Question 1

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults.Which action is most important?

Accepted Answer

A)   Encourage adolescents and young adults to avoid crowds in the winter.
B)   Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
C)   Immunize adolescents and college freshman against Neisseria meningitides.
D)   Emphasize the importance of hand washing to prevent the spread of infection. C

Question 2

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

Accepted Answer

A)   Coordinate the transfer of the patient to the operating room.
B)   Provide discharge instructions about monitoring neurologic status.
C)   Transport the patient to radiology for magnetic resonance imaging (MRI) .
D)   Arrange to admit the patient to the neurologic unit for 24 hours of observation. B

Question 3

Which finding for a patient who has a head injury should the nurse report immediately to the health care provider?

Accepted Answer

A)   Intracranial pressure is 16 mm Hg when patient is turned.
B)   Pale yellow urine output is 1200 mL over the last 2 hours.
C)   LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
D)   Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours. B

Question 4

The nurse is admitting a patient with a basal skull fracture.The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose.Which admission order should the nurse question?

Accepted Answer

A)   Keep the head of bed elevated.
B)   Insert nasogastric tube to low suction.
C)   Turn patient side to side every 2 hours
D)   Apply cold packs intermittently to face.

Question 5

During change-of-shift report,the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation.Which positioning shown in the accompanying figure will the nurse expect to observe?

Accepted Answer

A)   1
B)   2
C)   3
D)   4

Question 6

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling.Which nursing intervention will be included in the plan of care?

Accepted Answer

A)   Encourage coughing and deep breathing.
B)   Position the patient with knees and hips flexed.
C)   Keep the head of the bed elevated to 30 degrees.
D)   Cluster nursing interventions to provide rest periods.

Question 7

After endotracheal suctioning,the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg.Which action should the nurse take first?

Accepted Answer

A)   Document the increase in intracranial pressure.
B)   Ensure that the patient's neck is in neutral position.
C)   Notify the health care provider about the change in pressure.
D)   Increase the rate of the prescribed propofol (Diprivan)  infusion.

Question 8

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C)and a severe headache.Which order for collaborative intervention should the nurse implement first?

Accepted Answer

A)   Administer ceftizoxime (Cefizox)  1 g IV.
B)   Give acetaminophen (Tylenol)  650 mg PO.
C)   Use a cooling blanket to lower temperature.
D)   Swab the nasopharyngeal mucosa for cultures.

Question 9

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?

Accepted Answer

A)   Encourage the use of effective insect repellents during mosquito season.
B)   Remind patients that most cases of viral encephalitis can be cared for at home.
C)   Teach about the importance of prophylactic antibiotics after exposure to encephalitis.
D)   Arrange for screening of school-age children for West Nile virus during the school year.

Question 10

The nurse has administered prescribed IV mannitol (Osmitrol)to an unconscious patient.Which parameter should the nurse monitor to determine the medication's effectiveness?

Accepted Answer

A)   Blood pressure
B)   Oxygen saturation
C)   Intracranial pressure
D)   Hemoglobin and hematocrit

Question 11

When a brain-injured patient responds to nail bed pressure with internal rotation,adduction,and flexion of the arms,the nurse reports the response as

Accepted Answer

A)   flexion withdrawal.
B)   localization of pain.
C)   decorticate posturing.
D)   decerebrate posturing.

Question 12

A 20-year-old male patient is admitted with a head injury after a collision while playing football.After noting that the patient has developed clear nasal drainage,which action should the nurse take?

Accepted Answer

A)   Have the patient gently blow the nose.
B)   Check the drainage for glucose content.
C)   Teach the patient that rhinorrhea is expected after a head injury.
D)   Obtain a specimen of the fluid to send for culture and sensitivity.

Question 13

A 46-year-old patient with a head injury opens the eyes to verbal stimulation,curses when stimulated,and does not respond to a verbal command to move but attempts to push away a painful stimulus.The nurse records the patient's Glasgow Coma Scale score as

Accepted Answer

A)   9.
B)   11.
C)   13.
D)   15.

Question 14

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries,which patient should the nurse assess first?

Accepted Answer

A)   A 20-year-old patient whose cranial x-ray shows a linear skull fracture
B)   A 30-year-old patient who has an initial Glasgow Coma Scale score of 13
C)   A 40-year-old patient who lost consciousness for a few seconds after a fall
D)   A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

Question 15

A 68-year-old male patient is brought to the emergency department (ED)by ambulance after being found unconscious on the bathroom floor by his spouse.Which action will the nurse take first?

Accepted Answer

A)   Check oxygen saturation.
B)   Assess pupil reaction to light.
C)   Verify Glasgow Coma Scale (GCS)  score.
D)   Palpate the head for hematoma or bony irregularities.

Question 16

A 42-year-old patient who has bacterial meningitis is disoriented and anxious.Which nursing action will be included in the plan of care?

Accepted Answer

A)   Encourage family members to remain at the bedside.
B)   Apply soft restraints to protect the patient from injury.
C)   Keep the room well-lighted to improve patient orientation.
D)   Minimize contact with the patient to decrease sensory input.

Question 17

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP)of 106/52 mm Hg and an intracranial pressure (ICP)of 14 mm Hg.Which action should the nurse take first?

Accepted Answer

A)   Document the BP and ICP in the patient's record.
B)   Report the BP and ICP to the health care provider.
C)   Elevate the head of the patient's bed to 60 degrees.
D)   Continue to monitor the patient's vital signs and ICP.

Question 18

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department.Which action will the nurse plan to take?

Accepted Answer

A)   Administer IV furosemide (Lasix) .
B)   Prepare the patient for craniotomy.
C)   Initiate high-dose barbiturate therapy.
D)   Type and crossmatch for blood transfusion.

Question 19

When assessing a 53-year-old patient with bacterial meningitis,the nurse obtains the following data.Which finding should be reported immediately to the health care provider?

Accepted Answer

A)   The patient exhibits nuchal rigidity.
B)   The patient has a positive Kernig's sign.
C)   The patient's temperature is 101° F (38.3° 
C)  .
D)   The patient's blood pressure is 88/42 mm Hg.

Question 20

To assess for functional deficits,which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumor?

Accepted Answer

A)   "Do you have difficulty in hearing?"
B)   "Are you experiencing visual problems?"
C)   "Are you having any trouble with your balance?"
D)   "Have you developed any weakness on one side?"

Exam 57: Nursing Management: Acute Intracranial Problems