PNR 408 FINAL EXAM (FOCUS ON CH 54, 56, 59, 61, 63
OF MED-SURG NURSING (LEWIS) AND MIX OF SOME
PREV QUESTIONS FROM THE TEST 1 AND TEST 2 SETS.)
| QUESTIONS AND ANSWERS | SOLVED 100%
CORRECT!!
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.
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?
,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 - 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.
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.
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.
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?
a)Surgery
b)Chemotherapy
c)Radiation therapy
d)Pharmacological treatment Answer - A
Surgery is preferred if possible
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
OF MED-SURG NURSING (LEWIS) AND MIX OF SOME
PREV QUESTIONS FROM THE TEST 1 AND TEST 2 SETS.)
| QUESTIONS AND ANSWERS | SOLVED 100%
CORRECT!!
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.
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?
,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 - 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.
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.
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.
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?
a)Surgery
b)Chemotherapy
c)Radiation therapy
d)Pharmacological treatment Answer - A
Surgery is preferred if possible
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
