MSN 377 COMPREHENSIVE EXAM UPDATED
QUESTIONS AND SOLUTIONS RATED A+
✔✔A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head
injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is
most appropriate?
A. test the drainage for the presence of glucose
B. apply a loose gauze pad under the patient's nose
C. place the patient in a modified trendelenburg position
D. ask the patient to gently blow the nose to clear the drainage - ✔✔B. apply a loose
gauze pad under the patient's nose
Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may
occur with a frontal skull fracture. A loose collection pad may be placed under the nose,
and if thin bloody fluid is present, the blood will coalesce and a yellow halo will form if
CSF is present.
✔✔The nurse is caring for a patient admitted with a subdural hematoma after a motor
vehicle accident. What change in vital signs would the nurse interpret as a manifestation
of increased intracranial pressure (ICP)?
A. tachypnea
B. bradycardia
C. hypotension
D. narrowing pulse pressure - ✔✔B. bradycardia
✔✔What nursing intervention should be implemented for a patient experiencing
increased intracranial pressure (ICP)?
A. monitor fluid and electrolyte status carefully
B. position the patient in a high Fowler's position
C. administer vasoconstrictors to maintain cerebral perfusion
D. maintain physical restraints to prevent episodes of agitation - ✔✔A. monitor fluid and
electrolyte status carefully
✔✔The nurse prepares to administer temozolomide (Temodar) to a 59-yr-old white
male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse
assess before giving the medication?
A. serum potassium and serum sodium levels
B. urine osmolality and urine specific gravity
C. absolute neutrophil count and platelet count
D. cerebrospinal fluid pressure and cell count - ✔✔C. absolute neutrophil count and
platelet count
✔✔The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old
male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP
reading is 21 mm Hg. It is most important for the nurse to take which action?
, A. document the ICP reading in the chart
B. determine if the patient has a headache
C. assess the patient's level of consciousness
D. position the patient with the head elevated to 60 degrees - ✔✔C. assess the patient's
level of consciousness
The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most
sensitive and reliable indicator of neurologic status is level of consciousness. The
Glasgow Coma Scale may be used to determine the degree of impaired consciousness.
✔✔The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old
woman with an ischemic stroke. Which action by the student will require the nurse to
intervene?
A. giving the patient 1 oz of water to swallow
B. telling the patient to perform a chin tuck before swallowing
C. assisting the patient to sit in a chair before feeding the patient
D. assessing cranial nerves III, IV, VI before attempting the feeding - ✔✔D. Assessing
cranial nerves III, IV, and VI before attempting feeding
The majority of patients after a stroke have dysphagia. The gag reflex and swallowing
ability (cranial nerves IX and X) should be assessed before the first oral feeding. Cranial
nerves III, IV, and VI are responsible for ocular movements. To assess swallowing
ability, the nurse should elevate the head of the bed to an upright position (unless
contraindicated) and give the patient a small amount of crushed ice or ice water to
swallow. The patient should remain in a high Fowler's position, preferably in a chair with
the head flexed forward, for the feeding and for 30 minutes following.
✔✔A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic
stroke develops constipation. Which action should the nurse take first?
A. assist the patient to the bathroom every 2 hours
B. provide incontinence briefs to wear during the day
C. administer dulcolax rectal suppository every day
D. arrange for several servings per day of cooked fruits and vegetables - ✔✔D. arrange
for several servings per day of cooked fruits and vegetables
Patients after a stroke frequently have constipation. Dietary management includes the
following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes
daily, cooked fruit three times daily, cooked vegetables three times daily, and whole-
grain cereal or bread three to five times daily.
✔✔The nurse is planning psychosocial support for the family of the patient who suffered
a stroke. What factor will have the greatest impact on family coping?
A. specific patient neurologic deficits
B. the patient's ability to communicate
C. rehabilitation potential of the patient
QUESTIONS AND SOLUTIONS RATED A+
✔✔A 19-yr-old woman is hospitalized for a frontal skull fracture from a blunt force head
injury. Thin bloody fluid is draining from the patient's nose. What action by the nurse is
most appropriate?
A. test the drainage for the presence of glucose
B. apply a loose gauze pad under the patient's nose
C. place the patient in a modified trendelenburg position
D. ask the patient to gently blow the nose to clear the drainage - ✔✔B. apply a loose
gauze pad under the patient's nose
Cerebrospinal fluid (CSF) rhinorrhea (clear or bloody drainage from the nose) may
occur with a frontal skull fracture. A loose collection pad may be placed under the nose,
and if thin bloody fluid is present, the blood will coalesce and a yellow halo will form if
CSF is present.
✔✔The nurse is caring for a patient admitted with a subdural hematoma after a motor
vehicle accident. What change in vital signs would the nurse interpret as a manifestation
of increased intracranial pressure (ICP)?
A. tachypnea
B. bradycardia
C. hypotension
D. narrowing pulse pressure - ✔✔B. bradycardia
✔✔What nursing intervention should be implemented for a patient experiencing
increased intracranial pressure (ICP)?
A. monitor fluid and electrolyte status carefully
B. position the patient in a high Fowler's position
C. administer vasoconstrictors to maintain cerebral perfusion
D. maintain physical restraints to prevent episodes of agitation - ✔✔A. monitor fluid and
electrolyte status carefully
✔✔The nurse prepares to administer temozolomide (Temodar) to a 59-yr-old white
male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse
assess before giving the medication?
A. serum potassium and serum sodium levels
B. urine osmolality and urine specific gravity
C. absolute neutrophil count and platelet count
D. cerebrospinal fluid pressure and cell count - ✔✔C. absolute neutrophil count and
platelet count
✔✔The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old
male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP
reading is 21 mm Hg. It is most important for the nurse to take which action?
, A. document the ICP reading in the chart
B. determine if the patient has a headache
C. assess the patient's level of consciousness
D. position the patient with the head elevated to 60 degrees - ✔✔C. assess the patient's
level of consciousness
The patient has an increased ICP (normal ICP ranges from 5 to 15 mm Hg). The most
sensitive and reliable indicator of neurologic status is level of consciousness. The
Glasgow Coma Scale may be used to determine the degree of impaired consciousness.
✔✔The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old
woman with an ischemic stroke. Which action by the student will require the nurse to
intervene?
A. giving the patient 1 oz of water to swallow
B. telling the patient to perform a chin tuck before swallowing
C. assisting the patient to sit in a chair before feeding the patient
D. assessing cranial nerves III, IV, VI before attempting the feeding - ✔✔D. Assessing
cranial nerves III, IV, and VI before attempting feeding
The majority of patients after a stroke have dysphagia. The gag reflex and swallowing
ability (cranial nerves IX and X) should be assessed before the first oral feeding. Cranial
nerves III, IV, and VI are responsible for ocular movements. To assess swallowing
ability, the nurse should elevate the head of the bed to an upright position (unless
contraindicated) and give the patient a small amount of crushed ice or ice water to
swallow. The patient should remain in a high Fowler's position, preferably in a chair with
the head flexed forward, for the feeding and for 30 minutes following.
✔✔A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic
stroke develops constipation. Which action should the nurse take first?
A. assist the patient to the bathroom every 2 hours
B. provide incontinence briefs to wear during the day
C. administer dulcolax rectal suppository every day
D. arrange for several servings per day of cooked fruits and vegetables - ✔✔D. arrange
for several servings per day of cooked fruits and vegetables
Patients after a stroke frequently have constipation. Dietary management includes the
following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes
daily, cooked fruit three times daily, cooked vegetables three times daily, and whole-
grain cereal or bread three to five times daily.
✔✔The nurse is planning psychosocial support for the family of the patient who suffered
a stroke. What factor will have the greatest impact on family coping?
A. specific patient neurologic deficits
B. the patient's ability to communicate
C. rehabilitation potential of the patient
