Multiple Choice Questions

- Lethargy and stuporAs ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.
  • What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? - A bounding pulse - Bradycardia - Hypertension - Lethargy and stupor
  • You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?- Tetraplegia- Areflexia- Autonomic dysreflexia- Paraplegia
  • The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as- coma. - minimally responsive. - least responsive. - most responsive.
  • When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?- Decerebrate - Normal - Flaccid - Decorticate
BradycardiaHTNBradypneaThe bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.
  • Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?- Administering zolpidem tartrate (Ambien)- Assessing laboratory test results as ordered - Placing the client in Trendelenburg's position - Monitoring the patency of an indwelling urinary catheter
  • At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.Bradycardia Hypertension Bradypnea Hypotension Tachycardia
  • A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?- Decreased heart rate- Bradycardia- Alteration in level of consciousness (LOC)- Slurred speech
  • A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?- acute- chronic- subacute- intracerebral
- C5 At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion.
  • At which of the following spinal cord injury levels does the patient have full head and neck control?- C5 - C4 - C3 - C2
  • Which of the following is the earliest sign of increasing intracranial pressure (ICP)?- Change in level of consciousness (LOC)- Seizures- Restlessness- Pupil changes
  • Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?- T6- S2- L4- T10
  • A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?- Administer oxygen as prescribed. - Use mechanical ventilation. - Maintain a patent airway. - Suction the airway.
- Maintain cerebral perfusion pressure from 50 to 70 mm Hg The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP.
  • A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to the legs will illicit severe pain. The client is describing which type of pain?- allodynia- hyperalgesia- nociceptive- idiopathic
  • The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as- coma. - minimally responsive. - least responsive. - most responsive.
  • The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?- Position the client in the supine position- Maintain cerebral perfusion pressure from 50 to 70 mm Hg - Restrain the client, as indicated - Administer enemas, as needed
  • The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the- dorsal recumbent position. - supine position with the head slightly elevated. - prone position with the head turned to the unaffected side. - Trendelenburg position.
- Body temperatureIt is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor.
  • When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?- Extreme thirst- Intake and output- Nutritional status- Body temperature
  • The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as- coma. - minimally responsive. - least responsive. - most responsive.
  • A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:- raccoon's eyes and Battle sign.- nuchal rigidity and Kernig's sign.- motor loss in the legs that exceeds that in the arms.- pupillary changes.
  • When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?- Decerebrate - Normal - Flaccid - Decorticate
- Autonomic dysreflexiaAutonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides.
  • The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?- Position the client in the supine position- Maintain cerebral perfusion pressure from 50 to 70 mm Hg - Restrain the client, as indicated - Administer enemas, as needed
  • What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? - A bounding pulse - Bradycardia - Hypertension - Lethargy and stupor
  • You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?- Tetraplegia- Areflexia- Autonomic dysreflexia- Paraplegia
  • A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to the legs will illicit severe pain. The client is describing which type of pain?- allodynia- hyperalgesia- nociceptive- idiopathic
- An area of bruising over the mastoid boneFractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign). Basilar skull fractures are suspected when cerebrospinal fluis (CSF) escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a CSF leak.
  • The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the- dorsal recumbent position. - supine position with the head slightly elevated. - prone position with the head turned to the unaffected side. - Trendelenburg position.
  • The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?- Position the client in the supine position- Maintain cerebral perfusion pressure from 50 to 70 mm Hg - Restrain the client, as indicated - Administer enemas, as needed
  • The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation?- A bloodstain surrounded by a yellowish stain on the head dressing- An area of bruising over the mastoid bone- Escape of cerebrospinal fluid from the client's ear- Escape of cerebrospinal fluid from the client's nose
  • When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?- Decerebrate - Normal - Flaccid - Decorticate
- Monitoring the patency of an indwelling urinary catheterA full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder.
  • Which of the following is the earliest sign of increasing intracranial pressure (ICP)?- Change in level of consciousness (LOC)- Seizures- Restlessness- Pupil changes
  • Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?- Administering zolpidem tartrate (Ambien)- Assessing laboratory test results as ordered - Placing the client in Trendelenburg's position - Monitoring the patency of an indwelling urinary catheter
  • When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?- Shock - Encephalitis- Increased intracranial pressure (ICP)-Status epilepticus
  • A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?- Decreased heart rate- Bradycardia- Alteration in level of consciousness (LOC)- Slurred speech
- Decerebrate Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.
  • The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation?- A bloodstain surrounded by a yellowish stain on the head dressing- An area of bruising over the mastoid bone- Escape of cerebrospinal fluid from the client's ear- Escape of cerebrospinal fluid from the client's nose
  • When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?- Decerebrate - Normal - Flaccid - Decorticate
  • The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the- dorsal recumbent position. - supine position with the head slightly elevated. - prone position with the head turned to the unaffected side. - Trendelenburg position.
  • The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as- coma. - minimally responsive. - least responsive. - most responsive.
- supine position with the head slightly elevated. After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.
  • The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as- coma. - minimally responsive. - least responsive. - most responsive.
  • The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?- Position the client in the supine position- Maintain cerebral perfusion pressure from 50 to 70 mm Hg - Restrain the client, as indicated - Administer enemas, as needed
  • The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation?- A bloodstain surrounded by a yellowish stain on the head dressing- An area of bruising over the mastoid bone- Escape of cerebrospinal fluid from the client's ear- Escape of cerebrospinal fluid from the client's nose
  • The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the- dorsal recumbent position. - supine position with the head slightly elevated. - prone position with the head turned to the unaffected side. - Trendelenburg position.
- dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.
  • Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?- T6- S2- L4- T10
  • A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?- Administer oxygen as prescribed. - Use mechanical ventilation. - Maintain a patent airway. - Suction the airway.
  • When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?- Shock - Encephalitis- Increased intracranial pressure (ICP)-Status epilepticus
  • An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to- control fever. - control shivering. - dehydrate the brain and reduce cerebral edema. - reduce cellular metabolic demand.
- Change in level of consciousness (LOC)The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported immediately. Seizures, restlessness, and pupil changes may occur, but these are not the earliest signs.
  • Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?- Administering zolpidem tartrate (Ambien)- Assessing laboratory test results as ordered - Placing the client in Trendelenburg's position - Monitoring the patency of an indwelling urinary catheter
  • Which of the following is the earliest sign of increasing intracranial pressure (ICP)?- Change in level of consciousness (LOC)- Seizures- Restlessness- Pupil changes
  • At which of the following spinal cord injury levels does the patient have full head and neck control?- C5 - C4 - C3 - C2
  • When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?- Shock - Encephalitis- Increased intracranial pressure (ICP)-Status epilepticus
- acuteSubdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.
  • A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?- Decreased heart rate- Bradycardia- Alteration in level of consciousness (LOC)- Slurred speech
  • A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?- Keep the client's neck in a neutral position (no flexing).- Avoid sedation.- Cluster all procedures together.- Keep the head of the client's bed flat.
  • A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?- acute- chronic- subacute- intracerebral
  • A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? - Maintaining adequate hydration- Administering prescribed antipyretics- Restricting fluid intake and hydration- Hyperoxygenation before and after tracheal suctioning
- Suction the airway.Suctioning the airway helps remove secretions. An artificial airway increases the production of respiratory secretions.
  • A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?- Decreased heart rate- Bradycardia- Alteration in level of consciousness (LOC)- Slurred speech
  • A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?- Administer oxygen as prescribed. - Use mechanical ventilation. - Maintain a patent airway. - Suction the airway.
  • A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? - Maintaining adequate hydration- Administering prescribed antipyretics- Restricting fluid intake and hydration- Hyperoxygenation before and after tracheal suctioning
  • A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?- Sciatic nerve pain- Herniation- Paresthesia- Paralysis
- ParesthesiaWhen a client reports numbness and tingling in an area, he is reporting a paresthesia.
  • A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?- Decreased heart rate- Bradycardia- Alteration in level of consciousness (LOC)- Slurred speech
  • A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?- Administer oxygen as prescribed. - Use mechanical ventilation. - Maintain a patent airway. - Suction the airway.
  • A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? - Maintaining adequate hydration- Administering prescribed antipyretics- Restricting fluid intake and hydration- Hyperoxygenation before and after tracheal suctioning
  • A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?- Sciatic nerve pain- Herniation- Paresthesia- Paralysis
- coma. The GCS is a tool for assessing a client's response to stimuli. A score of 7 or less is generally interpreted as a coma. The lowest score is 3 (least responsive/deep coma); the highest is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head injury. No category is termed "least" responsive.
  • The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as- coma. - minimally responsive. - least responsive. - most responsive.
  • When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?- Decerebrate - Normal - Flaccid - Decorticate
  • The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?- Position the client in the supine position- Maintain cerebral perfusion pressure from 50 to 70 mm Hg - Restrain the client, as indicated - Administer enemas, as needed
  • The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the- dorsal recumbent position. - supine position with the head slightly elevated. - prone position with the head turned to the unaffected side. - Trendelenburg position.
- Keep the client's neck in a neutral position (no flexing).To assist in controlling ICP in clients with severe brain injury, the following are recommended: elevate the head of the bed as prescribed (gravity helps drain fluid), maintain head/neck in neutral alignment (no twisting or flexing), give sedation as ordered to prevent agitation, and avoid noxious stimuli (scatter procedures so that client does not become overtired).
  • A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:- hold the client's arm still to keep him from hitting anything.- carefully move the client to a flat surface and turn him on his side.- allow the client to remain in the chair but move all objects out of his way.- place an oral airway in the client's mouth to maintain an open airway.
  • A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?- acute- chronic- subacute- intracerebral
  • A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?- Keep the client's neck in a neutral position (no flexing).- Avoid sedation.- Cluster all procedures together.- Keep the head of the client's bed flat.
  • A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?- Decreased heart rate- Bradycardia- Alteration in level of consciousness (LOC)- Slurred speech
- raccoon's eyes and Battle sign.A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.
  • When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?- Extreme thirst- Intake and output- Nutritional status- Body temperature
  • When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?- Decerebrate - Normal - Flaccid - Decorticate
  • A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:- raccoon's eyes and Battle sign.- nuchal rigidity and Kernig's sign.- motor loss in the legs that exceeds that in the arms.- pupillary changes.
  • You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?- Tetraplegia- Areflexia- Autonomic dysreflexia- Paraplegia
0 h : 0 m : 1 s

Multiple Choice Questions
Answered Not Answered Not Visited Correct : 0 Incorrect : 0