NUR 257 Final Exam - Questions & Solutions
A patient is being admitted to the neurologic ICU following an acute head
injury that has resulted in cerebral edema. When planning this patient's
care, the nurse would expect to administer what priority medication?
A) Hydrochlorothiazide (HydroDIURIL)
B) Furosemide (Lasix)
C) Mannitol (Osmitrol)
D) Spirolactone (Aldactone) Correct Ans - C
The nurse is providing care for a patient who is unconscious. What nursing
intervention takes highest priority?
A) Maintaining accurate records of intake and output
B) Maintaining a patent airway
C) Inserting a nasogastric (NG) tube as ordered
D) Providing appropriate pain control Correct Ans - B
The nurse is caring for a patient in the ICU who has a brain stem herniation
and who is exhibiting an altered level of consciousness. Monitoring reveals
that the patient's mean arterial pressure (MAP) is 60 mm Hg with an
intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most
appropriate action?
A) Position the patient in the high Fowler's position as tolerated.
B) Administer osmotic diuretics as ordered.
C) Participate in interventions to increase cerebral perfusion pressure.
D) Prepare the patient for craniotomy Correct Ans - C
The nurse is caring for a patient who is postoperative following a
craniotomy. When writing the plan of care, the nurse identifies a diagnosis
of "deficient fluid volume related to fluid restriction and osmotic diuretic
use." What would be an appropriate intervention for this diagnosis?
A) Change the patient's position as indicated.
B) Monitor serum electrolytes.
C) Maintain NPO status.
D) Monitor arterial blood gas (ABG) values. Correct Ans - B
,A patient with a documented history of seizure disorder experiences a
generalized seizure. What nursing action is most appropriate?
A) Restrain the patient to prevent injury.
B) Open the patient's jaws to insert an oral airway.
C) Place patient in high Fowler's position.
D) Loosen the patient's restrictive clothing. Correct Ans - D
A patient who has been on long-term phenytoin (Dilantin) therapy is
admitted to the unit. In light of the adverse of effects of this medication, the
nurse should prioritize which of the following in the patient's plan of care?
A) Monitoring of pulse oximetry
B) Administration of a low-protein diet
C) Administration of thorough oral hygiene
D) Fluid restriction as ordered Correct Ans - C
A nurse is admitting a patient with a severe migraine headache and a
history of acute coronary syndrome. What migraine medication would the
nurse question for this patient?
A) Rizatriptan (Maxalt)
B) Naratriptan (Amerge)
C) Sumatriptan succinate (Imitrex)
D) Zolmitriptan (Zomig) Correct Ans - C
The nurse is caring for a patient with increased intracranial pressure (ICP).
The patient has a nursing diagnosis of "ineffective cerebral tissue
perfusion." What would be an expected outcome that the nurse would
document for this diagnosis?
A) Copes with sensory deprivation.
B) Registers normal body temperature.
C) Pays attention to grooming.
D) Obeys commands with appropriate motor responses. Correct Ans -
D
,A patient exhibiting an altered level of consciousness (LOC) due to blunt-
force trauma to the head is admitted to the ED. The physician determines
the patient's injury is causing increased intracranial pressure (ICP). The
nurse should gauge the patient's LOC on the results of what diagnostic
tool?
A) Monro-Kellie hypothesis
B) Glasgow Coma Scale
C) Cranial nerve function
D) Mental status examination Correct Ans - B
While completing a health history on a patient who has recently
experienced a seizure, the nurse would assess for what characteristic
associated with the postictal state?
A) Epileptic cry
B) Confusion
C) Urinary incontinence
D) Body rigidity Correct Ans - B
A patient with increased ICP has a ventriculostomy for monitoring ICP. The
nurse's most recent assessment reveals that the patient is now exhibiting
nuchal rigidity and photophobia. The nurse would be correct in suspecting
the presence of what complication?
A) Encephalitis
B) CSF leak
C) Meningitis
D) Catheter occlusion Correct Ans - C
The nurse is participating in the care of a patient with increased ICP. What
diagnostic test is contraindicated in this patient's treatment?
A) Computed tomography (CT) scan
B) Lumbar puncture
C) Magnetic resonance imaging (MRI)
D) Venous Doppler studies Correct Ans - B
, The nurse is caring for a patient who is in status epilepticus. What
medication does the nurse know may be given to halt the seizure
immediately?
A) Intravenous phenobarbital (Luminal)
B) Intravenous diazepam (Valium)
C) Oral lorazepam (Ativan)
D) Oral phenytoin (Dilantin) Correct Ans - B
The nurse has created a plan of care for a patient who is at risk for
increased ICP. The patient's care plan should specify monitoring for what
early sign of increased ICP?
A) Disorientation and restlessness
B) Decreased pulse and respirations
C) Projectile vomiting
D) Loss of corneal reflex Correct Ans - A
The neurologic ICU nurse is admitting a patient following a craniotomy
using the supratentorial approach. How should the nurse best position the
patient?
A) Position the patient supine.
B) Maintain head of bed (HOB) elevated at 30 to 45 degrees.
C) Position patient in prone position.
D) Maintain bed in Trendelenberg position. Correct Ans - B
A clinic nurse is caring for a patient diagnosed with migraine headaches.
During the patient teaching session, the patient questions the nurse
regarding alcohol consumption. What would the nurse be correct in telling
the patient about the effects of alcohol?
A) Alcohol causes hormone fluctuations.
B) Alcohol causes vasodilation of the blood vessels.
C) Alcohol has an excitatory effect on the CNS.
D) Alcohol diminishes endorphins in the brain. Correct Ans - B
A patient is being admitted to the neurologic ICU following an acute head
injury that has resulted in cerebral edema. When planning this patient's
care, the nurse would expect to administer what priority medication?
A) Hydrochlorothiazide (HydroDIURIL)
B) Furosemide (Lasix)
C) Mannitol (Osmitrol)
D) Spirolactone (Aldactone) Correct Ans - C
The nurse is providing care for a patient who is unconscious. What nursing
intervention takes highest priority?
A) Maintaining accurate records of intake and output
B) Maintaining a patent airway
C) Inserting a nasogastric (NG) tube as ordered
D) Providing appropriate pain control Correct Ans - B
The nurse is caring for a patient in the ICU who has a brain stem herniation
and who is exhibiting an altered level of consciousness. Monitoring reveals
that the patient's mean arterial pressure (MAP) is 60 mm Hg with an
intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most
appropriate action?
A) Position the patient in the high Fowler's position as tolerated.
B) Administer osmotic diuretics as ordered.
C) Participate in interventions to increase cerebral perfusion pressure.
D) Prepare the patient for craniotomy Correct Ans - C
The nurse is caring for a patient who is postoperative following a
craniotomy. When writing the plan of care, the nurse identifies a diagnosis
of "deficient fluid volume related to fluid restriction and osmotic diuretic
use." What would be an appropriate intervention for this diagnosis?
A) Change the patient's position as indicated.
B) Monitor serum electrolytes.
C) Maintain NPO status.
D) Monitor arterial blood gas (ABG) values. Correct Ans - B
,A patient with a documented history of seizure disorder experiences a
generalized seizure. What nursing action is most appropriate?
A) Restrain the patient to prevent injury.
B) Open the patient's jaws to insert an oral airway.
C) Place patient in high Fowler's position.
D) Loosen the patient's restrictive clothing. Correct Ans - D
A patient who has been on long-term phenytoin (Dilantin) therapy is
admitted to the unit. In light of the adverse of effects of this medication, the
nurse should prioritize which of the following in the patient's plan of care?
A) Monitoring of pulse oximetry
B) Administration of a low-protein diet
C) Administration of thorough oral hygiene
D) Fluid restriction as ordered Correct Ans - C
A nurse is admitting a patient with a severe migraine headache and a
history of acute coronary syndrome. What migraine medication would the
nurse question for this patient?
A) Rizatriptan (Maxalt)
B) Naratriptan (Amerge)
C) Sumatriptan succinate (Imitrex)
D) Zolmitriptan (Zomig) Correct Ans - C
The nurse is caring for a patient with increased intracranial pressure (ICP).
The patient has a nursing diagnosis of "ineffective cerebral tissue
perfusion." What would be an expected outcome that the nurse would
document for this diagnosis?
A) Copes with sensory deprivation.
B) Registers normal body temperature.
C) Pays attention to grooming.
D) Obeys commands with appropriate motor responses. Correct Ans -
D
,A patient exhibiting an altered level of consciousness (LOC) due to blunt-
force trauma to the head is admitted to the ED. The physician determines
the patient's injury is causing increased intracranial pressure (ICP). The
nurse should gauge the patient's LOC on the results of what diagnostic
tool?
A) Monro-Kellie hypothesis
B) Glasgow Coma Scale
C) Cranial nerve function
D) Mental status examination Correct Ans - B
While completing a health history on a patient who has recently
experienced a seizure, the nurse would assess for what characteristic
associated with the postictal state?
A) Epileptic cry
B) Confusion
C) Urinary incontinence
D) Body rigidity Correct Ans - B
A patient with increased ICP has a ventriculostomy for monitoring ICP. The
nurse's most recent assessment reveals that the patient is now exhibiting
nuchal rigidity and photophobia. The nurse would be correct in suspecting
the presence of what complication?
A) Encephalitis
B) CSF leak
C) Meningitis
D) Catheter occlusion Correct Ans - C
The nurse is participating in the care of a patient with increased ICP. What
diagnostic test is contraindicated in this patient's treatment?
A) Computed tomography (CT) scan
B) Lumbar puncture
C) Magnetic resonance imaging (MRI)
D) Venous Doppler studies Correct Ans - B
, The nurse is caring for a patient who is in status epilepticus. What
medication does the nurse know may be given to halt the seizure
immediately?
A) Intravenous phenobarbital (Luminal)
B) Intravenous diazepam (Valium)
C) Oral lorazepam (Ativan)
D) Oral phenytoin (Dilantin) Correct Ans - B
The nurse has created a plan of care for a patient who is at risk for
increased ICP. The patient's care plan should specify monitoring for what
early sign of increased ICP?
A) Disorientation and restlessness
B) Decreased pulse and respirations
C) Projectile vomiting
D) Loss of corneal reflex Correct Ans - A
The neurologic ICU nurse is admitting a patient following a craniotomy
using the supratentorial approach. How should the nurse best position the
patient?
A) Position the patient supine.
B) Maintain head of bed (HOB) elevated at 30 to 45 degrees.
C) Position patient in prone position.
D) Maintain bed in Trendelenberg position. Correct Ans - B
A clinic nurse is caring for a patient diagnosed with migraine headaches.
During the patient teaching session, the patient questions the nurse
regarding alcohol consumption. What would the nurse be correct in telling
the patient about the effects of alcohol?
A) Alcohol causes hormone fluctuations.
B) Alcohol causes vasodilation of the blood vessels.
C) Alcohol has an excitatory effect on the CNS.
D) Alcohol diminishes endorphins in the brain. Correct Ans - B
