Management Of Clients With Neurologic Trauma

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Question 1
Free
Multiple Choice

An elderly client who was found unresponsive at home now opens his eyes when spoken to and answers simple questions when asked; and left alone usually sleeps. The nurse would document this information in the Glasgow Coma Scale using the categories of

Choose correct answer/s
A

best verbal response and best motor response.

B

eye opening and best verbal response.

C

eye opening and motor activity.

D

motor activity and motor response.

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Question 2
Free
Multiple Choice

The nurse explains that irreversible brain tissue damage is probable when the blood flow to the brain is reduced by

Choose correct answer/s
A

10%.

B

30%.

C

40%.

D

60%.

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Question 3
Free
Multiple Choice

The client who is unconscious following a fall has a blood pressure of 90/60 mm Hg. The most appropriate action by the nurse is to

Choose correct answer/s
A

increase the patient's intravenous (IV) fluids.

B

notify the physician immediately.

C

provide hyperventilation by adjusting ventilator settings.

D

retake the blood pressure in 15 minutes.

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Question 4
Free
Multiple Choice

When the nurse assesses brain tissue extruding through an unstable skull fracture, it is documented as which type of herniation syndrome?

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A

Central transtentorial

B

Cingulate

C

Tonsillar

D

Transcalvarial

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Question 5
Free
Multiple Choice

When the client being treated with a hypothermia blanket begins to shiver, the nurse should

Choose correct answer/s
A

assess the temperature and blood pressure.

B

increase the O2 to 4 L/minute.

C

give prescribed antipyretic medication.

D

take off the hypothermia blanket.

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Question 6
Multiple Choice

Vital signs on a brain-injured client 1 hour ago were T 98.8° F, P 76, BP 124/72 . When the nurse takes a current set of vital signs that are T 98.4° F, P 56, BP 160/54, the nurse should

Choose correct answer/s
A
administer prn pain medications.
B
check the client's blood glucose level.
C
lower the head of the bed.
D
prepare to administer mannitol.
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Question 7
Multiple Choice

To assess motor response, the nurse performing a neurologic assessment on a client in a coma would ask the client to

Choose correct answer/s
A
cough and deep breathe.
B
grasp the nurse's fingers.
C
repeat a phrase.
D
wiggle the toes.
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Question 8
Multiple Choice

The emergency department nurse should position the client with cranial injuries

Choose correct answer/s
A
in high-Fowler position and knees elevated.
B
side-lying with head of bed elevated 20 degrees.
C
supine with head of bed elevated 30 degrees.
D
supine with the bed completely flat.
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Question 9
Multiple Choice

When the nurse caring for a client using an ICP monitor reads ICP as 20 mm Hg, the nurse would interpret this as

Choose correct answer/s
A
an incorrect reading.
B
higher than normal.
C
lower than normal.
D
normal.
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Question 10
Multiple Choice

The nurse teaches a group of high school students that the best way to avoid a spinal cord injury is to avoid

Choose correct answer/s
A
cervical spondylosis.
B
myelitis.
C
trauma.
D
vascular disease.
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Question 11
Multiple Choice

When the client who has been in flaccid spinal shock dorsiflexes the great toe and fans the other toes when the sole of his foot is stroked, the nurse is

Choose correct answer/s
A
alarmed, because this indicates increased ICP.
B
alerted, because this indicates possible meningeal irritation.
C
distressed, because this indicates deterioration.
D
pleased, because this indicates a reduction of spinal shock.
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Question 12
Multiple Choice

When the client who has an incomplete lesion of the spinal cord complains of more weakness in his upper extremities than in his lower extremities, the nurse recognizes these manifestations to be consistent with

Choose correct answer/s
A
anterior cord syndrome.
B
Brown-Séquard syndrome.
C
central cord syndrome.
D
cervical cord syndrome.
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Question 13
Multiple Choice

Following a spinal cord injury, assessment revealed left-side motor paralysis with loss of vibratory and position sense, and right-side loss of pain and temperature sensation. The nurse recognizes the spinal cord syndrome of

Choose correct answer/s
A
anterior cord syndrome.
B
Brown-Séquard syndrome.
C
central cord syndrome.
D
spinal shock syndrome.
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Question 14
Multiple Choice

A client arrives in the emergency department after being involved in a motor vehicle accident; the client exhibits a complete loss of motor, sensory, autonomic, and reflex activity below the injury level. The nurse can determine if he is experiencing spinal shock by assessing

Choose correct answer/s
A
blood pressure and pulse rate.
B
for muscle spasm.
C
the presence of bowel sounds.
D
the pupillary response.
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Question 15
Multiple Choice

The nurse is assessing a client for manifestations of recovery from spinal shock. Which of the following assessment findings would indicate that spinal shock is resolving?

Choose correct answer/s
A
Flaccid paralysis
B
Hyperreflexia
C
Loss of Babinski's response
D
Urinary retention
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Question 16
Multiple Choice

A client with a spinal cord lesion experiences a sudden, painful spasm of his lower limbs. The priority action by the nurse is to

Choose correct answer/s
A
administer pain medication.
B
assess for bladder distention.
C
massage the client's legs.
D
position the client upright.
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Question 17
Multiple Choice

The nurse explains to a family that immediate medical-surgical stabilization after a severe cervical injury would include

Choose correct answer/s
A
cervical brace.
B
halo jacket.
C
skeletal traction.
D
spinal fusion.
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Question 18
Multiple Choice

When a client with upper motor neuron damage following a spinal cord injury is experiencing a neurogenic bowel, the nurse would alter the plan of care to include

Choose correct answer/s
A
giving a suppository daily.
B
having the client take a daily laxative.
C
instilling daily soapsuds enemas.
D
manually disimpacting the stool.
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Question 19
Multiple Choice

Urinary complications can be prevented if the nurse adjusts the care plan to include

Choose correct answer/s
A
checking for post void residuals.
B
encouraging voiding every 2 hours.
C
monitoring the client's urinalysis.
D
placing an indwelling Foley catheter.
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Question 20
Multiple Choice

The nurse encourages the client who has sustained a C5 complete spinal cord injury that he should anticipate that he will be able to

Choose correct answer/s
A
dress totally independently.
B
feed himself.
C
learn to type or use a computer.
D
self-catheterize.
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