Nervous System | Neurological Disorders NCLEX Quiz 45
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An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
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Reposition the client to avoid neck flexion
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Administer 1 g Mannitol IV as ordered
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Increase the ventilator’s respiratory rate to 20 breaths/minute
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Administer 100 mg of pentobarbital IV as ordered.
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All questions are shown, but the results will only be given after you’ve finished the quiz. You are given 1 minute per question, a total of 10 minutes in this quiz.
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- 2.
A client with a subarachnoid hemorrhage is prescribed a 1.000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
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Therapeutic drug levels should be maintained between 20 to 30 mg/ml.
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Rapid Dilantin administration can cause cardiac arrhythmias.
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Dilantin should be mixed in dextrose in water before administration.
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Dilantin should be administered through an IV catheter in the client’s hand.
Correct Answer
A. Rapid Dilantin administration can cause cardiac arrhythmias.Explanation
Dilantin IV shouldn’t be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium. causing arrhythmias.Option A: Therapeutic drug levels range from 10 to 20 mg/ml.Option C: Dilantin shouldn’t be mixed in solution for administration. However. because it’s compatible with normal saline solution. it can be injected through an IV line containing normal saline.Option D: When given through an IV catheter hand. Dilantin may cause purple glove syndrome.Rate this question:
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- 3.
A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing interventions should be done first?
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Assess full ROM to determine extent of injuries
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Call for an immediate chest x-ray
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Immobilize the client’s head and neck
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Open the airway with the head-tilt-chin-lift maneuver
Correct Answer
A. Immobilize the client’s head and neckExplanation
All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. The airway doesn’t need to be opened since the client appears alert and not in respiratory distress.Option A: ROM would be contraindicated at this time.Option B: There is no indication that the client needs a chest x-ray.Option D: In addition. the head-tilt-chin-lift maneuver wouldn’t be used until the cervical spine injury is ruled out.Rate this question:
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- 4.
A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage. which may be shown by which of the following signs?
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Bloody drainage from the ears
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Frequent swallowing
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Guaiac-positive stools
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Hematuria
Correct Answer
A. Frequent swallowingExplanation
Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx.Option A: Blood or fluid draining from the ear may indicate a basilar skull fracture.Rate this question:
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- 5.
While in the ER. a client with C8 tetraplegia develops a blood pressure of 80/40. pulse 48. and RR of 18. The nurse suspects which of the following conditions?
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Autonomic dysreflexia
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Hemorrhagic shock
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Neurogenic shock
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Pulmonary embolism
Correct Answer
A. Neurogenic shockExplanation
Symptoms of neurogenic shock include hypotension. bradycardia. and warm. dry skin due to the loss of adrenergic stimulation below the level of the lesion.Option A: Hypertension. bradycardia. flushing. and sweating of the skin are seen with autonomic dysreflexia.Option B: Hemorrhagic shock presents with anxiety. tachycardia. and hypotension; this wouldn’t be suspected without an injury.Option D: Pulmonary embolism presents with chest pain. hypotension. hypoxemia. tachycardia. and hemoptysis; this may be a later complication of spinal cord injury due to immobility.Rate this question:
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- 6.
When evaluating an ABG from a client with a subdural hematoma. the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result?
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Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
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Emergent; the client is poorly oxygenated.
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Normal
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Significant; the client has alveolar hypoventilation.
Correct Answer
A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).Explanation
A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore. lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels.Option B: Oxygenation is evaluated through PaO2 and oxygen saturation.Option D: Alveolar hypoventilation would be reflected in an increased PaCO2.Rate this question:
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- 7.
A client with head trauma develops a urine output of 300 ml/hr. dry skin. and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
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Evaluate urine specific gravity
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Anticipate treatment for renal failure
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Provide emollients to the skin to prevent breakdown
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Slow down the IV fluids and notify the physician
Correct Answer
A. Evaluate urine specific gravityExplanation
Urine output of 300 ml/hr may indicate diabetes insipidus. which is a failure of the pituitary to produce the anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity. increased serum osmolarity. and dehydration.Option B: There’s no evidence that the client is experiencing renal failure.Option C: Providing emollients to prevent skin breakdown is important. but doesn’t need to be performed immediately.Option D: Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.Rate this question:
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- 8.
After a hypophysectomy. vasopressin is given IM for which of the following reasons?
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To treat growth failure
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To prevent syndrome of inappropriate antidiuretic hormone (SIADH)
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To reduce cerebral edema and lower intracranial pressure
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To replace antidiuretic hormone (ADH) normally secreted by the pituitary.
Correct Answer
A. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.Explanation
After hypophysectomy or removal of the pituitary gland. the body can’t synthesize ADH.Option A: Somatropin or growth hormone. not Vasopressin is used to treat growth failure.Option B: SIADH results from excessive ADH secretion.Option C: Mannitol or corticosteroids are used to decrease cerebral edema.Rate this question:
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- 9.
A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?
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Bladder distension
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Neurological deficit
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Pulse ox readings
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The client’s feelings about the injury
Correct Answer
A. Pulse ox readingsExplanation
After a spinal cord injury. ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4. so assessment of adequate oxygenation and ventilation is necessary.Options A. B. and D: Although the other options would be necessary at a later time. observation for respiratory failure is the priority.Rate this question:
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- 10.
A client with a C6 spinal injury would most likely have which of the following symptoms?
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Aphasia
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Hemiparesis
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Paraplegia
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Tetraplegia
Correct Answer
A. TetraplegiaExplanation
Tetraplegia occurs as a result of cervical spine injuries.Option C: Paraplegia occurs as a result of injury to the thoracic cord and below.Rate this question:
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Mar 22, 2023Quiz Edited by
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Sep 27, 2017Quiz Created by
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