Neuro (chapter 14)

Question 1

The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patients plan of care?

a. Frequent neurological assessments
b. Side to side position changes
c. Range of motion to extremities
d. Frequent oropharyngeal suctioning

Answer 1

a. Frequent neurological assessments

Question 2

A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?

a. 54mmHg
b. 72mmHg
c. 90mmHg
d. 126 mm Hg

Answer 2

c. 90mmHg

Question 3

FYI*

Answer 3

CPP = MAP ICP. In this case, CPP = 108 mm Hg 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect

Question 4

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse?

a. Both pressures are high.
b. Both pressures are low.
c. ICP is high; CPP is normal.
d. ICP is high; CPP is low.

Answer 4

c. ICP is high; CPP is normal.

Question 5

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse?

a. Hyperoxygenate during endotracheal suctioning.
b. Elevate the patients head of the bed 30 degrees.
c. Apply bilateral heel protectors after repositioning.
d. Provide rest periods between nursing interventions.

Answer 5

d. Provide rest periods between nursing interventions.

Question 6

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patients left naris. What is the best nursing action?

a. Have the patient blow the nose until clear.
b. Insert bilateral cotton nasal packing.
c. Place a nasal drip pad under the nose.
d. Suction the left nares until the drainage clears.

Answer 6

c. Place a nasal drip pad under the nose.

Question 7

The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action?

a. Stimulate the patient hourly.
b. Continue to monitor the patient.
c. Elevate the head of the bed.
d. Notify the physician immediately.

Answer 7

d. Notify the physician immediately.

Question 8

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action?

a. ICP of 10 mm Hg
b. CPP of 70 mm Hg
c. GCS score of 5
d. CVP of 2 mm Hg

Answer 8

d. CVP of 2 mm Hg

Question 9

The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow?

a. Altered cerebral spinal fluid production and reabsorption
b. Decreased cerebral blood volume due to vessel constriction
c. Increased cerebral blood volume due to vessel dilation
d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)

Answer 9

c. Increased cerebral blood volume due to vessel dilation

Question 10

The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action?

a. Monitor the patients airway patency.
b. Elevate the head of the patients bed.
c. Increase supplemental oxygen delivery.
d. Support bony prominences with padding.

Answer 10

a. Monitor the patients airway patency.

Question 11

The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse?

a. The patient is exhibiting extension posturing.
b. The patient is exhibiting flexion posturing.
c. The patient is exhibiting purposeful movement.
d. The patient is withdrawing to stimulation.

Answer 11

c. The patient is exhibiting purposeful movement.

Question 12

The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action?

a. Insert bilateral ear plugs.
b. Monitor airway patency.
c. Maintain neutral head position.
d. Apply a small nasal drip pad.

Answer 12

d. Apply a small nasal drip pad.

Question 13

While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102 F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)?

a. Ensure adequate periods of rest between nursing interventions.
b. Insert an oral airway and monitor respiratory rate and depth.
c. Maintain neutral head alignment and avoid extreme hip flexion.
d. Reduce ambient room temperature and administer antipyretics.

Answer 13

Reduce ambient room temperature and administer antipyretics.

Question 14

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action?

a. Assist the patient to the floor and provide soft head support.
b. Insert a nasogastric tube and connect to continuous wall suction.
c. Open the patients mouth and insert a padded tongue blade.
d. Restrain the patients extremities until the seizure subsides.

Answer 14

a. Assist the patient to the floor and provide soft head support.

Question 15

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury?

a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg
b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg
c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg

Answer 15

c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg

Question 16

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse?

a. Administer acetaminophen as ordered for the headache.
b. Assess for a kinked urinary catheter and assess for bowel impaction.
c. Encourage the patient to take slow, deep breaths.
d. Notify the physician of the patients blood pressure.

Answer 16

b. Assess for a kinked urinary catheter and assess for bowel impaction.

Question 17

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action?

a. Assess for the presence of a headache.
b. Assess the patients general orientation.
c. Determine the patients drug allergies.
d. Determine the time of symptom onset.

Answer 17

d. Determine the time of symptom onset.

Question 18

. Which patient being cared for in the emergency department should the charge nurse evaluate first?

a. A patient with a complete spinal injury at the C5 dermatome level
b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula
c. An alert patient with a subdural bleed who is complaining of a headache
d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg

Answer 18

a. A patient with a complete spinal injury at the C5 dermatome level

Question 19

The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action?

a. Keep the neck in the hyperextended position.
b. Maintain proper head and neck alignment.
c. Prepare for immediate endotracheal intubation.
d. Remove cervical collar upon arrival to the ED.

Answer 19

b. Maintain proper head and neck alignment.

Question 20

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action?

a. Maintain body temperature.
b. Monitor blood pressure.
c. Pad all bony prominences.
d. Use proper hand washing.

Answer 20

b. Monitor blood pressure.

Question 21

The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23 hours. What is the total 24-hour dose for the 70-kg patient?

a. 2478 mg
b. 5000 mg
c. 10,794 mg
d. 12,750 mg

Answer 21

c. 10,794 mg

Question 22

The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which physician order should the nurse institute first?

a. Mannitol 1 g intravenous
b. Portable chest x-ray
c. Seizure precautions d. Ancef 1 g intravenous

Answer 22

a. Mannitol 1 g intravenous

Question 23

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5 F. Which physician order should the nurse institute first?

a. Blood cultures (2 specimens) for temperature > 101 F
b. Acetaminophen (Tylenol) 650 mg per rectum
c. 500 mL albumin infusion intravenously
d. Decadron 20 mg intravenous push every 4 hours

Answer 23

c. 500 mL albumin infusion intravenously

Question 24

The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine (Cardene) infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patients blood pressure to be 160/90 mm Hg. What is the best action by the nurse?

a. Stop the infusion for 5 minutes.
b. Increase the dose by 2.5 mg/hr.
c. Notify the physician of the BP.
d. Begin weaning the infusion.

Answer 24

b. Increase the dose by 2.5 mg/hr.

Question 25

The nurse is preparing to administer a routine dose of phenytoin (Dilantin). The physician orders phenytoin (Dilantin) 500 mg intravenous every 6 hours. What is the best action by the nurse? a. Administer over 2 minutes. b. Administer with 0.9% normal saline intravenous. c. Contact the physician. d. Assess cardiac rhythm.

Answer 25

c. Contact the physician.

Question 26

The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which order by the physician should the nurse implement first? a. Obtain stat serum electrolytes. b. Administer lorazepam (Ativan). c. Obtain stat portable chest x-ray. d. Administer phenytoin (Dilantin).

Answer 26

b. Administer lorazepam (Ativan).

Question 27

The physician orders fosphenytoin (Cerebyx), 1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus. What is the most important action by the nurse? a. Contact the admitting physician. b. Administer drug over 10 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

Answer 27

b. Administer drug over 10 minutes.

Question 28

The nurse is to administer 100 mg phenytoin (Dilantin) intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? a. Administer over 2 minutes. b. Administer over 5 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

Answer 28

b. Administer over 5 minutes.

Question 29

The nurse is preparing to administer 100 mg of phenytoin (Dilantin) to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse? a. Ensure patency of intravenous (IV) line. b. Mix drug with 0.9% normal saline. c. Evaluate serum K+ level. d. Obtain an IV infusion pump.

Answer 29

a. Ensure patency of intravenous (IV) line.

Question 30

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the physician orders, which order is of the highest priority? a. Lasix 20 mg intravenous push as needed b. 500 mL albumin intravenous infusion c. Decadron 10 mg intravenous push d. Dilantin 50 mg intravenous push

Answer 30

b. 500 mL albumin intravenous infusion

Question 31

After receiving the hand-off report from the day shift charge nurse, which patient should the evening charge nurse assess first? a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F

Answer 31

d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F

Question 32

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? a. Implement droplet precautions upon admission. b. Wash hands thoroughly before leaving the room. c. Scrub the hub of all central line ports prior to use. d. Dispose of all bloody dressings in biohazard bags.

Answer 32

a. Implement droplet precautions upon admission.

Question 33

The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5 F. What is the priority nursing action? a. Elevate the head of the bed 30 degrees. b. Keep lights dim at all times. c. Implement seizure precautions. d. Maintain bedrest at all times.

Answer 33

c. Implement seizure precautions.

Question 34

The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a. Use of a heparin flush solution b. Manually flushing the device prn c. Recording ICP as a mean value d. Use of a pressurized flush system e. Zero referencing the transducer system

Answer 34

c. Recording ICP as a mean value | e. Zero referencing the transducer system

Question 35

In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.) a. Dolls eyes absent indicate a disruption in normal brainstem processing. b. Dolls eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex.

Answer 35

a. Dolls eyes absent indicate a disruption in normal brainstem processing. b. Dolls eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex

Question 36

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patients plan of care? (Select all that apply.) a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration. e. Restrain affected limb to prevent injury.

Answer 36

a. Make frequent neurological assessments. | c. Maintain MAP less than 130 mm Hg.