2024 CCRN REAL EXAM TEST BANK
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The patient sustained an ischemic stroke and developed a loss of
vision in the left half visual field of each eye (left homonymous
hemianopsia). This is a sign that the stroke has affected which
cranial nerve?
a. olfactory nerve
b. optic nerve
c. oculomotor nerve
d. trochlear nerve Correct Answer b. optic nerve
The patient is days post-op from an aneurysm repair following a
subarachnoid hemorrhage (SAH). What is an appropriate nursing
intervention that is specific to the care of this patient?
a. contact the surgeon if there is a decrease in the serum Na+
b. maintain a systolic BP of 100-110
c. administer diltiazem (Cardizem)
d. restrict fluids Correct Answer a. contact the surgeon if there is a
decrease in the serum Na+
The patient presented with a basilar skull fracture after sustaining
a blow to the head. The nurse determined that the nasal drainage
was spinal fluid because the fluid was positive for glucose, and
the drainage from the ear demonstrated the "halo sign". What
additional intervention is indicated for the care of this patient?
a. provide a tissue to the patient to blow her nose
b. assess for cranial nerve I damage
c. administer antibiotics, and prep the patient for surgery
,d. pack sterile gauze into the patient's nose and ear Correct
Answer b. assess for cranial nerve I damage
The patient sustained a large right cerebral ischemic stroke. What
clinical sign is the patient most likely to exhibit
a. right Babinski reflex
b. aphasia
c. right pupil dilation
d. eye deviation to the left Correct Answer c. right pupil dilation
Which clinical pathology is likely to be seen in a patient with
status epilepticus?
a. hypotension
b. death due to hypoventilation
c. rhabdomyolysis
d. hypernatremia Correct Answer c. rhabdomyolysis
The patient is admitted with a skull fracture. Which of the following
assessments of the patient's level of consciousness (LOC)
indicates the greatest change from what is considered normal?
a. the patient is arousable to voice and is oriented to time, person,
and place
b. the patient is arousable to shaking and is oriented to person
c. the patient is arousable to touch and is oriented to place and
person
d. the patient is awake and is oriented to time, place, and person
Correct Answer b. the patient is arousable to shaking and is
oriented to person
The presence of which of the following criteria is necessary for the
confirmation of brain death?
,a. negative apnea
b. absence of all cortical and brain stem function
c. absence of brain flow on a cerebral angiogram
d. reversible comatose state Correct Answer b. absence of all
cortical and brain stem function
The patient has diffuse cerebral edema secondary to hypoxic
encephalopathy. Which clinical sign is typical of diffuse brain
swelling with downward displacement of brain hemispheres?
a. a pupil change before a change in LOC
b. a unilateral Babinski reflex
c. bilateral pupil constriction followed by bilateral pupil dilation
d. rapid development of signs and symptoms Correct Answer c.
bilateral pupil constriction followed by bilateral pupil dilation
The nurse is caring for a patient with a traumatic brain injury (TBI)
who has intraventricular catheter in place. What will the nurse
include in the plan of care for this patient?
a. hold enteral feedings until the ICP stabilizes
b. contact the surgeon because he patient has developed a fever
c. restrain the patient because he has become agitated
d. hyperextend the patinet's neck to promote cerebral outflow
Correct Answer b. contact the surgeon because he patient has
developed a fever
The patient is experiencing a generalize tonic-clonic seizure.
What is the nursing priority?
a. insert a bite block
b. administer phenytonin (Dilantin)
c. place the patient supine
d. administer lorazepam (Ativan) Correct Answer d. administer
lorazepam (Ativan)
, The patient has hepatic failure. Which of the following
interventions will the nurse anticipate?
a. furosemide to treat ascites
b. neomycin to decrease gut bacteria that produce NH3
c. lactated ringer's for hypotension
d. acetylcysteine (until acetaminophen levels are normal) to treat
an acetaminophen overdose Correct Answer b. neomycin to
decrease gut bacteria that produce NH3
Upon arrival at the emergency department, the patient presented
with Kehr's sign. Which clinical sign would the patient with Kehr's
sign be expected to demonstrate?
a. left shoulder pain
b. bowel sounds in the chest
c. free air in the abdomen
d. left flank ecchymosis Correct Answer a. left shoulder pain
Kehr's sign is due to a ruptured spleen causing diaphragmatic
irritation, which leads to referred pain to the left shoulder
During orientation, the nurse is told by the preceptor that the
patient with upper GI bleeding needs to be closely monitored for
ST segment elevation and chest pain. This monitoring is
necessary for which of the following treatments for GI bleeding?
a. administration of octreotide
b. infusion of blood products
c. administration of vasopressin
d. infusion of isotonic fluids Correct Answer c. administration of
vasopressin
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