Nur 258 Exam 3 UPDATED ACTUAL Questions and CORRECT Answers
Question: CT Contrast? Y/N Labs? NPO? Y/N
Correct Answer: Contrast: Yes & no, Usually yes Labs: BUN/CR NPO: Yes
Question: CT Education/Care
Correct Answer: -Allergies -Renal function -Hold metformin -NPO 4hrs prior -PO/IV fluids after scan if
with contrast
Question: MRI Contrast? Y/N Labs? NPO? Y/N
Correct Answer: Contrast: Yes & No, usually yes Labs: BUN/CR NPO: Yes
Question: MRI Education/Care
Correct Answer: -Same as CT with contrast -Remove Metal
Question: Angiogram Contrast? Y/N Labs? NPO? Y/N
Correct Answer: Contrast: Yes Labs: Coags (Pt, Ptt, INR) & CBC (H+H, Plt) NPO: Yes
Question: Angiogram Education/Care
Correct Answer: -Consent -Mild sedation -Neuro checks after -Assess for: ***Bleeding ***Circulation
(distal pulses) -Bedrest (4hrs lying FLAT)
Question: Lumbar Puncture Contrast? Y/N Labs? NPO? Y/N
Correct Answer: Contrast: No Labs: Coags & CBC NPO: No
Question: Lumbar Puncture Education/Care
Correct Answer: -Consent -No sedation needed (local only) -Side-lying position -Assess for: ***Bleeding
***CSF Leakage -Bedrest (4hrs lying FLAT to avoid Spinal headache caused by CSF leakage at puncture
site)
Question: EEG Contrast? Y/N Labs? NPO? Y/N
Correct Answer: Contrast: No Labs: None NPO: No
Question: EEG Education/Care
Correct Answer: No stimulants/caffeine prior - Painless procedure - Keep hair clean/dry - May be asked to
stay awake prior to test
Question: Picture of Labs
Correct Answer: Picture of Labs is the key item for this question. It identifies the relevant definition,
function, procedure, or principle for this topic.
Question: Changes in Neuro status
Correct Answer: “ LOC Weakness, numbness, vision changes Aphasia Behavior changes Headache
Question: Decreased LOC
Correct Answer: Goals of Nursing management: •Airway •Protection from injury •Correct fluid volume
balance •Stable vital signs •Skin integrity •Thermoregulation •Promote bowel and bladder function (Cath
needed?) •Reduce Stimuli •Absence of complications
, Question: Management of reduced LOC
Correct Answer: ABC's Nutritional support Prevention of complications Potential complications:
Respiratory failure, pneumonia, pressure injury, Aspiration, VTE, contractures
Question: ICP Cause & Early SSx
Correct Answer: Cause: increased CSF, blood entering CSF, head trauma/infection, tumors - Changes in
LOC - Confusion - Headache - Vision changes
Question: ICP Tx & Education
Correct Answer: Tx: - mannitol, corticosteroid - 3% NS - semi-fowlers, elevate HOB(#1 intervention) -
Quiet environment Educate: - avoid: coughing, sneezing, vomiting, rapid IV bolus, suctioning -
constipation: stool softeners
Question: Cushing's Triad
Correct Answer: Cushing's Triad is the key item for this question. It identifies the relevant definition,
function, procedure, or principle for this topic.
Question: ICP Late SSx
Correct Answer: S/S: - ‘ Temp and BP - “ HR and RR (two rates go down) - Cushing's Triad - vomiting -
dilated pupils - seizures, coma, posturing
Question: Abnormal Posturing
Correct Answer: decorticate and decerebrate CORE (hands to chest) Tx: -Rapid response (Mannitol)
-They are Comatose -risk for cardiac arrest/resp failure
Question: ICP Management
Correct Answer: Monitor ICP - Control Fever - O2, Airway management - Prevent Infection - Fluid
Restriction - Seizure precautions
Question: Glasgow Coma Scale
Correct Answer: 15 = Awake and Alert 8 = 8 or Less than 8 Intubate 6 = Coma 3 = Brain dead
Question: Seizure disorders Tx
Correct Answer: Antiepileptic: Phenytoin -lifelong -compliance -gum hyperplasia side effect -blood work
to be sure in therapeutic range Vagal nerve stimulation -partial seizures Actively seizing now? -Diazepam,
Lorazepam
Question: Interventions during seizure
Correct Answer: -Stay w/ client, call for help -Protect client from injury (move furniture, hold head in lap
if on the floor) -Airway (O2?) -Prep to suction oral secretions. -Turn the client to the side; aspiration risk
-Loosen clothing -Do not restrain -Nothing in mouth -Time it! -Meds: Benzo
Question: After seizure Interventions
Correct Answer: Postictal phase -side-lying -vitals -injuries? -Neuro check -REST -Reorient -Triggers?
Question: Status Epilepticus
Correct Answer: -Seizure lasting more than 5 min -Multiple seizures in 30min -medical emergency!
-seizure prevention = establish IV access w/ Benzo
Question: CT Contrast? Y/N Labs? NPO? Y/N
Correct Answer: Contrast: Yes & no, Usually yes Labs: BUN/CR NPO: Yes
Question: CT Education/Care
Correct Answer: -Allergies -Renal function -Hold metformin -NPO 4hrs prior -PO/IV fluids after scan if
with contrast
Question: MRI Contrast? Y/N Labs? NPO? Y/N
Correct Answer: Contrast: Yes & No, usually yes Labs: BUN/CR NPO: Yes
Question: MRI Education/Care
Correct Answer: -Same as CT with contrast -Remove Metal
Question: Angiogram Contrast? Y/N Labs? NPO? Y/N
Correct Answer: Contrast: Yes Labs: Coags (Pt, Ptt, INR) & CBC (H+H, Plt) NPO: Yes
Question: Angiogram Education/Care
Correct Answer: -Consent -Mild sedation -Neuro checks after -Assess for: ***Bleeding ***Circulation
(distal pulses) -Bedrest (4hrs lying FLAT)
Question: Lumbar Puncture Contrast? Y/N Labs? NPO? Y/N
Correct Answer: Contrast: No Labs: Coags & CBC NPO: No
Question: Lumbar Puncture Education/Care
Correct Answer: -Consent -No sedation needed (local only) -Side-lying position -Assess for: ***Bleeding
***CSF Leakage -Bedrest (4hrs lying FLAT to avoid Spinal headache caused by CSF leakage at puncture
site)
Question: EEG Contrast? Y/N Labs? NPO? Y/N
Correct Answer: Contrast: No Labs: None NPO: No
Question: EEG Education/Care
Correct Answer: No stimulants/caffeine prior - Painless procedure - Keep hair clean/dry - May be asked to
stay awake prior to test
Question: Picture of Labs
Correct Answer: Picture of Labs is the key item for this question. It identifies the relevant definition,
function, procedure, or principle for this topic.
Question: Changes in Neuro status
Correct Answer: “ LOC Weakness, numbness, vision changes Aphasia Behavior changes Headache
Question: Decreased LOC
Correct Answer: Goals of Nursing management: •Airway •Protection from injury •Correct fluid volume
balance •Stable vital signs •Skin integrity •Thermoregulation •Promote bowel and bladder function (Cath
needed?) •Reduce Stimuli •Absence of complications
, Question: Management of reduced LOC
Correct Answer: ABC's Nutritional support Prevention of complications Potential complications:
Respiratory failure, pneumonia, pressure injury, Aspiration, VTE, contractures
Question: ICP Cause & Early SSx
Correct Answer: Cause: increased CSF, blood entering CSF, head trauma/infection, tumors - Changes in
LOC - Confusion - Headache - Vision changes
Question: ICP Tx & Education
Correct Answer: Tx: - mannitol, corticosteroid - 3% NS - semi-fowlers, elevate HOB(#1 intervention) -
Quiet environment Educate: - avoid: coughing, sneezing, vomiting, rapid IV bolus, suctioning -
constipation: stool softeners
Question: Cushing's Triad
Correct Answer: Cushing's Triad is the key item for this question. It identifies the relevant definition,
function, procedure, or principle for this topic.
Question: ICP Late SSx
Correct Answer: S/S: - ‘ Temp and BP - “ HR and RR (two rates go down) - Cushing's Triad - vomiting -
dilated pupils - seizures, coma, posturing
Question: Abnormal Posturing
Correct Answer: decorticate and decerebrate CORE (hands to chest) Tx: -Rapid response (Mannitol)
-They are Comatose -risk for cardiac arrest/resp failure
Question: ICP Management
Correct Answer: Monitor ICP - Control Fever - O2, Airway management - Prevent Infection - Fluid
Restriction - Seizure precautions
Question: Glasgow Coma Scale
Correct Answer: 15 = Awake and Alert 8 = 8 or Less than 8 Intubate 6 = Coma 3 = Brain dead
Question: Seizure disorders Tx
Correct Answer: Antiepileptic: Phenytoin -lifelong -compliance -gum hyperplasia side effect -blood work
to be sure in therapeutic range Vagal nerve stimulation -partial seizures Actively seizing now? -Diazepam,
Lorazepam
Question: Interventions during seizure
Correct Answer: -Stay w/ client, call for help -Protect client from injury (move furniture, hold head in lap
if on the floor) -Airway (O2?) -Prep to suction oral secretions. -Turn the client to the side; aspiration risk
-Loosen clothing -Do not restrain -Nothing in mouth -Time it! -Meds: Benzo
Question: After seizure Interventions
Correct Answer: Postictal phase -side-lying -vitals -injuries? -Neuro check -REST -Reorient -Triggers?
Question: Status Epilepticus
Correct Answer: -Seizure lasting more than 5 min -Multiple seizures in 30min -medical emergency!
-seizure prevention = establish IV access w/ Benzo
