The nurse describes a concussion as a closed head injury in which
The brain tissue is bruised
No loss of consciousness occurs.
There is amnesia related to the incident
There are no subsequent symptoms
Why is the older adult more at risk for a cranial bleed following a head injury
The older adult’s brain is smaller, which allows for more movement inside the cranium
The older adult’s brain features fragile vessels more likely to rupture
The older adult’s brain contains less cerebrospinal fluid (CSF) to cushion the brain
The older adult’s brain has less flexible meninges to absorb impact
The emergency room nurse is assessing a newly admitted patient with a head injury. The nurse observes clear drainage from the nose. Which action should the nurse perform first?
Document the presence of rhinorrhea
Inform the physician of the assessment
Assess the fluid for a halo sign
Tape a drip pad under the nose
In assessing the patient with a significant right intracerebral hemorrhage, the nurse anticipates that the patient will demonstrate which signs?
A. Left-sided hemiplegia with dilated right pupil
B. Right-sided hemiplegia with brisk right pupil response
C. Bilateral motor hemiplegia with bilaterally dilated pupils
D. Left-sided hemiplegia and bilateral PERRLA
The nurse is caring for an older adult patient who was admitted to the hospital following a closed head injury that resulted in a 5-minute period of unconsciousness. The nurse most carefully monitors the patient for which change?
A. Increasing respiratory rate
B. Decreasing heart rate
C. Decreasing pulse pressure
D. Decreasing level of consciousness (LOC)
. The patient with a suspected subdural hematoma is on an intravenous (IV) drip of mannitol infusing at 50 mL/h. The nurse explains that the slow infusion rate is essential for what purpose?
A. To ensure effectiveness of the drug
B. To avoid fluid overload
C. To maintain electrolyte balance
D. To maintain adequate blood pressure (BP)
7. Following a craniotomy to relieve increased intracranial pressure (ICP), which implementation should the nurse implement?
A. Elevate the head of the bed 20 to 30 degrees.
B. Place drip pad or cotton to absorb cerebrospinal fluid (CSF) drainage from the nose or ears.
C. Stimulate the patient to better assess changing level of consciousness (LOC).
D. Reposition the patient frequently for comfort.
The unconscious patient with a closed head injury is on mechanical ventilation. To improve brain perfusion through increased blood pressure, the carbon dioxide (CO2) should be maintained at what level?
A. 10 to 15 mm Hg
B. 15 to 20 mm Hg
C. 20 to 25 mm Hg
D. 25 to 30 mm Hg
The nurse is caring for a patient with a closed head injury. Which finding causes the nurse to suspect that the patient has developed diabetes insipidus (DI)?
A. Increased lethargy
B. Widening pulse pressure
C. Copious pale urine output
D. Increasing blood glucose levels
10. Which position is best for an unconscious patient with a right-sided closed head injury?
A. High Fowler
B. Right side-lying
C. Flat with small pillow under head
D. Head of bed 20 to 30 degrees
The nurse is caring for a patient with a neurologic injury who is awake. On assessment, the patient displays mild disorientation to surroundings and time and needs additional verbal cues to stimulate response to commands. The nurse correctly documents the patient’s level of consciousness (LOC) by using which term?
Alert
Confused
Lethargic
Obtunded
The nurse is caring for an adolescent who has lower limb paralysis after sustaining a spinal injury yesterday. The patient’s anxious mother asks if the paralysis is permanent. Which response is most appropriate for the nurse to make?
It is possible that motor function may or may not return after spinal cord swelling has subsided.”
Motor function may improve, but there will always be a deficit.”
In all likelihood, the paralysis will be permanent
Have you asked the physician about your concerns?
. The nurse is caring for a patient with flaccid paralysis after sustaining a spinal cord injury 3 days earlier. The family excitedly notifies the nurse that the patient has flexed his arm. Which response is best for the nurse to make?
A. “I will give the doctor this wonderful news.”
B. “Avoid directly touching the arm muscles so that you don’t cause more muscle spasms.”
C. “This movement means that the spinal cord is adjusting to the injury.”
D. “These muscles spasms are a type of involuntary movement that happens frequently in patients with spinal cord injuries.”
. The nurse is caring for a patient with spastic paralysis. Which technique is most appropriate for the nurse to use when moving the patient?
A. Firmly grasp the muscles.
B. Use the palms of hands to support the joints.
C. Logroll the patient as a unit.
D. Perform passive range of motion (ROM)
The nurse is caring for a patient with a spinal cord injury who develops autonomic dysreflexia (AD). Which action is most important for the nurse to take first?
A. Elevate the head of the bed.
B. Notify the charge nurse.
C. Decrease the IV fluid rate.
D. Administer antihypertensive medication.
When turning the patient who is in Crutchfield tongs traction, the nurse should employ which technique?
A. Turn the patient as a unit by logrolling.
B. Release the weights to prevent injury while turning.
C. Turn the patient quickly to avoid muscle spasms.
D. Advise the patient to hold his breath and bear down during turning.
A patient presents to the health clinic with low back pain that radiates into the buttocks and below the knee. The nurse suspects which condition?
A. Herniated disk
B. Muscle spasm in lower back
C. Spinal cord injury
D. Sciatica
. The student nurse is planning care for a patient with a recent spinal cord injury. Which intervention indicates that the student nurse requires further instruction regarding appropriate care for this patient?
A. Keep the halo jacket fastened unless the patient is in a supine position.
B. Monitor the bladder every 4 h for signs of bladder distention.
C. Instruct unlicensed assistive personnel (UAP) to turn and reposition the patient every 2 h
D. Assess compression stockings for proper fit.
The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). Family members ask the nurse why their father had a seizure. Which response is best for the nurse to make?
The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain.”
The stroke generated a toxin that excites the brain cells.”
The stroke causes an alteration in the cells adjacent to the blood clot.”
The stroke causes an increase in the depolarization of the brain cells due to the clot formation.
The nurse is providing teaching to a patient newly diagnosed with focal seizure disorder. Which statement by the nurse is most accurate?
Your seizures will typically only affect one side of your body
“Simple partial seizures may result in an alteration of consciousness
The simple partial seizure may cause motor impairment to begin in all of your extremities
Simple partial seizures are not treatable
The nurse is caring for an anxious 20-year-old college student who just suffered his first seizure in his dorm room. The patient asks the nurse if he is now an epileptic. What is the nurse’s best response?
No. All other causes of seizure activity must be ruled out before the diagnosis of epilepsy is made
Yes, but you may never have another seizure since it has just now manifested itself.”
No, but you should see a physician to get a prescription for a preventative antispasmodic.”
Yes. All seizures are considered to be epilepsy
The nurse instructs a person taking phenytoin (Dilantin) that periodic blood tests will be necessary. The nurse explains that the laboratory checks will monitor for which potential medication-induced change?
A. Potassium depletion
B. Liver damage
C. Increasing creatinine
D. Increasing sedimentation rates
The nurse is assessing a patient on intravenous (IV) phenytoin (Dilantin). Which assessment finding is most concerning to the nurse?
A. Blood pressure (BP) 138/92
B. Frequent hiccups
C. Irregular apical pulse
D. Nausea and vomiting
The nurse is providing medication teaching to a patient with epilepsy who is taking phenytoin (Dilantin). Which statement best indicates that the nurse’s teaching has been successful?
A. “I should decrease my alcohol intake to a single drink per day.”
B. “I should visit the dentist every 3 to 6 months while taking this medication.”
C. “I should take my antacid an hour after my Dilantin.”
D. “This medication may turn my urine orange.”
. The nurse reinforces the information given by the physician that endarterectomy as an intervention for stroke prevention is reserved for people who have carotid obstruction of greater than what percentage?
A. 30%
B. 40%
C. 50%
D. 60%
The dysarthric patient seated in the dining room of the long-term care facility yells, “Poon! Poon! Poon!” with increasing frustration. What is the nurse’s best response?
A. “Slow down so that I can understand what you are saying.”
B. “Are you asking for a spoon?”
C. “Not being able to speak is frustrating.”
D. “If you tell me what you want, I will get it.”
The nurse is assisting a patient with agnosia after a CVA. Which intervention is most appropriate?
A. Showing the patient a spoon while calling it by name and describing its purpose
B. Moving the patient’s hand with a toothbrush in repetitive motion to brush teeth
C. Describing the placement of food on the plate
Adaptive
10. Which nursing intervention best encourages self-feeding in a patient with right-sided paralysis after a CVA?
A. Place finger foods on the left side of the plate.
B. Support the right hand in holding an adaptive cup.
C. Seat the patient in the dining room with other residents.
D. Place large helpings of food in the center of the plate.
11. Which symptom is a key sign of a brain tumor?
A. Morning nausea
B. Difficulty reading
C. A headache that awakens patient
D. Increasing blood pressure
The nurse is caring for a patient with brain tumor–related hydrocephalus who is scheduled to undergo placement of a ventriculoperitoneal (V-P) shunt. Which information is most important for the nurse to include when explaining the purpose of the procedure?
A. A V-P shunt redirects the cerebrospinal fluid (CSF) from the ventricles to the peritoneum.
B. A V-P shunt stimulates ventricles to reabsorb excess CSF.
C. A V-P shunt channels excess CSF to the left atrium.
D. A V-P shunt provides a port from which excess CSF can be aspirated.
Following a craniotomy for the removal of a brain tumor, the patient exhibits nuchal rigidity, rash on the chest, headache, and a positive Brudzinski sign. What do these assessment findings indicate to the nurse?
A. Intracranial bleeding
B. Encephalitis
C. Increasing intracranial pressure
D. Meningitis
14. The nurse is caring for a patient with bacterial meningitis. What interventions should the nurse include in the plan of care?
A. Maintain a quiet environment with minimal stimulation.
B. Provide all care using sterile technique.
C. Limit intake of oral fluids.
D. Provide magazines and other activities to reduce daytime naps.
The patient reports intense intermittent headaches over the last 6 months that are preceded by specific symptoms. What symptom is
the patient most likely experiencing?
A. Nausea and vomiting
B. Focal seizures
C. Scotoma
D. Fainting
A patient was recently diagnosed as having Bell palsy. Which nursing intervention is most important for the nurse to include in the
patient’s care plan?
A. Administer pain medication as needed.
B. Administer artificial tears and acyclovir.
C. Implement aspiration precautions.
D. Offer the patient a small fan to cool the face.
The nurse is writing the care plan for a cerebrovascular accident (CVA) patient who has partial left-sided paralysis and is
experiencing ataxia. Which intervention is most beneficial for this patient?
A. Encourage the patient to ambulate as much as possible when she feels the energy to do so.
B. Ensure the patient receives pureed foods and thickened liquids.
C. Place the patient’s call light on the right side of the patient and remind her to call for assistance before getting up.
D. Encourage the patient to use a communication board.
The nurse is caring for a stroke patient who is experiencing homonymous hemianopsia. The patient asks if he is going to have any
limitations when discharged from the hospital. The nurse anticipates the patient will be restricted from what activity?
A. Ambulating independently
B. Cooking on a stove
C. Reading a book
D. Driving a vehicle
A patient diagnosed with a primary brain tumor asks the nurse if this is a common disease. Which response is most appropriate for
the nurse to make?
A. “Brain tumors are very rare.”
B. “About 80,000 people a year are diagnosed with a brain tumor.”
C. “It doesn’t really matter. We are just concerned with helping you.”
D. “Almost all primary brain tumors are malignant.”
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