Chapter 48-Nursing Care of Patients with CNS Disorders Revision Exam Questions Already Solved.
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Course
Spinal disorders
Institution
Spinal Disorders
1. 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...
Chapter 48-Nursing Care of Patients with
CNS Disorders Revision Exam
Questions Already Solved.
1. 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. Decreased level of consciousness
Initial symptoms of increased ICP include restlessness, irritability, and decreased level of consciousness,
because cerebral cortex function is impaired. If not intubated, the patient may hyperventilate, causing
vasoconstriction as the body attempts to compensate. As the pressure increases, the oculomotor nerve
may be compressed on the side of the impairment.
2. 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. Blood
pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min
Vital sign changes are a late indication of increasing ICP. Cushings response is a classic late sign of
increased ICP. Cushings response (or Cushings triad) is characterized by bradycardia, bradypnea, and
arterial hypertension (increasing systolic blood pressure while diastolic blood pressure remains the
same), resulting in widening pulse pressure.
,3. 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. Have the patients next of kin
sign a consent form
The patient is unlikely to be able to sign a consent form, and it must be signed for surgery to begin
4. 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.
Opioid analgesics are used as a last resort for headaches
Opioids are habit forming and are used only as a last resort for headaches.
5. 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. Touch the chin to the chest
Ability to touch the chin to the chest indicates improvement in nuchal rigidity
, 6. 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. Tension headaches are a result of stress and sustained muscle contraction of the head and neck
Persistent contraction of the scalp, facial, cervical, and upper thoracic muscles can cause tension
headaches. A cycle of muscle tension, muscle tenderness, and further muscle tension is established.
7. 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. Keep a headache diary
The patient can identify aggravating factors by keeping a headache diary for a time, recording the time of
day the headache occurs, foods eaten or other aggravating factors, description of the pain, identification
of associated symptoms such as nausea or visual disturbances, and other factors related to headache
symptoms.
8. 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. Have the patient rate the pain on a
scale of 0 to 10
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