 1: CT scans do not necessarily provide more patient movement while the test is being conducted.

Rationale 2: The CT scan is the test of choice with head injury patients because MRIs take longer.

Rationale 3: MRIs are typically more expensive, but the nurse should not use this as a rationale for the choice when talking with the family.

Rationale 4: CT scans are noninvasive.

Rationale 5: MRIs show more tissue detail than do CT scans.

Question 45

A patient has a spinal cord injury at C6–T1. During his bath the nurse notes piloerection. What nursing interventions are indicated? (select all that apply)

1. Ask the patient about the presence of a headache.
2. Ignore the occurrence and continue with the bath.
3. Determine if the patient’s indwelling urinary catheter tubing is twisted.
4. Lower the head of the patient’s bed.
5. Cover the exposed portions of the patient’s body with a warm bath blanket.

Answer 45

Correct Answer: 1,3

Rationale 1: Piloerection and headache may be indicators of autonomic dysreflexia.

Rationale 2: Piloerection may indicate a serious complication and should not be ignored.

Rationale 3: Occlusion of the tubing from an indwelling urinary catheter may result in a full bladder, which is sufficient noxious stimulus to trigger a serious complication. Simply untwisting the tubing and allowing the bladder to drain may reverse this complication.

Rationale 4: The head of the bed should be raised.

Rationale 5: If this patient is experiencing a complication of spinal cord injury, piloerection is not related to cool environment.

Question 46

A patient is admitted with a fractured mandible and several fractured ribs. Which priority intervention would the nurse anticipate?

1. Providing pain medication
2. Determining lung function by chest x-ray
3. Maintaining spinal cord injury precautions
4. Stabilizing the rib fractures

Answer 46

Correct Answer: 3

Rationale 1: Provision of pain medication is indicated for this patient, but it is not the highest priority.

Rationale 2: It is important to determine the status of this patient’s lung function but this is not the intervention of highest priority.

Rationale 3: Since a spinal cord injury should be suspected in a patient with maxillofacial injury and clavicle or upper rib fractures, the patient should be maintained on spinal cord injury precautions until the injury has been ruled out.

Rationale 4: It is important to stabilize rib fractures, but this is not the intervention of highest priority.

Question 47

A ventilator-dependent patient has been in a coma for several weeks. Which finding would the nurse evaluate as indicating there is possibility of reversing this coma state?

1. Testing indicates that the patient has brain function.
2. The patient has clear breath sounds with no indications of pneumonia.
3. The patient cardiac rhythm strip reveals normal sinus rhythm.
4. The patient’s urinary output has remained adequate throughout the coma state.

Answer 47

Correct Answer: 1

Rationale 1: Coma is characterized by the absence of arousal and awareness and may be reversible as long as brain function continues. Since the patient has been assessed to have brain function, the patient is not brain dead and the coma can be reversed.

Rationale 2: While the complication of pneumonia would be a compounding factor in reversing coma, the absence of pneumonia does not indicate potential for reversal.

Rationale 3: Presence of cardiac dysrhythmias is a compounding factor in reversing coma, but absence of dysrhythmia does not indicate potential for reversal.

Rationale 4: Development of renal failure would compound the reversal of the coma state, but presence of normal kidney function is does not indicate potential for reversal.

Question 48

An elderly patient in the intensive care unit recovering from an abdominal aortic aneurysm repair begins to show signs of decreased responsiveness. The nurse realizes that which situation is the most likely cause of this change in mentation?

1. The patient’s intravenous line is infiltrated.
2. The patient has been NPO for an extended period of time.
3. The patient’s oxygen saturation has dropped from 96% to 90%.
4. The patient was started on a PCA pump with morphine.

Answer 48

Correct Answer: 4

Rationale 1: Infiltration of an intravenous line would not be a likely cause of change in mentation.

Rationale 2: NPO status, as long as the patient is receiving fluids and nutrition parenterally, is not a likely etiology for this change in mentation.

Rationale 3: This amount of change in oxygen saturation is not the likely cause of the patient’s mental status change since the level is still within normal limits.

Rationale 4: Medications are seen as the most prevalent modifiable risk factor for delirium in acute or critically ill elderly patients. Opioid narcotics, such as morphine and fentanyl, are linked to the development of delirium. This is what the nurse should suspect as the cause of the patient’s new onset of decreasing responsiveness.

Question 49

A patient in the critical care unit has a seizure that was determined to be caused by a low blood glucose level. The patient’s blood glucose level is currently normal. Which additional intervention should be implemented to prevent future seizure activity in this patient?

1. Administer valium orally twice each day.
2. Establish a low-dose continuous phenytoin infusion.
3. Increase the frequency of blood glucose assessment.
4. Frequently monitor brain wave activity.

Answer 49

Correct Answer: 3

Rationale 1: If the cause of the seizure is identified and corrected, pharmacologic intervention for seizure prevention is often not indicated.

Rationale 2: Since the cause of the seizure was identified and corrected pharmacological intervention is often not necessary.

Rationale 3: The cause of the patient’s seizure has been identified as low blood glucose. The best plan of action is to prevent low blood glucose. An effective intervention is to increase frequency of blood glucose measurement to ensure early intervention for hypoglycemia.

Rationale 4: The cause of the patient’s seizure has been identified and corrected. It is not necessary to undertake frequent monitoring of brain wave activity.

Question 50

A patient is demonstrating confusion and difficulty focusing. Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia? (select all that apply)

1. The confusion cleared when the patient was rehydrated.
2. The patient does not recognize her daughter.
3. The patient’s daughter reports that her mother has been becoming increasingly confused over the last 6 months.
4. The patient’s mentation was clear yesterday.
5. The patient does not recognize that she is confused.

Answer 50

Correct Answer: 1,4

Rationale 1: Delirium is an acute state of mental status change that can be triggered by metabolic conditions such as dehydration. Since the confusion cleared with rehydration, the diagnosis of delirium is supported.

Rationale 2: It is not possible to determine if the inability to recognize familiar people is due to delirium, dementia, or another physiologic cause.

Rationale 3: Increasing confusion is more likely to support the diagnosis of dementia.

Rationale 4: Delirium is situational, reversible, and acute. Since the patient’s mentation was clear yesterday, it is more likely to reflect delirium rather than dementia.

Rationale 5: Ability to recognize that one is confused does not differentiate between delirium and dementia.

Question 51

A nurse is monitoring the intracranial pressure of a patient with a closed-head injury. Which pressure would the nurse evaluate as requiring no additional intervention?

1. 12 mm Hg
2. 22 mm Hg
3. 25 mm Hg
4. 30 mm Hg

Answer 51

Correct Answer: 1

Rationale 1: The normal intracranial pressure ranges from 0 to 15 mm Hg.

Rationale 2: This pressure exceeds normal.

Rationale 3: This pressure exceeds normal.

Rationale 4: This pressure exceeds normal.