NUR 222 Ch 45 Exam Questions and Correct Answers

NUR 222 Ch 45 Exam Questions and Correct Answers Patient admitted to hospital after sustaining a closed head injury in a skiing accident. Physician ordered neurologic assessments every 2 hours. Patient's neurologic assessments unchanged since admission. Patient is complaining of a headache. Which intervention by the nurse is best? - ANSWER Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. (p. 1187) Which Glasgow Coma Scale score is indicative of a severe head injury? - ANSWER 7 (p. 1190) A client has sustained a *traumatic brain injury* with involvement of the *hypothalamus*. The health care team is concerned about the complication of *diabetes insipidus*. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? - ANSWER Record intake and output. (p. 1197) You are a *neurotrauma* nurse working in a neuro ICU. What would you know is an *acute emergency* and is seen in clients with a *cervical or high thoracic spinal cord injury* *after the spinal shock subsides*? - ANSWER Autonomic dysreflexia (pp. ) A nurse observes an abnormal posture response in an unconscious patient. She documents "extension and outward rotation of the upper extremities and plantar flexion of the feet." She is aware that this posture is a clinical indicator of which of the following? - ANSWER Decerebrate positioning implying severe dysfunction and brain pathology (p. 1188, 1193) A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? - ANSWER A small amount of yellow drainage at the left pin insertion site (p. 1186) The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? - ANSWER Neurologic examination (p. 1190) Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. - ANSWER Eye opening; Verbal response; Motor response (p. 1192) The nurse is offering suggestions regarding reproductive options to a husband and para-plegic wife. Which option is most helpful? - ANSWER Conception is not impaired; the birth process is determined with the physician. Osmotic diuretics are an essential intervention for reducing cerebral edema. Which of the following drugs is most frequently prescribed for this situation? - ANSWER Mannitol (p. 1194, 1197)