Test 2 review questions from lecture Flashcards Preview

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Flashcards in Test 2 review questions from lecture Deck (27):

The gcs assesses?



decorticate motor response indicates

cerebral hemispheric dysfunction


Pupils are bilaterally pinpoint andn nonreactive to light.  What does this indicate?

severe herniation


in cases of brain stem injury dolls eye movement will remain

fixed at the midpoint position


rhythmic waxing and wayning followed by period of apnea

cheyne stokes


elevated wave form on monitor that is clinically significant

a wave


During administration of t-PA the nurse should perform neurovascular checks?

  • Every 15 minutes
  • Every hour
  • Every 4 hours
  • Every shift


Every 15 minutes


during assessment the pt. asks if something is burning.  Nurse realizes the pt. is demonstrating?

a focal seizure


preparing to administer med to pt. to reduce cerebral edema caused by a brain tumor.  Med is most likely?

glucocorticoid med (mannitoL)


plan of care after posterior fossa surgery?

assess vital signs every 15 minutes


a pt. after craniotomy and has a headache, hob elevated, damp mark on pt. pillow.  Nurse should?

alert physician, check for glucose in drainage


pt with intracerebral hemmorrhage.  What is most common cause?



major management goals in caring for the donor patient include

maintain stable hemodynamic status, fluid and electrolute balance, optimal oxygenation


general guidelines in determination of organ transplant include?

  • Children have priority over adults
  • Body habitus
  • Blood group
  • Human leukocyte antigens (HLA) match
  • High panel reactive antibody (PRA) score: highly sensitized recipients




pt is considered apneic if paco2 is

greater than 60, or greater than 20 rise above the baseline


A 30 year old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident.  Which of the following assessments would take priority?

-bladder distention

-neurologic deficit

-pulse ox readings

-clients feelings about the injury

bladder distention


While in the ER, a client with c8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR 18.  The nurse suspects which of the following onditions?

-autonomic dysreflexia

-hemorrhagic shock

-neurogenic shock

-pulmonary embolism

neruogenic shock


a 22 yr old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a hr of 50bpm.   Which of the following nursing interventions should be done first?

-place the client flat in bed

-assess patency of the indwelling urinary catheter

-give one SL nitroglycerin tab

-raise the head of the bed immediately to 90 degrees

assess patency of the indewelling urinary catheter


The nurse is caring for an elderly client diagnosed with a herniated nucleus pulposus of l4-l5.  Which scientific rationale explains the incidence of a ruptured disk in the elderly?

-the client did not use good body mechanics when lifting an object

-there is an increased blood supply to the back as the body ages

-older clients develop atherosclerotic joint disease as a result of fat deposits

-client develop intervertebral disc degeneration as they age

clients develop intervertebral disc degeneration as they age


A client is admitted with a spinal cord injury at the level of t12.  He has limited movement of his upper extremities.  Which of the following medications would be used to control edema of the spinal cord?

-acetazolamide (diamox)

-furosemide (lasix)

-methylprednisolone (Solu-Medrol)

-Sodium bicarbonate

methylprednisolone (solu-medrol)


A client with a cervical spine injury has gardner-wells tons inserted for which of the following reasons?

-to hasten wound healing

-to immobilize the surgical spine

-to prevent autonomic dysreflexia

-to hold bony fragments of the skull together

immobilize the surgical spine


Which of the following interventions describes an appropriate bladder program for a client in rehab 

-insert an indewelling urinary cath to straight drainage

-schedule internittent cath every 2-4 hours

-perform a straight cath every 8 hrs while awake

-perform crede's maneuver to the lower abdomen before the client voids

schedule intermittent cath every 2-4 hours


A client has a cervial spine injury at the level of c5.  Which of the following conditions would the nurse anticipate during the acute phase?

-absent corneal reflex

-decerbate posturing

-movement of only the right or left half ot the body

-the need for mechanical ventilation

the need for mechanical vent


The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury.  Which of the following observaions by the nurse indicates that spinal sock persists?

-positive reflexs


-inability to elicit a babinski reflex

-reflex emptying of the bladder

inability to elicit the babinski reflex


Your t1 spinal cord injured patient complains of a headache.  You should?

-give him prn tylenol

-disempact his bowels

-call the dr.

-take hid BP

take his blood pressure


What can the nurse do to best speed the patients recovery from a laminectomy of L5?

-keep pt. flat in bed

-teach the back school approach

-medicate for pain q2 hrs

ambulate as soon as orders permit

keep the patient flat in bed


Your patient has a malignant metastatic lesion at t8 and is in for palliative radiation.  What is your main goal with this patient?

-teach self cath

-ensure pt. recieved pain meds as needed

-encourage pt. to discuss fears

-ambulate twice a shift

ensure patient receives pain medication as needed