NCM 118 EXAM QUESTIONS WITH COMPLETE
SOLUTIONS
Which of the following blood pressure changes alerts the nurse to increase ICP,
| | | | | | | | | | | | |
and should be reportted immediately?
| | | |
A. Rapid drop followed by gradual increase
| | | | | |
B. Widening pulse pressure
| | |
C. Rapid fluctuations
| |
D. Gradual increase - CORRECT ANSWER✔✔-B. Widening pulse pressure
| | | | | | | |
Which of the following nursing interventions will help prevent a further increase
| | | | | | | | | | | |
in ICP?
|
A. Reposition the patient frequently
| | | |
B. Provide physical therapy
| | |
C. Elevate head of the bed
| | | | |
D. Encourage fluids - CORRECT ANSWER✔✔-C. Elevate head of the bed
| | | | | | | | | |
A man sustained lower spine injury after a vehicular accident, the nurse lightly
| | | | | | | | | | | | |
stroke the inner thigh and observe for scrotal elevation to assess for
| | | | | | | | | | | |
genitourinary nerve involvement. Which of the following reflex is the nurse
| | | | | | | | | | |
observing?
,A. Cremasteric reflex
| |
B. Babinski reflex
| |
C. Anal reflex
| |
D. Moro startle reflex - CORRECT ANSWER✔✔-A. Cremasteric reflex
| | | | | | | |
The least serious form of brain trauma, characterized by a brief loss of
| | | | | | | | | | | | |
consciousness and period of confusion, is called: | | | | | |
A. Contusion
|
B. Coup |
C. Countercoup
|
D. Concussion - CORRECT ANSWER✔✔-D. Concussion
| | | | |
A college student sustained TBI after an alleged hazing incident. He was rushed to
| | | | | | | | | | | | |
the hospital and craniotomy procedure was done to evacuate hematoma in the
| | | | | | | | | | | | |
brain tissue. Postoperatively was confined in the ICU. Upon monitoring there was
| | | | | | | | | | | |
no measurable activity in the brain and the brainstem. This state of consciousness
| | | | | | | | | | | |
is described as:
| | |
A. Minimally conscious state
| | |
B. coma |
C. Brain death
| |
D. Vegetative state - CORRECT ANSWER✔✔-C. Brain death
| | | | | | |
, What is the most life-threatening complication the nurse must be alert for in
| | | | | | | | | | | | |
caring for the patient with CVA?
| | | | |
a. Hypertension
|
b. Hypotension
|
c. Oliguria
|
d. Increasing ICP - CORRECT ANSWER✔✔-d. Increasing ICP
| | | | | | |
An IV is started on a patient who is suffering a head injury from a car wreck two
| | | | | | | | | | | | | | | | | |
hours ago. The patient is exhibiting signs suffered of increasing ICP. The nurse will
| | | | | | | | | | | | | |
set the fluid rate at:
| | | |
a. 30 cc/hr
| |
b. 75 cc /hr
| | |
c. 100 cc/hr
| |
d. 125 cc/hr - CORRECT ANSWER✔✔-a. 30 cc/hr
| | | | | | |
Which observation indicates the need for a nurse to stay with a client admitted to
| | | | | | | | | | | | | |
the emergency room following a car wreck?
| | | | | | |
a. Disorientation and irregular vital signs
| | | | |
b. Rapid respirations and agitation
| | | |
c. Irregular vital signs and hostility
| | | | |
d. Elevated vital signs and apprehension - CORRECT ANSWER✔✔-a.
| | | | | | | | |
Disorientation and irregular vital signs | | | |
SOLUTIONS
Which of the following blood pressure changes alerts the nurse to increase ICP,
| | | | | | | | | | | | |
and should be reportted immediately?
| | | |
A. Rapid drop followed by gradual increase
| | | | | |
B. Widening pulse pressure
| | |
C. Rapid fluctuations
| |
D. Gradual increase - CORRECT ANSWER✔✔-B. Widening pulse pressure
| | | | | | | |
Which of the following nursing interventions will help prevent a further increase
| | | | | | | | | | | |
in ICP?
|
A. Reposition the patient frequently
| | | |
B. Provide physical therapy
| | |
C. Elevate head of the bed
| | | | |
D. Encourage fluids - CORRECT ANSWER✔✔-C. Elevate head of the bed
| | | | | | | | | |
A man sustained lower spine injury after a vehicular accident, the nurse lightly
| | | | | | | | | | | | |
stroke the inner thigh and observe for scrotal elevation to assess for
| | | | | | | | | | | |
genitourinary nerve involvement. Which of the following reflex is the nurse
| | | | | | | | | | |
observing?
,A. Cremasteric reflex
| |
B. Babinski reflex
| |
C. Anal reflex
| |
D. Moro startle reflex - CORRECT ANSWER✔✔-A. Cremasteric reflex
| | | | | | | |
The least serious form of brain trauma, characterized by a brief loss of
| | | | | | | | | | | | |
consciousness and period of confusion, is called: | | | | | |
A. Contusion
|
B. Coup |
C. Countercoup
|
D. Concussion - CORRECT ANSWER✔✔-D. Concussion
| | | | |
A college student sustained TBI after an alleged hazing incident. He was rushed to
| | | | | | | | | | | | |
the hospital and craniotomy procedure was done to evacuate hematoma in the
| | | | | | | | | | | | |
brain tissue. Postoperatively was confined in the ICU. Upon monitoring there was
| | | | | | | | | | | |
no measurable activity in the brain and the brainstem. This state of consciousness
| | | | | | | | | | | |
is described as:
| | |
A. Minimally conscious state
| | |
B. coma |
C. Brain death
| |
D. Vegetative state - CORRECT ANSWER✔✔-C. Brain death
| | | | | | |
, What is the most life-threatening complication the nurse must be alert for in
| | | | | | | | | | | | |
caring for the patient with CVA?
| | | | |
a. Hypertension
|
b. Hypotension
|
c. Oliguria
|
d. Increasing ICP - CORRECT ANSWER✔✔-d. Increasing ICP
| | | | | | |
An IV is started on a patient who is suffering a head injury from a car wreck two
| | | | | | | | | | | | | | | | | |
hours ago. The patient is exhibiting signs suffered of increasing ICP. The nurse will
| | | | | | | | | | | | | |
set the fluid rate at:
| | | |
a. 30 cc/hr
| |
b. 75 cc /hr
| | |
c. 100 cc/hr
| |
d. 125 cc/hr - CORRECT ANSWER✔✔-a. 30 cc/hr
| | | | | | |
Which observation indicates the need for a nurse to stay with a client admitted to
| | | | | | | | | | | | | |
the emergency room following a car wreck?
| | | | | | |
a. Disorientation and irregular vital signs
| | | | |
b. Rapid respirations and agitation
| | | |
c. Irregular vital signs and hostility
| | | | |
d. Elevated vital signs and apprehension - CORRECT ANSWER✔✔-a.
| | | | | | | | |
Disorientation and irregular vital signs | | | |
