[Ex4] - C17 - AP

Question 1

17-1. A nurse is preparing to teach staff about the most common type of traumatic brain injury.
Which type of traumatic brain injury should the nurse discuss?

a. Penetrating trauma
b. Diffuse axonal injury
c. Focal brain injury
d. Concussion

Answer 1

ANS: D

A concussion is the most common type of traumatic brain injury. A concussion is a much
more common brain injury than penetrating trauma, diffuse axonal injury, or focal injury.

Question 2

17-2. A coup injury resulting from a blow to the frontal portion of the skull would occur in which
region of the brain?

a. Frontal
b. Temporal
c. Parietal
d. Occipital

Answer 2

ANS: A
When there is force applied to the skull, an injury may occur to the corresponding location on
the brain. The injury may be coup (injury at site of impact) or contrecoup (injury from brain
rebounding and hitting opposite side of skull).

Question 3

17-3. What is the main source of bleeding in extradural (epidural) hematomas?

a. Arterial
b. Venous
c. Capillary
d. Sinus

Answer 3

ANS: A

An artery is the source of bleeding in 85% of extradural hematomas. The bleeding associated
with an extradural hematoma is not a result of damage to a vein, a capillary, or a sinus.

Question 4

17-4. A 69-year-old patient with a history of alcohol abuse presents to the emergency room (ER)
after a month-long episode of headaches and confusion. The patient’s history and
symptomology support which medical diagnosis?

a. Concussion
b. Chronic subdural hematoma
c. Epidural hematoma
d. Subacute subdural hematoma

Answer 4

ANS: B

Chronic subdural hematomas are commonly found in persons who abuse alcohol and develop
over weeks to months. A concussion is more acute in nature. Epidural hematomas are not
associated with the patient’s history or symptoms. Subacute subdural hematomas present with
confusion but are more acute in nature.

Question 5

17-5. Immediately after being struck by a motor vehicle, a patient is unconscious, but the patient
regains consciousness before arriving at the hospital and appears alert and oriented. The next
morning the patient is confused and demonstrates impaired responsiveness. The patient’s
history and symptoms support which medical diagnosis?

a. Mild concussion
b. Subdural hematoma
c. Extradural (epidural) hematoma
d. Mild diffuse axonal injury

Answer 5

ANS: C

Individuals with extradural hematomas lose consciousness at injury; one third then become
lucid for a few minutes to a few days. Mild concussion is characterized by immediate but
transitory confusion that lasts for one to several minutes, possibly with amnesia for events
preceding the trauma. Subdural hematomas begin with headache, drowsiness, restlessness or
agitation, slowed cognition, and confusion. These symptoms worsen over time and progress to
loss of consciousness, respiratory pattern changes, and pupillary dilation. Individuals with
mild diffuse axonal injury display decerebrate or decorticate posturing and may experience
prolonged periods of stupor or restlessness.

Question 6

17-6. Which assessment finding by the nurse characterizes a mild concussion?

a. A brief loss of consciousness
b. Significant behavioral changes
c. Retrograde amnesia
d. Permanent confusion

Answer 6

ANS: C

Mild concussion is characterized by immediate but transitory confusion that lasts for one to
several minutes, possibly with amnesia for events preceding the trauma. Individuals with
extradural hematomas lose consciousness at injury; one third then become lucid for a few
minutes to a few days. Persons with diffuse brain injury demonstrate behavioral changes.
Individuals with a mild concussion experience transient, not permanent, confusion.

Question 7

17-7. A CT scan reveals that a patient has an open basilar skull fracture. Which major complication
should the nurse observe for in this patient?

a. Hematoma formation
b. Meningeal infection
c. Increased intracranial pressure (ICP)
d. Cognitive deficits

Answer 7

ANS: B

Individuals with an open basilar skull fractures should be observed for meningitis. Such a
basilar skull fracture does not increase a patient’s risk for hematoma formation, ICP, or
cognitive deficits.

Question 8

17-8. A patient diagnosed with a diffuse brain injury (DBI) is at increased risk for which
complication?

a. Complete loss of vision
b. Arrhythmia
c. Acute brain swelling
d. Meningitis infection

Answer 8

ANS: C

DBI is not associated with intracranial hypertension immediately after injury; however, acute
brain swelling caused by increased intravascular blood flow within the brain, vasodilation,
and increased cerebral blood volume is seen often and can result in death.
Individuals who experience diffuse brain injury may experience visual impairments but do not
experience loss of vision. A diffuse brain injury is not associated with arrhythmias.
Individuals experiencing basilar skull fractures are at increased risk for the development of
meningitis.

Question 9

17-9. After falling, a patient’s Glasgow Coma Scale (GCS) was 5 initially and 7 after 1 day. The
patient remained unconscious for 2 weeks but is now awake, confused, and experiencing
anterograde amnesia. This history supports which medical diagnosis?

a. Mild diffuse brain injury
b. Moderate diffuse brain injury
c. Severe diffuse brain injury
d. Postconcussive syndrome

Answer 9

ANS: B

In moderate diffuse axonal injury, the score on the GCS is 4–8 initially and 6–8 by 24 hours,
and the person is confused and suffers a long period of posttraumatic anterograde and
retrograde amnesia. In mild diffuse axonal injury, coma lasts 6–24 hours, with 30% of persons
displaying decerebrate or decorticate posturing. They may experience prolonged periods of
stupor or restlessness. In severe diffuse axonal injury, the person experiences immediate
autonomic dysfunction that disappears in a few weeks. Increased ICP appears 4–6 days after
the injury. In postconcussive syndrome, the individual experiences headache, nervousness or
anxiety, irritability, insomnia, depression, inability to concentrate, forgetfulness, and
fatigability.

Question 10

17-10. Who is most at risk of spinal cord injury because of preexisting degenerative disorders?

a. Infants
b. Men
c. Women
d. The elderly

Answer 10

ANS: D

Elderly people are particularly at risk from minor trauma that results in serious spinal cord
injury because of preexisting degenerative vertebral disorders. Neither females nor infants are
at any particular risk for spinal cord injuries. Males are at great risk for spinal cord injury but
not as a result of preexisting disorders.

Question 11

17-11. A patient is brought to the ER for treatment of injuries received in a motor vehicle accident.
An MRI reveals spinal cord injury, and his body temperature fluctuates markedly. The most
accurate explanation of this phenomenon is that:

a. he developed pneumonia.
b. his sympathetic nervous system has been damaged.
c. he has a brain injury.
d. he has septicemia from an unknown source.

Answer 11

ANS: B

The patient experiences disturbed thermal control because the sympathetic nervous system is
damaged. The hypothalamus cannot regulate body heat through vasoconstriction and
increased metabolism; therefore, the individual assumes the temperature of the air. In this
situation, there is no evidence to support the presence of pneumonia, brain injury, or
septicemia.

Question 12

17-12. Six weeks ago a patient suffered a T6 spinal cord injury. What complication does the nurse
suspect when the patient develops a blood pressure of 200/120, a severe headache, blurred
vision, and bradycardia?

a. Extreme spinal shock
b. Acute anxiety
c. Autonomic hyperreflexia
d. Parasympathetic areflexia

Answer 12

ANS: C

The patient is experiencing autonomic hyperreflexia, which is manifested by paroxysmal
hypertension (up to 300 mm Hg, systolic), a pounding headache, blurred vision, sweating
above the level of the lesion with flushing of the skin, nasal congestion, nausea, piloerection
caused by pilomotor spasm, and bradycardia (30-40 beats/min). The patient in extreme spinal
shock experiences paralysis and flaccidity in muscles, absence of sensation, loss of bladder
and rectal control, transient drop in blood pressure, and poor venous circulation. The patient
may experience acute anxiety, but the symptoms of elevated blood pressure with severe
headache are due to autonomic hyperreflexia.
It is autonomic hyperreflexia, not parasympathetic areflexia, that produces paroxysmal
hypertension (up to 300 mm Hg, systolic), a pounding headache, blurred vision, sweating
above the level of the lesion with flushing of the skin, nasal congestion, nausea, piloerection
caused by pilomotor spasm, and bradycardia (30-40 beats/min).

Question 13

17-13. A patient diagnosed with a spinal cord injury experienced spinal shock lasting 15 days. The
patient is now experiencing an uncompensated cardiovascular response to sympathetic
stimulation. What does the nurse suspect caused this condition?

a. Toxic accumulation of free radicals below the level of the injury
b. Pain stimulation above the level of the spinal cord lesion
c. A distended bladder or rectum
d. An abnormal vagal response

Answer 13

ANS: C

The described symptoms indicate autonomic hyperreflexia and are due to a distended bladder
or rectum. The described symptoms are not due to the accumulation of free radicals, pain
stimulation, or an abnormal vagal response.

Question 14

17-14. A patient presents with acute low back pain. There is no history of trauma. An MRI reveals
that the vertebra at L5 has slipped forward relative to those below it. Which of the following
conditions will be documented on the chart?

a. Degenerative disk disease
b. Spondylolysis
c. Spondylolisthesis
d. Spinal stenosis

Answer 14

ANS: C

Spondylolisthesis occurs when there are vertebra slides forward or slips in relation to below it.
Degenerative disk disease is a pathophysiologic cause of spondylolisthesis but is not the
definition of the displacement. Spondylolysis is a structural defect of the spine.
Spinal stenosis is a narrowing of the spinal canal.

Question 15

17-15. The majority of intervertebral disk herniations occur between which vertebral levels (cervical,
C; thoracic, T; lumbar, L; sacral, S)?

a. C1-C3
b. T1-T4
c. T12-L3
d. L4-S1

Answer 15

ANS: D

The most common disks affected by herniation are the lumbosacral disks—that is, L5-S1 and
L4-L5.

Question 16

17-16. A 30-year-old white male recently suffered a cerebrovascular accident. Which of the
following is the most likely factor that contributed to his stroke?

a. Age
b. Gender
c. Diabetes
d. Race

Answer 16

ANS: C

The most likely contributing factor to the patient’s stroke is that he has diabetes with a
fourfold increase in stroke incidence and an eightfold increase in stroke mortality. Age greater
than 65 years is contributing factor. Men are affected, but for the 30-year-old male, his type 2
diabetes mellitus contributes to a fourfold increase in stroke incidence and an eightfold
increase in stroke mortality. Blacks are affected more than whites, and it is this patient’s
diabetes that places him at risk.

Question 17

17-17. Which of the following would increase a patient’s risk for thrombotic stroke?

a. Hyperthyroidism
b. Hypertension
c. Anemia
d. Dehydration

Answer 17

ANS: D

Dehydration is a risk factor because it increases blood viscosity and decreases cerebral
perfusion. Hyperthyroidism would lead to increased blood pressure but does not place the
patient at risk for thrombotic stroke. Hypotension, not hypertension, is a risk factor for
thrombotic stroke. Anemia would decrease

Question 18

17-18. Of the following groups, who are at highest risk for a cerebrovascular accident (CVA)?

a. Blacks over 65 years of age
b. Whites over 65 years of age
c. Blacks under 65 years of age
d. Whites under 65 years of age

Answer 18

ANS: A

The individuals at highest risk for cerebrovascular accident are blacks over 65 years of age.
Older adults are at greater risk than younger adults, and blacks are at greater risk than whites.

Question 19

17-19. A 72-year-old patient demonstrates left-sided weakness of upper and lower extremities. The
symptoms lasted less than an hour and resolved with no evidence of infarction. The patient
most likely experienced a(n):

a. stroke in evolution.
b. arteriovenous malformation.
c. transient ischemic attack.
d. cerebral hemorrhage.

Answer 19

ANS: C

When symptoms resolve with complete recovery, it is a transient ischemic attack. A stroke in
evolution is an impending stroke, and symptoms would not resolve. An arteriovenous
malformation is an abnormal arrangement of blood vessels that could lead to stroke but is not
a disorder in itself. Cerebral hemorrhage would not resolve.

Question 20

17-20. A major contributing process in CVAs is the development of atheromatous plaques in cerebral
circulation. Where do these plaques most commonly form?

a. In the larger veins
b. Near capillary sphincters
c. In cerebral arteries
d. In the venous sinuses

Answer 20

ANS: C

Over 20–30 years, atheromatous plaques (stenotic lesions) form at branchings and curves in
the cerebral circulation, primarily the arteries, not in veins, near the sphincters, or in the
venous sinuses.

Question 21

17-21. A 60-year-old patient with a recent history of head trauma and a long-term history of
hypertension presents to the ER for changes in mental status. MRI reveals that the patient has
experienced a subarachnoid hemorrhage. What does the nurse suspect caused this type of
stroke?

a. Rheumatic heart disease
b. Thrombi
c. Aneurysm
d. Hypotension

Answer 21

ANS: C

The primary causative factor of subarachnoid hemorrhagic bleeding is an aneurysm, not
thrombi, which would lead to thrombotic stroke. A thrombi would lead to a CVA from
blockage but not to hemorrhagic bleeding. Hypertension, not hypotension, would lead to a
hemorrhagic stroke. Rheumatic heart disease is not associated with subarachnoid
hemorrhages.

Question 22

17-22. A 75-year-old patient experienced a lacunar stroke. When looking through the history of the
patient’s chart, which of the following would the nurse expect to find?

a. An embolus
b. An ischemic lesion
c. A hemorrhage
d. An aneurysm

Answer 22

ANS: B

A lacunar stroke is associated with occlusion of a single, deep perforating artery that supplies
small penetrating subcortical vessels, causing ischemic lesions, not an embolus, hemorrhage,
or aneurysm.

Question 23

17-23. Upon autopsy of a 25 year old, abnormalities in the media of the arterial wall and
degenerative changes were detected. Which of the following would most likely accompany
this finding?

a. Fusiform aneurysm
b. Saccular aneurysm
c. Arteriovenous malformation
d. Thrombotic stroke

Answer 23

ANS: B

Saccular aneurysms (berry aneurysms) occur frequently (in approximately 2% of the
population) and likely result from congenital abnormalities in the media of the arterial wall
and degenerative changes. Fusiform aneurysms (giant aneurysms) occur as a result of diffuse
arteriosclerotic changes and are found most commonly in the basilar arteries or terminal
portions of the internal carotid arteries. Arteriovenous malformation (AVM) is a tangled mass
of dilated blood vessels creating abnormal channels between the arterial and venous systems.
Thrombotic stroke would show signs of necrotic tissue, not degenerative changes.

Question 24

17-24. A 48-year-old patient presents at the ER reporting an acute severe headache, nausea,
photophobia, and nuchal rigidity. Which medical diagnosis is supported by these signs and
symptoms?

a. Diffuse brain injury
b. Subarachnoid hemorrhage
c. Epidural hematoma
d. Classic concussion

Answer 24

ANS: B

With subarachnoid hemorrhage, meningeal irritation occurs, leading to nuchal rigidity.
Nuchal rigidity is not associated with a diffuse brain injury, an epidural hematoma, or a
classic concussion.

Question 25

17-25. A 65-year-old patient diagnosed with a subarachnoid hemorrhage secondary to uncontrolled
hypertension appears drowsy and confused with pronounced focal neurologic deficits. This
symptomology would place this hemorrhage at which grade?

a. I
b. II
c. III
d. IV

Answer 25

ANS: C

With grade III, the patient experiences drowsiness and confusion with or without focal
neurologic deficits and pronounced meningeal signs. With grade I, neurologic status is intact
with mild headache and slight nuchal rigidity. With grade II, neurologic deficit is evidenced
by cranial nerve involvement and moderate-to-severe headache with more pronounced
meningeal signs (e.g., photophobia, nuchal rigidity). With grade IV, the patient is stuporous
with pronounced neurologic deficits (e.g., hemiparesis, dysphasia) and nuchal rigidity.

Question 26

17-26. A patient presents to a primary care provider reporting fever, headache, nuchal rigidity, and
decreased consciousness. History includes a previously treated sinusitis. Which medical
diagnosis is best supported by this assessment data?

a. Aseptic meningitis
b. Bacterial meningitis
c. Fungal meningitis
d. Nonpurulent meningitis

Answer 26

ANS: B

Bacterial meningitis can occur secondary to sinusitis and is manifested by fever, tachycardia,
chills, and a petechial rash with a severe throbbing headache, severe photophobia, and nuchal
rigidity. The clinical manifestations of aseptic meningitis are milder than bacterial meningitis
and are not associated with a previous infection such as sinusitis. Fungal meningitis presents
as dementia. Nonpurulent meningitis is the same as aseptic and is milder and not associated
with conditions such as sinusitis.

Question 27

17-27. Most causes of encephalitis are which of the following?

a. Bacterial
b. Viral
c. Fungal
d. Toxoid

Answer 27

ANS: B

Most causes of encephalitis are viral, not bacterial, fungal, or toxoid.

Question 28

17-28. A 15-month-old child from Pennsylvania was brought to the ER with symptomology that
includes fever, seizure activity, cranial palsies, and paralysis. Which form of encephalitis is
best supported by the available assessment data?

a. Eastern equine encephalitis
b. Venezuelan encephalitis
c. St. Louis encephalitis
d. West Nile encephalitis

Answer 28

ANS: A

The symptoms indicate encephalitis, and given the residence of the child and the symptoms,
the diagnosis is Eastern equine encephalitis. Venezuelan occurs in Texas, Florida, and the
South. St. Louis occurs in Canada and the Pacific coast. West Nile occurs throughout the
United States but primarily affects the elderly.

Question 29

17-29. A patient is newly diagnosed with multiple sclerosis (MS). What physiologic change is
causing the patient’s symptoms?

a. Depletion of dopamine in the central nervous system (CNS)
b. Demyelination of nerve fibers in the CNS
c. The development of neurofibril webs in the CNS
d. Reduced amounts of acetylcholine at the neuromuscular junction

Answer 29

ANS: B

The pathophysiology of MS includes demyelination of nerve fibers. Depletion of dopamine is
related to Parkinson disease. The development of neurofibrils is related to Alzheimer disease.
Myasthenia gravis is due to decreased amounts of acetylcholine at the junction.

Question 30

17-30. When a patient asks, “What is the cause of multiple sclerosis?” the nurse bases the answer on
the interaction between:

a. vascular and metabolic factors.
b. bacterial infection and the inflammatory response.
c. autoimmunity and genetic susceptibility.
d. neurotransmitters and inherited genes.

Answer 30

ANS: C

Multiple sclerosis is due to an interaction between the autoimmune response and genetics.
Multiple sclerosis is an autoimmune disorder that is thought to have developed secondary to a
viral infection. It is not bacterial, nor is it related to a neurotransmitter dysfunction or vascular
or metabolic factors.

Question 31

17-31. Patient teaching is considered successful regarding myasthenia gravis when the patient
identifies its cause as being:

a. viral infection of skeletal muscle.
b. atrophy of motor neurons in the spinal cord.
c. demyelination of skeletal motor neurons.
d. autoimmune injury at the neuromuscular junction.

Answer 31

ANS: D

Myasthenia gravis is a disorder resulting from autoimmune injury at the neuromuscular
junction, not from a viral infection. It is not due to motor neuron atrophy, but a lack of
acetylcholine. Multiple sclerosis (MS) is due to demyelination of skeletal motor neurons.

Question 32

17-32. Patients diagnosed with myasthenia gravis often have tumors or pathologic changes in the:

a. brain.
b. pancreas.
c. thymus.
d. lungs.

Answer 32

ANS: C

Patients diagnosed with myasthenia gravis experience tumors in the thymus, not the brain, the
pancreas, or the lungs.

Question 33

17-33. What are the most common primary central nervous system (CNS) tumors in adults?

a. Meningiomas
b. Oligodendrogliomas
c. Astrocytomas
d. Ependymomas

Answer 33

ANS: C

Astrocytomas are the most common primary tumors in the CNS, accounting for over 50%.
Meningioma tumors usually originate from the arachnoidal (meningeal) cap cells in the dura
mater and account for 30% of tumors. Oligodendrogliomas account for about 2% of tumors.
Ependymomas are more common in children.

Question 34

17-34. A patient presents with seizures. An MRI reveals a meningioma most likely originating from
the:

a. dura mater and arachnoid membrane.
b. astrocytes.
c. pia mater.
d. CNS neurons.

Answer 34

ANS: A

Meningioma tumors usually originate from the arachnoidal (meningeal) cap cells in the dura
mater. Astrocytes are found in the brain but are not related to meningiomas. The pia mater is
the location of the infection meningitis. Neurons are located throughout all regions of the
brain.

Question 35

17-35. The patient reports generalized muscle weakness. The health care provider orders
administration of the medication edrophonium chloride (Tensilon). This medication is used in
the diagnosis of:

a. amyotrophic lateral sclerosis (ALS).
b. myasthenia gravis.
c. multiple sclerosis (MS).
d. autonomic hyperreflexia.

Answer 35

ANS: B

The diagnosis of myasthenia gravis is made on the basis of a response to edrophonium
chloride (Tensilon). This medication is not associated with the diagnosis of ALS, MS, or
autonomic hyperreflexia.

Question 36

17-36. Which information is basic to the assessment findings associated with a patient diagnosed
with an aneurysm?

a. A headache is the most common symptom.
b. The majority are asymptomatic.
c. Nosebleeds are an early symptom.
d. Epidural hemorrhage occurs in over 80% of patients.

Answer 36

ANS: B

Aneurysms often are asymptomatic. A headache can occur but is not the most common
symptom. Nosebleeds do not occur. Subarachnoid hemorrhage is the first indication.

Question 37

17-37. What is the most common early symptom of a brain abscess?

a. Neck rigidity
b. Vomiting
c. Drowsiness
d. Headache

Answer 37

ANS: D

Early manifestations include low-grade fever, headache (most common symptom), nausea and
vomiting, neck pain and stiffness, confusion, drowsiness, sensory deficits, and communication
deficits.