Med-surg Tb Neuro 22-24

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| By Victoria.roco
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Med-surg Tb Neuro 22-24 - Quiz

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Questions and Answers
  • 1. 

    The nurse is caring for the patient who has had an injury to the hypothalamus. Which intervention will the nurse be most concerned with implementing?

    • A.

      Maintaining environmental temperature control

    • B.

      Monitoring for signs of hemorrhage

    • C.

      Protecting the eyes from bright lights

    • D.

      Providing care designed to preserve skin integrity

    Correct Answer
    A. Maintaining environmental temperature control
    Explanation
    The hypothalamus regulates body temperature; therefore, it is important to maintain adequate temperature control of the environment since the body’s ability to regulate the temperature will be affected by injury to the organ. Bleeding, photophobia, and skin integrity are not issues associated with the hypothalamus.

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  • 2. 

    The nurse differentiates the sympathetic from the parasympathetic nervous systems in that the sympathetic system:

    • A.

      Provides energy for “fight or flight” in stressful situations.

    • B.

      Slows the heart rate after a stressful situation.

    • C.

      Supports deep sleep after large expenditures of energy.

    • D.

      Relaxes blood vessels to counteract hypertension.

    Correct Answer
    A. Provides energy for “fight or flight” in stressful situations.
    Explanation
    The sympathetic nervous system “gears up” the body for “fight or flight” situations with epinephrine that will raise the blood pressure, reduce bowel motility, and energize the whole body to defend itself in a stressful situation.

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  • 3. 

    The nurse assessing an 80-year-old attributes the slowed knee jerk reflex with which age-related change?

    • A.

      Diminished brain cells

    • B.

      Degeneration of myelin sheath

    • C.

      Weakened muscles

    • D.

      Irritation of nerve roots

    Correct Answer
    B. Degeneration of myelin sheath
    Explanation
    Loss of nerve fibers in the autonomic nervous system will cause diminished reflexes in the older adult.

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  • 4. 

    A student nurse questions the nurse about the difference between a quadriplegic and a tetraplegic patient. The nurse correctly reports that a tetraplegic patient:

    • A.

      Has fewer fine motor movements.

    • B.

      Can experience pain in paralyzed parts.

    • C.

      Is more easily rehabilitated.

    • D.

      Means the same as a quadriplegic.

    Correct Answer
    D. Means the same as a quadriplegic.
    Explanation
    Tetraplegia is the newer term for the old term quadriplegia.

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  • 5. 

    The nurse requesting the patient to stick out the tongue and move it rapidly from side to side is assessing the __________ nerve.

    • A.

      Hypoglossal

    • B.

      Glossopharyngeal

    • C.

      Vagal

    • D.

      Abducens

    Correct Answer
    A. Hypoglossal
    Explanation
    The test described is the test for the effectiveness of the hypoglossal nerve (CN XII), which is a cranial motor nerve responsible for tongue movement and articulation of speech.

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  • 6. 

    The nurse may record a positive Romberg’s test if during the test, the patient:

    • A.

      Cannot keep his eyes closed.

    • B.

      Cannot touch his nose with eyes closed.

    • C.

      Complains of dizziness.

    • D.

      Sways from side to side.

    Correct Answer
    D. Sways from side to side.
    Explanation
    The patient is asked to stand with his feet together and to close his eyes. Swaying from side to side during the Romberg’s test is a positive sign for impaired balance.

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  • 7. 

    The nurse explains that a reflex is a simple automatic response requiring only:

    • A.

      One efferent and one afferent impulse and a synapse.

    • B.

      Two efferent impulse and one synapse.

    • C.

      Two synapses with efferent and afferent impulses.

    • D.

      Two afferent impulses and one synapse.

    Correct Answer
    A. One efferent and one afferent impulse and a synapse.
    Explanation
    The reflex only requires an efferent and an afferent impulse and one synapse, a very simple response.

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  • 8. 

    The nurse interprets the physician’s finding of a grade of 2/5 on the Achilles tendon to mean what has occurred?

    • A.

      Hyperreflexive response for the fifth and sixth cervical nerves

    • B.

      Exaggerated response for the seventh and eighth cervical nerves

    • C.

      Normal response for the first and second sacral nerves

    • D.

      Weak response for the second through the fourth lumbar nerves

    Correct Answer
    C. Normal response for the first and second sacral nerves
    Explanation
    A score of 2/5 is a normal grade. The Achilles tendon reflex evaluates the first and second sacral nerves.

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  • 9. 

    The reflex that indicates an abnormality in the motor control pathways from the cerebral cortex is the __________ reflex.

    • A.

      Babinski

    • B.

      Biceps

    • C.

      Brachioradialis

    • D.

      Knee jerk

    Correct Answer
    A. Babinski
    Explanation
    A positive Babinski reflex indicates an abnormality in the motor pathways from the cerebral cortex.

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  • 10. 

    The vital sign assessment of a person with a head injury was temperature (T), 97° F; pulse (P), 86; respiration (R), 18; and blood pressure (BP), 140/86 at 1:00. Which vital sign assessment made 30 minutes later is indicative of increasing intracranial pressure (ICP)?

    • A.

      T, 98° F; P, 78; R, 14; BP, 150/82

    • B.

      T, 97° F; P, 90; R, 20; BP, 148/94

    • C.

      T, 98° F; P, 82; R, 18; BP, 140/74

    • D.

      T, 99° F; P, 92; R, 16; BP, 136/82

    Correct Answer
    A. T, 98° F; P, 78; R, 14; BP, 150/82
    Explanation
    An increasing temperature, decreasing pulse and respirations, and a widening pulse pressure are indicative of increasing ICP.

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  • 11. 

    The nurse notes that the Glasgow Coma Scale rating made on the patient 4 hours ago indicated a fully alert patient with a score of _____ points.

    • A.

      25

    • B.

      20

    • C.

      15

    • D.

      10

    Correct Answer
    C. 15
    Explanation
    The Glasgow Coma Scale is used to evaluate a patient’s neurologic functioning and level of consciousness. Scores range from 3 to 15 points. The higher the score, the higher the level of consciousness. A score of 15 points on the Glasgow Coma Scale indicates a fully alert patient.

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  • 12. 

    The assessment of a patient’s ability to think can be evaluated by asking the patient:

    • A.

      To add three numbers together in his head.

    • B.

      To identify the name of the present month.

    • C.

      What he would do in the event of a fire.

    • D.

      What the last major holiday was.

    Correct Answer
    A. To add three numbers together in his head.
    Explanation
    Thinking can be evaluated by asking the patient to perform simple arithmetic functions in his head.

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  • 13. 

    The nurse is performing a neurologic assessment on a newly admitted head injury patient. Which sign does the nurse recognize as that most indicative of a brainstem injury?

    • A.

      Nystagmus

    • B.

      Decerebrate posturing

    • C.

      Seizure activity

    • D.

      Glasgow Coma Scale score of 3

    Correct Answer
    B. Decerebrate posturing
    Explanation
    The appearance of decerebrate as well as decorticate posturing is an indicator of brainstem injury. Nystagmus, seizures, and a Glasgow score of 3 are not necessarily signs of brainstem injury.

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  • 14. 

    The crossed arms of the examiner when assessing muscle strength in a neurologic assessment is done in order to:

    • A.

      Align the examiner’s hands with the patient’s hands.

    • B.

      Create greater distance between the examiner and the patient.

    • C.

      Allow a comfortable stance for the examiner.

    • D.

      Equalize sensitivity of the examiner’s hands.

    Correct Answer
    A. Align the examiner’s hands with the patient’s hands.
    Explanation
    By crossing the arms, the examiner’s hands and the patient’s hands are aligned. Whatever the examiner feels in her right hand would be happening in the patient’s right hand as well.

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  • 15. 

    When feeding a patient with dysphagia with a left-sided hemiplegia, how should the nurse position the patient?

    • A.

      Side-lying on the right side

    • B.

      Semi-Fowler’s

    • C.

      High Fowler’s

    • D.

      Upright at a table in a wheelchair

    Correct Answer
    C. High Fowler’s
    Explanation
    High Fowler’s is the most comfortable and safe position. Sitting upright at a table may prove stressful because of weakness and impaired balance.

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  • 16. 

    Bladder training begins with toileting the patient every:

    • A.

      Hour

    • B.

      2 hours

    • C.

      3 hours

    • D.

      4 hours

    Correct Answer
    B. 2 hours
    Explanation
    Bladder training begins with toileting the patient every 2 hours.

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  • 17. 

    A patient is admitted to the hospital to rule out the possibility of bacterial meningitis. Which test will be most helpful in diagnosing this condition?

    • A.

      Magnetoencephalography (MEG)

    • B.

      Myelography

    • C.

      Cerebral angiography

    • D.

      Lumbar puncture for cerebrospinal fluid (CSF) analysis and culture

    Correct Answer
    D. Lumbar puncture for cerebrospinal fluid (CSF) analysis and culture
    Explanation
    A lumbar puncture is performed to remove a sample of CSF to detect abnormalities that are indicative of specific neurologic problems and determine which organism is responsible for an infection such as bacterial meningitis.

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  • 18. 

    The patient scheduled for a PET (positron emission tomography) scan of the brain asks if there is any special preparation for the test. The nurse correctly responds with which statements? (Select all that apply.)

    • A.

      “There is no special preparation involved with this test since it is noninvasive.”

    • B.

      “You should avoid any tranquilizers or sedatives the night before and the day of the test.”

    • C.

      “You will need to sign a consent form for this test to be performed.”

    • D.

      "You will have an IV inserted for the exam.”

    • E.

      “I’m not really sure. The technician’s performing the test will let you know.”

    Correct Answer(s)
    B. “You should avoid any tranquilizers or sedatives the night before and the day of the test.”
    C. “You will need to sign a consent form for this test to be performed.”
    D. "You will have an IV inserted for the exam.”
    Explanation
    During a PET scan, radioactive material is given through an IV and provides differing color in areas of cellular activity. A consent form is required because this is an invasive test, and tranquilizers and sedatives should be avoided because this PET scan is of brain activity. Telling the patient that the nurse is unsure does not instill confidence or meet the need of the patient.

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  • 19. 

    The loss of neurons in the autonomic nervous system (ANS) of the older adult will cause the older adult to take longer to: (Select all that apply.)

    • A.

      Recuperate from an illness.

    • B.

      Apply brakes to stop a car.

    • C.

      Form words into sentences.

    • D.

      Climb stairs.

    • E.

      Learn new material.

    Correct Answer(s)
    A. Recuperate from an illness.
    B. Apply brakes to stop a car.
    Explanation
    Recuperation and response times are lengthened with the loss of neurons from the ANS. The other options have to do with loss of strength and mentation.

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  • 20. 

    The nurse can be proactive in reducing neurologic injuries by: (Select all that apply.)

    • A.

      Insisting everyone “buckle up” before starting the car.

    • B.

      Encouraging children to wear bike helmets.

    • C.

      Reminding swimmers to test water depth before diving.

    • D.

      Encouraging use of hard hats at industrial sites.

    • E.

      Discouraging recreational drug use that could bring on a stroke.

    Correct Answer(s)
    A. Insisting everyone “buckle up” before starting the car.
    B. Encouraging children to wear bike helmets.
    C. Reminding swimmers to test water depth before diving.
    D. Encouraging use of hard hats at industrial sites.
    E. Discouraging recreational drug use that could bring on a stroke.
    Explanation
    All options would be supportive of the reduction of CNS injury.

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  • 21. 

    The FOUR (Full Outline of UnResponsiveness) tool is based on the assessment of the status of the: (Select all that apply.)

    • A.

      Eye response.

    • B.

      Motor response.

    • C.

      Brainstem response.

    • D.

      Respiratory function.

    • E.

      Reflex response.

    Correct Answer(s)
    A. Eye response.
    B. Motor response.
    C. Brainstem response.
    D. Respiratory function.
    Explanation
    Reflex response is not part of the assessment tool.

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  • 22. 

    The nurse performs a reflex test on a newly admitted adult patient. The nurse runs a tongue blade along the sole of the foot and the patient responds with the great toe bending backward (upward) and the smaller toes fanning outward. The nurse suspects the patient may be suffering from what? (Select all that apply.)

    • A.

      Injury to the CNS causing an abnormality in the motor control pathways leading from the cerebral cortex

    • B.

      A myocardial infarction that has caused hypoxemia

    • C.

      The influence of chemical substances

    • D.

      Damage to the peripheral nervous system (PNS)

    • E.

      Trauma to the hypothalamus

    Correct Answer(s)
    A. Injury to the CNS causing an abnormality in the motor control pathways leading from the cerebral cortex
    C. The influence of chemical substances
    Explanation
    This response in the adult indicates a positive Babinski reflex, indicative of an abnormality in the motor control pathways leading from the cerebral cortex, or from the influence of chemical substances. Hypoxemia, damage to the PNS, and trauma to the hypothalamus would not cause a positive Babinski reflex.

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  • 23. 

    The nurse describes a concussion as a closed head injury in which:

    • A.

      The brain tissue is bruised.

    • B.

      No loss of consciousness occurs.

    • C.

      There is amnesia related to the incident.

    • D.

      There are no subsequent symptoms.

    Correct Answer
    C. There is amnesia related to the incident.
    Explanation
    A concussion is a closed head injury in which there is a brief disruption of consciousness, amnesia, and subsequent headaches that may last for several weeks.

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  • 24. 

    The nurse is aware that the older adult is more at risk for a cranial bleed following a head injury because the older adult has:

    • A.

      A smaller brain, which allows for more movement inside the cranium.

    • B.

      Fragile vessels more likely to rupture.

    • C.

      Less cerebrospinal fluid to cushion the brain.

    • D.

      Less flexibility of the meninges to absorb impact.

    Correct Answer
    A. A smaller brain, which allows for more movement inside the cranium.
    Explanation
    Atrophy of the brain leaves increased intracranial space, allowing increased movement of the brain in the event of head trauma.

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  • 25. 

    The emergency room nurse assessing clear drainage from the nose of a newly admitted patient with a head injury should perform which intervention?

    • A.

      Document the presence of rhinorrhea.

    • B.

      Inform the physician of the assessment.

    • C.

      Test fluid with a glucose Accu-Chek or Dextrostix.

    • D.

      Tape a drip pad under the nose.

    Correct Answer
    C. Test fluid with a glucose Accu-Chek or Dextrostix.
    Explanation
    The presence of glucose in the fluid from the nose confirms that the fluid is cerebrospinal fluid. Documentation and informing the physician should occur after confirmation of the character of the fluid.

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  • 26. 

    In assessing the patient with a significant right-sided closed head injury, the nurse would anticipate the patient to demonstrate which sign?

    • A.

      Left-sided motor deficit with sluggish right pupil response

    • B.

      Right-sided motor deficit with brisk right pupil response

    • C.

      Bilateral motor deficit with bilaterally sluggish pupil response

    • D.

      Left-sided motor deficit and bilateral PERRLA

    Correct Answer
    A. Left-sided motor deficit with sluggish right pupil response
    Explanation
    A right-sided injury will cause contralateral (opposite side) motor deficit and ipsilateral (same side) pupillary response.

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  • 27. 

    The older adult who is admitted to the hospital following a closed head injury that resulted in a 5-minute period of unconsciousness will be observed for which change?

    • A.

      Increasing respiratory rate

    • B.

      Decreasing heart rate

    • C.

      Decreasing pulse pressure

    • D.

      Decreasing level of consciousness (LOC)

    Correct Answer
    D. Decreasing level of consciousness (LOC)
    Explanation
    Assessment of level of consciousness provides the greatest amount of information about neurologic condition. A reduction in level of consciousness may signal the onset of complications in the patient who has had a head injury.

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  • 28. 

    The patient with a suspected subdural hematoma is on an IV drip of mannitol infusing at 50 mL/hr. The nurse explains that the slow infusion rate is essential for what purpose?

    • A.

      Ensure effectiveness of the drug.

    • B.

      Avoid fluid overload.

    • C.

      Maintain electrolyte balance.

    • D.

      Maintain adequate blood pressure.

    Correct Answer
    B. Avoid fluid overload.
    Explanation
    The slow infusion rate will not cause fluid overload, which would add to the possibility of increased intracranial pressure.

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  • 29. 

    Following a craniotomy to relieve increased intracranial pressure (ICP), the nurse will implement which intervention?

    • A.

      Elevate the head of the bed 30 to 45 degrees.

    • B.

      Place drip pad or cotton to absorb cerebrospinal fluid drainage from the nose or ears.

    • C.

      Keep the patient stimulated to better assess changing level of consciousness.

    • D.

      Allow the patient to change positions frequently for comfort.

    Correct Answer
    A. Elevate the head of the bed 30 to 45 degrees.
    Explanation
    The head of bed is elevated to aid in reduction of ICP. Drip pads, patient stimulation, and changing positions frequently may increase ICP.

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  • 30. 

    The unconscious patient with a closed head injury is on mechanical ventilation. To improve brain perfusion through increased blood pressure, the CO2 level is maintained at _____ mm Hg.

    • A.

      10 to 15

    • B.

      15 to 20

    • C.

      20 to 25

    • D.

      25 to 30

    Correct Answer
    D. 25 to 30
    Explanation
    The carbon dioxide level is set to be maintained at 25 to 30 mm Hg to create vascular constriction, raise blood pressure, and perfuse the cerebrum.

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  • 31. 

    The nurse caring for a patient with an epidural hematoma suspects diabetes insipidus when the patient exhibits increased:

    • A.

      Lethargy

    • B.

      Pulse pressure.

    • C.

      Urinary output.

    • D.

      Blood glucose levels.

    Correct Answer
    C. Urinary output.
    Explanation
    A large increase in urinary output of pale urine with a low specific gravity is the clue to the development of diabetes insipidus related to edema of the posterior pituitary. Lethargy and increased pulse pressure are not typical signs of diabetes insipidus. Increased serum glucose levels is a sign of diabetes mellitus.

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  • 32. 

    The most beneficial and safe positioning of an unconscious patient who has a rightsided closed head injury is:

    • A.

      High Fowler’s.

    • B.

      Right side-lying.

    • C.

      Flat with small pillow under head.

    • D.

      Head of bed 20 to 30 degrees.

    Correct Answer
    D. Head of bed 20 to 30 degrees.
    Explanation
    Keeping the head of the bed 20 to 30 degrees with the body in good alignment will help reduce intracranial pressure and keep the airway patent.

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  • 33. 

    The nurse assesses the level of consciousness (LOC) of a patient with a neurologic injury as mildly disoriented to surroundings and time, but awake and needs additional verbal cues to stimulate response to commands. Which documentation is the most accurate in regard to LOC?

    • A.

      Alert

    • B.

      Confused

    • C.

      Lethargic

    • D.

      Obtunded

    Correct Answer
    B. Confused
    Explanation
    The confused patient is awake, but slightly confused and needs coaching to respond to commands. Alert indicates appropriate response to questions and commands with little stimulation. Lethargic is described as the patient being drowsy, but easily aroused. Obtunded patients are more difficult to arouse and respond slowly to stimulation.

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  • 34. 

    The anxious mother of an adolescent who sustained a spinal injury yesterday and has paralysis of the lower limbs asks if the paralysis is permanent. Which response by the nurse is most helpful?

    • A.

      “Motor function sometimes returns after the edema of the spinal cord has subsided.”

    • B.

      “Motor function may improve, but there will always be a deficit.”

    • C.

      “In all likelihood the paralysis will be permanent.”

    • D.

      “The physician is the best source for that information.”

    Correct Answer
    A. “Motor function sometimes returns after the edema of the spinal cord has subsided.”
    Explanation
    Until spinal cord edema has subsided, the extent or the permanency of the paralysis cannot be evaluated. It would be incorrect to indicate that there will definitely be a deficit or paralysis. Not addressing the question and suggesting only to talk to the physician will likely frighten the parent.

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  • 35. 

    The patient who suffered a spinal cord injury (SCI) 3 days ago resulting in flaccid paralysis begins to flex his arm. The concerned family is instructed that this muscle activity may be related to:

    • A.

      Increased intracranial pressure.

    • B.

      Increased edema of the cord.

    • C.

      Return of voluntary motor activity.

    • D.

      Muscle spasms.

    Correct Answer
    D. Muscle spasms.
    Explanation
    Muscle spasms occur several days after the spinal cord injury and are spinal recovery indicators. Concerned family should be reminded that spasms are not necessarily an indication of the return of motor function.

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  • 36. 

    To avoid stimulation of painful muscle spasms, the nurse will:

    • A.

      Grasp the muscle firmly when moving the patient.

    • B.

      Use palms of hands to support joints when moving the patient.

    • C.

      Log roll the patient as a unit.

    • D.

      Perform passive range of motion (ROM).

    Correct Answer
    B. Use palms of hands to support joints when moving the patient.
    Explanation
    Using the palms of the hands and not grasping the muscle will reduce the incidence of spasm. Log rolling and ROM may initiate spasms.

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  • 37. 

    In the event of autonomic dysreflexia (AD) in the patient with a spinal cord injury, the initial intervention should be to:

    • A.

      Elevate the head of the bed to lower blood pressure.

    • B.

      Notify the charge nurse to get assistance.

    • C.

      Increase IV fluid rate to ensure adequate circulating volume.

    • D.

      Administer anti-hypertensive medication.

    Correct Answer
    A. Elevate the head of the bed to lower blood pressure.
    Explanation
    Autonomic dysreflexia (hyperreflexia) response is potentially dangerous to the patient, because it can produce vasoconstriction of the arterioles with an immediate elevation of blood pressure. Elevating the head of bed is the initial intervention to decrease the rising blood pressure. Notifying the charge nurse can be done after initial interventions. Increasing the IV fluid rate may further increase the blood pressure. The cause of AD should be addressed before administering any hypertensive medication.

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  • 38. 

    When turning the patient who is in Crutchfield tongs traction, the nurse will:

    • A.

      Turn the patient as a unit by log rolling.

    • B.

      Release the weights to prevent injury while turning.

    • C.

      Turn quickly to avoid muscle spasms.

    • D.

      Advise the patient to hold his breath and bear down during turning.

    Correct Answer
    A. Turn the patient as a unit by log rolling.
    Explanation
    Turning the patient as a unit by log rolling with the weights in place immobilizes the affected vertebrae and maintains alignment. Releasing the weights or turning quickly will affect vertebrae and alignment. Deep breathing will decrease muscle tension.

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  • 39. 

    The patient presents in the health clinic with low back pain that radiates into the buttocks and below the knee. The nurse suspects which condition?

    • A.

      Herniated disk

    • B.

      Muscle spasm in lower back

    • C.

      Spinal cord injury

    • D.

      Sciatica

    Correct Answer
    A. Herniated disk
    Explanation
    Herniated disks typically cause compression on the sciatic nerve and allow the pain to radiate into the buttocks and leg. Muscle spasm in the lower back will result in back pain. There is no indication of spinal cord injury. Pain from sciatica does not involve back pain.

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  • 40. 

    The student nurse is planning care for a patient with a recent spinal cord injury. Which intervention indicates the need for further instruction regarding care of the patient with a spinal cord injury?

    • A.

      Keep the halo jacket fastened unless the patient is in a supine position.

    • B.

      Monitor the bladder every 4 hours for signs of bladder distention.

    • C.

      Instruct unlicensed assistive personnel (UAP) to turn and reposition the patient every 2 hours.

    • D.

      Assess compression stockings for proper fit.

    Correct Answer
    C. Instruct unlicensed assistive personnel (UAP) to turn and reposition the patient every 2 hours.
    Explanation
    Moving or positioning the patient with neurologic injury or surgery should not be delegated to unlicensed personnel. Following proper instruction, the UAP can assist the nurse with moving or repositioning the patient. Halo jackets must be kept fastened unless the patient is in a supine position in order to prevent sudden head movement. Bladder distention should be avoided to prevent infection or autonomic dysreflexia. Compression stockings are used to prevent deep vein thrombosis.

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  • 41. 

    The nurse uses a visual aid to demonstrate how a coup-contrecoup injures the brain by: (Select all that apply.)

    • A.

      Allowing the brain to twist on the brainstem.

    • B.

      Moving forward to strike the anterior interior skull.

    • C.

      Allowing the brain to compress on itself.

    • D.

      Striking the bony area opposite the site of impact.

    • E.

      Losing small amounts of cerebrospinal fluid.

    Correct Answer(s)
    B. Moving forward to strike the anterior interior skull.
    D. Striking the bony area opposite the site of impact.
    Explanation
    In a coup-contrecoup injury, the brain moves forward, striking the anterior interior wall of the cranium, and moves back, striking the bony area opposite the site of the impact, causing two areas of injury.

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  • 42. 

    After an older adult falls, the nurse suspects the development of a subdural hematoma based on which assessment findings? (Select all that apply.)

    • A.

      Increasing irritability

    • B.

      Complaint of a dull headache

    • C.

      Frequent “nodding off” in chair during the day

    • D.

      Focal seizures

    • E.

      Staggering gait

    Correct Answer(s)
    A. Increasing irritability
    B. Complaint of a dull headache
    C. Frequent “nodding off” in chair during the day
    Explanation
    Increasing irritability and complaint of headache as well as changing level of consciousness are signs of increasing intracranial pressure. Seizures and staggering gait are not specifically indicative of subdural hematoma.

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  • 43. 

    The nurse documents all the signs of epidural hematoma in a patient with a closed head injury, which are: (Select all that apply.)

    • A.

      Mottling of extremities.

    • B.

      Periorbital ecchymosis.

    • C.

      Battle’s sign.

    • D.

      Nausea and vomiting.

    • E.

      PERRLA.

    Correct Answer(s)
    B. Periorbital ecchymosis.
    C. Battle’s sign.
    D. Nausea and vomiting.
    Explanation
    Raccoon eyes (periorbital ecchymosis), bruising behind the ears, and nausea and vomiting are some of the typical signs of epidural hematoma.

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  • 44. 

    The nurse is aware that an epidural hematoma warrants immediate intervention based on which criteria? (Select all that apply.)

    • A.

      An epidural hematoma is related to bleeding from arterial venous source.

    • B.

      An epidural hematoma can increase intracranial pressure quickly.

    • C.

      An epidural hematoma changes overall condition quickly.

    • D.

      An epidural hematoma can cause death.

    • E.

      An epidural hematoma can cause irreversible brain damage.

    Correct Answer(s)
    B. An epidural hematoma can increase intracranial pressure quickly.
    C. An epidural hematoma changes overall condition quickly.
    D. An epidural hematoma can cause death.
    E. An epidural hematoma can cause irreversible brain damage.
    Explanation
    Bleeding is related to an arterial source. All other options are the complications of an epidural hematoma. An epidural hematoma is a medical emergency.

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  • 45. 

    The nurse is caring for a patient who has a complete transection of the cord at C7. The patient asks the nurse what functions he will be able to perform. The nurse responds that the patient will most likely be able to perform which activities? (Select all that apply.)

    • A.

      Transferring himself

    • B.

      Dressing himself

    • C.

      Using a wheelchair with standard hand rims

    • D.

      Feeding himself

    • E.

      Effectively typing using all digits

    Correct Answer(s)
    A. Transferring himself
    B. Dressing himself
    C. Using a wheelchair with standard hand rims
    D. Feeding himself
    Explanation
    The patient with an injury at C7 does not have full control of all digits. The third finger is the most functional. With physical and occupational therapy, the patient may be able to perform all other functions listed.

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  • 46. 

    The nurse caring for a patient with autonomic dysreflexia assesses the patient for which conditions or situations? (Select all that apply.)

    • A.

      Distended bladder

    • B.

      Constipation

    • C.

      Increased fluid intake

    • D.

      Wrinkles in bed linens

    • E.

      Abrupt environmental temperature changes

    Correct Answer(s)
    A. Distended bladder
    B. Constipation
    D. Wrinkles in bed linens
    E. Abrupt environmental temperature changes
    Explanation
    Bladder distention, constipation, wrinkled bed linens, and temperature changes are potential triggers for autonomic dysreflexia (AD) that the nurse should assess for. This condition causes a rapid increase in blood pressure.

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  • 47. 

    The nurse is evaluating the patient to determine if adequate learning has occurred regarding care of lower back pain. The nurse determines no further teaching is required when observing which patient activities? (Select all that apply.)

    • A.

      The patient carries items away from the center of the body.

    • B.

      The patient bends the knees, with the back straight, and crouches to lift an item off the floor.

    • C.

      The patient uses a lumbar pillow or roll when sitting for long periods.

    • D.

      The patient performs proper back exercises twice a day.

    • E.

      The patient maintains proper body weight.

    Correct Answer(s)
    B. The patient bends the knees, with the back straight, and crouches to lift an item off the floor.
    C. The patient uses a lumbar pillow or roll when sitting for long periods.
    D. The patient performs proper back exercises twice a day.
    E. The patient maintains proper body weight.
    Explanation
    The patient should carry items close to the center of the body rather than away from the center of the body. All other options demonstrated correct care of the lower back.

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  • 48. 

    The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). The family asks the nurse why their father had a seizure. What is the best response by the nurse?

    • A.

      “The seizure was most likely caused by brain cells being deprived of oxygen due to a blood a clot in the brain.”

    • B.

      “The stroke generated a toxin that excites the brain cells.”

    • C.

      “The stroke causes an alteration in the cells adjacent to the blood clot.”

    • D.

      “The stroke causes an increase in the depolarization of the brain cells due to the clot formation.”

    Correct Answer
    A. “The seizure was most likely caused by brain cells being deprived of oxygen due to a blood a clot in the brain.”
    Explanation
    Thrombi from a CVA can occlude vessels, cutting off oxygen supply to cells of the brain and causing a seizure.

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  • 49. 

    The nurse is providing teaching to a patient newly diagnosed with simple partial seizure disorder. Which statement by the nurse is most accurate?

    • A.

      “Your seizures will typically only affect one side of your body.”

    • B.

      “Simple partial seizures may result in an alteration of consciousness.”

    • C.

      “The simple partial seizure may cause motor impairment to begin in all of your extremities.”

    • D.

      “Simple partial seizures are not treatable.”

    Correct Answer
    A. “Your seizures will typically only affect one side of your body.”
    Explanation
    Simple partial seizures only involve one side of the brain and one side of the body. Complex partial seizures may or may not result in an alteration in level of consciousness. Generalized seizures affect both sides of the body. Simple partial seizures may respond to treatment.

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  • 50. 

    The anxious 20-year-old college student who just suffered his first seizure in his dorm room asks the nurse if he is now an epileptic. What is the nurse’s best response?

    • A.

      “No. All other causes of seizure activity must be ruled out before the diagnosis of epilepsy is made.”

    • B.

      “Yes, but you may never have another seizure since it has just now manifested itself.”

    • C.

      “No, but you should see a physician to get a prescription for a preventative antispasmodic.”

    • D.

      “Yes. All seizures are considered to be epilepsy.”

    Correct Answer
    A. “No. All other causes of seizure activity must be ruled out before the diagnosis of epilepsy is made.”
    Explanation
    Epilepsy diagnosis is made after all other causes of seizure activity have proven negative. All seizures are not considered to be epilepsy.

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Quiz Review Timeline +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Feb 03, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Dec 10, 2018
    Quiz Created by
    Victoria.roco
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