PNR 408 FINAL EXAM | Vancouver Island University | UPDATED
Questions with 100% Verified Answers
Question: The nurse is caring for a client with a suspected closed head injury who has bloody nasal drainage.
Which of the following observations should the nurse recognize as being a cerebro- spinal fluid (CSF) leak?
a)A halo sign on the nasal drip pad b)Decreased blood pressure and urinary output c)A positive reading for
glucose on a test-tape strip d)Clear nasal drainage along with the bloody discharge
Answer:
A When drainage containing both cerebro-spinal fluid (CSF) and blood is allowed to drip onto a white pad,
within a few minutes the blood will coalesce into the centre, and a yellowish ring of CSF will encircle the
blood, giving a halo or ring effect. The presence of glucose would be unreliable for determining the presence of
CSF because blood also contains glucose.
Question: The nurse is assessing a client for signs of meningeal irritation and observes for nuchal rigidity.
Which of the following findings indicates the presence of this sign of meningeal irritation?
Answer:
D Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the client will resist passive
flexion of the neck by the health care provider.
Question: a)Tonic spasms of the legs b)Curling in a fetal position c)Arching of the neck and back d)Resistance
to flexion of the neck
Answer:
Question: The nurse is caring for a client admitted with a subdural hematoma following a motor vehicle
accident. Which of the following changes in vital signs should the nurse interpret as a manifestation of
increased intracranial pressure? a)Tachypnea b)Bradycardia c)Hypotension d)Narrowing pulse pressure
Answer:
B Changes in vital signs indicative of increased intracranial pressure are known as Cushing's triad, which
consists of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding
pulse, and irregular respirations.
Question: Which of the following nursing actions should be implemented in the care of a client who is
experiencing increased intracranial pressure (ICP)? a)Monitor fluid and electrolyte status astutely. b)Position
the client in a high Fowler's position. c)Administer vasoconstrictors to maintain cerebral perfusion. d)Maintain
physical restraints to prevent episodes of agitation.
Answer:
A Fluid and electrolyte disturbances can have an adverse effect on intracranial pressure (ICP) and must be
monitored vigilantly. The head of the client's bed should be kept at 30 degrees in most circumstances, and
physical restraints are not applied unless absolutely necessary.
, Question: Magnetic resonance imaging (MRI) has revealed the presence of a brain tumour in a client. The
nurse would recognize the client's likely need for which of the following treatment modalities?
Answer:
A Surgery is preferred if possible
Question: a)Surgery b)Chemotherapy c)Radiation therapy d)Pharmacological treatment
Answer:
Question: The nurse is caring for a client admitted for evaluation and surgical removal of a brain tumour. The
nurse will plan interventions for this client based on knowledge that brain tumours can lead to which of the
following complications? (Select all that apply.) a)Vision loss b)Cerebral edema c)Pituitary dysfunction
d)Parathyroid dysfunction e)Focal neurological deficits
Answer:
A, B, C, E Brain tumours can manifest themselves in a wide variety of symptoms depending on location,
including vision loss and focal neurological deficits. Tumours that put pressure on the pituitary can lead to
dysfunction of the gland. As the tumour grows, clinical manifestations of increased intracranial pressure (ICP)
and cerebral edema can appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary
gland.
Question: The nurse is providing care for a client who has been admitted to the hospital with a head injury and
who requires regular neurological vital signs. Which of the following assessments are components of the
Glasgow Coma Scale (GCS)? (Select all that apply.)
Answer:
B, D, E
Question: a)Judgement b)Eye opening c)Abstract reasoning d)Best verbal response e)Best motor response
Answer:
Question: The nurse is caring for a client who has been receiving scheduled doses of phenytoin and begins to
experience diplopia. Which of the following assessments should the nurse complete immediately? a)An aura
b)Nystagmus or confusion c)Abdominal pain or cramping d)Irregular pulse or palpitations
Answer:
B Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include
neurological changes such as nystagmus, ataxia, confusion, dizziness, or slurred speech.
Question: Which of the following characteristics of a client's recent seizure is congruent with a complex partial
seizure? a)The client lost consciousness during the seizure. b)The seizure involved lip smacking and repetitive
movements. c)The client fell to the ground and became stiff for 20 seconds. d)The etiology of the seizure
involved both sides of the client's brain.
Questions with 100% Verified Answers
Question: The nurse is caring for a client with a suspected closed head injury who has bloody nasal drainage.
Which of the following observations should the nurse recognize as being a cerebro- spinal fluid (CSF) leak?
a)A halo sign on the nasal drip pad b)Decreased blood pressure and urinary output c)A positive reading for
glucose on a test-tape strip d)Clear nasal drainage along with the bloody discharge
Answer:
A When drainage containing both cerebro-spinal fluid (CSF) and blood is allowed to drip onto a white pad,
within a few minutes the blood will coalesce into the centre, and a yellowish ring of CSF will encircle the
blood, giving a halo or ring effect. The presence of glucose would be unreliable for determining the presence of
CSF because blood also contains glucose.
Question: The nurse is assessing a client for signs of meningeal irritation and observes for nuchal rigidity.
Which of the following findings indicates the presence of this sign of meningeal irritation?
Answer:
D Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the client will resist passive
flexion of the neck by the health care provider.
Question: a)Tonic spasms of the legs b)Curling in a fetal position c)Arching of the neck and back d)Resistance
to flexion of the neck
Answer:
Question: The nurse is caring for a client admitted with a subdural hematoma following a motor vehicle
accident. Which of the following changes in vital signs should the nurse interpret as a manifestation of
increased intracranial pressure? a)Tachypnea b)Bradycardia c)Hypotension d)Narrowing pulse pressure
Answer:
B Changes in vital signs indicative of increased intracranial pressure are known as Cushing's triad, which
consists of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding
pulse, and irregular respirations.
Question: Which of the following nursing actions should be implemented in the care of a client who is
experiencing increased intracranial pressure (ICP)? a)Monitor fluid and electrolyte status astutely. b)Position
the client in a high Fowler's position. c)Administer vasoconstrictors to maintain cerebral perfusion. d)Maintain
physical restraints to prevent episodes of agitation.
Answer:
A Fluid and electrolyte disturbances can have an adverse effect on intracranial pressure (ICP) and must be
monitored vigilantly. The head of the client's bed should be kept at 30 degrees in most circumstances, and
physical restraints are not applied unless absolutely necessary.
, Question: Magnetic resonance imaging (MRI) has revealed the presence of a brain tumour in a client. The
nurse would recognize the client's likely need for which of the following treatment modalities?
Answer:
A Surgery is preferred if possible
Question: a)Surgery b)Chemotherapy c)Radiation therapy d)Pharmacological treatment
Answer:
Question: The nurse is caring for a client admitted for evaluation and surgical removal of a brain tumour. The
nurse will plan interventions for this client based on knowledge that brain tumours can lead to which of the
following complications? (Select all that apply.) a)Vision loss b)Cerebral edema c)Pituitary dysfunction
d)Parathyroid dysfunction e)Focal neurological deficits
Answer:
A, B, C, E Brain tumours can manifest themselves in a wide variety of symptoms depending on location,
including vision loss and focal neurological deficits. Tumours that put pressure on the pituitary can lead to
dysfunction of the gland. As the tumour grows, clinical manifestations of increased intracranial pressure (ICP)
and cerebral edema can appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary
gland.
Question: The nurse is providing care for a client who has been admitted to the hospital with a head injury and
who requires regular neurological vital signs. Which of the following assessments are components of the
Glasgow Coma Scale (GCS)? (Select all that apply.)
Answer:
B, D, E
Question: a)Judgement b)Eye opening c)Abstract reasoning d)Best verbal response e)Best motor response
Answer:
Question: The nurse is caring for a client who has been receiving scheduled doses of phenytoin and begins to
experience diplopia. Which of the following assessments should the nurse complete immediately? a)An aura
b)Nystagmus or confusion c)Abdominal pain or cramping d)Irregular pulse or palpitations
Answer:
B Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include
neurological changes such as nystagmus, ataxia, confusion, dizziness, or slurred speech.
Question: Which of the following characteristics of a client's recent seizure is congruent with a complex partial
seizure? a)The client lost consciousness during the seizure. b)The seizure involved lip smacking and repetitive
movements. c)The client fell to the ground and became stiff for 20 seconds. d)The etiology of the seizure
involved both sides of the client's brain.
