MEDICAL SURG 3 145 QUESTIONS WITH
CORRECT ANSWERS LATEST UPDATE 2023
/2024. A+ GUARANTEED
1. Following a craniotomy to relieve increased intracranial pressure (ICP), which
implementation should the nurse implement?
a. Elevate the head of the bed 20 to 30 degrees.
b. Place drip pad or cotton to absorb cerebrospinal fluid (CSF) drainage from the
nose or ears.
c. Stimulate the patient to better assess changing level of consciousness (LOC).
d. Reposition the patient frequently for comfort.: ANS: A
A patent airway must be secured, and the head raised 20 to 30 degrees with the body in
correct alignment. Elevation helps reduce ICP. Neurologic signs are monitored closely. An
IV line is inserted for access for diuretic drugs, if needed, and for administration of fluid.
IV fluids are infused very slowly to prevent fluid overload that would increase the ICP.
Diuretics are used to decrease vascular volume and keep ICP as low as possible. Drip
pads, patient stimulation, and changing positions frequently may increase ICP.
2. The unconscious patient with a closed head injury is on mechanical ventilation. To
improve brain perfusion through increased blood pressure, the carbon dioxide (CO2)
should be maintained at what level? a. 10 to 15 mm Hg
b. 15 to 20 mm Hg
c. 20 to 25 mm Hg
d. 25 to 30 mm Hg: ANS: D
The CO2 level is set to be maintained at 25 to 30 mm Hg to create vascular constriction,
raise blood pressure, and perfuse the cerebrum.
3. The nurse is caring for a patient with a closed head injury. Which finding causes the
nurse to suspect that the patient has developed diabetes insipidus (DI)?
a. Increased lethargy
b. Widening pulse pressure
c. Copious pale urine output
d. Increasing blood glucose levels: ANS: C
,A large increase in urinary output of pale urine with a low specific gravity is the clue to the
development of DI related to edema of the posterior pituitary. Antidiuretic hormone is
released in inadequate amounts, resulting in polyuria, and the awake patient may complain
of polydipsia (excessive thirst). IV vasopressin and fluid replacement are the preferred
treatments. Lethargy and increased pulse pressure are not typical signs of DI. Increased
serum glucose levels is a sign of diabetes mellitus, not DI.
4. Which position is best for an unconscious patient with a right-sided closed head
injury?
a. High Fowler
b. Right side-lying
c. Flat with small pillow under head
d. Head of bed 20 to 30 degrees: ANS: D
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.
5. The nurse is caring for an adolescent who has lower limb paralysis after sustaining
a spinal injury yesterday. The patient's anxious mother asks if the paralysis is
permanent. Which response is most appropriate for the nurse to make?
a. "It is possible that motor function may or may not return after spinal cord
swelling has subsided."
b. "Motor function may improve, but there will always be a deficit."
c. "In all likelihood, the paralysis will be permanent."
d. "Have you asked the physician about your concerns?": ANS: A
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.
6. 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: ANS: D 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.
7. 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.: ANS: C
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.
8. Why is the older adult more at risk for a cranial bleed following a head injury?
a. The older adult's brain is smaller, which allows for more movement inside the
cranium.
b. The older adult's brain features fragile vessels more likely to rupture.
c. The older adult's brain contains less cerebrospinal fluid (CSF) to cushion the
brain.
d. The older adult's brain has less flexible meninges to absorb impact.: ANS:
A
The brain atrophies with age and does not take up as much space in the cranial vault. This
change allows for more movement and more potential for torn vessels and contusions on
the brain when an accident occurs that involves a head injury.
9. The emergency room nurse is assessing a newly admitted patient with a head
injury. The nurse observes clear drainage from the nose. Which action should the
nurse perform first?
a. Document the presence of rhinorrhea.
b. Inform the physician of the assessment.
c. Test the fluid with a Dextrostix.
d. Tape a drip pad under the nose.: ANS: C
Head injury symptoms may include rhinorrhea (fluid from the nose) or otorrhea (fluid from
the ear), among many others. Rhinorrhea and otorrhea should be tested to determine if there
is a cerebrospinal fluid (CSF) leak. Testing with a Dextrostix will determine whether glucose
is present; the presence of glucose indicates CSF. Documentation, informing the physician,
and applying a drip pad under the nose are actions that should occur after confirmation of
the fluid type.
, 10. In assessing the patient with a significant right intracerebral hemorrhage, the
nurse anticipates that the patient will demonstrate which signs?
a. Left-sided hemiplegia with dilated right pupil
b. Right-sided hemiplegia with brisk right pupil response
c. Bilateral motor hemiplegia with bilaterally dilated pupils
d. Left-sided hemiplegia and bilateral PERRLA: ANS: A
An acute intracerebral bleed causing hematoma formation is accompanied by
unconsciousness, hemiplegia on the contralateral (opposite) side, and a dilated pupil on the
ipsilateral (same) side. However, the symptoms indicating a slow buildup of pressure
within the skull are more subtle and less easily detected.
11. The nurse is caring for an older adult patient who was admitted to the hospital
following a closed head injury that resulted in a 5-minute period of unconsciousness.
The nurse most carefully monitors the patient for which change?
a. Increasing respiratory rate
b. Decreasing heart rate
c. Decreasing pulse pressure
d. Decreasing level of consciousness (LOC): ANS: D
Assessment of LOC provides the greatest amount of information about neurologic
condition. A reduction in LOC may signal the onset of complications in the patient who
has had a head injury.
12. The patient with a suspected subdural hematoma is on an intravenous (IV) drip of
mannitol infusing at 50 mL/hr. The nurse explains that the slow infusion rate is
essential for what purpose?
a. To ensure effectiveness of the drug.
b. To avoid fluid overload.
c. To maintain electrolyte balance.
d. To maintain adequate blood pressure (BP).: ANS: B
The slow infusion rate will not cause fluid overload, which would add to the possibility of
increased intracranial pressure (ICP).
13. The nurse is caring for a patient with flaccid paralysis after sustaining a spinal
cord injury 3 days earlier. The family excitedly notifies the nurse that the patient has
flexed his arm. Which response is best for the nurse to make? a. "I will give the
doctor this wonderful news."
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