NR 464 Exam 3 (PowerPoint Questions) – Study Guide, Practice Questions &
Revision Notes
Successful achievement of patient outcomes for the patient with cranial surgery would best be
indicated by the
a) Ability to meet all self-care needs.
b) Acceptance of residual neurologic deficits.
c) Absence of signs and symptoms of increased ICP.
d) Initiation of oral intake 72 hours after surgery. - correct answer ✔✔c) Absence of signs and
symptoms of increased ICP.
When a patient is admitted to the emergency department following a head injury, the nurse's
first priority in management of the patient once a patent airway is confirmed is:
a) Maintaining cervical spine precautions.
b) Determining the presence of increased ICP.
c) Monitoring for changes in neurologic exam.
d) Establishing IV access with a large-bore catheter. - correct answer ✔✔a) Maintaining cervical
spine precautions.
A patient with a head injury has clear drainage from the ear. To determine whether CSF is
present in the drainage the nurse (Select on that apply):
a) Examines the tympanic membrane for a tear.
b) Tests the fluid with for a halo sign on a white dressing
c) Sends the drainage to the lab to check protein content.
, d) Tests the fluid with a glucose-identifying strip or stick - correct answer ✔✔b) Tests the fluid
with for a halo sign on a white dressing
d) Tests the fluid with a glucose-identifying strip or stick
The nurse recognizes the presence of Cushing's triad in the patient with:
a) Increased pulse, irregular respirations, increased BP
b) Decreased pulse, irregular respirations, increased pulse pressure
c) Increased pulse, decreased respiration, increased pulse pressure
d) Decreased pulse, increased respirations, decreased systolic BP - correct answer ✔✔b)
Decreased pulse, irregular respirations, increased pulse pressure
The earliest signs of increased ICP the nurse should assess for include:
a) Cushing's triad
b) Unexpected vomiting
c) Decreasing level of consciousness (LOC)
d) Dilated pupil with sluggish response to light - correct answer ✔✔c) Decreasing level of
consciousness (LOC)
A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells
the nurse he is recovering some function. The nurse's best response to the patient is:
a) "It is really still too soon to know if you will have a return of function."
b) "That could be a really positive finding. Can you show me the movement?"
c) "That's wonderful. We will start exercising your legs more frequently now."
Revision Notes
Successful achievement of patient outcomes for the patient with cranial surgery would best be
indicated by the
a) Ability to meet all self-care needs.
b) Acceptance of residual neurologic deficits.
c) Absence of signs and symptoms of increased ICP.
d) Initiation of oral intake 72 hours after surgery. - correct answer ✔✔c) Absence of signs and
symptoms of increased ICP.
When a patient is admitted to the emergency department following a head injury, the nurse's
first priority in management of the patient once a patent airway is confirmed is:
a) Maintaining cervical spine precautions.
b) Determining the presence of increased ICP.
c) Monitoring for changes in neurologic exam.
d) Establishing IV access with a large-bore catheter. - correct answer ✔✔a) Maintaining cervical
spine precautions.
A patient with a head injury has clear drainage from the ear. To determine whether CSF is
present in the drainage the nurse (Select on that apply):
a) Examines the tympanic membrane for a tear.
b) Tests the fluid with for a halo sign on a white dressing
c) Sends the drainage to the lab to check protein content.
, d) Tests the fluid with a glucose-identifying strip or stick - correct answer ✔✔b) Tests the fluid
with for a halo sign on a white dressing
d) Tests the fluid with a glucose-identifying strip or stick
The nurse recognizes the presence of Cushing's triad in the patient with:
a) Increased pulse, irregular respirations, increased BP
b) Decreased pulse, irregular respirations, increased pulse pressure
c) Increased pulse, decreased respiration, increased pulse pressure
d) Decreased pulse, increased respirations, decreased systolic BP - correct answer ✔✔b)
Decreased pulse, irregular respirations, increased pulse pressure
The earliest signs of increased ICP the nurse should assess for include:
a) Cushing's triad
b) Unexpected vomiting
c) Decreasing level of consciousness (LOC)
d) Dilated pupil with sluggish response to light - correct answer ✔✔c) Decreasing level of
consciousness (LOC)
A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells
the nurse he is recovering some function. The nurse's best response to the patient is:
a) "It is really still too soon to know if you will have a return of function."
b) "That could be a really positive finding. Can you show me the movement?"
c) "That's wonderful. We will start exercising your legs more frequently now."
