Neuro Review 3 Questions with Complete Answers.
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this ...
Neuro Review 3 Questions with Complete Answers.
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: a Subdural hematoma
b Epidural hematoma
c Concussion
d Skull fracture - CORRECT ANSWER The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: b. Epidural hematoma
The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly.
After a hypophysectomy (surgical removal of the pituitary gland), vasopressin is given IM for which of the following reasons? a. To reduce cerebral edema and lower intracranial pressure b. To treat growth failure c. To replace antidiuretic hormone (ADH) normally secreted by the pituitary d. To prevent syndrome of inappropriate antidiuretic hormone (SIADH) - CORRECT ANSWER After a hypophysectomy, vasopressin is given IM for which of the following reasons? c. To replace antidiuretic hormone (ADH) normally secreted by the pituitary
After hypophysectomy, or removal of the pituitary gland, the body can't synthesize ADH. Somatropin or growth hormone, not vasopressin is used to treat growth failure. SIADH results from excessive ADH secretion. Mannitol or corticosteroids are used to decrease cerebral edema.
A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? a. Decreased urine output or oliguria b. Respiratory depression c. Hypertension and bradycardia d. Symptoms of shock - CORRECT ANSWER A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? c. Hypertension and bradycardia
Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect.
Which of the following respiratory patterns indicate increasing ICP in the brain stem? a. Asymmetric chest expansion b. Nasal flaring c. Slow, irregular respirations d. Rapid, shallow respirations - CORRECT ANSWER Which of the following respiratory patterns indicate increasing ICP in the brain stem? c. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.
A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? a. "Clean the meatus with soap and water." b. "Measure the quantity of urine." c. "Clean the meatus from back to front." d. "Gently rotate the catheter during removal." - CORRECT ANSWER A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? a. "Clean the meatus with soap and water." Intermittent catheterization may be performed chronically with clean technique, using soap and water to clean the urinary meatus. The meatus is always cleaned from front to back in a woman, or in expanding circles working outward from the meatus in a man. It isn't necessary to measure the urine. The catheter doesn't need to be rotated during removal.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? a. Tachycardia b. Unequal pupil size c. Decreasing body temperature d. Decreasing systolic blood pressure - CORRECT ANSWER A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? b. Unequal pupil size Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a BP of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. a. Loosen constrictive clothing b. Administer antihypertensive medication c. Use a fan to reduce diaphoresis d. Assess for bladder distention and bowel impaction e. Elevate the HOB to 90 degrees - CORRECT ANSWER The nurse is caring for a client with a T5 complete
spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a BP of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. a. Loosen constrictive clothing b. Administer antihypertensive medication d. Assess for bladder distention and bowel impaction e. Elevate the HOB to 90 degrees
The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is
caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control
over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the
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