Nervous System | Neurological Disorders NCLEX Quiz 45

1. 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?

Reposition the client to avoid neck flexion

Administer 1 g Mannitol IV as ordered

Increase the ventilator’s respiratory rate to 20 breaths/minute

Administer 100 mg of pentobarbital IV as ordered.

The nurse should first attempt nursing interventions. such as repositioning the client to avoid neck flexion. which increases venous return and lowers ICP.Options B. C. and D: If nursing measures prove ineffective notify the physician. who may prescribe mannitol. pentobarbital. or hyperventilation therapy.

Explanation

The nurse should first attempt nursing interventions. such as repositioning the client to avoid neck flexion. which increases venous return and lowers ICP.Options B. C. and D: If nursing measures prove ineffective notify the physician. who may prescribe mannitol. pentobarbital. or hyperventilation therapy.

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?

Therapeutic drug levels should be maintained between 20 to 30 mg/ml.

Rapid Dilantin administration can cause cardiac arrhythmias.

Dilantin should be mixed in dextrose in water before administration.

Dilantin should be administered through an IV catheter in the client’s hand.

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.

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.

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?

Assess full ROM to determine extent of injuries

Call for an immediate chest x-ray

Immobilize the client’s head and neck

Open the airway with the head-tilt-chin-lift maneuver

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.

Explanation

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.

4. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage. which may be shown by which of the following signs?

Bloody drainage from the ears

Frequent swallowing

Guaiac-positive stools

Hematuria

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.

Explanation

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.

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?

Autonomic dysreflexia

Hemorrhagic shock

Neurogenic shock

Pulmonary embolism

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.

Explanation

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.

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?

Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).

Emergent; the client is poorly oxygenated.

Normal

Significant; the client has alveolar hypoventilation.

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.

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.

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?

Evaluate urine specific gravity

Anticipate treatment for renal failure

Provide emollients to the skin to prevent breakdown

Slow down the IV fluids and notify the physician

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.

Explanation

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.

8. After a hypophysectomy. vasopressin is given IM for which of the following reasons?

To treat growth failure

To prevent syndrome of inappropriate antidiuretic hormone (SIADH)

To reduce cerebral edema and lower intracranial pressure

To replace antidiuretic hormone (ADH) normally secreted by the pituitary.

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.

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.

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?

Bladder distension

Neurological deficit

Pulse ox readings

The client’s feelings about the injury

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.

Explanation

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.

10. A client with a C6 spinal injury would most likely have which of the following symptoms?

Aphasia

Hemiparesis

Paraplegia

Tetraplegia

Tetraplegia occurs as a result of cervical spine injuries.Option C: Paraplegia occurs as a result of injury to the thoracic cord and below.

Explanation

Tetraplegia occurs as a result of cervical spine injuries.Option C: Paraplegia occurs as a result of injury to the thoracic cord and below.