Nursing Management Acute Intracranial Problems

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Question 1
Free
Multiple Choice

Family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a client. Which of the following responses by the nurse is best?

Choose correct answer/s
A

"This type of monitoring system is complex and highly skilled staff are needed."

B

"The monitoring system helps show whether blood flow to the brain is adequate."

C

"The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure."

D

"This monitoring system has multiple benefits including facilitation of cerebro-spinal fluid drainage."

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Question 2
Free
Multiple Choice

The nurse is caring for a client with a head injury and has admission vital signs of blood pressure 128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute. Which of these vital signs, if taken 1 hour after admission, will be of most concern tothenurse?

Choose correct answer/s
A

Blood pressure 156/60, pulse 55, respirations 12

B

Blood pressure 130/72, pulse 90, respirations 32

C

Blood pressure 148/78, pulse 112, respirations 28

D

Blood pressure 110/70, pulse 120, respirations 30

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Question 3
Free
Multiple Choice

The nurse is assessing a client who is unconscious and applies a painful stimulus to the nail beds. The client responds with internal rotation, adduction, and flexion of the arms. Which of the following terms should the nurse use when documenting the findings?

Choose correct answer/s
A

Flexion withdrawal

B

Localization of pain

C

Decorticate posturing

D

Decerebrate posturing

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Question 4
Free
Multiple Choice

Which of the following parameters is best for the nurse to monitor to determine whether the prescribed IV mannitol has been effective for an unconscious client?

Choose correct answer/s
A

Hematocrit

B

Blood pressure

C

Oxygen saturation

D

Intracranial pressure

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Question 5
Free
Multiple Choice

Aclient with a head injury opens his or her eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. Which of the following Glasgow Coma Scale scores should the nursedocument?

Choose correct answer/s
A

9

B

11

C

13

D

15

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Question 6
Multiple Choice

The nurse is admitting a client to the emergency department (ED) who is unconscious following a head injury. The client's spouse and children stay at the client's side and constantly ask about the treatment being given. What of the following actions is bestfor the nurse to take?

Choose correct answer/s
A
Ask the family to stay in the waiting room until the initial assessment is completed.
B
Allow the family to stay with the client and briefly explain all procedures to them.
C
Call the family's pastor or spiritual advisor to support them while initial care is given.
D
Refer the family members to the hospital counselling service to deal with their anxiety.
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Question 7
Multiple Choice

Aclient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which of the following nursing interventions should be included in the plan of care?

Choose correct answer/s
A
Keep the head of the bed elevated to 30 degrees.
B
Position the client with the knees and hips flexed.
C
Encourage coughing and deep breathing to improve oxygenation.
D
Cluster nursing interventions to provide uninterrupted rest periods.
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Question 8
Multiple Choice

The nurse is caring for a client with a head injury who has clear nasal drainage. Which of the following actions should the nurse take?

Choose correct answer/s
A
Have the client blow the nose.
B
Check the nasal drainage for glucose.
C
Assure the client that rhinorrhea is normal after a head injury.
D
Obtain a specimen of the fluid to send for culture and sensitivity.
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Question 9
Multiple Choice

The nurse is caring for a client who has a head injury and is diagnosed with a concussion. Which of the following actions should the nurse plan to take?

Choose correct answer/s
A
Coordinate the transfer of the client to the operating room.
B
Provide discharge instructions about monitoring neurological status.
C
Transport the client to radiology for magnetic resonance imaging (MRI) of the brain.
D
Arrange to admit the client to the neurological unit for observation for 24 hours.
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Question 10
Multiple Choice

A client who is suspected of having an epidural hematoma is admitted to the emergency department. Which of the following actions should the nurse plan to take?

Choose correct answer/s
A
Administer IV furosemide.
B
Initiate high-dose barbiturate therapy.
C
Type and crossmatch for blood transfusion.
D
Prepare the client for immediate craniotomy.
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Question 11
Multiple Choice

The nurse is admitting a client with a basal skull fracture and notes clear drainage from the client's nose. Which of these admission orders should the nurse's question?

Choose correct answer/s
A
Insert nasogastric tube.
B
Turn client every 2 hours.
C
Keep the head of bed elevated.
D
Apply cold packs for facial bruising.
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Question 12
Multiple Choice

Which of the following assessment information should the nurse collect to determine whether a client is developing post-concussion syndrome?

Choose correct answer/s
A
Muscle resistance
B
Short-term memory
C
Glasgow coma scale
D
Pupil reaction to light
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Question 13
Multiple Choice

The nurse is admitting a client who has a tumour of the right frontal lobe. Which of the following findings should the nurse expect to observe?

Choose correct answer/s
A
Judgement changes
B
Expressive aphasia
C
Right-sided weakness
D
Difficulty swallowing
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Question 14
Multiple Choice

Which of the following statements by a client who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse?

Choose correct answer/s
A
"I will return if I feel dizzy or nauseated."
B
"I am going to drive home and go to bed."
C
"I do not even remember being in an accident."
D
"I can take acetaminophen for my headache."
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Question 15
Multiple Choice

The nurse is caring for a client following a craniectomy and left anterior fossae incision who has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. Which of the following is an appropriate nursingintervention?

Choose correct answer/s
A
Position the bed flat and log roll the client.
B
Cluster nursing activities to allow longer rest periods.
C
Turn and reposition the client side to side every 2 hours.
D
Perform range-of-motion (ROM) exercises every 4 hours.
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Question 16
Multiple Choice

The nurse is caring for a client who has increased intracranial pressure and is disoriented and anxious. Which of the following nursing actions should be included in the plan of care?

Choose correct answer/s
A
Encourage family members to remain at the bedside.
B
Apply soft restraints to protect the client from injury.
C
Keep the room well lighted to improve client orientation.
D
Minimize contact with the client to decrease sensory input.
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Question 17
Multiple Choice

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which of the following nursing actions is most important?

Choose correct answer/s
A
Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
B
Emphasize the importance of handwashing to prevent spread of infection.
C
Immunize adolescents and postsecondary students against Neisseria meningitidis.
D
Encourage adolescents and young adults to avoid crowded areas in the winter.
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Question 18
Multiple Choice

The nurse is caring for a client who has just been admitted with meningococcal meningitis. Which of the following observations requires the nurse to act?

Choose correct answer/s
A
The bedrails at the head and foot of the bed are both elevated.
B
The client receives a regular diet from the dietary department.
C
The student nurse goes into the client's room without a mask.
D
The lights in the client's room are turned off and the blinds are shut.
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Question 19
Multiple Choice

The nurse is assessing a client with bacterial meningitis and obtains the following data. Which of the following findings should be reported immediately to the health care provider?

Choose correct answer/s
A
The client has a positive Kernig's sign.
B
The client complains of having a stiff neck.
C
The client's temperature is 38.3°C (100.9°F).
D
The client's blood pressure is 86/42 mm Hg.
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Question 20
Multiple Choice

The nurse is caring for a client who has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which of the following actions should the nurse take first?

Choose correct answer/s
A
Elevate the head of the client's bed to 60 degrees.
B
Document the BP and ICP in the client's record.
C
Report the BP and ICP to the health care provider.
D
Continue to monitor the client's vital signs and ICP.
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