Question 1

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 order by the physician should the nurse implement first?

Accepted Answer

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

Question 2

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 bedrest at all times. C

Question 3

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 D

Question 4

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 5

A patient with a head injury has an intracranial pressure (ICP)of 18 mm Hg.Her blood pressure is 144/90 mm Hg,and her 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 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 ( ED )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 physician immediately.

Question 7

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 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 physician order 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 8

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 9

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 10

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.

Question 11

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 12

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 13

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 14

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 15

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 16

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 physician of the patient's blood pressure.

Question 17

In an unconscious patient,eye movements are tested by the oculocephalic response.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 18

The nurse,caring for a patient following a subarachnoid hemorrhage,begins a nicardipine (Cardene)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 physician of the BP.
D)   Begin weaning the infusion.

Question 19

After receiving the hand-off 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 20

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)

Exam 13: Nervous System Alterations

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?

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?

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

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 ( ED ) 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 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?

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

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.)

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 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?

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?

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

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

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?