Neuro Nursing: Assessing & Managing Brain and Spinal Injuries, Exams of Nursing

Download Neuro Nursing: Assessing & Managing Brain and Spinal Injuries and more Exams Nursing in PDF only on Docsity! NURS 140 EXAM Questions and Answers Verified Rated A+ Guaranteed Success Latest Update 2024 A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? • Disturbed sensory perception (visual) related to neurologic trauma • Feeding self-care deficit related to neurologic trauma • Impaired verbal communication related to confusion • Risk for injury related to neurologic deficit The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? • Drainage of cerebrospinal fluid from the ears • Ecchymosis over the mastoid • Bruising under the eyes • Drainage of cerebrospinal fluid from the nose A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture? • Linear • Simple • Basilar • Comminuted The earliest sign of serious impairment of brain circulation related to increased ICP is: • A bounding pulse. • Hypertension. • A change in consciousness. • Bradycardia. While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? • concussion • skull fracture • laceration • contusion • Normal • Decerebrate The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation? • An area of bruising over the mastoid bone • Escape of cerebrospinal fluid from the client’s nose • A bloodstain surrounded by a yellowish stain on the head dressing • Escape of cerebrospinal fluid from the client’s ear The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? • It refers to the permanent deficits seen after the rehabilitation process. • It results from inadequate delivery of nutrients and oxygen to the cells. • It refers to the difficulties suffered by the client and family related to the changes in the client. • It results from initial damage to the brain from the traumatic event. A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? • Bleeding continues into the intracerebral area. • The crash cart with defibrillator is kept nearby. • Monitoring is needed as rapid neurologic deterioration may occur. • Symptoms will evolve over a period of 1 week. Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. • Verbal response • Muscle strength • Intelligence • Motor response • Eye opening The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? • Cardiogenic shock • Spinal shock • Tetraplegia • Paraplegia A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client • sleeps for short periods of time. • reports a headache. • reports generalized weakness. • vomits. Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? • Akathisia • Myoclonus • Spasticity • Ataxia Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? • L4 • S2 • T6 • T10 A client with weakness and tingling in both legs is admitted to the medical- surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? • Evaluation for signs and symptoms of increased intracranial pressure (ICP) • Evaluation of pain and discomfort • Lung auscultation and measurement of vital capacity and tidal volume • Evaluation of nutritional status and metabolic state Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)? • Maintain cerebral perfusion pressure from 50 to 70 mm Hg • Restrain the client, as indicated A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as: • Mild TBI. • Severe TBI. • Brain death. • Moderate TBI. A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? • Shaves the hair around the wound • Irrigates the wound to remove debris • Administers acetaminophen (Tylenol) for headache • Administers an oral analgesic for pain Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers? • Meticulous cleanliness • Allowing the client to choose the position of comfort • Avoidance of all lotions and lubricants • Continuous use of an indwelling catheter A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? • Autonomic dysreflexia • Spinal shock • Thrombophlebitis • Orthostatic hypotension For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? • To increase cerebral perfusion pressure • Because hypoxemia can create or worsen a neurologic deficit of the spinal cord • To prevent secondary brain injury • So that the patient will not have a respiratory arrest Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? • Placing the client in Trendelenburg's position • Monitoring the patency of an indwelling urinary catheter • Assessing laboratory test results as ordered • Administering zolpidem tartrate (Ambien) Which are risk factors for spinal cord injury (SCI)? Select all that apply. • Alcohol use • Young age • Female gender • Drug abuse • European American ethnicity A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? • Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. • Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. • Notify the physician; a headache is an early sign of worsening neurologic status. • Reassure the client that a headache is expected and will go away without treatment. The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? • Urine testing for acetone • Serum sodium concentration testing • Out of bed to the chair three times a day • Insertion of a nasogastric (NG) tube A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the • Concussion A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do? • Place the client in a sitting position. • Notify the physician. • Apply antiembolic stockings. • Lay the client flat. At a certain point, the brain’s ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing’s triad? Select all that apply. • Tachycardia • Hypotension • Bradycardia • Bradypnea • Hypertension A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make? • “They help prevent the development of contractures.” • “They prepare you to function in the absence of your leg function.” • “They help stabilize total body functioning.” • “They aid in restoring your skeletal integrity.” A client with a spinal cord injury develops an excruciating headache and profuse diuresis. Which action will the nurse take first? • Examine the rectum for a fecal mass. • Place in a seated position. • Asses the skin for areas of pressure. • Palpate the bladder for distention. The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? • Cervical collar • Cast • Traction with weights and pulleys • Turning frame The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? • A large volume enema • Digital stimulation • Insertion of a nasogastric tube • Bowel surgery After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? • Flat • Supine, with the head of the bed elevated 30 degrees • A head elevation of 90 degrees to prevent cerebral swelling • Flat, except for logrolling as needed The Monro-Kellie hypothesis refers to which of the following? • Unresponsiveness to the environment • A condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function • The brain’s attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure • The dynamic equilibrium of cranial contents The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? • The client prefers to rest in the semi-Fowler’s position. • The client’s level of consciousness has improved. • The client has periorbital edema and ecchymosis. • The client’s vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family? • Sweating • Dantrium The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe? • Numbness and vomiting • Ptosis and diplopia • Hyporeflexia in the lower extremities • Headache and nuchal rigidity Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord? • Multiple sclerosis • Parkinson disease • Creutzfeldt-Jakob disease • Huntington disease The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? • Increased pulse rate, adventitious breath sounds • Decreased pulse rate, abdominal breathing • Increased pulse rate, respirations of 16 breaths/minute • Decreased pulse rate, respirations of 20 breaths/minute Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at • controlling seizures and increased intracranial pressure. • preventing renal insufficiency. • maintaining hemodynamic stability and adequate cardiac output. • preventing muscular atrophy. Which nursing intervention is the priority for a client in myasthenic crisis? • Preparing for plasmapheresis • Administering intravenous immunoglobin (IVIG) per orders • Assessing respiratory effort • Ensuring adequate nutritional support Which of the following is the medication of choice in the treatment of herpes simplex virus (HSV)? • Phenytoin (Dilantin) • Dexamethasone (Decadron) • Vancomycin • Acyclovir (Zovirax) Which nursing intervention is appropriate for a client with double vision in the right eye due to MS? • Apply an eye patch to the right eye. • Place needed items on the right side. • Administer eye drops as needed. • Exercise the right eye twice a day. Bell palsy is a disorder of which cranial nerve? • Vagus (X) • Trigeminal (V) • Vestibulocochlear (VIII) • Facial (VII) Which is the most common cause of acute encephalitis in the United States? • Western equine virus • West Nile virus • St. Louis virus • Herpes simplex virus Which is the primary vector of arthropod-borne viral encephalitis in North America? • Spiders • Birds • Mosquitoes • Ticks educating the client about plasmapheresis and explains this in which of the following statements? • The thymus gland is removed. • Mestinon therapy is initiated. • Antibodies are removed from the plasma. • Immune globulin is given intravenously. The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis? • Ptosis and muscle weakness of upper extremities • Fever and cough • Muscle weakness and hyporeflexia of the lower extremities • Hyporeflexia and skin rash A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant? • Urine output of 40 ml/hour • Uneven, labored respirations • Warm, dry skin • Soft, nondistended abdomen The diagnosis of multiple sclerosis is based on which test? • Magnetic resonance imaging • Evoked potential studies • Neuropsychological testing • CSF electrophoresis A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test? • Immunoglobulin G (Iveegam EN) • Edrophonium (Tensilon) • Cyclosporine (Sandimmune) • Azathioprine (Imuran) A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective? • Relief from constipation • Relief from pain • Reduced muscle spasticity • Increased ability to sleep Which is a component of the nursing management of the client with new variant Creutzfeldt- Jakob disease (vCJD)? • Providing supportive care • Preparing for organ donation • Initiating isolation procedures • Administering amphotericin B Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)? • Providing palliative care • Preparing for organ donation • Administering amphotericin B • Initiating isolation procedures A patient with Bell’s palsy says to the nurse, “It doesn’t hurt anymore to touch my face. How am I going to get muscle tone back so I don’t look like this anymore?” What interventions can the nurse suggest to the patient? • Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. • Inform the patient that the muscle function will return as soon as the virus dissipates. • Suggest applying cool compresses on the face several times a day to tighten the muscles. • Tell the patient to smile every 4 hours. The nurse is administering the IV antiviral medication ganciclovir (Cytovene) to the patient with HSV-1 encephalitis. What is the best way for the nurse to administer the medication to avoid crystallization of the medication in the urine? • Administer the medication rapidly over 15 minutes with 100 mL of normal saline. • Dilute the medicine in 500 mL of lactated Ringer’s solution. • Administer via slow IV over 1 hour. • Administer in a drip over 4 hours. • indicate the need for immediate blood and cerebral spinal fluid (CSF) cultures. A client with a neurologic impairment reports having problems with constipation. Which foods might the nurse recommend? • ice cream • meat • white rice • vegetables A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate? • Ensure that client takes nothing by mouth. • Initiate seizure precautions. • Assess for facial weakness. • Assess visual acuity. A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical- surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? • Nasal cannula and oxygen • Suction machine with catheters • Sphygmomanometer • Padded tongue blade The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action? • Assess facial weakness 5 minutes after injection. • Administer edrophonium chloride per orders. • Document the results. • Ensure atropine is readily available. The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence? • The client ambulates with the assistance of one. • The client grasps the affected arm at the wrist and raises it. • The client uses a mechanical lift to climb steps. • The client arranges a community service to deliver meals. Which of the following is the first-line therapy for myasthenia gravis (MG)? • Pyridostigmine bromide (Mestinon) • Deltasone (Prednisone) • Azathioprine (Imuran) • Lioresal (Baclofen) The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur? • After administration of the medication, there will be no change in the status of the ptosis or facial weakness. • Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms. • The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon. • Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates “Impaired physical mobility” as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis? • Use pressure-relieving devices when the client is in bed or in a wheelchair. • Change body position every 2 hours. • Help the client perform range-of-motion (ROM) exercises every 8 hours. • Use a footboard and trochanter rolls. Which is often the most disabling clinical manifestation of multiple sclerosis? • Spasticity • Fatigue • Ataxia • Pain Which of the following is standard test for early diagnosis of herpes simplex virus (HSV)-1 encephalitis? • Electroencephalogram (EEG) • Cerebrospinal fluid (CSF) exam • Polymerase chain reaction (PCR) • Lumbar puncture