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NURS 618 Saunders Med Surg Neuro Revised 2023
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  • NURS 490 (NURS490)
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  • Nevada State College

NURS 618 Saunders Med Surg Neuro Revised 2023 Saunders Med Surg Neuro 1. The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure ...

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  • 26 juli 2023
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  • nurs 618 saunders med surg neuro revised 2023
  • the nurse is assessing the motor and sensory funct

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  • Nevada State College
  • NURS 490 (NURS490)
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NURS 618 Saunders Med Surg Neuro Revised 2023


Saunders Med Surg Neuro



1. The nurse is assessing the motor and sensory function of an unconscious client. The

nurse should use which technique to test the client's peripheral response to pain?

1. Sternal rub

2. Nail bed pressure

3. Pressure on the orbital rim

4. Squeezing of the sternocleidomastoid muscle



Answer:

2. Nail bed pressure



Rationale:

Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral

responses to pain are tested using a sternal rub, placing upward pressure on the orbital

rim, or squeezing the clavicle or sternocleidomastoid muscle.



2. The nurse is caring for the client with increased intracranial pressure. The nurse

would note which trend in vital signs if the intracranial pressure is rising?

1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood

pressure

,2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood

pressure

3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing

blood pressure

4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood

pressure



Answer:

2. Increasing temperature, decreasing pulse, decreasing respirations,

increasing blood pressure



Rationale:

A change in vital signs may be a late sign of increased intracranial pressure. Trends

include increasing temperature and blood pressure and decreasing pulse and

respirations. Respiratory irregularities also may occur.



3. A client recovering from a head injury is participating in care. The nurse determines

that the client understands measures to prevent elevations in intracranial pressure if the

nurse observes the client doing which activity?

1. Blowing the nose

2. Isometric exercises

3. Coughing vigorously

4. Exhaling during repositioning

,Answer:

4. Exhaling during repositioning



Rationale:

Activities that increase intrathoracic and intraabdominal pressures cause an indirect

elevation of the intracranial pressure. Some of these activities include isometric

exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling

during activities such as repositioning or pulling up in bed opens the glottis, which

prevents intrathoracic pressure from rising.



4. A client has clear fluid leaking from the nose following a basilar skull fracture. Which

finding would alert the nurse that cerebrospinal fluid is present?

1. Fluid is clear and tests negative for glucose.

2. Fluid is grossly bloody in appearance and has a pH of 6.

3. Fluid clumps together on the dressing and has a pH of 7.

4. Fluid separates into concentric rings and tests positive for glucose.



Answer:

4. Fluid separates into concentric rings and tests positive for glucose.



Rationale:

Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull

fracture. CSF can be distinguished from other body fluids because the drainage will

, separate into bloody and yellow concentric rings on dressing material, called a halo sign.

The fluid also tests positive for glucose.



5. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The

nurse should include which measures in the plan of care to minimize the risk of

occurrence? Select all that apply.

1. Keeping the linens wrinkle-free under the client

2. Preventing unnecessary pressure on the lower limbs

3. Limiting bladder catheterization to once every 12 hours

4. Turning and repositioning the client at least every 2 hours

5. Ensuring that the client has a bowel movement at least once a week



Answers:

1. Keeping the linens wrinkle-free under the client

2. Preventing unnecessary pressure on the lower limbs

4. Turning and repositioning the client at least every 2 hours



Rationale:

The most frequent cause of autonomic dysreflexia is a distended bladder. Straight

catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too

infrequent), and urinary catheters should be checked frequently to prevent kinks in the

tubing. Constipation and fecal impaction are other causes, so maintaining bowel

regularity is important. Ensuring a bowel movement once a week is much too

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