Quiz 5

Question 1

Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, 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

Answer 1

a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min

Question 2

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

Answer 2

b. Check the drainage for glucose content.

Question 3

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).

Answer 3

b. Provide discharge instructions about monitoring neurologic status.

Question 4

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 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.

Answer 4

b. Insert nasogastric tube to low suction.

Question 5

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

Answer 5

a. Short-term memory

Question 6

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.”

Answer 6

b. “I am going to drive home and go right to bed.”

Question 7

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm HO of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops:

a. oxygen saturation of 93%.
b. respirations of 20 breaths/minute.
c. green nasogastric tube drainage.
d. increased jugular venous distention.

Answer 7

d. increased jugular venous distention.

Question 8

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.

Answer 8

b. The patient takes warfarin (Coumadin) daily.

Question 9

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

a.Hypotension
b.Polyuria
c.Hypoglycemia
d.Absence of bowel sounds
e. Weakened gag reflex

Answer 9

a.Hypotension
d.Absence of bowel sounds
e. Weakened gag reflex

Question 10

A nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

A. Allow the client to control the timing and frequency of the therapy.
B. Limit visiting hours until the client begins to participate in therapy
C. Establish a plan of care with the client that sets attainable goals.
D. Inform the client that privileges are related to participation in therapy.

Answer 10

C. Establish a plan of care with the client that sets attainable goals.

Question 11

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

A. The client’s bladder becomes distended.
B. The client states having a severe headache.
C. The client’s blood pressure becomes elevated.
D. The client states having nasal congestion.

Answer 11

A. The client’s bladder becomes distended.

Question 12

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

A. Hemiplegia
B. Quadriplegia
C. Paresthesia
D. Paraplegia

Answer 12

D. Paraplegia

Question 13

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

A. Massage over erythematous bony prominences.
B. Minimize skin exposure to moisture.
C. Use pillows to keep heels off the bed surface.
D. Implement a turning schedule every 4 hours.
E. Keep the client’s skin dry with powder.

Answer 13

B. Minimize skin exposure to moisture.
C. Use pillows to keep heels off the bed surface.

Question 14

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

A. Administer a nitrate antihypertensive.
B. Obtain the client’s heart rate.
C. Assess the client for bladder distention.
D. Place the client in a high-Fowler’s position.

Answer 14

D. Place the client in a high-Fowler’s position.

Question 15

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

A. The purpose of this device is to immobilize the cervical spine.”
B. The purpose of this device is to allow for neck movement during the healing process.”
C. “Apply talcum powder under the vest to limit friction.”
D. Tum the screws on the device once each day.”

Answer 15

A. The purpose of this device is to immobilize the cervical spine.”

Question 16

A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take?

A. Position the client in a high-Fowler’s position if clear drainage is noted on the dressing
B. Monitor sensory perception of the lower extremities.
C. Assist the client into a knee-chest position to manage postoperative discomfort.
D. Maintain strict bed rest for the first 48 hr postoperative.

Answer 16

B. Monitor sensory perception of the lower extremities.

Question 17

The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

A. Shrug shoulders against resistance.
B. Stand up slowly with eyes closed.
C. Turn head from side to side.
D. Raise both arms overhead

Answer 17

A. Shrug shoulders against resistance.

Question 18

A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?

A. Urge incontinence
B. Dribbling of urine
C. Weight gain
D. Rectal distention

Answer 18

B. Dribbling of urine

Question 19

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

A. Flexes the upper and extends the lower extremities in response to the painful stimulus
B. Pushes the painful stimulus away
C. Shows no reaction to the painful stimulus
D. Extends her body toward the painful stimulus

Answer 19

B. Pushes the painful stimulus away

Question 20

A nurse is caring for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

A. Monitor the client for an elevated temperature.
B. Ensure the halo jacket is snug against the client’s skin.
C. Provide range of motion to the client’s neck
D. Remove the vest daily to inspect the client’s skin integrity.

Answer 20

A. Monitor the client for an elevated temperature.

Question 21

A nurse is assessing a client who has Bell’s palsy. Which of the following findings should the nurse expect? (Select all that apply)

A. Impaired taste
B. Pain behind the ear.
C. Muscle distortion
D. Facial twitching
E. Hearing loss

Answer 21

A. Impaired taste
B. Pain behind the ear.
C. Muscle distortion

Question 22

A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?

a. Offer the client bar soap.
b. Provide the client with a fixed shower head.
c. Give the client a long-handled sponge.
d. Fill the client’s bathtub with water at 48° C (118.4° F).

Answer 22

c. Give the client a long-handled sponge.

Question 23

A nurse in the ED is caring for a client who sustained a head injury. The nurse notes the client’s IV fluids are infusing at 125ml/hr. Which of the following is an appropriate nursing action by the nurse?

a. slow the rate to 20 mL/hr
b. continue the rate at 125 mL/hr
c. slow the rate to 50 mL/hr
d. increase the rate to 250 mL/hr

Answer 23

c. slow the rate to 50 mL/hr

Question 24

A nurse is instructing a client’s family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

A. Encourage brief exercise before meals to promote appetite.
B. Encourage the client to take small bites.
C. Place the client with the head reclined back to facilitate swallowing.
D. Place food in the affected side of the mouth.

Answer 24

B. Encourage the client to take small bites.

Question 25

A nurse is reinforcing discharge instructions with a client following a laminectomy. Which of the following instructions should the nurse include?

a. “Sit in straight-back chairs.”
b. “Sleep on a soft mattress.”
c. “Walk around at least every 3 hours when sitting for long periods of time.”
d. “Bend at the waist when lifting objects.”

Answer 25

a. “Sit in straight-back chairs.”

Question 26

After the emergency department nurse has received a status report on the following patients who have been admitted 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 50-yr-old patient who has an initial Glasgow Coma Scale score of 13
C. A 30-yr-old patient who lost consciousness for a few seconds after a fall
D. A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light

Answer 26

D. A 40-yr-old patient whose right pupil is 10 mm and unresponsive to light

Question 27

A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?

a. Assessment of the patient for left leg pain
b. Assessment of the patient for left arm weakness
c. Positioning the patient’s right leg when turning the patient
d. Teaching the patient to look at the left leg to verify its position

Answer 27

c. Positioning the patient’s right leg when turning the patient

Question 28

A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for?
(Select All that Apply.)

A. Pupillary dilation
B. Persistent headache
C. Presence of hand tremors
D. Difficulty waking
E. Foot drop

Answer 28

A. Pupillary dilation
B. Persistent headache
D. Difficulty waking

Question 29

A newly licensed nurse is learning about coup and contrecoup injuries.
Which statement by the newly licensed nurse demonstrates a clear understanding of the topic?

A. A contrecoup injury is not viewed as a “true” injury, while a coup injury can have more severe consequences.
B. Contrecoup injuries are generally less severe and heal more quickly over time.
C. The coup injury is the primary point of injury, with the contrecoup injury occurring on the brain’s opposite side.
D. The coup injury happens secondary to the contrecoup injury but does not impact the brain’s blood supply.

Answer 29

C. The coup injury is the primary point of injury, with the contrecoup injury occurring on the brain’s opposite side.

Question 30

Describe the manifestations of a basilar skull fracture

Answer 30

battle’s signs
raccoon eyes (ecchymosis)
CSF leak (otorrhea or rhinorrhea)

Question 31

The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range?

A. Dexamethasone (Decadron)
B. Hydrochlorothiazide (HydroDIURIL)
C. Mannitol (Osmitrol)
D. Phenytoin (Dilantin)

Answer 31

C. Mannitol (Osmitrol)

Question 32

Which of the following should the nurse understand is a possible consequence of traumatic brain injury?

a. increased synaptic connections from pressure
b. damage to brain tissue from decreased pressure shockwaves
c. increased blood supply and edema in the area of injury
d. disruption of cellular function and blood vessel damage

Answer 32

d. disruption of cellular function and blood vessel damage