Question 1

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

Accepted Answer

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. B

Question 2

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?

Accepted Answer

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 provider of the patient's blood pressure. B

Question 3

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 4

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?

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 5

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 6

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 7

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 8

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.

Question 9

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

Accepted Answer

A)   2478 mg
B)   5000 mg
C)   10,794 mg
D)   12,750 mg

Question 10

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?

Accepted Answer

A)   Hyperoxygenate during endotracheal suctioning.
B)   Elevate the patient's head of the bed 30 degrees.
C)   Apply bilateral heel protectors after repositioning.
D)   Provide rest periods between nursing interventions.

Question 11

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 12

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 provider prescription should the nurse institute first?

Accepted Answer

A)   Mannitol 1 g intravenous
B)   Portable chest x-ray
C)   Seizure precautions
D)   Ancef 1 g intravenous

Question 13

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?

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 14

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.

Question 15

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 16

In an unconscious patient,eye movements are tested by the oculocephalic reflex.Which statements regarding the testing of this reflex are true?

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 17

The nurse is preparing to administer 100 mg of phenytoin to a patient in status epilepticus.To prevent patient complications,what is the best action by the nurse?

Accepted Answer

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.

Question 18

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?

Accepted Answer

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

Question 19

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

Accepted Answer

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.

Question 20

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.

Exam 14: Nervous System Alterations

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