NR 464 EXAM REVIEW QUESTIONS WITH
100% VERIFIED ANSWERS!!
The nurse is caring for a client with a head injury. The client's intracranial pressure
reading is 8 mm Hg. Which condition should the nurse document?
1. The intracranial pressure reading is normal.
2. The intracranial pressure reading is elevated.
3. The intracranial pressure reading is borderline.
4. An intracranial pressure reading of 8 mm Hg is low
1. The intracranial pressure reading is normal.
The nurse in the neurological unit is monitoring a client for signs of increased intracranial
pressure (ICP). The nurse reviews the assessment findings for the client and notes
documentation of the presence of Cushing's reflex. The nurse determines that the presence
of this reflex is obtained by assessing which item?
1. Blood pressure
2. Motor response
3. Pupillary response
4. Level of consciousness
1. Blood pressure
The nurse is developing a plan of care for an older client that addresses interventions to
prevent cold discomfort and the development of accidental hypothermia. The nurse should
document which desired outcome in the plan of care?
,1. The client's fingers and toes are cool to touch.
2. The client's body temperature is 98°F (36.7°C).
3. The client remains in a fetal position when in bed.
4. The client complains of coolness in the hands and feet only.
2. The client's body temperature is 98°F (36.7°C).
The nurse in the neurological unit is caring for a client with a supratentorial lesion. The
nurse assesses which measurement as the most critical index of central nervous system
(CNS) dysfunction?
1. Temperature
2. Blood pressure
3. Ability to speak
4. Level of consciousness
4. Level of consciousness
The nurse is caring for a client after a craniotomy and monitors the client for signs of
increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate
an early sign of increased ICP?
1. Confusion
2. Bradycardia
3. Sluggish pupils
, 4. A widened pulse pressure
1. Confusion
The nurse is caring for a client who sustained a spinal cord injury. During administration
of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia.
Which initial nursing action should the nurse take?
1. Elevate the head of the bed.
2. Examine the rectum digitally.
3. Assess the client's blood pressure.
4. Place the client in the prone position.
1. Elevate the head of the bed.
The home care nurse is making a visit to a client who requires use of a wheelchair after a
spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse
ensures that which intervention has been done to prevent an episode of autonomic
dysreflexia (hyperreflexia)?
1. Updating the home safety sheet
2. Leaving the client in an unchilled area of the room
3. Noting a bowel movement on the client progress note
4. Recording the amount of urine obtained with catheterization
2. Leaving the client in an unchilled area of the room
100% VERIFIED ANSWERS!!
The nurse is caring for a client with a head injury. The client's intracranial pressure
reading is 8 mm Hg. Which condition should the nurse document?
1. The intracranial pressure reading is normal.
2. The intracranial pressure reading is elevated.
3. The intracranial pressure reading is borderline.
4. An intracranial pressure reading of 8 mm Hg is low
1. The intracranial pressure reading is normal.
The nurse in the neurological unit is monitoring a client for signs of increased intracranial
pressure (ICP). The nurse reviews the assessment findings for the client and notes
documentation of the presence of Cushing's reflex. The nurse determines that the presence
of this reflex is obtained by assessing which item?
1. Blood pressure
2. Motor response
3. Pupillary response
4. Level of consciousness
1. Blood pressure
The nurse is developing a plan of care for an older client that addresses interventions to
prevent cold discomfort and the development of accidental hypothermia. The nurse should
document which desired outcome in the plan of care?
,1. The client's fingers and toes are cool to touch.
2. The client's body temperature is 98°F (36.7°C).
3. The client remains in a fetal position when in bed.
4. The client complains of coolness in the hands and feet only.
2. The client's body temperature is 98°F (36.7°C).
The nurse in the neurological unit is caring for a client with a supratentorial lesion. The
nurse assesses which measurement as the most critical index of central nervous system
(CNS) dysfunction?
1. Temperature
2. Blood pressure
3. Ability to speak
4. Level of consciousness
4. Level of consciousness
The nurse is caring for a client after a craniotomy and monitors the client for signs of
increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate
an early sign of increased ICP?
1. Confusion
2. Bradycardia
3. Sluggish pupils
, 4. A widened pulse pressure
1. Confusion
The nurse is caring for a client who sustained a spinal cord injury. During administration
of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia.
Which initial nursing action should the nurse take?
1. Elevate the head of the bed.
2. Examine the rectum digitally.
3. Assess the client's blood pressure.
4. Place the client in the prone position.
1. Elevate the head of the bed.
The home care nurse is making a visit to a client who requires use of a wheelchair after a
spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse
ensures that which intervention has been done to prevent an episode of autonomic
dysreflexia (hyperreflexia)?
1. Updating the home safety sheet
2. Leaving the client in an unchilled area of the room
3. Noting a bowel movement on the client progress note
4. Recording the amount of urine obtained with catheterization
2. Leaving the client in an unchilled area of the room
