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Subdural hematomas and brain hemorrhages can sometimes happen spontaneously.

A. True 

B. False 

 

2. A client has been in the ICU for 6 weeks for treatment of a traumatic head injury. Brain death has just been declared. Which assessment findings would be more? Select all that apply.

A. Normal temperature 

B. Presence of coma

C. Loss of brainstem reflexes 

D. Apnea

E. Constricted pupils

 

3. A client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority?

A. Maintain an adequate airway.

B. Assess neurological status. 

C. Monitor pulse, respiration, and blood pressure.

D. Administer intravenous fluid.

 

4. The Emergency department nurse is triaging client. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment?

A. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14

B. History of Bell’s palsy with unilateral facial droop and drooling 

C. History of multiple sclerosis and reporting recent blurred vision 

D. Reports unilateral facial pain when consuming hot foods 

 

5. The nurse is caring for a client with increased intracranial pressure ( ICP) . Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse?

A. ” You should do deep breathing and coughing exercises.”

B. ” I will raise the head of the bed so it is easier to see the television” 

C. “I will turn down the lights when I leave.” 

D. “Let me move your belongings closer so you can reach them.”

 

6.A patient with increased intracranial pressure (ICP) is receiving mannitol IV . Which of the following statements about Mannitol are true? Select all that apply                                                                A. Mannitol will remove water from the brain and place it in the blood to be removed from the body             B. Mannitol will cause water and electrolytes reabsorption in the in the renal tubules.                                    C. When a patient receives mannitol, the nurse must monitor the patient for both fluid volume overload and depletion.                           D. Mannitol is not for patients who are experiencing anuria                 

 

7. A patient within an increased ICP is prescribed Mannitol. Which option is the best indication that the drug is achieving the desired therapeutic effect? 

  A. The patient’s level of consciousness improves 

B. Urine output increases from 30 mL to 50 mL/hour 

C. Blood pressure remains less than 150/90

D. No crackles are auscultated in the lung fields 

 

8. A patient requires 4mg of Morphine. Morphine is available as 10 mg/mL . How many ML will you draw up?

A. 0.4 ml 

B. 1ml 

C. 1.4ml

D. 0.004ml

 

9. The nurse is caring for a patient admitted to the unit with an acute head injury and is experiencing an increased intracranial pressure. The provider prevented Phenytoin (Dilantin) IV for the patient. What is the reason for giving this patient the medication. Phenytoin ( Dilantin) ?

A. Phenytoin ( Dilantin) is an anticonvulsant that is used prophylactically to prevent or treat seizures   

 B. Phenytoin ( Dilantin) is an antimicrobial  for Increased intracranial pressure 

C. Phenytoin (Dilantin) is an adjunct therapy for confusion 

D. Phenytoin (Dilantin) is given to prevent meningitis in patients with head trauma 

 

10 Which of the following trend in vital signs indicate that the patient’s intracranial pressure is rising?

A. Increasing temperature, decreasing pulse, decreasing respiration, increasing blood pressure .

B. Increasing temperature, increasing pulse, increasing respiration, decreasing blood pressure.

C. Decreasing temperature, decreasing pulse ,increasing respiration, decreasing blood pressure.

D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

SCIENCE
HEALTH SCIENCE
NURSING
NURS 331A

 

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