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Question 1 of 25
1. Question
An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
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Question 2 of 25
2. Question
A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
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Question 3 of 25
3. Question
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
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Question 4 of 25
4. Question
When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result?
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Question 5 of 25
5. Question
A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs?
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Question 6 of 25
6. Question
After a hypophysectomy, vasopressin is given IM for which of the following reasons?
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Question 7 of 25
7. Question
A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing interventions should be done first?
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Question 8 of 25
8. Question
A client with a C6 spinal injury would most likely have which of the following symptoms?
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Question 9 of 25
9. Question
A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?
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Question 10 of 25
10. Question
While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions?
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Question 11 of 25
11. Question
A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?
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Question 12 of 25
12. Question
A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
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Question 13 of 25
13. Question
A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?
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Question 14 of 25
14. Question
Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?
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Question 15 of 25
15. Question
A client who is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
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Question 16 of 25
16. Question
A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
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Question 17 of 25
17. Question
When discharging a client from the ER after
- An interval when the client’s speech is garbled.
head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best describes a lucid interval?
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Question 18 of 25
18. Question
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
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Question 19 of 25
19. Question
Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia?
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Question 20 of 25
20. Question
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
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Question 21 of 25
21. Question
During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions?
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Question 22 of 25
22. Question
A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected?
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Question 23 of 25
23. Question
A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase?A. Absent corneal reflex.
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Question 24 of 25
24. Question
A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated?
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Question 25 of 25
25. Question
A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given?
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