NUR 211 NEURO PRACTICE
QUESTIONS AND CORRECT
ANSWERS
The nurse is assess the client who has Type II Diabetes. Which findings indicate to the nurse that the
client is experiencing HHNS? Select all that apply
Serum osmolality 364 mOsm/kg
Blood glucose level 160 mg/dL
Very dry mucous membranes
Blood pressure of 90/42 mm Hg
Urine output 500 mL past 8 hours ANSW✅✅Answer: a, c & d
Serum osmolality of 364 is elevated. The extremely high blood glucose levels in HHNS increase
serum osmolality.
Blood glucose levels for HHNS are usually over 600 mg/dL
Persistent hyperglycemia in HHNS causes osmotic diuresis, a loss of water and electrolytes and
extreme dehydration. Very dry mucous membranes are a sign of dehydration.
Hypotension from the loss of water and electrolytes in HHNS
Urine output of 500 mL in 8 hours is normal. Clients with HHNS experience polyuria.
The client develops SIADH secondary to a pituitary tumor. The client's assessment findings include
thirst, weight gain, fatigue, and a serum sodium of 127 mEq/L. Which intervention, if prescribed
should the nurse implement to treat SIADH?
Elevate the head of the bed 55 degrees
Administer vasopressin IV
Restrict fluids to 800-1000 mL per day
Give 0.3% sodium chloride per IV infusion ANSW✅✅Answer: c
Incorrect - position client to promote venous return to the heart
Incorrect - Vasopressin is an ADH and will aggravate the client's problem
If symptoms are mild and hyponatremia is not severe, treatment includes fluid restriction to 800-
1000 ml/day.
Incorrect - Hypertonic saline should be reserved for treatment of severe hyponatremia
, The nurse is assessing the client with a tentative diagnosis of meningitis. Which findings should the
nurse associate with meningitis? Select all that apply
Nuchal rigidity
Severe headache
Pill
rolling tremor
Photophobia ANSW✅✅Answer: a, b, d
All answers are correct except pill-rolling tremors which are associated with Parkinson's disease.
The nurse is caring for the client with a spinal cord injury at the C6 vertebrae. Which findings support
the nurse's conclusion that the client may be experiencing autonomic dysreflexia? Select all that
apply
Blurred vision
BP 198/102
Heart rate 150 bpm
Extreme headache
Sweaty face and arms ANSW✅✅Answer: a, b, d, & e
Blurred vision results from the HTN occurring with autonomic dysreflexia
HTN is a symptom of autonomic dysreflexia from overstimulation of the SNS
Bradycardia (not tachycardia) is a symptom of autonomic dysreflexia
HA results from the HTN
Sweating results from the sympathetic stimulation above the level of injury
The nurse learns in report that the client admitted with a vertebral fracture has a halo external
fixation device in place. Which intervention should the nurse plan?
Ensure the traction weight hangs freely
Remove the vest from the device at bedtime
Cleanse sites where the pins enter the skull
Screw the pins in the skull daily to tighten ANSW✅✅Answer: c
There are no weights involved in a halo device
The vest is never removed until the fracture has completely stabilized.
QUESTIONS AND CORRECT
ANSWERS
The nurse is assess the client who has Type II Diabetes. Which findings indicate to the nurse that the
client is experiencing HHNS? Select all that apply
Serum osmolality 364 mOsm/kg
Blood glucose level 160 mg/dL
Very dry mucous membranes
Blood pressure of 90/42 mm Hg
Urine output 500 mL past 8 hours ANSW✅✅Answer: a, c & d
Serum osmolality of 364 is elevated. The extremely high blood glucose levels in HHNS increase
serum osmolality.
Blood glucose levels for HHNS are usually over 600 mg/dL
Persistent hyperglycemia in HHNS causes osmotic diuresis, a loss of water and electrolytes and
extreme dehydration. Very dry mucous membranes are a sign of dehydration.
Hypotension from the loss of water and electrolytes in HHNS
Urine output of 500 mL in 8 hours is normal. Clients with HHNS experience polyuria.
The client develops SIADH secondary to a pituitary tumor. The client's assessment findings include
thirst, weight gain, fatigue, and a serum sodium of 127 mEq/L. Which intervention, if prescribed
should the nurse implement to treat SIADH?
Elevate the head of the bed 55 degrees
Administer vasopressin IV
Restrict fluids to 800-1000 mL per day
Give 0.3% sodium chloride per IV infusion ANSW✅✅Answer: c
Incorrect - position client to promote venous return to the heart
Incorrect - Vasopressin is an ADH and will aggravate the client's problem
If symptoms are mild and hyponatremia is not severe, treatment includes fluid restriction to 800-
1000 ml/day.
Incorrect - Hypertonic saline should be reserved for treatment of severe hyponatremia
, The nurse is assessing the client with a tentative diagnosis of meningitis. Which findings should the
nurse associate with meningitis? Select all that apply
Nuchal rigidity
Severe headache
Pill
rolling tremor
Photophobia ANSW✅✅Answer: a, b, d
All answers are correct except pill-rolling tremors which are associated with Parkinson's disease.
The nurse is caring for the client with a spinal cord injury at the C6 vertebrae. Which findings support
the nurse's conclusion that the client may be experiencing autonomic dysreflexia? Select all that
apply
Blurred vision
BP 198/102
Heart rate 150 bpm
Extreme headache
Sweaty face and arms ANSW✅✅Answer: a, b, d, & e
Blurred vision results from the HTN occurring with autonomic dysreflexia
HTN is a symptom of autonomic dysreflexia from overstimulation of the SNS
Bradycardia (not tachycardia) is a symptom of autonomic dysreflexia
HA results from the HTN
Sweating results from the sympathetic stimulation above the level of injury
The nurse learns in report that the client admitted with a vertebral fracture has a halo external
fixation device in place. Which intervention should the nurse plan?
Ensure the traction weight hangs freely
Remove the vest from the device at bedtime
Cleanse sites where the pins enter the skull
Screw the pins in the skull daily to tighten ANSW✅✅Answer: c
There are no weights involved in a halo device
The vest is never removed until the fracture has completely stabilized.
