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COMPREHENSIVE FINAL EXAM QUESTIONS AND ANSWERS
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COMPREHENSIVE FINAL EXAM QUESTIONS AND ANSWERS
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COMPREHENSIVE FINAL EXAMQUESTIONS AND ANSWERS
The nurse is caring for a patient brought to the emergency department after an
automobile accident. The patient is fully conscious. For what early signs of increased
intracranial pressure (ICP) should the nurse be alert?
a. Bradycardia
b. Hypothermia
c. Pinpoint pupils
d. Decreased level of consciousness - Answer-d
The vital signs for a client with a possible head injury were on admission: blood
pressure 128/72 mm Hg, pulse 90 beats/min, and respirations 66 breaths/min. Which
vital sign assessment conducted four hours later most likely indicates the presence of
increased intracranial pressure (ICP)?
a. Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min
b. Blood pressure 160/90 mm Hg, pulse 112 beats/min, respirations 16 breaths/min
c. Blood pressure 130/72 mm Hg, pulse 50 beats/min, respirations 24 breaths/min
d. Blood pressure 100/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min -
Answer-a
A patient who was in an industrial accident has had a sudden increase in intracranial
pressure and is being prepared for placement of an emergency subarachnoid bolt.
Which action should the nurse make a priority at this time?
a. Find out how the accident happened.
b. Ensure the patient is bathed before surgery.
c. Have the patients next of kin sign a consent form.
d. Send the patients belongings home with a family member. - Answer-c
A patient with a severe headache due to viral meningitis requests an opioid analgesic.
What explanation about opioids should the nurse provide?
a. Opioid analgesics increase intracranial pressure.
b. Opioid analgesics are used as a last resort for headaches.
c. Opioid analgesics are contraindicated in patients with meningitis.
d. Acetaminophen (Tylenol) is more effective in treating meningitis-related headaches. -
Answer-b
The nurse concludes that a patients meningitis is improving. What activity did the
patient perform for the nurse to come to this conclusion?
a. Dorsiflex both feet.
b. Sit up and drink water.
c. Touch the chin to the chest.
d. Maintain a side-lying position in bed. - Answer-c
,The nurse is assisting with teaching a patient about tension headaches. Which
explanation of tension headaches should the nurse provide?
a. Tension headaches result from release of pain mediators in the periphery.
b. Tension headaches are caused by stress, which causes cerebral vessel constriction.
c. Tension headaches are a result of stress and sustained muscle contraction of the
head and neck.
d. Tension headaches are caused by blood sugar fluctuations that result from excessive
stress. - Answer-c
The nurse is determining care for a patient with acute migraine headaches. What should
the nurse teach the patient to do first in order to determine a plan of care for the
headaches?
a. Keep a headache diary.
b. Avoid sugar and caffeine.
c. Avoid bright light and noise.
d. Avoid taking analgesics until the cause has been determined. - Answer-a
The nurse administers an analgesic to a patient with a headache. How should the nurse
assess the patients response to the medication?
a. Observe the patients behavior.
b. Ask the patient to describe the pain.
c. Monitor the patients blood pressure and pulse.
d. Have the patient rate the pain on a scale of 0 to 10. - Answer-d
A student under a great deal of stress develops a severe tension headache and goes to
the school clinic. What strategy should the nurse teach the student for dealing with the
onset of headaches in the future?
a. Aerobic exercise
b. Relaxation exercises
c. Use of vitamin C and zinc
d. Use of distraction techniques - Answer-b
While walking to the bathroom a patient begins having a generalized tonic-clonic
seizure. What should the nurse do first?
a. Reduce external stimuli.
b. Maintain the patients airway.
c. Maintain the patients privacy.
d. Perform a brief neurological assessment. - Answer-b
A patient recovering from surgery to remove a brain tumor is found jerking rhythmically
in the bed and unresponsive to verbal stimuli. What should the nurse do first?
a. Call the physician.
b. Find another nurse to assist.
c. Hold the patient firmly to keep the patient from injuring someone.
d. Protect the patient from injury and observe the sequence of events. - Answer-d
,A patient is incontinent during a seizure and sleeps for several hours afterward. What
type of seizure did the patient most likely experience?
a. Absence
b. Tonic-clonic
c. Simple partial
d. Status epilepticus - Answer-b
A patient in the post-ictal period after a seizure remembers smelling something like
dead fish prior to the seizure. Which response by the nurse is best?
a. Today is Friday; the hospital always cooks fish on Fridays.
b. You were probably hallucinating; I will ask for an order for an anti-hallucinatory agent.
c. The smell of dead fish might be your aura; you should call for help immediately if you
smell it again.
d. Most people see a flash of light before a seizure; if this occurs, you should get to
safety immediately. - Answer-c
A patient with a newly diagnosed seizure disorder is being prepared for discharge. What
medication should the nurse anticipate will be prescribed for the patient to prevent
recurrent seizures?
a. Selegiline (Eldepryl)
b. Haloperidol (Haldol)
c. Gabapentin (Neurontin)
d. Dexamethasone (Decadron) - Answer-c
A patient who has had a seizure is crying, saying life is over, and that working and
driving will no longer be possible. Which response by the nurse is most appropriate?
a. With good seizure control, you should be able to work and drive again.
b. Maybe the social worker can help you identify some alternative activities.
c. You may be able to work again in time; you can use public transportation.
d. You should be able to discontinue your medication within a month and return to work.
- Answer-a
The nurse is assessing a patient recovering from a tonic-clonic seizure. Which finding
indicates a need for immediate nursing intervention?
a. The patient is difficult to arouse.
b. The patient has been incontinent of urine.
c. The patient has frothy sputum in the pharynx and gurgling respirations.
d. The patient becomes belligerent when the nurse does neurological assessments. -
Answer-c
A 17-year-old patient with a new onset of seizures is diagnosed with epilepsy. What
should the nurse include in the patient teaching?
a. Aspirin can inhibit the action of anticonvulsants.
b. Sudden withdrawal of anticonvulsants can lead to status epilepticus.
c. Anticonvulsants must be taken frequently during the day to prevent seizures.
, d. When the seizures have been controlled, the medications can be discontinued. -
Answer-b
A patient arriving in the emergency department with a bullet wound to the left frontal
lobe is comatose. What should the nurse make a priority for this patient?
a. Evaluate fluid balance.
b. Maintain an open airway.
c. Maintain body temperature.
d. Evaluate neurological status - Answer-b
The nurse is caring for a patient admitted to the emergency department with massive
trauma to the right frontal lobe of the brain. Which data should the nurse collect related
to the location of the injury?
a. Presence of intact smell
b. Presence of intact pupillary reflex
c. Ability to remember the name of the current president
d. Ability to use extraocular muscles (EOMs) of the eyes - Answer-c
A patient with a cerebral injury is experiencing increased intracranial pressure (ICP).
Which intervention should the nurse use to help prevent further increasing intracranial
pressure?
a. Avoid touching the patient as much as possible.
b. Provide stimulation such as radio and television for 12 hours each day.
c. Provide as much nursing care at one time as possible to allow the patient to rest.
d. Space nursing care at intervals so that necessary care is distributed evenly
throughout a shift. - Answer-d
The nurse is caring for a patient with a traumatic brain injury. Which assessment finding
alerts the nurse to possible diabetes insipidus?
a. Headache
b. Confusion
c. Frequent urination
d. Elevated blood glucose - Answer-c
The physician prescribes intravenous mannitol for a patient who has a head injury and
increased intracranial pressure (ICP). Which assessment finding indicates to the nurse
that the patient is having a therapeutic response to the mannitol?
a. Return of the gag reflex
b. Increased blood glucose
c. Increased urinary output
d. Decreased Glasgow Coma Scale (GCS) score - Answer-c
A teen is experiencing a headache and dizziness after falling of a bicycle and hitting the
head. The physician diagnoses a concussion. What explanation should the nurse
provide to the patients mother?
a. The patient may lose consciousness before beginning to recover.
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