WILKES NSG 500 ACTUAL EXAM
QUESTIONS AND CORRECT ANSWERS
COMPLETE STUDY GUIDE
●● lumbar puncture
Answer: - Requires informed consent
- Ask patient to empty bladder (must lay flat for 1 hour after)
- Positioning: Lateral recumbent preferred (can measure CSF pressure)
- Tripod or orthopneic position if LR contraindicated (higher risk of disc
herniation, cannot measure CSF pressure)
- Strict sterile technique
- Contraindicated in increased ICP if space-occupying lesions
Post-op care:
- Occlusive dressing (do not remove)
- Monitor for bleeding or CSF leakage
- Supine x 1 hour
- Push fluids to prevent headache
- Monitor I&O
- Alert provider immediately if leakage (may use blood patch)
Nursing considerations: Bedrest as ordered, monitor VS, quiet and
nonstimulating environment, antipyretics, antibiotics, analgesics, seizure
precautions, monitor for increased ICP, isolation precautions, elevate
HOB 30 degrees and avoid neck flexion and extreme hip flexion
,Prevention: Vaccine, prophylactic abx for close exposure
- EBP recommends checking a head CT before a lumbar puncture to rule
out space occupying lesion
●● brain tumors
Answer: - Classified as benign or malignant and primary or secondary
- Most commonly secondary tumors in the brain
S/S: Headache (severe, especially upon awakening), papilledema
(swelling of optic disc), seizures, increased ICP, unequal pupil size,
bradycardia, HTN, N/V, hemiparesis, altered mentation
Diagnostics: Neurological exam, EEG, LP, MRI, PET scan, biopsy
Treatment: Radiation, dexamethasone, chemo, dilantin (anti-seizure),
mannitol (osmotic diuretic), anticoagulants, surgery (gamma knife,
craniotomy, stereotactic)
Complications: Increased ICP, herniation/ischemia, rupture/hemorrhage,
seizures, hydrocephalus, SIADH/DI/pituitary dysfunction,
fluid/electrolyte imbalances
Care: Frequent neuro checks, monitor VS, pain management, positioning
(upright unless contraindicated), decrease stimuli, prevent increased ICP,
aspiration risk, seizure precautions
●● spinal cord tumors
Answer: - Classified based on anatomic location
Intramedullary: within the cord
, Extramedullary: extradural, outside of the dural membrane
S/S: Pain, weakness, loss of motor and sensory function
Treatment: related to type of tumor and location, usually surgery and
measures to relieve compression (dexamethasone with radiation)
Nursing care: Oral hygiene before meals (to stimulate appetite), plan
meals for comfortable times, offer preferred foods, daily weights, dietary
supplements
●● encephalitis
Answer: Inflammation of the brain tissue itself (most often viral)
- May be caused by herpes simplex
S/S: Severe headache, fever, confusion, nausea/vomiting, alterations in
LOC, bizarre behavior, S/S of increased ICP
Hx: Recent illness, herpes simplex, west nile, EEE, warm climates
Dx: MRI/CT (may show small hemorrhagic lesions), lumbar puncture,
CBC, blood cultures, throat cultures, EEG, brain biopsy
Care: Isolation precautions (droplet), supportive care, antibiotics if
bacterial, pain/fever control, steroids, monitor and decreased ICP,
antivirals, maintain bedrest as ordered, nonstimulating environment,
neuro assessments every 2-4 hours, seizure precautions
●● head injuries
Answer: primary injury: caused by the initial trauma
secondary injury: result of the damage of the initial insult
QUESTIONS AND CORRECT ANSWERS
COMPLETE STUDY GUIDE
●● lumbar puncture
Answer: - Requires informed consent
- Ask patient to empty bladder (must lay flat for 1 hour after)
- Positioning: Lateral recumbent preferred (can measure CSF pressure)
- Tripod or orthopneic position if LR contraindicated (higher risk of disc
herniation, cannot measure CSF pressure)
- Strict sterile technique
- Contraindicated in increased ICP if space-occupying lesions
Post-op care:
- Occlusive dressing (do not remove)
- Monitor for bleeding or CSF leakage
- Supine x 1 hour
- Push fluids to prevent headache
- Monitor I&O
- Alert provider immediately if leakage (may use blood patch)
Nursing considerations: Bedrest as ordered, monitor VS, quiet and
nonstimulating environment, antipyretics, antibiotics, analgesics, seizure
precautions, monitor for increased ICP, isolation precautions, elevate
HOB 30 degrees and avoid neck flexion and extreme hip flexion
,Prevention: Vaccine, prophylactic abx for close exposure
- EBP recommends checking a head CT before a lumbar puncture to rule
out space occupying lesion
●● brain tumors
Answer: - Classified as benign or malignant and primary or secondary
- Most commonly secondary tumors in the brain
S/S: Headache (severe, especially upon awakening), papilledema
(swelling of optic disc), seizures, increased ICP, unequal pupil size,
bradycardia, HTN, N/V, hemiparesis, altered mentation
Diagnostics: Neurological exam, EEG, LP, MRI, PET scan, biopsy
Treatment: Radiation, dexamethasone, chemo, dilantin (anti-seizure),
mannitol (osmotic diuretic), anticoagulants, surgery (gamma knife,
craniotomy, stereotactic)
Complications: Increased ICP, herniation/ischemia, rupture/hemorrhage,
seizures, hydrocephalus, SIADH/DI/pituitary dysfunction,
fluid/electrolyte imbalances
Care: Frequent neuro checks, monitor VS, pain management, positioning
(upright unless contraindicated), decrease stimuli, prevent increased ICP,
aspiration risk, seizure precautions
●● spinal cord tumors
Answer: - Classified based on anatomic location
Intramedullary: within the cord
, Extramedullary: extradural, outside of the dural membrane
S/S: Pain, weakness, loss of motor and sensory function
Treatment: related to type of tumor and location, usually surgery and
measures to relieve compression (dexamethasone with radiation)
Nursing care: Oral hygiene before meals (to stimulate appetite), plan
meals for comfortable times, offer preferred foods, daily weights, dietary
supplements
●● encephalitis
Answer: Inflammation of the brain tissue itself (most often viral)
- May be caused by herpes simplex
S/S: Severe headache, fever, confusion, nausea/vomiting, alterations in
LOC, bizarre behavior, S/S of increased ICP
Hx: Recent illness, herpes simplex, west nile, EEE, warm climates
Dx: MRI/CT (may show small hemorrhagic lesions), lumbar puncture,
CBC, blood cultures, throat cultures, EEG, brain biopsy
Care: Isolation precautions (droplet), supportive care, antibiotics if
bacterial, pain/fever control, steroids, monitor and decreased ICP,
antivirals, maintain bedrest as ordered, nonstimulating environment,
neuro assessments every 2-4 hours, seizure precautions
●● head injuries
Answer: primary injury: caused by the initial trauma
secondary injury: result of the damage of the initial insult
