MSN 377 UPDATED EXAM SCRIPT QUESTIONS AND
SOLUTIONS RATED A+
✔✔Intracranial pressure - ✔✔the amount of pressure inside the skull controlled by the
three essential components of pressure in the skull: brain tissue, blood, CSF
✔✔A nurse is caring for a client who has a basilar skull fracture following a fall from a
ladder. Which of the following assessment findings should the nurse report to the
provider?
A. glasgow coma scale score of 15
B. intracranial pressure reading of 15mmHg
C. ecchymosis at base of skull
D. clear drainage from nose - ✔✔D. clear drainage from nose
clear drainage indicates that CSF is leaking from the skill fracture
✔✔A nurse in an emergency department is caring for a client who suddenly lost
consciousness and fell in her home. the provider determines that the client had an
embolic stroke. Which of the following medications should the nurse administer?
A. Tissue plasminogen activator
B. Recombinant factor VIII
C. Nitroglycerin
D. Lidocaine - ✔✔A. tissue plasminogen activatior
a thrombolytic that should dissolve the clot that caused the stroke
✔✔A nurse is assessing a client who had a right hemispheric stoke. Which of the
following neurologic deficits should the nurse expect?
A. aphasia
B. right sided neglect
C. impulsive behavior
D. inability to read - ✔✔C. impulsive behavior
the nurse should expect impulsive behavior, poor judgment, and lack of awareness of
neurologic deficits
✔✔A nurse is assessing a client who is quadriplegic following a cervical fracture at
vertebral level C5. the client reports a throbbing headache and nausea. the nurse notes
facial drooping and a blood pressure of 220/110. Which of the following actions should
the nurse take first?
A. administer hydralazine via IV bolus
B. loosen the clients clothing
C. empty the client's bladder
D. elevate the head of the client's bed - ✔✔D. elevate the head of the client's bed
,indicate autonomic dysreflexia and they are at risk for possible rupture of a cerebral
vessel or increased intracranial pressure. The first action the nurse should take is to
move the client from supine to an upright position which will result in rapid postural
hypotension.
✔✔A nurse is caring for a patient who has a history of status epilepticus and requires
seizure precautions. Which of the following actions should the nurse take?
A. assess hourly for a spike in blood pressure
B. keep the client on bed rest
C. keep a padded tongue blade at the bedside
D. establish IV access - ✔✔D. establish IV access
The nurse should plan to establish IV access with a large-bore catheter and administer
0.9% sodium chloride if seizures are imminent. If the client is stable, the nurse should
initiate a saline lock.
✔✔A nurse is assessing a client who has a head injury following a motor vehicle
accident. The nurse should identify that which of the following findings indicates
increasing ICP?
A. restlessness
B. dizziness
C. hypotension
D. fever - ✔✔A. restlessness
Behavioral changes, such as restlessness and irritability, are early manifestations of
increased intracranial pressure.
✔✔A nurse is caring for a client who has multiple sclerosis. Which of the following
findings should the nurse expect?
A. hypoactive deep tendon reflexes
B. ascending paralysis
C. intention tremors
D. increased lacrimation - ✔✔C. intention tremors
Clients who have multiple sclerosis are at risk for motor dysfunction, with intention
tremors, poor coordination, and loss of balance.
✔✔A nurse is caring for a client who is recovering from a stroke and has right sided
homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse
should take which of the following actions?
A. check the clients cheek on his affected side after he eats to be sure no food remains
there
B. encourage the client to sit upright with his head tilted slightly forward during meals
C. provide the client eating utensils that have large handles
, D. remind the client to look consciously at both sides of his meal tray - ✔✔D. remind the
client to look consciously at both sides of his meal tray
Clients who have right-sided homonymous hemianopsia have lost the right visual field
of both eyes and might only eat the food he is able to see on the left half of the meal
tray. Therefore, the nurse should remind the client to look at both sides of his meal tray
to help him compensate for the visual loss.
✔✔A nurse in an ED is assessing a client who has myasthenia gravis. The client reports
recent increasing muscle weakness and the nurse suspects the client is having a
myasthenic crisis, which of the following actions is the nurse's priority?
A. administer artificial tears
B. assist with a tensilon test
C. administer immunosuppressants
D. assist with plasmapheresis - ✔✔B. assist with a tensilon test
The first action the nurse should take using the nursing process is to assess the client.
The Tensilon test will determine whether the client is having a myasthenic crisis or a
cholinergic crisis.
✔✔A nurse is caring for a client who has a spastic bladder following a spinal cord injury.
which of the following actions should the nurse take to help stimulate micturition?
A. encourage the client to use the valsalva maneuver
B. stroke the clients inner thigh
C. perform the crede maneuver
D. administer a diuretic - ✔✔B. stroke the clients inner thigh
The nurse should stimulate micturition by stroking the client's inner thigh. Other
techniques include pinching the skin above the groin and providing digital anal
stimulation.
✔✔A nurse is planning care for a client who has a closed head injury from a fall and is
receiving mechanical ventilation. Which of the following interventions is the nurse's
priority?
A. maintain PaCO2 of approximately 35mmHg
B. provide small doses of fentanyl via IV bolus for pain management
C. measure body temperature every 1-2 hrs
D. reposition the client every 2 hours - ✔✔A. maintain PaCO2 of approximately
35mmHg
The greatest risk to this client is injury from increased intracranial pressure. Therefore,
the nurse's priority action is to maintain the PaCO2 at 35 to 38 mm Hg to prevent
hypercarbia and subsequent vasodilation that can lead to an increase in intracranial
pressure.
SOLUTIONS RATED A+
✔✔Intracranial pressure - ✔✔the amount of pressure inside the skull controlled by the
three essential components of pressure in the skull: brain tissue, blood, CSF
✔✔A nurse is caring for a client who has a basilar skull fracture following a fall from a
ladder. Which of the following assessment findings should the nurse report to the
provider?
A. glasgow coma scale score of 15
B. intracranial pressure reading of 15mmHg
C. ecchymosis at base of skull
D. clear drainage from nose - ✔✔D. clear drainage from nose
clear drainage indicates that CSF is leaking from the skill fracture
✔✔A nurse in an emergency department is caring for a client who suddenly lost
consciousness and fell in her home. the provider determines that the client had an
embolic stroke. Which of the following medications should the nurse administer?
A. Tissue plasminogen activator
B. Recombinant factor VIII
C. Nitroglycerin
D. Lidocaine - ✔✔A. tissue plasminogen activatior
a thrombolytic that should dissolve the clot that caused the stroke
✔✔A nurse is assessing a client who had a right hemispheric stoke. Which of the
following neurologic deficits should the nurse expect?
A. aphasia
B. right sided neglect
C. impulsive behavior
D. inability to read - ✔✔C. impulsive behavior
the nurse should expect impulsive behavior, poor judgment, and lack of awareness of
neurologic deficits
✔✔A nurse is assessing a client who is quadriplegic following a cervical fracture at
vertebral level C5. the client reports a throbbing headache and nausea. the nurse notes
facial drooping and a blood pressure of 220/110. Which of the following actions should
the nurse take first?
A. administer hydralazine via IV bolus
B. loosen the clients clothing
C. empty the client's bladder
D. elevate the head of the client's bed - ✔✔D. elevate the head of the client's bed
,indicate autonomic dysreflexia and they are at risk for possible rupture of a cerebral
vessel or increased intracranial pressure. The first action the nurse should take is to
move the client from supine to an upright position which will result in rapid postural
hypotension.
✔✔A nurse is caring for a patient who has a history of status epilepticus and requires
seizure precautions. Which of the following actions should the nurse take?
A. assess hourly for a spike in blood pressure
B. keep the client on bed rest
C. keep a padded tongue blade at the bedside
D. establish IV access - ✔✔D. establish IV access
The nurse should plan to establish IV access with a large-bore catheter and administer
0.9% sodium chloride if seizures are imminent. If the client is stable, the nurse should
initiate a saline lock.
✔✔A nurse is assessing a client who has a head injury following a motor vehicle
accident. The nurse should identify that which of the following findings indicates
increasing ICP?
A. restlessness
B. dizziness
C. hypotension
D. fever - ✔✔A. restlessness
Behavioral changes, such as restlessness and irritability, are early manifestations of
increased intracranial pressure.
✔✔A nurse is caring for a client who has multiple sclerosis. Which of the following
findings should the nurse expect?
A. hypoactive deep tendon reflexes
B. ascending paralysis
C. intention tremors
D. increased lacrimation - ✔✔C. intention tremors
Clients who have multiple sclerosis are at risk for motor dysfunction, with intention
tremors, poor coordination, and loss of balance.
✔✔A nurse is caring for a client who is recovering from a stroke and has right sided
homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse
should take which of the following actions?
A. check the clients cheek on his affected side after he eats to be sure no food remains
there
B. encourage the client to sit upright with his head tilted slightly forward during meals
C. provide the client eating utensils that have large handles
, D. remind the client to look consciously at both sides of his meal tray - ✔✔D. remind the
client to look consciously at both sides of his meal tray
Clients who have right-sided homonymous hemianopsia have lost the right visual field
of both eyes and might only eat the food he is able to see on the left half of the meal
tray. Therefore, the nurse should remind the client to look at both sides of his meal tray
to help him compensate for the visual loss.
✔✔A nurse in an ED is assessing a client who has myasthenia gravis. The client reports
recent increasing muscle weakness and the nurse suspects the client is having a
myasthenic crisis, which of the following actions is the nurse's priority?
A. administer artificial tears
B. assist with a tensilon test
C. administer immunosuppressants
D. assist with plasmapheresis - ✔✔B. assist with a tensilon test
The first action the nurse should take using the nursing process is to assess the client.
The Tensilon test will determine whether the client is having a myasthenic crisis or a
cholinergic crisis.
✔✔A nurse is caring for a client who has a spastic bladder following a spinal cord injury.
which of the following actions should the nurse take to help stimulate micturition?
A. encourage the client to use the valsalva maneuver
B. stroke the clients inner thigh
C. perform the crede maneuver
D. administer a diuretic - ✔✔B. stroke the clients inner thigh
The nurse should stimulate micturition by stroking the client's inner thigh. Other
techniques include pinching the skin above the groin and providing digital anal
stimulation.
✔✔A nurse is planning care for a client who has a closed head injury from a fall and is
receiving mechanical ventilation. Which of the following interventions is the nurse's
priority?
A. maintain PaCO2 of approximately 35mmHg
B. provide small doses of fentanyl via IV bolus for pain management
C. measure body temperature every 1-2 hrs
D. reposition the client every 2 hours - ✔✔A. maintain PaCO2 of approximately
35mmHg
The greatest risk to this client is injury from increased intracranial pressure. Therefore,
the nurse's priority action is to maintain the PaCO2 at 35 to 38 mm Hg to prevent
hypercarbia and subsequent vasodilation that can lead to an increase in intracranial
pressure.
