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NUR1306 Test #2 QUESTIONS Neurology graded A+
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NUR1306 Test #2 QUESTIONS Neurology/NUR1306 Test #2 QUESTIONS Neurology/NUR1306 Test #2 QUESTIONS Neurology
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NUR1306 Test #2 QUESTIONS NeurologyAn 18-year-old client is admitted with a closed head injury sustained in a MVA. His
intracranial pressure (ICP) shows an upward trend. Which intervention should the
nurse perform first?
1. Reposition the client to avoid neck flexion
2. Administer 1 g Mannitol IV as ordered
3. Increase the ventilator's respiratory rate to 20 breaths/minute
4. Administer 100 mg of pentobarbital IV as ordered. - correct answer 1.
Reposition the client to avoid neck flexion
The nurse should first attempt nursing interventions, such as repositioning the
client to avoid neck flexion, which increases venous return and lowers ICP. If
nursing measures prove ineffective, notify the physician, who may prescribe
mannitol, pentobarbital, or hyperventilation therapy.
A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of
Dilantin IV. Which consideration is most important when administering this dose?
1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml.
2. Rapid dilantin administration can cause cardiac arrhythmias.
3. Dilantin should be mixed in dextrose in water before administration.
4. Dilantin should be administered through an IV catheter in the client's hand. -
correct answer 2. Rapid dilantin administration can cause cardiac arrhythmias.
Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid
administration can depress the myocardium, causing arrhythmias. Therapeutic
drug levels range from 10 to 20 mg/ml. Dilantin shouldn't be mixed in solution for
administration.
When given through an IV catheter hand, dilantin may cause purple glove
syndrome.
,NUR1306 Test #2 QUESTIONS Neurology
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry
mucous membranes. Which of the following nursing interventions is the most
appropriate to perform initially?
1. Evaluate urine specific gravity
2. Anticipate treatment for renal failure
3. Provide emollients to the skin to prevent breakdown
4. Slow down the IV fluids and notify the physician - correct answer 1. Evaluate
urine specific gravity
Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the
pituitary to produce anti-diuretic hormone. This may occur with increased
intracranial pressure and head trauma; the nurse evaluates for low urine specific
gravity, increased serum osmolarity, and dehydration.
Slowing the rate of IV fluid would contribute to dehydration when polyuria is
present.
When evaluating an ABG from a client with a subdural hematoma, the nurse
notes the PaCO2 is 30 mm Hg. Which of the following responses best describes
this result?
1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP)
2. Emergent; the client is poorly oxygenated.
3. Normal
4. Significant; the client has alveolar hypoventilation. - correct answer 1.
Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP)
A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties;
therefore, lowering PaCO2 through hyperventilation will lower ICP caused by
dilated cerebral vessels.
,NUR1306 Test #2 QUESTIONS Neurology
A client who had a transsphenoidal hypophysectomy should be watched carefully
for hemorrhage, which may be shown by which of the following signs?
1. Bloody drainage from the ears
2. Frequent swallowing
3. Guaiac-positive stools
4. Hematuria - correct answer 2. Frequent swallowing
Frequent swallowing after brain surgery may indicate fluid or blood leaking from
the sinuses into the oropharynx. Blood or fluid draining from the ear may indicate
a basilar skull fracture.
After a hypophysectomy, vasopressin is given IM for which of the following
reasons?
1. To treat growth failure
2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH)
3. To reduce cerebral edema and lower intracranial pressure
4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary. -
correct answer 4. 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 comes into the ER after hitting his head in an MVA. He's alert and
oriented. Which of the following nursing interventions should be done first?
1. Assess full ROM to determine extent of injuries
, NUR1306 Test #2 QUESTIONS Neurology
2. Call for an immediate chest x-ray
3. Immobilize the client's head and neck
4. Open the airway with the head-tilt chin-lift maneuver - correct answer 3.
Immobilize the client's head and neck
All clients with a head injury are treated as if a cervical spine injury is present until
x-rays confirm their absence.
A client with a C6 spinal injury would most likely have which of the following
symptoms?
1. Aphasia
2. Hemiparesis
3. Paraplegia
4. Tetraplegia - correct answer 4. Tetraplegia
A 30-year-old was admitted to the progressive care unit with a C5 fracture from a
motorcycle accident. Which of the following assessments would take priority?
1. Bladder distension
2. Neurological deficit
3. Pulse ox readings
4. The client's feelings about the injury - correct answer 3. Pulse ox readings
After a spinal cord injury, ascending cord edema may cause a higher level of
injury. The diaphragm is innervated at the level of C4, so assessment of adequate
oxygenation and ventilation is necessary. Although the other options would be
necessary at a later time, observation for respiratory failure is the priority.
While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40,
pulse 48, and RR of 18. The nurse suspects which of the following conditions?
1. Autonomic dysreflexia
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