NURS 4500 - Final Test Questions and Answers 100%
Solved
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A) Slow, irregular respirations
B) Rapid, shallow respirations
C) Asymmetric chest expansion
D) Nasal flaring Correct-A
The nurse is caring for the client in the ER following a head injury. The client momentarily lost
consciousness at the time of the injury and then regained it. The client now has lost
consciousness again. The nurse takes quick action, knowing this is compatible with:
A) Skull fracture
B) Concussion
C) Subdural hematoma
D) Epidural hematoma Correct-D
,A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia.
After checking the client's vital signs, list in order of priority, the nurse's actions (Number 1
being the first priority and number 5 being the last priority).
A. Check for bladder distention
B. Raise the head of the bed
C. Contact the physician
D. Loosen tight clothing on the client
E. Administer an antihypertensive medication B, D, A, C, E.
A) A, B, C, D, E
B) B, D, A, C, E.
C) C, A, D, E, B
D) C, D, A, B, E Correct-B,D,A,C,E
When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2
is 30 mm Hg. Which of the following responses best describes this result?
A) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
B) Emergent; the client is poorly oxygenated.
,C) Normal
D) Significant; the client has alveolar hypoventilation. Correct-A
An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial
pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
A) Reposition the client to avoid neck flexion
B) Administer 1 g Mannitol IV as ordered
C) Increase the ventilator's respiratory rate to 20 breaths/minute
D) Administer 100 mg of pentobarbital IV as ordered. Correct-A
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy,
which of the following is contraindicated when positioning the client?
A) Keeping the client flat on one side or the other
B) Elevating the head of the bed to 30 degrees
C) Log rolling or turning as a unit when turning
D) Keeping the head in neutral position Correct-B
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to
monitor?
, A) Unequal pupil size
B) Decreasing systolic blood pressure
C) Tachycardia
D) Decreasing body temperature Correct-A
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after
recent intracranial occipital bleeding. Which action would be most appropriate?
A) Count the rate to be sure the ventilations are deep enough to be sufficient
B) Call the physician while another nurse checks the vital signs and ascertains the patient's
Glasgow Coma score.
C) Call the physician to adjust the ventilator settings.
D) Check deep tendon reflexes to determine the best motor response Correct-B
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The
underlying cause of epidural hematoma is usually related to which of the following
conditions?
A) Laceration of the middle meningeal artery
Solved
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
A) Slow, irregular respirations
B) Rapid, shallow respirations
C) Asymmetric chest expansion
D) Nasal flaring Correct-A
The nurse is caring for the client in the ER following a head injury. The client momentarily lost
consciousness at the time of the injury and then regained it. The client now has lost
consciousness again. The nurse takes quick action, knowing this is compatible with:
A) Skull fracture
B) Concussion
C) Subdural hematoma
D) Epidural hematoma Correct-D
,A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia.
After checking the client's vital signs, list in order of priority, the nurse's actions (Number 1
being the first priority and number 5 being the last priority).
A. Check for bladder distention
B. Raise the head of the bed
C. Contact the physician
D. Loosen tight clothing on the client
E. Administer an antihypertensive medication B, D, A, C, E.
A) A, B, C, D, E
B) B, D, A, C, E.
C) C, A, D, E, B
D) C, D, A, B, E Correct-B,D,A,C,E
When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2
is 30 mm Hg. Which of the following responses best describes this result?
A) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
B) Emergent; the client is poorly oxygenated.
,C) Normal
D) Significant; the client has alveolar hypoventilation. Correct-A
An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial
pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
A) Reposition the client to avoid neck flexion
B) Administer 1 g Mannitol IV as ordered
C) Increase the ventilator's respiratory rate to 20 breaths/minute
D) Administer 100 mg of pentobarbital IV as ordered. Correct-A
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy,
which of the following is contraindicated when positioning the client?
A) Keeping the client flat on one side or the other
B) Elevating the head of the bed to 30 degrees
C) Log rolling or turning as a unit when turning
D) Keeping the head in neutral position Correct-B
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to
monitor?
, A) Unequal pupil size
B) Decreasing systolic blood pressure
C) Tachycardia
D) Decreasing body temperature Correct-A
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after
recent intracranial occipital bleeding. Which action would be most appropriate?
A) Count the rate to be sure the ventilations are deep enough to be sufficient
B) Call the physician while another nurse checks the vital signs and ascertains the patient's
Glasgow Coma score.
C) Call the physician to adjust the ventilator settings.
D) Check deep tendon reflexes to determine the best motor response Correct-B
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The
underlying cause of epidural hematoma is usually related to which of the following
conditions?
A) Laceration of the middle meningeal artery
