NURS 4 exam 5 practice questions only ( 2021 latest update )

NURS 4 exam 5 practice questions. 1. The client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. A. Bite block at the bedside B. Intravenous access C. Continuous sedation D. Suction equipment at the bedside E. Siderails up 2. The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? A. Absence B. Myoclonic C. Simple partial D. Tonic Seizures 3. The client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What will the nurse do first? A. Administer phenytoin (Dilantin) B. Draw blood C. Assess the need for additional support D. Start an intravenous (IV) line 4. The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure B. Forces a tongue blade in the mouth C. Restrains the client D. Positions the client on the side 5. The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Select all that apply. A. Alopecia B. Headaches C. Dizziness D. Diplopia 6. The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C) 7. The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been requested for treatment of epilepsy. The nurse plans to instruct the client to avoid which beverage? A. Apple juice B. Grape juice C. Grapefruit juice D. Milk 8. A client with a history of seizures is placed on seizure precautions. What emergency equipment will the nurse provide at the bedside? Select all that apply. A. Padded tongue blade B. Oxygen setup C. Nasogastric tube D. Suction setup E. Artificial oral airway 9. Following a generalized tonic-clonic seizure, the patient is tired and sleepy. The nurse should: a) suction the patient before allowing him to rest b) allow the patient to sleep as long as he feels sleepy c) stimulate the patient to increase his level of consciousness d) check the patient's level of consciousness every 15 minutes for an hour 10. The nurse finds a patient in bed having a generalized tonic-clonic seizure. During the seizure activity, the nurse should: a) turn the patient to the side b) suction the patient and administer oxygen c) insert an oral airway into the patient's mouth d) restrain the patient's extremities to prevent soft tissue and bone injury 11. When teaching a patient with a seizure disorder about the medication regimen, it is most important for the nurse to stress that: a) the patient should increase the dosage of the medication if stress is increased b) if gingival hypertrophy occurs the drug should be stopped and the health care provider notified c) stopping the medication abruptly may increase the intensity and frequency of seizures d) most over-the-counter and prescription drugs are safe to take with anticonvulsant drugs 12. A patient admitted to the hospital following a generalized tonic-clonic seizure asks the nurse what caused the seizure. The best response by the nurse is: a) "So many factors can cause epilepsy that it is impossible to say what caused your seizure." b) "Epilepsy is an inherited disorder. Does anyone else in your family have a seizure disorder?" c) "In seizures, some type of trigger causes sudden, abnormal bursts of electrical brain activity." d) "Scar tissue in the brain alters the chemical balance, creating uncontrolled electrical discharges." 13. Generalized seizures differ from partial seizures in that: a)Partial seizure are confined to one side of the brain and remain focal in nature b)Generalized seizures result in loss of consciousness while partial seizures do not. c)Generalized seizures result in temporary residual deficits during the postictal phase. d)Generalized seizures have no warning because the entire brain is affected at the onset. 14. The client experiences low back pain near the end of each day. The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions will the nurse plan to include in teaching the client about preventing low back pain and injury? Select all that apply. A. "Standing for long periods of time will help to prevent low back pain." B. "Keep weight within 50% of ideal body weight." C. "Begin a regular exercise program." D. "When lifting something, the back should be straight and the knees bent." E. "Do not wear high-heeled shoes." 15. The client is admitted with a spinal cord injury at the fifth thoracic vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? A. Auscultating bowel sounds every 2 hours B. Beginning a bladder retraining program C. Monitoring nutritional status D. Positioning the client to maximize ventilation potential 16. To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the health care team is a nursing priority? A. Nutritional therapy B. Occupational therapy C. Physical therapy D. Respiratory therapy 17. In addition to frequent repositioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury? A. Gel pad B. TED (thromboembolism disease) hose C. Trapeze D. Water bottle 18. The nurse is teaching the client and her husband about sexuality issues after a spinal cord injury. Which comment by the client indicates understanding of the nurse's instruction? A. "I can no longer become pregnant." B. "If I become pregnant, I cannot give birth." C. "I may still be able to get pregnant." D. "My children will be paralyzed." 19. The client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates understanding of the nurse's instruction? A. "I can go home the day of the procedure." B. "I can go home 48 hours after the procedure." C. "I'll have a drain in place after the procedure." D. "I'll need to wear special stockings after the procedure." 20. In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? A. Patent airway B. Indication of allergies C. Level of consciousness D. Loss of sensation 21. In assessing the client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? A. Gait B. Mobility C. Sensation D. Strength 22. Which nursing intervention is best for preventing complications of immobility when caring for the client with spinal cord health problems? A. Frequent ambulation B. Proper positioning C. Regular turning and repositioning D. Special pressure relief devices 23. The client who has just undergone spinal surgery must be moved. How will the nurse plan to move this client? A. Getting the client up in a chair B. Keeping the client in the Trendelenburg position C. Lifting the client in unison with other health care personnel D. Log rolling the client 24. The nurse is providing instructions to a client with a spinal injury about caring for the halo device. The nurse plans to include which instructions? A. Begin driving 1 week after discharge. B. Avoid using a pillow under the head while sleeping. C. Swimming is recommended to keep active. D. Keep straws available for drinking fluids. 25. The client with a spinal cord tumor and a poor prognosis has lost bladder control. The client asks the nurse whether the suggested surgery will be "worth it." What is the nurse's best response? A. "It should help return bladder control." B. "Let me call the surgeon so you can ask the rest of your questions." C. "What do you think?" D. "What does your family think?" 26. The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will request which medication? A. Dopamine hydrochloride (Inotropin) B. Hydralazine (Apresoline) C. Methylprednisolone (Solu-Medrol) D. Ziconotide (Prialt) 27. The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? A. Neck pain is at a level 7 (0 to 10 scale). B. The client has hoarseness and some difficulty swallowing secretions. The client has numbness and tingling bilaterally down the arms. C. The client has numbness and tingling bilaterally down the arms. D. Serosanguineous fluid oozes onto the neck dressing. 28. The nurse is caring for a client in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action? A. Electrocardiographic monitoring shows a sinus bradycardia at a rate of 50. B. The client demonstrates flaccid paralysis below the level of injury. C. The client's chest moves very little with each respiration. D. After two fluid boluses, the client's systolic blood pressure remains 80. 29. A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action will the nurse take first? A. Check for fecal impaction. B. Insert a straight catheter. C. Help the client sit up. D. Loosen the client's clothing. 30. When providing discharge teaching to a client after a lumbar laminectomy, the nurse teaches him or her to call the surgeon immediately for which potential complication? A. Discomfort at the incision site B. Decreased appetite in the morning C. Slight redness and itching at the incision site D. Clear drainage from the incision site 31. A client was admitted this morning with an incomplete spinal cord injury and is placed in a halo fixator vest after surgery. Which assessment finding will the nurse report immediately to the health care provider? A. Pulse rate of 78 beats/min B. Blood pressure of 88/42 mm Hg C. Pain level of 4 on a 0-to-10 pain scale D. Loosened halo vest 32. The client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What will the nurse do next? A. Allow the client to remain undisturbed. B. Assess the client's vital signs. C. Remove the cloth because it can harbor microorganisms. D. Turn on the lights for a neurologic assessment. 33. The nurse is teaching the client newly diagnosed with migraine about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A. "I can still eat Chinese food." B. "I must not miss meals." C. "It is okay to drink a few wine coolers." D. "I need to use fake sugar in my coffee." 34. The client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A. Stroke B. Tension headache C. Classic migraine D. Cluster headache 35. The female client with newly diagnosed migraine is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? A. "Sumatriptan should be taken as a last resort." B. "I must report any chest pain right away." C. "Birth control is not needed while taking sumatriptan." D. "St. John's wort can also be taken to help my symptoms." 36. A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse? A. Chest tightness B. Skin flushing C. Tingling feelings D. Warm sensation 37. the nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for treatment of intractable partial seizures. The nurse plans to contact the health care provider if the client has which condition? A. Bipolar disorder B. Diabetes mellitus C. Glaucoma D. Hypothyroidism 38. The nurse is preparing a teaching plan for a client with migraine headaches who is receiving propranolol (Inderal) for migraine headaches. What health teaching by the nurse is important for the client? A. "Take this drug only when you have symptoms at the beginning of a migraine headache." B. "This drug is low dose, so you don't have to worry about your heart rate or blood pressure." C. "This drug will relieve the pain during the aura phase soon after a headache has started." D. "Take this drug as prescribed every day, even when feeling well, to prevent a migraine." 39. A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this client's teaching? a. "Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache." b. "Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches." c. "This drug will relieve the pain during the aura phase soon after a headache has started." d. "This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines." 40. A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue 41. A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider? a. Bronchial asthma b. Prinzmetal's angina c. Diabetes mellitus d. Chronic kidney disease 42. A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure 43. A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take? a. Start fluids via a large-bore catheter. b. Turn the client's head to the side. c. Administer IV push diazepam. d. Prepare to intubate the client. 44. A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil) 45. After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "To prevent complications, I will drink at least 2 liters of water daily." b. "This medication will stop me from getting an aura before a seizure." c. "I will not drive a motor vehicle while taking this medication." d. "Even when my seizures stop, I will continue to take this drug. 46. After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will wear my medical alert bracelet at all times." b. "While taking my epilepsy medications, I will not drink any alcoholic beverages." c. "I will tell my doctor about my prescription and over-the-counter medications." d. "If I am nauseated, I will not take my epilepsy medication." 47. A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this client's teaching? a. "Place a warm compress on your forehead at the onset of the headache." b. "Wear dark sunglasses when you are in brightly lit spaces." c. "Lie down in a darkened room when you experience a headache." d. "Set your alarm to ensure you do not sleep longer than 6 hours at one time." 48. A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. "Participate in an exercise program to strengthen muscles." b. "Purchase a mattress that allows you to adjust the firmness." c. "Wear flat instead of high-heeled shoes to work each day." d. "Keep your weight within 20% of your ideal body weight." 49. A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this client's plan of care? a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers. 50. A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first? a. Sleepy but arouses to voice b. Dry and cracked oral mucosa c. Pain present in lower back d. Bladder palpated above pubis 51. A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A 36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a walker 52. A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions? a. "Only lift items that are 10 pounds or less." b. "Wear your brace whenever you are out of bed." c. "You must remain in bed for 3 weeks after surgery." d. "You are prescribed medications to prevent rejection." 53. A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders 54. A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker. 55. An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status. 56. An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin) 57. A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let the provider know." b. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first." 58. After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate." 59. A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask? a. "Are you taking a nonsteroidal anti-inflammatory drug?" b. "Do you have a mental health disorder?" c. "Are you able to swallow medications?" d. "Do you smoke cigarettes or any illegal drugs?" 60. A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies 61. After teaching a client with a spinal cord tumor, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "Even though turning hurts, I will remind you to turn me every 2 hours." b. "Radiation therapy can shrink the tumor but also can cause more problems." c. "Surgery will be scheduled to remove the tumor and reverse my symptoms." d. "I put my affairs in order because this type of cancer is almost always fatal." e. "My family is moving my bedroom downstairs for when I am discharged home." 62. After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation." 63. A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction. 64. A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache 65. A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure. 66. A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation 67. A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the client's oral fluid intake. e. Assess the chest and back for skin breakdown. 68. A male client is having a tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the client's arms and legs. c. Place a tongue blade in the client's mouth. d. Take measures to prevent injury. 69. The nurse is working on a surgical floor. The nurse must logroll a male client following a: a. laminectomy. b. thoracotomy. c. hemorrhoidectomy. d. cystectomy. 70. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? a. Immobilize the neck before the client is moved onto a stretcher. b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. c. Place a cap over the client's head. d. Administer a sedative as ordered. 71. During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: a. use the pointed end of the reflex hammer when striking the Achilles tendon. b. support the joint where the tendon is being tested. c. tap the tendon slowly and softly d. hold the reflex hammer tightly. 72. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? a. Disturbed sensory perception (visual) b. Self-care deficient: Dressing/grooming c. Impaired verbal communication d. Risk for injury 73. For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a. prevent respiratory alkalosis. b. lower arterial pH. c. promote carbon dioxide elimination. d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg 74. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle 75. A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? a. Side-lying, with a pillow under the hip b. Prone, with a pillow under the abdomen c. Prone, in slight-Trendelenburg's position d. Side-lying, with the legs pulled up and head bent down onto chest. 76. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. Head mildline b. Head turned to the side c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees 77. Answer B. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down. 78. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower limbs d. Limiting bladder catheterization to once every 12 hours 79. The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a. Loosening restrictive clothing b. Restraining the client's limbs c. Removing the pillow and raising padded side rails d. Positioning the client to side, if possible, with the head flexed forward 80. The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: a. The client has complete bilateral paralysis of the arms and legs. b. The client has weakness on the right side of the body, including the face and tongue. c. The client has lost the ability to move the right arm but is able to walk independently. d. The client has lost the ability to move the right arm but is able to walk independently. 81. A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety? a. Speak loudly to the client b. Test the temperature of the shower water c. Check the temperature of the food on the delivery tray. d. Provide a clear path for ambulation without obstacles 82. A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client's behavior. a. Is disoriented to person, place, and time b. Affect is flat, with periods of emotional lability c. Cannot recall what was eaten for breakfast today d. Demonstrate inability to add and subtract; does not know who is president 83. A client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What does the nurse do next? Allow the client to remain undisturbed. Assess the client's vital signs. Remove the cloth because it can harbor microorganisms. Turn on the lights for a neurologic assessment. 84. A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for A. an aura or focal seizure. B. nystagmus or confusion. C. abdominal pain or cramping. D. irregular pulse or palpitations. 85. Which characteristic of a patient's recent seizure is consistent with a focal seizure? A. The patient lost consciousness during the seizure. B. The seizure involved lip smacking and repetitive movements. C. The patient fell to the ground and became stiff for 20 seconds. D. The etiology of the seizure involved both sides of the patient's brain. 86. A female patient complains of a throbbing headache. When her history is obtained, the nurse discovers that the patient has had this type of headache before and experienced photophobia before the headache occurred. The nurse should know that what is probably the cause of this patient's headache? A. Polycythemia vera B. A cluster headache C. A migraine headache D. A hemorrhagic stroke 87. The patient with type 1 diabetes mellitus with hypoglycemia is having a seizure. Which medication should the nurse anticipate administering to stop the seizure? A. IV dextrose solution B. IV diazepam (Valium) C. IV phenytoin (Dilantin) D. Oral carbamazepine (Tegretol) 88. The nurse provides information to the caregiver of a 68-year-old man with epilepsy who has tonic-clonic seizures. Which statement, if made by the caregiver, requires further teaching? A. "It is normal for a person to be sleepy after a seizure." B. "I should call 911 if breathing stops during the seizure." C. "The jerking movements may last for 30 to 40 seconds." D. "Objects should not be placed in the mouth during a seizure." 89. A 50-year-old man complains of recurring headaches. He describes these as sharp, stabbing, and located around his left eye. He also reports that his left eye seems to swell and get teary when these headaches occur. Based on this history, you suspect that he has a. cluster headaches. b. tension headaches. c. migraine headaches. d. medication overuse headaches 90. The nurse is assessing the client with a traumatic brain injury after a skateboarding accident. Which symptom is the nurse most concerned about? Amnesia Head laceration Pupil changes to one side Restlessness 91. The client has had a traumatic brain injury and is comatose. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? Assessing for Turner's sign Maintaining PCO2 levels at 35 mm Hg Placing the client in the Trendelenburg position Suctioning the client frequently 92. A he client with a traumatic brain injury from a motor vehicle accident is monitored for signs of increased intracranial pressure (ICP). Which sign does the nurse monitor for? Changes in breathing pattern Dizziness Increasing level of consciousness Reactive pupils 93. The nurse is monitoring the client after supratentorial surgery. Which sign does the nurse report immediately to the provider? Periorbital edema Bilateral ecchymoses of both eyes Moderate amount of serosanguineous drainage on the head dressing Decorticate positioning 94. The nurse is monitoring the postoperative craniotomy client with intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? Dexamethasone (Decadron) Hydrochlorothiazide (HydroDIURIL) Mannitol (Osmitrol) Phenytoin (Dilantin) 95. . A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using "yes-or-no" questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms. 96. A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information 97. A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication. 98. A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache 99. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope. 100. The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102° F (38.9° C) 101. A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95° F (35° C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admission 102. A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? a. Carbamazepine (Tegretol) b. Dexmedetomidine (Precedex) c. Diazepam (Valium) d. Mannitol (Osmitrol) 103. A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. "I know I can take care of all these needs by myself." b. "I need to seek counseling because I am very angry." c. "Hopefully things will improve gradually over time." d. "With respite care and support, I think I can do this." 104. A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? a. Ensure that informed consent is on the chart. b. Document these findings in the client's record. c. Give the prescribed preprocedure sedation. d. Notify the provider of the findings immediately. 105. After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the client's magnesium level. b. Assess the client's sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour. 106. A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. "Increased pressure from the abscess can cause seizures." b. "Preventing febrile seizures with an abscess is important." c. "Seizures always occur in clients with brain abscesses." d. "This drug is used to sedate the client with an abscess." 107. A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device. 108. The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care 109. A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown 110. A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings. 111. A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group. 112. A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement. 113. A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home 114. A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client? a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the client's right side and speak into the right ear. d. Allow the client to use a white board to ask questions. 115. A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care? a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the client's legs. d. Assess the client's feet for wounds each shift. 116. A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this client's teaching? a. "Place soft rugs in your bathroom to decrease pain in your feet." b. "Bathe in warm water to increase your circulation." c. "Look at the placement of your feet when walking." d. "Walk barefoot to decrease pressure ulcers from your shoes." 117. A nurse assesses a client's recent memory. Which client statement confirms that the client's remote memory is intact? a. "A young girl wrapped in a shroud fell asleep on a bed of clouds." b. "I was born on April 3, 1967, in Johnstown Community Hospital." c. "Apple, chair, and pencil are the words you just stated." d. "I ate oatmeal with wheat toast and orange juice for breakfast." 118. A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding? a. Difficulty with proprioception b. Peripheral motor disorder c. Impaired cerebellar function d. Positive pronator drift 119. A nurse asks a client to take deep breaths during an electroencephalography. The client asks, "Why are you asking me to do this?" How should the nurse respond? a. "Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain." b. "Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform." c. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity." d. "Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures." 120. A nurse assesses a client recovering from a cerebral angiography via the client's right femoral artery. Which assessment should the nurse complete? a. Palpate bilateral lower extremity pulses. b. Obtain orthostatic blood pressure readings. c. Perform a funduscopic examination. d. Assess the gag reflex prior to eating. 121. A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement? a. Educate the client about strict bedrest after the procedure. b. Place an indwelling urinary catheter to closely monitor output. c. Obtain a prescription for intravenous fluids. d. Contact the provider to cancel the procedure. 122. A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which statement should the nurse include in this client's teaching? a. "Avoid caffeine-containing substances for 12 hours before the test." b. "Drink at least 3 liters of fluid during the first 24 hours after the test." c. "Do not take your cardiac medication the morning of the test." d. "Remove your dentures and any metal before the test begins." 123. A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, "I am worried I will not be able to care for my young children." How should the nurse respond? a. "Caring for your children is a priority. You may not want to ask for help, but you have to." b. "Our community has resources that may help you with some household tasks so you have energy to care for your children." c. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?" d. "Give me more information about what worries you, so we can see if we can do something to make adjustments." 124. A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next? a. Touch the pin on the same area of the left hand. b. Contact the provider with the assessment results. c. Ask the client about current medications. d. Continue the assessment on the client's feet. 125. A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include in this client's discharge teaching? a. "Connect a light to flash when your door bell rings." b. "Label your faucet knobs with hot and cold signs." c. "Ask a friend to drive you to your follow-up appointments." d. "Use a natural gas detector with an audible alarm." 126. A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating care for a client with cranial nerve II impairment? a. "Tell the client where food items are on the breakfast tray." b. "Place the client in a high-Fowler's position for all meals." c. "Make sure the client's food is visually appetizing." d. "Assist the client by placing the fork in the left hand." 127. A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider? a. Shingles on the client's back b. Client is claustrophobic c. Absence of intravenous access d. Paroxysmal nocturnal dyspnea 128. A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication of this procedure should alert the nurse to urgently contact the health care provider? a. Weak pedal pulses b. Nausea and vomiting c. Increased thirst d. Hives on the chest 129. A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How should the nurse document this client's assessment using the Glasgow Coma Scale shown below? a. 8 b. 10 c. 12 d. 14 130. A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Loss of smell b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex 131. An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball. For which clinical manifestations that are related to a temporal lobe injury should the nurse assess? (Select all that apply.) a. Memory loss b. Personality changes c. Difficulty with sound interpretation d. Speech difficulties e. Impaired taste 132. A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Diminished cognition 133. A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.) a. Ensure that an informed consent is present. b. Ask the client about any allergies. c. Evaluate the client's renal function. d. Auscultate bilateral breath sounds. e. Assess hematocrit and hemoglobin levels. 134. A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.) a. Long-term memory loss b. Slower processing time c. Increased sensory perception d. Decreased risk for infection e. Change in sleep patterns 135. The nurse is assessing a patient with damage to the lower motor neurons. Which findings should the nurse expect to assess in this patient? (Select all that apply) 1. loss of reflexes 2. increased muscle tone 3. decreased coordination 4. decreased muscle strength 5. muscle atrophy and fasciculations 136. Following a motorcycle crash, a patient is diagnosed with damage to the posterior spinal roots. What should the nurse expect to assess in this patient? 1. flaccid paralysis of the legs 2. loss of sensation to dull and sharp 3. decreased sense of smell and taste 4. changes in peripheral vision in both eyes 137. The nurse is document that a patient is demonstrating decorticate posturing. What does this statement indicate about the patient's physical posture? 1. in supine position, spine extended, legs extended 2. in prone position with arms, and knees sharply flexed 3. arms close to sides, elbows and wrists flexed, legs extended 4. neck extended, arms extended and pronated, feet plantar flexed 138. A patient with increased ICP is to receive IV mannitol (Osmitrol). Which nursing actions are taken concerning this drug? (Select all that apply.) a. Draw up the drug through a filtered needle. b. Insert a Foley catheter for strict measurement of urine output. c. Monitor serum and urine osmolality on a weekly basis. d. Assess for acute renal failure, weakness, or edema. e. Administer mannitol through a filter in the IV tubing. f. Administer furosemide (Lasix) as an adjunctive therapy. 139. A patient displays signs of increased ICP, confusion, slurred speech, and unilateral weakness in the upper extremity. Which diagnostic test for this patient does the nurse question? a. Lumbar puncture (LP) b. Computed tomography (CT) c. Positron emission tomography (PET) d. Magnetic resonance imaging (MRI) 140. In planning care for a patient with increased ICP, what does the nurse do to minimize ICP? a. Gives the bath, changes the linens, and does passive ROM exercises to hands/fingers then allows the patient to rest b. Gives the bath, allows the patient to rest, changes the linens, allows the patient to rest, and then performs passive ROM exercises to hands/fingers c. Defers the bath, changes the linens, and does passive ROM exercises to extremities until the danger of increased ICP as passed. d. Contacts the physician for specific orders about all activities related to the care of the patient that might cause increased ICP 141. The nurse is caring for a patient at risk for increased ICP. Which sign is most likely to be the first indication of increased ICP? a. Decline of level of consciousness b. Increase in systolic blood pressure c. Change in pupil size and response d. Abnormal posturing of extremities 142. Which type of hematoma occurs between the skull and the dura? a. Epidural hematoma b. Subdural hematoma c. Intracranial hemorrhage d. Contusion 143. The nurse is caring for a patient admitted with the medical diagnosis of probably epidural hematoma and decreased level of consciousness. During the shift, the patient becomes lucid and is alert and talking. The family reports this is her baseline mental status. What is the nurse's next action? a. Stay with the patient and have the charge nurse alert the physician because this is an ominous sign for the patient. b. Document the patient's exact behaviors, compare to previous nursing entries, and continue the neurologic assessments every 2 hours. c. Point out to the family that the dangerous period has passed, but encourage them to leave so the patient does not become overly fatigued. d. Monitor the patient for the next 48 hours to 2 weeks because a subacute condition may be slowly developing. 144. A patient has been diagnosed with a large lesion of the parietal lobe and demonstrates loss of sensory function. Which nursing intervention is applicable for this patient? a. Play music for the patient for at least 30 minutes each day. b. Teach the patient to test the water temperature used for bathing c. Position the patient reclining in bed or in a chair for meals d. Use a picture of the patient's spouse and ask the patient to state the spouse's name. 145. A patient has been diagnosed with subarachnoid hemorrhage. Which drug does the nurse anticipate will be ordered to control cerebral vasospasm? a. Nimodipine (Nimotop) b. Phenytoin (Dilantin) c. Dexamethasone (Decadron) d. Clopidogrel (Plavix) 146. Which determination must be made first in assessing a patient with traumatic brain injury? a. Presence of spinal injury b. Whether the patient is hypotensive c. Presence of a patent airway d. Level of consciousness using the Glasgow coma scale 147. Which statement is true about a patient at risk for increased ICP? a. The appearance of abnormal posturing occurs only when the patient is not positioned for comfort. b. Cushing's reflex, an early sign of increased ICP, consists of severe hypertension, wideing pulse pressure, and bradycardia. c. Dilated or pinpoint pupils that are slow to react to light or nonreactive to light are signs of increased ICP. d. Areas of tenderness over the scalp indicate the presence of contrecoup injuries 148. A patient has sustained a traumatic brain injury. Which nursing intervention is best for this patient? a. Assess vital signs every 8 hours b. Position to avoid extreme flexion c. Increase fluid intake for the first 48 hours d. Administer glucocorticoids 149. The nurse is caring for a patient with a relatively minor head injury after a bump to the head. The nurse has the greatest concern about which symptom? a. Headache b. Nausea and vomiting c. Unequal pupils d. Dizziness 150. The nurse is assessing a patient who was struck in the head several times with a bat. There is clear fluid that appears to be leaking from the nose. What action does the nurse take? a. Hand the patient a tissue and ask him to gently blow the nose; observe the nasal discharge for blood clots. b. Immediately report the finding to the physician and document the observation in the nursing notes c. Place a drop of the fluid on a white absorbent background and look for a yellow halo d. Allow the patient to wipe his nose, but no other action is needed; he has most likely been crying 151. The nurse is taking a history on a teenager who was involved in a motor vehicle accident with friends. The patient has an obvious contusion of the forehead, seems confused, and is laughing loudly and yelling "Ruby! Ruby!" What is the best question for the nurse to ask the patient's friends? a. "Where and why did the accident occur?" b. How can we notify the family for consent for treatment?" c. "Was the patient using drugs or alcohol prior to the accident?" d. "Who is Ruby and why is the patient calling for her?" 152. The provider has prescribed barbiturate coma therapy for a patient with increased ICP. Which complication does the nurse monitor for? a. Decreased LOC b. Reduced gastric motility c. Decreased respiratory rate d. Reduced Glasgow coma scale score 153. The nurse is performing discharge teaching for the family and patient who has had prolonged hospitalization and rehabilitation therapy for severe craniocerebral trauma after a motor-cycle accident. What elements of instruction does the nurse include? (select all that apply) a. Review seizure precautions b. Stimulate the patient with frequent changes in the environment c. Develop a routine of activities with consistency and structure. d. Attend follow-up appointments with therapists e. Encourage the family to seek respite care if needed. f. Encourage the patient to wear a helmet when riding 154. A patient has sustained a major head injury and the nurse is assessing the patient's neurologic status every 2 hours. What early sign of increased ICP does the nurse monitor for? a. Change in the LOC b. Cheyne-Stokes respirations c. Severe hypertension with widened pulse pressure (Cushing's reflex) d. Dilated and nonreactive pupils 155. The nurse is giving a discharge instructions to the mother of a child who bumped her head on a table. Which statement by the mother indicates an understanding of instructions? a. "I should not let her fall asleep" b. She may have nausea or headache for the first 24 hours" c. "She should gently blow her nose and I'll observe for bleeding" d. "She can run and play as she usually does" 156. The nurse is caring for an intubated patient with increased ICP. If the patient needs to be suctioned, which nursing action does the nurse take to avoid further aggravating the increased ICP? a. Manually hyperventilate with 100% oxygen before passing the catheter b. Maintain strict sterile technique when performing endotracheal suctioning c. Perform oral suctioning frequently, but do not perform endotracheal suctioning d. Obtain an order for an arterial blood gas before suctioning the patient 157. Which are key features of a brainstem tumor? (select all that apply) a. Vomiting unrelated to food intake b. Facial pain or weakness c. Nystagmus d. Headache e. Hearing loss f. Hoarseness 158. The nurse is caring for a patient with a brain tumor. Which drug therapy does the nurse anticipate this patient will receive? a. Glucocorticosteroids for intracranial edema b. Nonsteroidal antiinflammatory drugs (NSAIDS) for pain c. Insulin for diabetes insipidus d. Ticlopidine hydrochloride (Ticlid) for platelet adhesiveness 159. Which statement is true about gamma knife therapy for brain tumors? a. It is used for easily reached tumors b. It is noninvasive and has few complications c. It is administered under general anesthesia d. It replaces conventional radiation therapy 160. A patient is scheduled for a craniotomy. What does the nurse tell the patient and family about the procedure? a. The head will not need to be shaved at the surgical site. b. There is a coma state for up to several days after surgery. c. Drainage of a small to moderate amount of cerebrospinal fluid after surgery is normal. d. The family will need to remind the patient of their names and relationships. 161. A patient has had an infratentorial craniotomy. Which position does the nurse use for this patient? a. High-Fowler's position, turned to the operative side b. Head of bed at 30 degrees, turned to the nonoperative side c. Flat in bed, turned to the operative side d. Flat in bed, may turn to either side. 162. The nurse is performing discharge teaching for a patient who underwent a craniotomy for a brain tumor. What instruction does the nurse include? (select all that apply) a. Suggestions to make the environment safe, such as removing scatter rugs b. Reminder that seizures could occur frequently for the first couple of months c. Information about drugs such as dose, administration, and side affects d. Directions about how and when to contact emergency services or the physician e. Advice about which over-the-counter products are safe to use f. Referral to a resource such as the American Brain Tumor Association 163. The nurse is providing education for a patient with a brain tumor. What educational elements does the nurse include? a. Instructions to avoid physical activity b. Instructions to avoid over-the-counter drugs c. Advice that seizures will occur in the immediate postoperative period d. Information about dietary changes to prevent recurrence of the tumor 164. A patient who had a craniotomy develops the postoperative complication of syndrome of inappropriate antidiuretic hormone(SIADH). The patient's sodium level is 126 mEq/L and the serum osmolality is decreased. In light of this development, which physician order does the nurse question? a. Encourage oral fluids b. Normal saline IV at 150Ml/hr c. Strict intake and output d. Daily weights 165. The nurse is assisting a patient who had a large brain tumor removed to get positioned in bed. Which recommended position does the nurse place the patient in? a. Operative side to protect the unaffected side of the brain b. Flat repositioned on either side to decrease tension on the incision c. Elevate the head of bed 30 degrees to promote venous drainage d. Reposition every 2 hours but do not turn the patient onto the operative side 166. The nurse observes that a patient who had surgery for a benign hemangioblastoma has bilateral periorbital edema and ecchymosis. Because the patient's care is based on the general principles of caring for the patient with a craniotomy, what is the nurse's first action? a. Immediately inform the surgeon b. Apply cold compresses c. Check the pupillary response d. Perform a full neurologic assessment 167. Which statement is true about increased ICP in a surgical patient? a. It is a minor postoperative complication b. Diuretics such as furosemide may be given to decrease it. c. Cerebral edema usually subsides within 72 hours d. If not contraindicated, the head of the bed should be placed at 30 degrees 168. Which organism is commonly involved in opportunistic central nervous system infections for patients with AIDS? a. Streptococcus b. Enterobacter c. Haemophilus influenzae d. Toxoplasmosis 169. The nurse who is providing postoperative care for a patient who had a craniotomy immediately notifies the surgeon of which assessment finding? a. Drainage in the Jackson-Pratt container of 45 mL/8 hours b. Intracranial pressure of 15 mm Hg c. Pco₂ level of 35 mm Hg d. Serum sodium of 117 mEq/L 170. What is most likely to be included in the history of a patient with a brain abscess? a. Family history of Huntington disease b. History of HIV/AIDS c. History of osteoarthritis d. Vaccination against influenza 171. Which are common causes of acquired hypoxic-anoxic brain injury? (select all that apply) a. Cardiac arrest b. Kidney failure c. Asphyxiation from attempted suicide d. Brain attack (stroke) e. Drug overdose f. Severe asthma 172. The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse