ACUTE NEURO BUNDLED ACTUAL
QUESTIONS AND ANSWERS VERIFIED
BY EXPERT (100% SATISFACTION
GUARANTEE)GRADED A+\LATEST
UPDATE 2025
A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes
profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?
autonomic dysreflexia
Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe,
pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It
occurs only with SCIs above T6 and is a hypertensive emergency.
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What
will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.
Bradycardia
Bradypnea
Hypertension
Tachycardia
Pupillary constriction
Bradypnea
Hypertension
Tachycardia
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which
nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?
give stool softners
To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP,
A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following
would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from
occurring?
Applying thigh-high elastic stockings
, A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP
include:
pupil cahnges
diminished responsivness
diminished responsivness
Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later.
Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur
even with a severe decrease in responsiveness.
When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing
and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has
occurred?
C5
T6
C3
L1
C5
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
Placing the client in Trendelenburg's position
Administering zolpidem tartrate (Ambien)
Monitoring the patency of an indwelling urinary catheter
Assessing laboratory test results as ordered
Monitoring the patency of an indwelling urinary catheter
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Hyperreflexia along with spastic extremities
Spasticity of all four extremities
Absence of reflexes along with flaccid extremities
Positive Babinski's reflex along with spastic extremities
Absence of reflexes along with flaccid extremities
When planning care for a client with a head injury, which position should the nurse include in the care
plan to enhance client outcomes?
Trendelenburg's
30-degree head elevation
Flat
Side-lying
30 DEGREE
A client has been diagnosed with a concussion and is to be released from the emergency department.
The nurse teaches the family or friends who will be caring for the client to contact the physician or
QUESTIONS AND ANSWERS VERIFIED
BY EXPERT (100% SATISFACTION
GUARANTEE)GRADED A+\LATEST
UPDATE 2025
A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes
profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?
autonomic dysreflexia
Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe,
pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It
occurs only with SCIs above T6 and is a hypertensive emergency.
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What
will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.
Bradycardia
Bradypnea
Hypertension
Tachycardia
Pupillary constriction
Bradypnea
Hypertension
Tachycardia
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which
nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?
give stool softners
To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP,
A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following
would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from
occurring?
Applying thigh-high elastic stockings
, A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP
include:
pupil cahnges
diminished responsivness
diminished responsivness
Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later.
Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur
even with a severe decrease in responsiveness.
When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing
and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has
occurred?
C5
T6
C3
L1
C5
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
Placing the client in Trendelenburg's position
Administering zolpidem tartrate (Ambien)
Monitoring the patency of an indwelling urinary catheter
Assessing laboratory test results as ordered
Monitoring the patency of an indwelling urinary catheter
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Hyperreflexia along with spastic extremities
Spasticity of all four extremities
Absence of reflexes along with flaccid extremities
Positive Babinski's reflex along with spastic extremities
Absence of reflexes along with flaccid extremities
When planning care for a client with a head injury, which position should the nurse include in the care
plan to enhance client outcomes?
Trendelenburg's
30-degree head elevation
Flat
Side-lying
30 DEGREE
A client has been diagnosed with a concussion and is to be released from the emergency department.
The nurse teaches the family or friends who will be caring for the client to contact the physician or
