NP V Flashcards
- A young man was running along an ocean pier; tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, “He was unconscious briefly and then became alert and behaved as though nothing had happend.” Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client’s ICP is increasing, the nurse would expect to observe which of the following signs first?
A. Pupillary asymmetry
B. Irregular breathing pattern
C. Abnormal posturing
D. Declining LOC
D. Declining LOC
RATIONALE
Earliest sign: Altered LOC
A, B, and C are late signs.
- A 50 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:
A. Reactive pupils
B. A depressed fontanel
C. Bruising on the mastoid bone
D. An elevated temperature
C. Bruising on the mastoid bone
RATIONALE
Battle sign which indicates Basal skull fracture.
A Normal
B For newborn with DHN
D Problem with hypothalamus; not life threatening
- A client arrives at the emergency department after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
A. Subdural hematoma
B. Subarachnoid hemorrhage
C. Epidural hematoma
D. Contusion
C. Epidural hematoma
RATIONALE
A Between dura mater and arachnoid
B Between arachnoid and pia mater
D Bruising of brain
- The nurse is aware that the most common manifestation of a ruptured cerebral aneurysm would be:
A. Tonic-clonic seizures
B. Decerebrate posturing
C. Narrowed pulse pressure
D. Sudden severe headache
D. Sudden severe headache
- Which of the following is TRUE regarding ICP?
A. Usually presents with headache when diminished
B. Valsalva is recommended in order to decrease ICP
C. Elevated in patients with acute bacterial meningitis
D. Patient’s position has no effect on ICP
C. Elevated in patients with acute bacterial meningitis
RATIONALE
A ⬆️ICP = headache
B Not recommended
D ⬆️HOB = ⬇️ICP ; ⬇️HOB = ⬆️ICP
- A client has a sustained ICP of 20 mmHg. The nurse should position the client:
A. With the HOB elevated 30 - 45 degrees
B. In trendelenburg position
C. In left Sim’s position
D. With the HOB elevated on two pillows
A. With the HOB elevated 30 - 45 degrees
RATIONALE
Position: LF - SF (30 - 45 degrees)
Best: LF (to prevent herniation)
B and C don’t decrease ICP
D is LF but flexes the neck which should be center, midline and neutral in position
- If a client with increased ICP demonstrates decorticate posturing, the nurse will observe:
A. Flexion of both upper and lower extremities
B. Extension of elbows and knees, plantar flexion of feet, flexion of the wrists
C. Flexion of elbows, extension of the knees, plantar flexion of the feet
D. Extension of upper extremities, flexion of lower extremities
C. Flexion of elbows, extension of the knees, plantar flexion of the feet
- The least serious form of brain trauma, characterized by a brief loss of consciousness and period of confusion, is called:
A. Contussion
B. Concussion
C. Basilar skull fracture
D. Cerebral aneurysm
B. Concussion
RATIONALE
No brain damage.
A Bruising of brain which may cause brain damage; serious form of brain trauma
C #2 dangerous
D #1 dangerous
- A client is receiving infusion of Mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
A. Decreased level of consciousness
B. Increased urine output
C. Elevated BP
D. Decreased heart rate
B. Increased urine output
- A 23-year old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing intervention should be done first?
A. Position the client flat in bed
B. Instruct client to blow his nose
C. Suction the nose to maintain airway patency
D. Insert nasal and ear packing with sterile gauze
D. Insert nasal and ear packing with sterile gauze
RATIONALE
There may be a skull fracture causing CSF leakage; patient is risk for infection. Management should include prevention of meningitis.
A, B, and C exacerbates the already high ICP.
- A client has a diagnosis of a stroke versus transient ischemic attack. Which if the following statements shows the difference between a TIA and a stroke?
A. TIAs typically resolve within 24 hours
B. TIAs may be hemorrhagic in origin
C. TIAs may cause a permanent motor deficit
D. TIAs may predispose the client to MI
A. TIAs typically resolve within 24 hours
RATIONALE
TIA is a mild stroke and resolves within 24 hours
B Correct: Ischemic in origin
C Correct: Temporary only
D Correct: Predisposes to CVA
- A client with thrombotic CVA experiences periods of emotional lability. The client alternately laughs and cries and intermittently becomes irritable and demanding. The nurse interprets that this behavior indicates that the:
A. Problem is likely to get worse before it gets better
B. Client is experiencing the usual sequel of CVA
C. Client is not adapting well to the disability
D. Client is experiencing side effects of the prescribed anticoagulants
B. Client is experiencing the usual sequel of CVA
RATIONALE
Patients with CVA manifest emotional lability or mood swing.
- A client with a stroke has right sided hemianopsia. The nurse plans to do which of the following to help the client adapt to his visual deficit?
A. Place all objects within the left visual field
B. Patch the client’s eye
C. Ensure that the family brings the client’s eyeglasses to the hospital
D. Teach the client to scan the environment
D. Teach the client to scan the environment
- For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?
A. Speaking loudly
B. Give client a pen and a paper
C. Writing direction so the client can read them
D. Use gestures without speaking
B. Give client a pen and a paper
- The nurse is teaching the family of the client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is inappropriate?
A. Maintain an upright position
B. Restricting the diet to liquid until swallowing improves
C. Introducing foods on the unaffected side of the mouth
D. Assess gag reflex before feeding
B. Restricting the diet to liquid until swallowing improves
RATIONALE
Risk for aspiration.
- A nurse is caring for a client who sustained a spinal cord injury. While the nurse is administering morning care, the client develops S/Sx of autonomic dysreflexia. The initial nursing action would be to:
A. Place the client in the prone position
B. Elevate the head of the bed
C. Digitally examine the rectum
D. Assess the client’s blood pressure
B. Elevate the head of the bed
RATIONALE
Decreases BP and prevents stroke.
- After a MVA, a client is admitted to the medical surgical unit with a cervical collar in place. The cervical spinal X-ray has not been read, so the nurse doesn’t know whether the client has a cervical spinal injury. When such an injury is ruled out, the nurse should restrict this client to which position?
A. Flat, with pillows under the knee
B. Supine, with the head of the bed elevated 30 degrees
C. Flat, except for logrolling as needed
D. A head elevation of 90 degrees to prevent cerebral swelling
C. Flat, except for logrolling as needed
- Which of the following clients on the rehabilitation unit is most likely to develop autonomic dysreflexia?
A. A client with brain injury
B. A client with herniated nucleus pulposus
C. A client with a high cervical spine injury
D. A client with a stroke
C. A client with a high cervical spine injury
- A client is admitted with a spinal cord injury at the level of T12. He has limited movement of the upper extremities. Which of the following medications would be used to control edema of the spinal cord?
A. Acetazolamide
B. Furosemide
C. Methylprednisolone
D. Sodium bicarbonate
C. Methylprednisolone
RATIONALE
It is anti-inflammatory.
- A client is admitted with a cervical spine injury sustained during driving accident. When planning the client’s care. The nurse should assign highest priority to which nursing diagnosis?
A. Airway patency
B. Impaired mobility
C. Ineffective breathing pattern
D. Dressing or grooming self-care deficit
C. Ineffective breathing pattern
RATIONALE
In the situation, there is possible injury of the diaphragm which may cause respiratory paralysis.
A Not a nursing diagnosis
B and D are irrelevant
- A hospitalized client had a tonic-clonic seizure while walking in the hall. During the seizure, the nurse’s priority should be:
A. Hold the client’s arms and legs firmly
B. Place the client immediately to soft surface
C. Protect the client’s head from injury
D. Attempt to insert a tongue depressor between the client’s teeth
C. Protect the client’s head from injury
- The nurse obtains a history from the father of a six year old boy with a history of epilepsy admitted with uncontrolled seizures. It is MOST important for the nurse to ask which of the following questions?
A. “What part of the body was affected by the seizure?”
B. “Is there a family history of seizure disorders?”
C. “What was your son been doing before the seizure?”
D. “How long has it been since his last episode of seizures?”
C. “What was your son been doing before the seizure?”
RATIONALE
Assesses what have triggered the onset of seizure.
- Which of this should the nurse not refrain from doing if a patient is having seizure?
A. Suction her PRN
B. Apply restraint to both arms
C. Raise the bedside rails
D. Put mouth gag in her mouth
C. Raise the bedside rails
Tip: Process of elimination.
- A client with epilepsy is having seizure. During the active seizure phase, the nurse should:
A. Place the client on his back, remove dangerous objects, and insert a bite block
B. Place the client on his side, remove dangerous objects and insert a bite block
C. Place the client on his back, remove dangerous objects, and hold down his arms
D. Place the client on his side, remove dangerous objects, and protect his head
D. Place the client on his side, remove dangerous objects, and protect his head
Tip: Process of elimination.