Nursing Care Planning and Clinical Decision-Making Examination: Initial Care
Planning, Ongoing Care Planning, Discharge Planning Strategies, Comprehensive
Client Assessment Integration, Nursing Diagnosis Development, Client-Centered
Goal Formulation, Measurable Desired Outcomes, Evidence-Based Nursing
Interventions, Nursing Outcomes Classification (NOC), Nursing Interventions
Classification (NIC), Priority Setting Frameworks, Multidisciplinary Collaboration,
Collaborative Care Planning, Standardized Care Plans, Individualized Client Care
Plans, Clinical Critical Pathways, Dependent Nursing Interventions, Independent
Nursing Interventions, Interdisciplinary Care Coordination, Nursing
Documentation Standards, Clinical Protocol Implementation, Agency Policy
Compliance, Standing Medical Orders, Client Safety Prioritization, Continuity of
Care Management, Evaluation of Client Outcomes, Nursing Process Application,
Evidence-Based Clinical Rationales Exam Questions Verified and Provided with
Complete A+ Graded Rationales Latest Updated 2026
A sudden explosive discharge of cerebral neurons is termed?
a. epilepsy
b. reflex
c. convulsion
d. seizure
D
A patient is having a tonic-clonic seizure. Which of the following describes a tonic-clonic seizure?
a. sudden loss of consciousness, tonic phase, clonic phase
b. initial drowsiness, clonic phase, tonic phase
c. sudden loss of consciousness, clonic phase, tonic phase
d. tonic phase, clonic phase, loss of consciousness
,a
The nurse sees a patient walking in the hallway who begins to have a seizure. The nurse should perform
which action first?
a. Maintain a patent airway
b. document the seizure activity observed
c. ease the patient to the floor
d. obtain vital signs
c
The nurse is assessing a patient in the postictal phase of a generalized tonic-clonic seizure. The nurse
should expect to find
a. drowsiness
b. inability to move
c. paresthesia
d. hypotension
a
When teaching a patient with a seizure disorder about the medication regimen, it is most important for
the nurse to stress that
a. the patient should increase the dosage of the medication if stress is increased
b. most over-the-counter & prescription drugs are safe to take with anti-seizure drugs
c. stopping the medication abruptly may increase the intensity and frequency of seizures
d. if gingival hypertrophy occurs, the drug should be stopped and the health care provider notified
,C
A 21 year old male is unconscious in the intensive care unity after sustaining a head injury in a river
rafting accident. The best assessment tool to evaluate the neurological status of this patient is
a. glasgow coma scale
b. mini mental state exam
c. 4 unrelated words test
d. PERRLA test
a
A patient is at increased risk for increased intracranial pressure. Which of the following is the priority for
the nurse to monitor
a. unequal pupil size
b. decreasing systolic blood pressure
c. tachycardia
d. decreasing body temperature
a
Which of the following respiratory patterns indicates increasing intracranial pressure on the brain stem?
a. slow, irregular respirations
b. rapid, shallow respirations
c. asymmetric chest excursion
d. nasal flaring
, a
the nurse administers mannitol to the patient with IICP. Which parameter requires close monitoring?
a. muscle relaxation
b. intake and output
c. widening of pulse pressure
d. pupil dilation
b
The nurse is monitoring the ICP of a patient with a head injury and notes the ICP is averaging 25 mmHg.
How should the nurse correctly interpret this result.
a. the result is normal
b. compensation is occuring; indicating adequate brain adaptation
c. ICP is increased indicating serious compromise in cerebral perfusion
d. ICP is borderline in elevation, indicating initial stage of decompensation
c
A patient was admitted with a closed head injury 6 hours ago. during initial assessment, the nurse finds
pt. has vomited and complains of dizziness and headache. What is the most important nursing action?
a. notify the physician
b. administer an antiemetic
c. reorient the patient to surroundings
d. change the patient's gown and bed linens
Planning, Ongoing Care Planning, Discharge Planning Strategies, Comprehensive
Client Assessment Integration, Nursing Diagnosis Development, Client-Centered
Goal Formulation, Measurable Desired Outcomes, Evidence-Based Nursing
Interventions, Nursing Outcomes Classification (NOC), Nursing Interventions
Classification (NIC), Priority Setting Frameworks, Multidisciplinary Collaboration,
Collaborative Care Planning, Standardized Care Plans, Individualized Client Care
Plans, Clinical Critical Pathways, Dependent Nursing Interventions, Independent
Nursing Interventions, Interdisciplinary Care Coordination, Nursing
Documentation Standards, Clinical Protocol Implementation, Agency Policy
Compliance, Standing Medical Orders, Client Safety Prioritization, Continuity of
Care Management, Evaluation of Client Outcomes, Nursing Process Application,
Evidence-Based Clinical Rationales Exam Questions Verified and Provided with
Complete A+ Graded Rationales Latest Updated 2026
A sudden explosive discharge of cerebral neurons is termed?
a. epilepsy
b. reflex
c. convulsion
d. seizure
D
A patient is having a tonic-clonic seizure. Which of the following describes a tonic-clonic seizure?
a. sudden loss of consciousness, tonic phase, clonic phase
b. initial drowsiness, clonic phase, tonic phase
c. sudden loss of consciousness, clonic phase, tonic phase
d. tonic phase, clonic phase, loss of consciousness
,a
The nurse sees a patient walking in the hallway who begins to have a seizure. The nurse should perform
which action first?
a. Maintain a patent airway
b. document the seizure activity observed
c. ease the patient to the floor
d. obtain vital signs
c
The nurse is assessing a patient in the postictal phase of a generalized tonic-clonic seizure. The nurse
should expect to find
a. drowsiness
b. inability to move
c. paresthesia
d. hypotension
a
When teaching a patient with a seizure disorder about the medication regimen, it is most important for
the nurse to stress that
a. the patient should increase the dosage of the medication if stress is increased
b. most over-the-counter & prescription drugs are safe to take with anti-seizure drugs
c. stopping the medication abruptly may increase the intensity and frequency of seizures
d. if gingival hypertrophy occurs, the drug should be stopped and the health care provider notified
,C
A 21 year old male is unconscious in the intensive care unity after sustaining a head injury in a river
rafting accident. The best assessment tool to evaluate the neurological status of this patient is
a. glasgow coma scale
b. mini mental state exam
c. 4 unrelated words test
d. PERRLA test
a
A patient is at increased risk for increased intracranial pressure. Which of the following is the priority for
the nurse to monitor
a. unequal pupil size
b. decreasing systolic blood pressure
c. tachycardia
d. decreasing body temperature
a
Which of the following respiratory patterns indicates increasing intracranial pressure on the brain stem?
a. slow, irregular respirations
b. rapid, shallow respirations
c. asymmetric chest excursion
d. nasal flaring
, a
the nurse administers mannitol to the patient with IICP. Which parameter requires close monitoring?
a. muscle relaxation
b. intake and output
c. widening of pulse pressure
d. pupil dilation
b
The nurse is monitoring the ICP of a patient with a head injury and notes the ICP is averaging 25 mmHg.
How should the nurse correctly interpret this result.
a. the result is normal
b. compensation is occuring; indicating adequate brain adaptation
c. ICP is increased indicating serious compromise in cerebral perfusion
d. ICP is borderline in elevation, indicating initial stage of decompensation
c
A patient was admitted with a closed head injury 6 hours ago. during initial assessment, the nurse finds
pt. has vomited and complains of dizziness and headache. What is the most important nursing action?
a. notify the physician
b. administer an antiemetic
c. reorient the patient to surroundings
d. change the patient's gown and bed linens
