Question 1

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?

Accepted Answer

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. C

Question 2

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°F.The patient is lethargic,responds to voice but falls asleep readily when not stimulated.Which nursing action is most important to include in this patient's plan of care?

Accepted Answer

A)   Frequent neurological assessments
B)   Side to side position changes
C)   Range-of-motion to extremities
D)   Frequent oropharyngeal suctioning A

Question 3

The nurse is to administer 100 mg phenytoin 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?

Accepted Answer

A)   Administer over 2 minutes.
B)   Administer over 20 to 30 minutes.
C)   Mix medication with 0.9% normal saline.
D)   Administer via central line. B

Question 4

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

Accepted Answer

A)   A patient with a complete spinal cord 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

Question 5

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.)

Accepted Answer

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

Question 6

The nurse is preparing to administer a routine dose of phenytoin.The provider orders phenytoin 500 mg intravenous every 6 hours.What is the best action by the nurse?

Accepted Answer

A)   Administer over 2 minutes.
B)   Administer with 0.9% normal saline intravenous.
C)   Contact the provider.
D)   Assess cardiac rhythm.

Question 7

In an unconscious patient,eye movements are tested by the oculocephalic reflex.Which statements regarding the testing of this reflex are true? (Select all that apply.)

Accepted Answer

A)   Doll's eyes absent indicate a disruption in normal brainstem processing.
B)   Doll's 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.

Question 8

The provider prescribes fosphenytoin,1.5 g intravenous (IV)loading dose,for a 75-kg patient in status epilepticus.What is the most important action by the nurse?

Accepted Answer

A)   Contact the admitting physician.
B)   Administer the drug over 10 minutes.
C)   Mix medication with 0.9% normal saline.
D)   Administer via central line.

Question 9

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?

Accepted Answer

A)   Maintain body temperature.
B)   Monitor blood pressure.
C)   Pad all bony prominences.
D)   Use proper hand washing.

Question 10

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

Accepted Answer

A)   54 mm Hg
B)   72 mm Hg
C)   90 mm Hg
D)   126 mm Hg

Question 11

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?

Accepted Answer

A)   Both pressures are high.
B)   Both pressures are low.
C)   ICP is high; CPP is normal.
D)   ICP is high; CPP is low.

Question 12

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 with a GCS score of 15.One hour later,the nurse assesses a GCS score of 3.What is the priority nursing action?

Accepted Answer

A)   Stimulate the patient hourly.
B)   Continue to monitor the patient.
C)   Elevate the head of the bed.
D)   Notify the provider immediately.

Question 13

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 patient's plan of care? (Select all that apply.)

Accepted Answer

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.

Question 14

The nurse is caring for a patient admitted to the emergency department 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 naris.What is the most appropriate nursing action?

Accepted Answer

A)   Insert bilateral ear plugs.
B)   Monitor airway patency.
C)   Maintain neutral head position.
D)   Apply a small nasal drip pad.

Question 15

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 of 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 provider prescription should the nurse institute first?

Accepted Answer

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

Question 16

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?

Accepted Answer

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)

Question 17

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?

Accepted Answer

A)   Monitor the patient's airway patency.
B)   Elevate the head of the patient's bed.
C)   Increase supplemental oxygen delivery.
D)   Support bony prominences with padding.

Question 18

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 prescription by the provider should the nurse implement first?

Accepted Answer

A)   Obtain stat serum electrolytes.
B)   Administer lorazepam.
C)   Obtain stat portable chest x-ray.
D)   Administer phenytoin.

Question 19

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?

Accepted Answer

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 patient's mouth and insert a padded tongue blade.
D)   Restrain the patient's extremities until the seizure subsides.

Question 20

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?

Accepted Answer

A)   Elevate the head of the bed 30 degrees.
B)   Keep lights dim at all times.
C)   Implement seizure precautions.
D)   Maintain bed rest at all times.

Exam 14: Nervous System Alterations

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?

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

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.)

The nurse is preparing to administer a routine dose of phenytoin.The provider orders phenytoin 500 mg intravenous every 6 hours.What is the best action by the nurse?

In an unconscious patient,eye movements are tested by the oculocephalic reflex.Which statements regarding the testing of this reflex are true? (Select all that apply.)

The provider prescribes fosphenytoin,1.5 g intravenous (IV) loading dose,for a 75-kg patient in status epilepticus.What is the most important action by the nurse?

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

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?

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 with a GCS score of 15.One hour later,the nurse assesses a GCS score of 3.What is the priority nursing action?

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?

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?