NRSG 3420 Exam 2 Nuero Part 1 With Correct Answers

NRSG 3420 Exam 2 Nuero Part 1 With
Correct Answers.




A patient with increased intracranial pressure (ICP) is agitated and restless. What is the nurse's priority
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action?
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A. Reassure the patient verbally
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B. Raise the head of the bed to 45 degrees
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C. Administer oral fluids
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D. Encourage the patient to sleep - CORRECT ANSWER✔✔B Elevating the head of the bed promotes venous
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drainage, which helps reduce ICP.
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A nurse observes decerebrate posturing in a patient with a traumatic brain injury. What does this indicate?
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A. Brainstem dysfunction
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B. Improvement in neurological function
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C. Mild brain injury
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D. Decreased spinal reflexes - CORRECT ANSWER✔✔A Decerebrate posturing is associated with severe
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brainstem damage and is a poor neurological sign.
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,A nurse is performing a neuro assessment and notes the patient is only responsive to painful stimuli. How
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should this level of consciousness be documented?
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A. Alertj j




B. Lethargic
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C. Obtunded
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D. Stuporous - CORRECT ANSWER✔✔D Stuporous patients respond only to vigorous or painful stimuli.
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The nurse is using the Glasgow Coma Scale (GCS). A patient scores 2 for eye response, 3 for verbal, and 5 for
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motor. What is the total score?
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A. 8 j j




B. 9 j j




C. 10 j j




D. 11 - CORRECT ANSWER✔✔A GCS total = 2 (eye) + 3 (verbal) + 5 (motor) = 10.
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Which of the following findings in a patient with increased ICP requires immediate intervention?
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A. Glasgow Coma Scale score of 15
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B. Pupils equal and reactive
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C. Cushing's triad
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D. Headache that improves with acetaminophen - CORRECT ANSWER✔✔C Cushing's triad (widened pulse
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pressure, bradycardia, irregular respirations) is a late and critical sign of increased ICP.
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What is the most appropriate action when suctioning a patient with increased ICP?
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A. Preoxygenate before suctioning
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B. Suction repeatedly until clear
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C. Hyperventilate after suctioning
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, D. Lower the head of the bed during suctioning - CORRECT ANSWER✔✔A Preoxygenating helps prevent
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hypoxia-induced increases in ICP during suctioning.
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The nurse is caring for a patient in a persistent vegetative state. What is the appropriate intervention?
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A. Encourage the patient to follow commands
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B. Provide comfort care and maintain safety
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C. Initiate speech therapy
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D. Discontinue nutrition support - CORRECT ANSWER✔✔B In a persistent vegetative state, the patient is
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non-responsive but requires basic care, safety, and comfort measures.
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A nurse notes asymmetrical facial movement in a neuro assessment. What does this likely indicate?
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A. Fatigue
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B. Bell's palsy or stroke
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C. Migraine aura
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D. Tension headache - CORRECT ANSWER✔✔B Asymmetry in the face may indicate cranial nerve
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involvement such as in stroke or Bell's palsy.
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A patient with altered LOC needs oral care. What is the best method for the nurse to perform this task?
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A. Place patient in high Fowler's
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B. Suction before brushing
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C. Use a padded tongue blade and suction while side-lying
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D. Use a toothbrush with the patient supine - CORRECT ANSWER✔✔C Placing the patient on their side
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reduces aspiration risk. Suction and tongue blade promote safe oral care.
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Which action best promotes cerebral perfusion in a patient with increased ICP?
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A. Keep head and neck aligned in a neutral position
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B. Encourage patient to cough and deep breathe frequently
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