Zati practice neuro shock burns 2 exam questions and answers., Exams of Neurology

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Neuro-Shock & Burns practice 1. A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected cervical cord injury. Which of the following immediate interventions should the nurse implement? (Select all that apply.) A. Hypotension . Polyuria . Hyperthermia . Absence of bowel sounds moo w . Weakened gag reflex 2. A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching? A. "Lwill notify my doctor before taking any other medications." B. "| have made an appointment to see my dentist next week." C. "| know that | cannot switch brands of this medication." D. "I'll be glad when | can stop taking this medicine." 3. A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide? A. The medication is to be applied when the client is experiencing eye pain. B. The medication will be used until the client's intraocular pressure returns to normal. GC. The medication should be applied on a regular schedule for the rest of the client's life. D. The medication is to be used for approximately 10 days, followed by a gradual tapering off. 4. A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Turn the client's head to the side. B. Check the client's motor strength. C. Loosen the clothing around the client's waist. D. Document the time the seizure began. Created on:1 1/26/2018 Page 1 Neuro-Shock & Burns practice 5. A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider? A. "My eye really itches, but I'm trying not to rub it." B. "I need something for the pain in my eye. | can't stand it." C. "It's hard to see with a patch on one eye. I'm afraid of falling." D. "The bright light in this room is really bothering me." 6. A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse’s initial action? A. Document the amount of drainage. B. Obtain a culture of the drainage. C. Check the drainage for glucose. D. Notify the client's provider. 7. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? A. pulse and blood pressure findings B. behavioral indicators and effect C. scheduled treatments and client illness D. . a self-report pain rating scale 8. A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache? A. Administer pain medication. B. Darken the client's room and close the door. C. Increase fluid intake. D. Elevate the head of the bed to 30°. Created on:1 1/26/2018 Page 2 Neuro-Shock & Burns practice 13.A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse, "I wish I could stay, but | need to go home to see how my children are doing. | really hate to leave." Which of the following responses should the nurse make? A. "Perhaps you could call your children to see how they are doing." B. "Don't worry. We'll take good care of your parent while you are gone." C. "You are feeling drawn in two separate directions." D. . "There's nothing you can do here. You should go home to your children." 14. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. Tachycardia B. Amnesia C. Hypotension D. Restlessness 15.A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? A. Call the family and ask them to stay with the client. B. Move the client to a room closer to the nurses' station. C. Apply wrist and leg restraints to the client. D. Administer medication to sedate the client. 16.A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take? A. Monitor sensory perception of the lower extremities. B. Assist the client into a knee-chest positian to manage postoperative discomfort. C. Maintain strict bed rest for the first 48 hr postoperative. D. Position the client in a high-Fowler's position if clear drainage is noted on the dressing. Created on:1 1/26/2018 Page 4 Neuro-Shock & Burns practice 17.A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform? A. Complete a neurological check. B. Administer the prescribed PRN antihypertensive medication. C. Increase the client's fluid intake. D. Hold the client's evening dose of digoxin. 18.A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the follawing assessment findings by the nurse supports this suspicion? A. Photophobia B. Nuchal rigidity C. Positive Kernig’s sign D. Restlessness 19.A nurse is caring for the client who has Méniére's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make? A. "Yes, you are free to move around as you wish." B. "No, you are on strict bedrest and must not be up." C. "Please ring for assistance when you wish to get out of bed." D. "We will have to get a prescription from your provider." 20.A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority? A. Place a pillow under the child's head. B. Position the child side-lying. C. Loosen restrictive clothing. D. Clear the area of hazards. LL Created on:1 1/26/2018 Page 5 Neuro-Shock & Burns practice 25.A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? A. Perform passive range of motion on each extremity. B. Monitor the client’s electrolyte levels. C. Suction saliva from the client's mouth. D. Record the client’s intake and output. 26.A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? A. Insert a padded tongue blade into the client’s mouth. B. Place a pillow under the client’s head. C. Gently restrain the client's extremities. D. Apply a face mask for oxygen administration. 27.A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonamic dysreflexia. Which of the following actions Should the nurse take first? A. Administer a nitrate antihypertensive. B. Assess the client for bladder distention. C. Place the client in a high-Fowler’s position. D. Obtain the client’s heart rate. 28.A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take? A. Place the client in protective isolation. B. Minimize environmental stimuli. C. Elevate the head of the client's bed 45°. D. Limit the client's ambulation to once a day. LL Created on:1 1/26/2018 Page 7 Neuro-Shock & Burns practice 29.A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority? A. Intracranial pressure B. Serum electrolytes C. Temperature D. Respiratory status 30.A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? A. Reduce edema of the brain. B. Provide fluid hydration. C. Increase cell size in the brain. D. Expand extracellular fluid volume. 31.A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include? A. "Bloodshot eyes on the day of surgery should be reported to the provider." B. "Warm compresses should be applied to the eye three times daily." C. "Photophobia is expected for 2 to 3 days." D. "Vision will be greatly improved on the day of surgery." 32.A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following action should the nurse take? A. Provide the client with water to test the gag reflex. B. Perform carotid massage. C. Notify emergency management services. D. Drive the client to the nearest medical facility. LL Created on:1 1/26/2018 Page 8 Neuro-Shock & Burns practice 37.A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? A. The client can follow simple motor commands. B. The client is unable to make vocal sound. C. The client is unconscious. D. The client opens his eyes when spoken to. 38.A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign? A. Pinpoint pupils B. Jerking contractions of the head and neck C. Pronation of the arms D. Dorsiflexion of the great toe 39.A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take? A. Teach controlled coughing and deep breathing. B. Provide a brightly lit environment. C. Elevate the head of the bed 20°. D. Encourage a minimum intake of 2000 mL (67.6 02) of clear fluids per day. 40.A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first? A. Evaluate the client's neurological status. B. Perform a complete blood count. C. Check the client's temperature. D. Administer an oral analgesic. LL Created on:1 1/26/2018 Page 10 Neuro-Shock & Burns practice 41.A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client? A. Narrowing pulse pressure B. Drainage of clear fluid from the ears C. Alternating periods of alertness and unconsciousness D. Extensive bruising in the mastoid area 42.A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take? A. Obtain a culture of the specimen using sterile swabs. B. Allow the drainage to drip onto a sterile gauze pad. C. Suction the nose gently with a bulb syringe. D. Insert sterile packing into the nares. 43.A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? A. "Turn the screws on the device once each day." B. "The purpose of this device is to immobilize the cervical spine." C. "Apply talcum powder under the vest to limit friction." D. . "The purpose of this device is to allow for neck movement during the healing process." 44.A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take? A. Prepare the client for mechanical ventilation. B. Administer an anticholinesterase medication. C. Instruct the client to perform the pursed lip breathing. D. Prepare to administer a vasoconstrictor. Created on:1 1/26/2018 Page 11 Neuro-Shock & Burns practice 49.A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan? A. Apply restraints. B. Administer opioids. C. Darken the room. D. Reduce stimuli. 50.A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings? A. Nuchal rigidity B. Pupils reactive to light C. Head turns to follow light D. Elevated temperature 51.A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplapia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? A. “Wear an eye patch on the right eye at all times.” B. "Plan to relax in a hot tub spa each day." C. "Engage in a vigorous exercise program." D. "Implement a schedule to include periods of rest." 52. A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrame (GBS). Which of the following questions should the nurse ask the client? A. "Do have a history of chronic alcoho! abuse?" B. "Have you had a recent influenza infection?" C. "Have traveled overseas recently?" D. "Are you taking a multivitamin?" 53. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? Created on:1 1/26/2018 Page 13 Neuro-Shock & Burns practice A. Severe headache B. Bradycardia C. Blurred vision D. Oriented to person, place, and year 54. A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? A. Check the client for a fecal impaction. B. Examine the client for areas of skin breakdown. C. Check the client's bladder for distention. D. Place the client in a sitting position. 55.A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect? A. Loss of consciousness lasting 30 to 60 min B. Glasgow Coma Scale score of 11 C. Nuchal rigidity D. Sensitivity to light 56.A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect? A. A lucid period followed by an immediate loss of consciousness B. A change in the level of consciousness that develops over 48 hr C. Neurologic deficits that increase up to 2 weeks post-injury D. Cognitive perception that decreases over several months post-injury 57.A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? A. Achange in the Glasgow Coma Scale score from 13 to 11 Created on:1 1/26/2018 Page 14 Neuro-Shock & Burns practice C. Electrical charge in a muscle increases in intensity. D. Muscle strength shows no change. 62. A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care? A. Monitor the client for an elevated temperature. B. Provide range of motion to the client's neck. C. Remove the vest daily to inspect the client's skin integrity. D. Check that the halo jacket is snug against the client's skin. 63. A nurse is reviewing the medication administration records of four clients who have a prescription for morphine PRN. Which of the following findings should the nurse identify as a contraindication to this medication? A. The client is experiencing a myocardial infarction. B. The client who is 24 hr postoperative following hip arthroplasty. C. The client who has bronchitis pleurisy. D. The client has a paralytic ileus. 64. A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which assessment should the nurse recognize as a late sign of ICP? (Select all that apply.) A. Confusion . Tachycardia . Hypotension . Nonreactive dilated pupils moon . Slurred speech 65.A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment? A. Lethargy B. Hyperactive deep tendon reflexes Created on:1 1/26/2018 Page 16 Neuro-Shock & Burns practice C. Prolonged ST segment D. Hyperactive bowel sounds 66.A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider? A. Edematous bruise on forehead B. Small drops of clear fluid in left ear C. Pupils are 4 mm and reactive to light D. Glasgow Coma Scale (GCS) score of 12 67.A nurse is caring for a client who reports a severe headache following a lumbar puncture. Which of the following actions should the nurse take? A. Provide a low-sodium diet. B. Administer sumatriptan. C. Place in high-Fowler’s position. D. Encourage oral fluids. 68.A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse? A. PaC02 35 mm Hg B. Intracranial pressure (ICP) 18 mm Hg C. Pulse oximetry 96% D. Blood pressure 140/82 mm Hg 69. A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe. B. Place the client in a supine position. C. Place a warming blanket on the client. LL Created on:1 1/26/2018 Page 17 Neuro-Shock & Burns practice 74.A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take? A. Obtain the telephone number of the client's provider. B. Find a location for the client to sit. C. Call emergency services. D. Drive the client to the nearest emergency department. 75.A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching? A. "Insert a padded tongue blade into the client's mouth." B. "Restrain the client." C. "Place the client on his back." D. "Move objects away from the client." 76.A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include? A. "Take aspirin for discomfort." B. "Restrict lifting objects greater than 10 pounds." C. "Expect reduced vision for 48 hours after procedure." D. "Apply warm compresses for discomfort." 77.A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take? A. Provide warming measures for the client. B. Hyperextend the client's neck. C. Flex the client's hip. D. Adjust the client's head of bed. LL Created on:1 1/26/2018 Page 19 Neuro-Shock & Burns practice 78.A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor for which of the following complications? A. Bradycardia B. Pulmonary embolism C. Peripheral vascular disease D. . Hypertension 79.A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? A. Gradual onset of several hours B. Manifestations preceded by a severe headache C. Maintains consciousness D. History of neurologic deficits lasting less than 1 hr 80.A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client? A. Short peripheral catheter B. Implanted infusion port C. Peripherally inserted central catheter D. Arteriovenous fistula 81.A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) Created on:1 1/26/2018 Page 20