Question 1

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 2

After receiving the handoff report from the day shift charge nurse,which patient should the evening charge nurse assess first?

Accepted Answer

A)  A patient with meningitis complaining of photophobia 
B)  A mechanically ventilated patient with a GCS of 6 
C)  A patient with bacterial meningitis on droplet precautions 
D)  A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F

Question 3

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

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

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 6

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 7

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 8

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 9

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 10

The nurse,caring for a patient following a subarachnoid hemorrhage,begins a nicardipine infusion.Baseline blood pressure assessed by the nurse is 170/100 mm Hg.Five minutes after beginning the infusion at 5 mg/hr,the nurse assesses the patient's blood pressure to be 160/90 mm Hg.What is the best action by the nurse?

Accepted Answer

A)  Stop the infusion for 5 minutes. 
B)  Increase the dose by 2.5 mg/hr. 
C)  Notify the provider of the BP. 
D)  Begin weaning the infusion.

Question 11

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness.What is the priority nursing action?

Accepted Answer

A)  Assess for the presence of a headache. 
B)  Assess the patient's general orientation. 
C)  Determine the patient's drug allergies. 
D)  Determine the time of symptom onset.

Question 12

While caring for a patient with a closed head injury,the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg,heart rate 60 beats/min,respirations 18 breaths/min,and a temperature of 102°F.To reduce the risk of increased intracranial pressure (ICP)in this patient,what is (are)the priority nursing action(s)?

Accepted Answer

A)  Ensure adequate periods of rest between nursing interventions. 
B)  Insert an oral airway and monitor respiratory rate and depth. 
C)  Maintain neutral head alignment and avoid extreme hip flexion. 
D)  Reduce ambient room temperature and administer antipyretics.

Question 13

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3.Following the administration of mannitol (Osmitrol),which assessment finding by the nurse requires further action?

Accepted Answer

A)  ICP of 10 mm Hg 
B)  CPP of 70 mm Hg 
C)  GCS score of 5 
D)  CVP of 2 mm Hg

Question 14

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm.Assessment by the nurse notes blood pressure 90/60 mm Hg,heart rate 115 beats/min,respiratory rate 28 breaths/min,oxygen saturation (SpO2)99% on supplemental oxygen at 3L/min by cannula,a Glasgow Coma Score of 4,and a central venous pressure (CVP)of 2 mm Hg.After reviewing the provider prescriptions,which order is of the highest priority?

Accepted Answer

A)  Lasix 20 mg intravenous push as needed 
B)  500 mL albumin intravenous infusion 
C)  Decadron 10 mg intravenous push 
D)  Dilantin 50 mg intravenous push

Question 15

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis.To prevent the spread of nosocomial infections to other patients,what is the best action by the nurse?

Accepted Answer

A)  Implement droplet precautions upon admission. 
B)  Wash hands thoroughly before leaving the room. 
C)  Scrub the hub of all central line ports before use. 
D)  Dispose of all bloody dressings in biohazard bags.

Exam 14: Nervous System Alterations

After receiving the handoff report from the day shift charge nurse,which patient should the evening charge nurse assess first?

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

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) ?

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 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?

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness.What is the priority nursing action?

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3.Following the administration of mannitol (Osmitrol) ,which assessment finding by the nurse requires further action?

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis.To prevent the spread of nosocomial infections to other patients,what is the best action by the nurse?