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Question 1 of 25
1. Question
An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions?
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Question 2 of 25
2. Question
Which neurotransmitter is responsible for many of the functions of the frontal lobe?
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Question 3 of 25
3. Question
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions?
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Question 4 of 25
4. Question
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
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Question 5 of 25
5. Question
After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect?
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Question 6 of 25
6. Question
A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client’s airway for rescue breathing?
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Question 7 of 25
7. Question
The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.
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Question 8 of 25
8. Question
The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client’s urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer:
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Question 9 of 25
9. Question
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with:
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Question 10 of 25
10. Question
The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for:
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Question 11 of 25
11. Question
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
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Question 12 of 25
12. Question
The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury?
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Question 13 of 25
13. Question
The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by:
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Question 14 of 25
14. Question
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
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Question 15 of 25
15. Question
A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client’s vital signs, list in order of priority, the nurse’s actions (Number 1 being the first priority and number 5 being the last priority).
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Raise the head of the bed.
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Contact the physician.
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Loosen tight clothing on the client.
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Check for bladder distention.
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Administer an antihypertensive medication.
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Question 16 of 25
16. Question
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
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Question 17 of 25
17. Question
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
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Question 18 of 25
18. Question
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
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Question 19 of 25
19. Question
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client’s condition?
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Question 20 of 25
20. Question
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
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Question 21 of 25
21. Question
Which of the following describes decerebrate posturing?
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Question 22 of 25
22. Question
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
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Question 23 of 25
23. Question
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client?
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Question 24 of 25
24. Question
A client has been pronounced brain dead. Which findings would the nurse assess? Select all that apply.
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Question 25 of 25
25. Question
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising?
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