1.

What is the priority nursing

d. A potential side effect of medications is

diagnosis for a patient experiencing a

rebound headache.

migraine headache dd?

e. Complementary therapies such as

a. Acute pain related to biologic and

chemical factors
b. Anxiety related to change in or threat to

relaxation may be helpful.

f. Continue taking estrogen as prescribed
by your physician.

health status

Answers: A, B, C, D & E Medications

c. Hopelessness related to deteriorating

such as estrogen supplements may

physiological condition

actually trigger a migraine headache

d. Risk for Side effects related to medical

attack. All of the other statements are

therapy

accurate. Focus: Prioritization

Answer: A The priority for

3. The patient with migraine headaches

interdisciplinary care for the patient

has a seizure. After the seizure, which

experiencing a migraine headache is pain

action can you delegate to the nursing

management. All of the other nursing

assistant?

diagnoses are accurate, but none of them

is as urgent as the issue of pain, which is
often incapacitating. Focus: Prioritization
2. You are creating a teaching plan for
a patient with newly diagnosed
migraine headaches. Which key items
should be included in the teaching
plan? (Choose all that apply).

a. Document the seizure.

b. Perform neurologic checks.
c. Take the patients vital signs.
d. Restrain the patient for protection.
Answer: C Taking vital signs is within the
education and scope of practice for a
nursing assistant. The nurse should
perform neurologic checks and document

a. Avoid foods that contain tyramine, such

the seizure. Patients with seizures should

as alcohol and aged cheese.

not be restrained; however, the nurse may

b. Avoid drugs such as Tagamet,

guide the patients movements as

nitroglycerin and Nifedipine.

necessary. Focus: Delegation/supervision

c. Abortive therapy is aimed at eliminating

the pain during the aura.

a.c.b.e.l.

4. You are preparing to admit a patient

with a seizure disorder. Which of the

following actions can you delegate to

d. Its OK to take over-the-counter

LPN/LVN?

medications.

a. Complete admission assessment.

Answer: D A patient with a seizure

b. Set up oxygen and suction equipment.

disorder should not take over-the-counter

c. Place a padded tongue blade at

medications without consulting with the

bedside.

physician first. The other three statements

d. Pad the side rails before patient arrives.

are appropriate teaching points for

Answer: B The LPN/LVN can set up the

equipment for oxygen and suctioning. The

patients with seizures disorders and their

families. Focus: Delegation/supervision

RN should perform the complete initial

6. A patient with Parkinsons disease

assessment. Padded side rails are

has a nursing diagnosis of Impaired

controversial in terms of whether they

Physical Mobility related to

actually provide safety and ay embarrass

neuromuscular impairment. You

the patient and family. Tongue blades

observe a nursing assistant

should not be at the bedside and should

performing all of these actions. For

never be inserted into the patients mouth

which action must you intervene?

after a seizure begins. Focus:

Delegation/supervision.

a. The NA assists the patient to ambulate

to the bathroom and back to bed.

5. A nursing student is teaching a

b. The NA reminds the patient not to look

patient and family about epilepsy prior

at his feet when he is walking.

to the patients discharge. For which

c. The NA performs the patients complete

statement should you intervene?

bath and oral care.

a. You should avoid consumption of all

forms of alcohol.

d. The NA sets up the patients tray and

encourages patient to feed himself.

b. Wear you medical alert bracelet at all

Answer: C The nursing assistant should

times.

assist the patient with morning care as

c. Protect your loved ones airway during

needed, but the goal is to keep this patient

a seizure.

as independent and mobile as possible.

Assisting the patient to ambulate,

a.c.b.e.l.

reminding the patient not to look at his feet

started a short time ago. Assessment

(to prevent falls), and encouraging the

of the patient reveals increased blood

patient to feed himself are all appropriate

pressure (168/94) and decreased heart

to goal of maintaining independence.

rate (48/minute), diaphoresis, and

Focus: Delegation/supervision

flushing of the face and neck. What

7. The nurse is preparing to discharge

action should you take first?

a patient with chronic low back pain.

a. Administer the ordered acetaminophen

Which statement by the patient

(Tylenol).

indicates that additional teaching is

b. Check the Foley tubing for kinks or

necessary?

obstruction.

a. I will avoid exercise because the pain

gets worse.
b. I will use heat or ice to help control the
pain.

c. Adjust the temperature in the patients

room.
d. Notify the physician about the change
in status.

c. I will not wear high-heeled shoes at

Answer: B These signs and symptoms

home or work.

are characteristic of autonomic

d. I will purchase a firm mattress to

dysreflexia, a neurologic emergency that

replace my old one.

must be promptly treated to prevent a

Answer: A Exercises are used to

strengthen the back, relieve pressure on
compressed nerves and protect the back
from re-injury. Ice, heat, and firm
mattresses are appropriate interventions
for back pain. People with chronic back
pain should avoid wearing high-heeled
shoes at all times. Focus: Prioritization
8. A patient with a spinal cord injury
(SCI) complains about a severe
throbbing headache that suddenly

a.c.b.e.l.

hypertensive stroke. The cause of this

syndrome is noxious stimuli, most often a
distended bladder or constipation, so
checking for poor catheter drainage,
bladder distention, or fecal impaction is
the first action that should be taken.
Adjusting the room temperature may be
helpful, since too cool a temperature in
the room may contribute to the problem.
Tylenol will not decrease the autonomic
dysreflexia that is causing the patients
headache. Notification of the physician
may be necessary if nursing actions do

not resolve symptoms. Focus:

has retained mobility.

Prioritization

c. Check blood pressure and pulse for

9. Which patient should you, as charge

nurse, assign to a new graduate RN
who is orienting to the neurologic unit?
a. A 28-year-old newly admitted patient
with spinal cord injury
b. A 67-year-old patient with stroke 3 days
ago and left-sided weakness
c. An 85-year-old dementia patient to be
transferred to long-term care today
d. A 54-year-old patient with Parkinsons
who needs assistance with bathing
Answer: B The new graduate RN who is
oriented to the unit should be assigned
stable, non-complex patients, such as the
patient with stroke. The patient with
Parkinsons disease needs assistance
with bathing, which is best delegated to
the nursing assistant. The patient being

signs of spinal shock.

d. Monitor respiratory effort and oxygen
saturation level.
Answer: D The first priority for the
patient with an SCI is assessing
respiratory patterns and ensuring an
adequate airway. The patient with a high
cervical injury is at risk for respiratory
compromise because the spinal nerves
(C3 5) innervate the phrenic nerve,
which controls the diaphragm. The other
assessments are also necessary, but not
as high priority. Focus: Prioritization
11. You are pulled from the ED to the
neurologic floor. Which action should
you delegate to the nursing assistant
when providing nursing care for a
patient with SCI?

transferred to the nursing home and the

a. Assess patients respiratory status

newly admitted SCI should be assigned to

every 4 hours.

experienced nurses. Focus: Assignment

b. Take patients vital signs and record

10. A patient with a spinal cord injury

at level C3-4 is being cared for in the
ED. What is the priority assessment?
a. Determine the level at which the patient
has intact sensation.
b. Assess the level at which the patient

a.c.b.e.l.

every 4 hours.
c. Monitor nutritional status including
calorie counts.
d. Have patient turn, cough, and deep
breathe every 3 hours.

Answer: B The nursing assistants

will not stimulate voiding. Focus:

training and education include taking and

Prioritization

recording patients vital signs. The nursing

assistant may assist with turning and
repositioning the patient and may remind
the patient to cough and deep breathe but
does not teach the patient how to perform
these actions. Assessing and monitoring
patients require additional education and
are appropriate to the scope of practice for
professional nurses. Focus:
Delegation/supervision
12. You are helping the patient with an
SCI to establish a bladder-retraining
program. What strategies may
stimulate the patient to void? (Choose
all that apply).
a. Stroke the patients inner thigh.
b. Pull on the patients pubic hair.
c. Initiate intermittent straight
catheterization.
d. Pour warm water over the perineum.
e. Tap the bladder to stimulate detrusor
muscle.

13. The patient with a cervical SCI has

been placed in fixed skeletal traction
with a halo fixation device. When
caring for this patient the nurse may
delegate which action (s) to the
LPN/LVN? (Choose all that apply).
a. Check the patients skin for pressure
form device.
b. Assess the patients neurologic status
for changes.
c. Observe the halo insertion sites for
signs of infection.
d. Clean the halo insertion sites with
hydrogen peroxide.
Answer: S A, C & D Checking and
observing for signs of pressure or
infection are within the scope of practice
of the LPN/LVN. The LPN/LVN also has
the appropriate skills for cleaning the halo
insertion sites with hydrogen peroxide.
Neurologic examination requires
additional education and skill appropriate

Answer: S A, B, D & E- All of the

to the professional RN. Focus:

strategies, except straight catheterization,

Delegation/supervision

may stimulate voiding in patients with SCI.

Intermittent bladder catheterization can be
used to empty the patients bladder, but it

a.c.b.e.l.

14. You are preparing a nursing care

plan for the patient with SCI including
the nursing diagnosis Impaired

Physical Mobility and Self-Care Deficit.

c. A 56-year-old patient with Guillain-Barre

The patient tells you, I dont know why

syndrome (GBS) in respiratory distress

were doing all this. My lifes over.

d. A 25-year-old patient admitted with CA

What additional nursing diagnosis

level spinal cord injury (SCI)

takes priority based on this statement?

Answer: B The traveling is relatively new

a. Risk for Injury related to altered mobility

to neurologic nursing and should be

b. Imbalanced Nutrition, Less Than Body

assigned patients whose conditions are

Requirements

stable and not complex. The newly

c. Impaired Adjustment to Spinal Cord

diagnosed patient will need to be

Injury

transferred to the ICU. The patient with C4

d. Poor Body Image related to

SCI is at risk for respiratory arrest. All

immobilization

three of these patients should be assigned

Answer: C The patients statement

indicates impairment of adjustment to the

to nurses experienced in neurologic

nursing care. Focus: Assignment

limitations of the injury and indicates the

16. The patient with multiple sclerosis

need for additional counseling, teaching,

tells the nursing assistant that after

and support. The other three nursing

physical therapy she is too tired to take

diagnoses may be appropriate to the

a bath. What is your priority nursing

patient with SCI, but they are not related

diagnosis at this time?

to the patients statement. Focus:

Prioritization

a. Fatigue related to disease state

b. Activity Intolerance due to generalized

15. Which patient should be assigned

weakness

to the traveling nurse, new to

c. Impaired Physical Mobility related to

neurologic nursing care, who has been

neuromuscular impairment

on the neurologic unit for 1 week?

d. Self-care Deficit related to fatigue and

a. A 34-year-old patient newly diagnosed

neuromuscular weakness

with multiple sclerosis (MS)

Answer: D At this time, based on the

b. A 68-year-old patient with chronic

patients statement, the priority is Self-

amyotrophic lateral sclerosis (ALS)

Care Deficit related to fatigue after

a.c.b.e.l.

physical therapy. The other three nursing

pressure (158/94), and was incontinent

diagnoses are appropriate to a patient

off urine and stool. What is your best

with MS, but they are not related to the

first action at this time?

patients statement. Focus: Prioritization

a. Administer an acetaminophen

17. The LPN/LVN, under your

suppository.

supervision, is providing nursing care

b. Notify the physician immediately.

for a patient with GBS. What

c. Recheck vital signs in 1 hour.

observation would you instruct the

d. Reschedule patients physical therapy.

LPN/LVN to report immediately?

. Answer: B The changes that the

a. Complaints of numbness and tingling

nursing assistant is reporting are

b. Facial weakness and difficulty speaking

characteristics of myasthenia crisis, which

c. Rapid heart rate of 102 beats per

often follows some type of infection. The

minute

patient is at risk for inadequate respiratory

d. Shallow respirations and decreased

function. In addition to notifying the

breath sounds

physician, the nurse should carefully

Answer: D The priority interventions for

the patient with GBS are aimed at
maintaining adequate respiratory function.
These patients are risk for respiratory
failure, which is urgent. The other findings
are important and should be reported to
the nurse, but they are not life-threatening.
Focus: Prioritization,
delegation/supervision
18. The nursing assistant reports to
you, the RN, that the patient with
myasthenia gravis (MG) has an
elevated temperature (102.20 F), heart
rate of 120/minute, rise in blood

a.c.b.e.l.

monitor the patients respiratory status.

The patient may need incubation and
mechanical ventilation. The nurse would
notify the physician before giving the
suppository because there may be orders
for cultures before giving acetaminophen.
This patients vital signs need to be rechecked sooner than 1 hour.
Rescheduling the physical therapy can be
delegated to the unit clerk and is not
urgent. Focus: Prioritization
19. You are providing care for a patient
with an acute hemorrhage stroke. The
patients husband has been reading a
lot about strokes and asks why his wife

did not receive alteplase. What is your

b. The student moves the patients tray to

best response?

the right side of her over-bed tray.

a. Your wife was not admitted within the

time frame that alteplase is usually given.
b. This drug is used primarily for patients
who experience an acute heart attack.
c. Alteplase dissolves clots and may

c. The student assists the patient with

passive range-of-motion (ROM) exercises.
d. The student combs the left side of the
patients hair when the patient combs only
the right side.

cause more bleeding into your wifes

Answer: A Patients with right cerebral

brain.

hemisphere stroke often present with

d. Your wife had gallbladder surgery just

neglect syndrome. They lean to the left

6 months ago and this prevents the use of

and when asked, respond that they

alteplase.

believe they are sitting up straight. They

Answer: C Alteplase is a clot buster.

With patient who has experienced
hemorrhagic stroke, there is already
bleeding into the brain. A drug like
alteplase can worsen the bleeding. The
other statements are also accurate about

often neglect the left side of their bodies

and ignore food on the left side of their
food trays. The nurse would need to
remind the student of this phenomenon
and discuss the appropriate interventions.
Focus: Delegation/supervision

use of alteplase, but they are not pertinent

21. Which action (s) should you

to this patients diagnosis. Focus:

delegate to the experienced nursing

Prioritization

assistant when caring for a patient with

20. You are supervising a senior

nursing student who is caring for a
patient with a right hemisphere stroke.

a thrombotic stroke with residual leftsided weakness? (Choose all that

apply).

Which action by the student nurse

a. Assist patient to reposition every 2

requires that you intervene?

hours.

a. The student instructs the patient to sit

up straight, resulting in the patients
puzzled expression.

a.c.b.e.l.

b. Reapply pneumatic compression boots.

c. Remind patient to perform active ROM.
d. Check extremities for redness and
edema.

Answer: A, B and C The experienced

handling secretions and is at risk for

nursing assistant would know how to

aspiration. This patient should be

reposition the patient and how to reapply

assessed further before feeding. Focus:

compression boots, and would remind the

Delegation/supervision

patient to perform activities he has been

taught to perform. Assessing for redness
and swelling (signs of deep venous
thrombosis {DVT}) requires additional
education and still appropriate to the
professional nurse. Focus:
Delegation/supervision
22.The patient who had a stroke needs
to be fed. What instruction should you
give to the nursing assistant who will
feed the patient?

23. You have just admitted a patient

with bacterial meningitis to the
medical-surgical unit. The patient
complains of a severe headache with
photophobia and has a temperature of
102.60 F orally. Which collaborative
intervention must be accomplished
first?
a. Administer codeine 15 mg orally for the
patients headache.
b. Infuse ceftriaxone (Rocephin) 2000 mg

a. Position the patient sitting up in bed

IV to treat the infection.

before you feed her.

c. Give acetaminophen (Tylenol) 650 mg

b. Check the patients gag and swallowing

orally to reduce the fever.

reflexes.

d. Give furosemide (Lasix) 40 mg IV to

c. Feed the patient quickly because there

decrease intracranial pressure.

are three more waiting.

d. Suction the patients secretions
between bites of food.

Answer: B Untreated bacterial

meningitis has a mortality are
approaching 100%, so rapid antibiotic

Answer: A Positioning the patient in a

treatment is essential. The other

sitting position decreases the risk of

interventions will help reduce CNS

aspiration. The nursing assistant is not

stimulation and irritation, and should be

trained to assess gag or swallowing

implemented as soon as possible. Focus:

reflexes. The patient should not be rushed

Prioritization

during feeding. A patient who needs to be

suctioned between bites of food is not

a.c.b.e.l.

24. You are mentoring a student nurse

25. A 23-year-old patient with a recent

in the intensive care unit (ICU) while

history of encephalitis is admitted to

caring for a patient with

the medical unit with new onset

meningococcal meningitis. Which

generalized tonic-clonic seizures.

action by the student requires that you

Which nursing activities included in

intervene immediately?

the patients care will be best to

a. The student enters the room without

putting on a mask and gown.

delegate to an LPN/LVN whom you are

supervising? (Choose all that apply).

b. The student instructs the family that

a. Document the onset time, nature of

visits are restricted to 10 minutes.

seizure activity, and postictal behaviors for

c. The student gives the patient a warm

all seizures.

blanket when he says he feels cold.

b. Administer phenytoin (Dilantin) 200 mg

d. The student checks the patients pupil

PO daily.

response to light every 30 minutes.

c. Teach patient about the need for good

Answer: A Meningococcal meningitis is

spread through contact with respiratory
secretions so use of a mask and gown is
required to prevent spread of the infection

oral hygiene.
d. Develop a discharge plan, including
physician visits and referral to the
Epilepsy Foundation.

to staff members or other patients. The

Answer: B Administration of medications

other actions may not be appropriate but

is included in LPN education and scope of

they do not require intervention as rapidly.

practice. Collection of data about the

The presence of a family member at the

seizure activity may be accomplished by

bedside may decrease patient confusion

an LPN/LVN who observes initial seizure

and agitation. Patients with hyperthermia

activity. An LPN/LVN would know to call

frequently complain of feeling chilled, but

the supervising RN immediately if a

warming the patient is not an appropriate

patient started to seize. Documentation of

intervention. Checking the pupil response

the seizure, patient teaching, and planning

to light is appropriate, but it is not needed

of care are complex activities that require

every 30 minutes and is uncomfortable for

RN level education and scope of practice.

a patient with photophobia. Focus:

Focus: Delegation

Prioritization
a.c.b.e.l.

26.While working in the ICU, you are

assessment will be of greatest

assigned to care for a patient with a

concern?

seizure disorder. Which of these

nursing actions will you implement
first if the patient has a seizure?

a. The gums appear enlarged and

inflamed.
b. The white blood cell count is

a. Place the patient on a non-rebreather

2300/mm3.

mask will the oxygen at 15 L/minute.

c. Patient occasionally forgets to take the

b. Administer lorazepam (Ativan) 1 mg IV.

phenytoin until after lunch.

c. Turn the patient to the side and protect

d. Patient wants to renew his drivers

airway.

license in the next month.

d. Assess level of consciousness during

and immediately after the seizure.

Answer: B Leukopenia is a serious

adverse effect of phenytoin and would

Answer: C The priority action during a

require discontinuation of the medication.

generalized tonic-clonic seizure is to

The other data indicate a need for further

protect the airway. Administration of

assessment and/or patient teaching, but

lorazepam should be the next action,

will not require a change in medical

since it will act rapidly to control the

treatment for the seizures. Focus:

seizure. Although oxygen may be useful

Prioritization

during the postictal phase, the hypoxemia

during tonic-clonic seizures is caused by
apnea. Checking the level of
consciousness is not appropriate during
the seizure, because generalized tonicclonic seizures are associated with a loss
of consciousness. Focus: Prioritization
27. A patient recently started on
phenytoin (Dilantin) to control simple
complex seizures is seen in the
outpatient clinic. Which information
obtained during his chart review and

a.c.b.e.l.

28. After receiving a change-of-shift

report at 7:00 AM, which of these
patients will you assess first?
a. A 23-year-old with a migraine headache
who is complaining of severe nausea
associated with retching
b. A 45-year-old who is scheduled for a
craniotomy in 30 minutes and needs
preoperative teaching
c. A 59-year-old with Parkinsons disease
who will need a swallowing assessment

before breakfast

movements of extremities.

d. A 63-year-old with multiple sclerosis

e. Assist the patient with prescribed

who has an oral temperature of 101.80 F

strengthening exercises.

and flank pain

f. Adapt the patients preferred activities to

Answer: D Urinary tract infections are a

his level of function.

frequent complication in patient with

Answer: S A, C and E NA education and

multiple sclerosis because of the effect on

scope of practice includes taking pulse

bladder function. The elevated

and blood pressure measurements. In

temperature and decreased breath

addition, NAs can reinforce previous

sounds suggest that this patient may have

teaching or skills taught by the RN or

pyelonephritis. The physician should be

other disciplines, such as speech or

notified immediately so that antibiotic

physical therapists. Evaluation of patient

therapy can be started quickly. The other

response to medication and development

patients should be assessed soon, but do

and individualizing the plan of care require

not have needs as urgent and this patient.

RN-level education and scope of practice.

Focus: Prioritization

Focus: Delegation

29. All of these nursing activities are

30. As the manager in a long-term-care

included in the care plan for a 78-year-

(LTC) facility, you are in charge of

old man with Parkinsons disease who

developing a standard plan of care for

has been referred to your home health

residents with Alzheimers disease.

agency. Which ones will you delegate

Which of these nursing tasks is best to

to a nursing assistant (NA)? (Choose

delegate to the LPN team leaders

all that apply).

working in the facility?

a. Check for orthostatic changes in pulse

a. Check for improvement in resident

and bloods pressure.

memory after medication therapy is

b. Monitor for improvement in tremor after

initiated.

levodopa (L-dopa) is given.

b. Use the Mini-Mental State Examination

c. Remind the patient to allow adequate

to assess residents every 6 months.

time for meals.

c. Assist residents to toilet every 2 hours

d. Monitor for abnormal involuntary jerky

to decrease risk for urinary intolerance.

a.c.b.e.l.

d. Develop individualized activity plans

a. Decreased Cardiac Output related to

after consulting with residents and family.

poor myocardial contractility

Answer: A LPN education and team

leader responsibilities include checking for
the therapeutic and adverse effects of
medications. Changes in the residents
memory would be communicated to the
RN supervisor, who is responsible for
overseeing the plan of care for each

b. Caregiver Role Strain related to

continuous need for providing care
c. Ineffective Therapeutic Regimen
Management related to poor patient
memory
d. Risk for Falls related to patient
wandering behavior during the night

resident. Assessment for changes on the

Answer: B The husbands statement

Mini-Mental State Examination and

about lack of sleep and anxiety over

developing the plan of care are RN

whether the patient is receiving the correct

responsibilities. Assisting residents with

medications are behaviors that support

personal care and hygiene would be

this diagnosis. There is no evidence that

delegated to nursing assistants working

the patients cardiac output is decreased.

the LTC facility. Focus: Delegation

The husbands statements about how he

31. A patient who has been admitted to

the medical unit with new-onset angina
also has a diagnosis of Alzheimers
disease. Her husband tells you that he
rarely gets a good nights sleep

monitors the patient and his concern with

medication administration indicate that the
Risk for Ineffective Therapeutic Regimen
Management and falls are not priorities at
this time. Focus: Prioritization

because he needs to be sure she does

32. You are caring for a patient with a

not wander during the night. He insists

recurrent glioblastoma who is

on checking each of the medications

receiving dexamethasone (Decadron) 4

you give her to be sure they are the

mg IV every 6 hours to relieve

same as the ones she takes at home.

symptoms of right arm weakness and

Based on this information, which

headache. Which assessment

nursing diagnosis is most appropriate

information concerns you the most?

for this patient?

a. The patient does not recognize family

members.

a.c.b.e.l.

b. The blood glucose level is 234 mg/dL.

a. Place on the hospital alcohol

c. The patient complains of a continued

withdrawal protocol.

headache.

b. Transfer to radiology for a CT scan.

d. The daily weight has increased 1 kg.

c. Insert a retention catheter to straight

Answer: A The inability to recognize a

family member is a new neurologic deficit

drainage.
d. Give phenytoin (Dilantin) 100 mg PO.

for this patient, and indicates a possible

Answer: B The patients history and

increase in intracranial pressure (ICP).

assessment data indicate that he may

This change should be communicated to

have a chronic subdural hematoma. The

the physician immediately so that

priority goal is to obtain a rapid diagnosis

treatment can be initiated. The continued

and send the patient to surgery to have

headache also indicates that the ICP may

the hematoma evacuated. The other

be elevated, but it is not a new problem.

interventions also should be implemented

The glucose elevation and weight gain are

as soon as possible, but the initial nursing

common adverse effects of

activities should be directed toward

dexamethasone that may require

treatment of any intracranial lesion. Focus:

treatment, but they are not emergencies.

Prioritization

Focus: Prioritization

34. Which of these patients in the

33. A 70-year-old alcoholic patient with

neurologic ICU will be best to assign to

acute lethargy, confusion, and

an RN who has floated from the

incontinence is admitted to the

medical unit?

hospital ED. His wife tells you that he

fell down the stairs about a month ago,
but he didnt have a scratch
afterward. She feels that he has
become gradually less active and
sleepier over the last 10 days or so.
Which of the following collaborative
interventions will you implement first?

a. A 26-year-old patient with a basilar skull

structure who has clear drainage coming
out of the nose
b. A 42-year-old patient admitted several
hours ago with a headache and
diagnosed with a ruptured berry
aneurysm.
c. A 46-year-old patient who was admitted
48 hours ago with bacterial meningitis and

a.c.b.e.l.

has an antibiotic dose due

contraindicated with increased ICP.

d. A 65-year-old patient with a

Vomiting may be caused by reasons other

astrocytoma who has just returned to the

than increased ICP; therefore, LP isnt

unit after having a craniotomy

strictly contraindicated. An LP may be

Answer: C This patient is the most

stable of the patients listed. An RN from
the medical unit would be familiar with

performed on clients needing mechanical

ventilation. Blood in the CSF is diagnostic
for subarachnoid hemorrhage and was

administration of IV antibiotics. The other

obtained before signs and symptoms of

patients require assessments and care

ICP.

from RNs more experienced in caring for

patients with neurologic diagnoses.

2. A client with a subdural hematoma

Focus: Assignment.

becomes restless and confused, with

dilation of the ipsilateral pupil. The

1. A client admitted to the hospital with

a subarachnoid hemorrhage has
complaints of severe headache, nuchal
rigidity, and projectile vomiting. The
nurse knows lumbar puncture (LP)
would be contraindicated in this client
in which of the following

physician orders mannitol for which of

the following reasons?
1. To reduce intraocular pressure
2. To prevent acute tubular necrosis
3. To promote osmotic diuresis to
decrease ICP
4. To draw water into the vascular system

circumstances?

to increase blood pressure

1. Vomiting continues

Answer: 3. Mannitol promotes osmotic

2. Intracranial pressure (ICP) is increased

3. The client needs mechanical ventilation
4. Blood is anticipated in the cerebrospinal
fluid (CSF)
Answer: 2. Sudden removal of CSF
results in pressures lower in the lumbar
area than the brain and favors herniation
of the brain; therefore, LP is

a.c.b.e.l.

diuresis by increasing the pressure

gradient, drawing fluid from intracellular to
intravascular spaces. Although mannitol is
used for all the reasons described, the
reduction of ICP in this client is a concern.
3. A client with subdural hematoma
was given mannitol to decrease
intracranial pressure (ICP). Which of

the following results would best show

1. Ataxia and confusion

the mannitol was effective?

2. Sodium depletion

1. Urine output increases

2. Pupils are 8 mm and nonreactive

3. Tonic-clonic seizure
4. Urinary incontinence

3. Systolic blood pressure remains at 150

Answer: 1. A therapeutic phenytoin level is

mm Hg

10 to 20 mg/dl. A level of 32 mg/dl

4. BUN and creatinine levels return to

indicates toxicity. Symptoms of toxicity

normal

include confusion and ataxia. Phenytoin

Answer: 1. Mannitol promotes osmotic

diuresis by increasing the pressure
gradient in the renal tubes. Fixed and

doesnt cause hyponatremia, seizure, or

urinary incontinence. Incontinence may
occur during or after a seizure.

dilated pupils are symptoms of increased

6. Which of the following signs and

ICP or cranial nerve damage. No

symptoms of increased ICP after head

information is given about abnormal BUN

trauma would appear first?

and creatinine levels or that mannitol is

being given for renal dysfunction or blood
pressure maintenance.
4. Which of the following values is
considered normal for ICP?

1. Bradycardia
2. Large amounts of very dilute urine
3. Restlessness and confusion
4. Widened pulse pressure
Answer: 3. The earliest symptom of

1. 0 to 15 mm Hg

elevated ICP is a change in mental status.

2. 25 mm Hg

Bradycardia, widened pulse pressure, and

3. 35 to 45 mm Hg

bradypnea occur later. The client may void

4. 120/80 mm Hg

large amounts of very dilute urine if theres

Answer: 1. Normal ICP is 0-15 mm Hg.

5. Which of the following symptoms
may occur with a phenytoin level of 32
mg/dl?

a.c.b.e.l.

damage to the posterior pituitary.

7. Problems with memory and learning
would relate to which of the following
lobes?

1. Frontal

following to test the clients peripheral

2. Occipital

response to pain?

3. Parietal
4. Temporal

1. Sternal rub
2. Pressure on the orbital rim

Answer: 4. The temporal lobe functions to

3. Squeezing the sternocleidomastoid

regulate memory and learning problems

muscle

because of the integration of the

4. Nail bed pressure

hippocampus. The frontal lobe primarily

functions to regulate thinking, planning,
and judgment. The occipital lobe functions
regulate vision. The parietal lobe primarily
functions with sensory function.

Answer: 4. Motor testing on the

unconscious client can be done only by
testing response to painful stimuli. Nail
Bed pressure tests a basic peripheral
response. Cerebral responses to pain are

8. While cooking, your client couldnt

testing using sternal rub, placing upward

feel the temperature of a hot oven.

pressure on the orbital rim, or squeezing

Which lobe could be dysfunctional?

the clavicle or sternocleidomastoid

1. Frontal

muscle.

2. Occipital

10. The client is having a lumbar

3. Parietal

puncture performed. The nurse would

4. Temporal

plan to place the client in which

Answer: 3. The parietal lobe regulates

position for the procedure?

sensory function, which would include the

1. Side-lying, with legs pulled up and head

ability to sense hot or cold objects. The

bent down onto the chest

frontal lobe regulates thinking, planning,

2. Side-lying, with a pillow under the hip

and judgment, and the occipital lobe is

3. Prone, in a slight Trendelenburgs

primarily responsible for vision function.

position

The temporal lobe regulates memory.

4. Prone, with a pillow under the

9. The nurse is assessing the motor

abdomen.

function of an unconscious client. The

Answer: 1. The client undergoing lumbar

nurse would plan to use which of the

puncture is positioned lying on the side,

a.c.b.e.l.

with the legs pulled up to the abdomen,

12. The nurse is caring for the client

and with the head bent down onto the

with increased intracranial pressure.

chest. This position helps to open the

The nurse would note which of the

spaces between the vertebrae.

following trends in vital signs if the ICP

11. A nurse is assisting with caloric

is rising?

testing of the oculovestibular reflex of

1. Increasing temperature, increasing

an unconscious client. Cold water is

pulse, increasing respirations, decreasing

injected into the left auditory canal.

blood pressure.

The client exhibits eye conjugate

2. Increasing temperature, decreasing

movements toward the left followed by

pulse, decreasing respirations, increasing

a rapid nystagmus toward the right.

blood pressure.

The nurse understands that this

3. Decreasing temperature, decreasing

indicates the client has:

pulse, increasing respirations, decreasing

1. A cerebral lesion
2. A temporal lesion
3. An intact brainstem
4. Brain death
Answer: 3. Caloric testing provides
information about differentiating between
cerebellar and brainstem lesions. After
determining patency of the ear canal, cold
or warm water is injected in the auditory
canal. A normal response that indicates

blood pressure.
4. Decreasing temperature, increasing
pulse, decreasing respirations, increasing
blood pressure.
Answer: 2. A change in vital signs may be
a late sign of increased intracranial
pressure. Trends include increasing
temperature and blood pressure and
decreasing pulse and respirations.
Respiratory irregularities also may arise.

intact function of cranial nerves III, IV, and

13. The nurse is evaluating the status

VIII is conjugate eye movements toward

of a client who had a craniotomy 3

the side being irrigated, followed by rapid

days ago. The nurse would suspect the

nystagmus to the opposite side. Absent or

client is developing meningitis as a

disconjugate eye movements indicate

complication of surgery if the client

brainstem damage.

exhibits:

a.c.b.e.l.

1. A positive Brudzinskis sign

3. Escape the source of pain

2. A negative Kernigs sign

4. Divert attention from the source of pain.

3. Absence of nuchal rigidity

4. A Glascow Coma Scale score of 15

Answer: 3. The clients innate responses

to pain are directed initially toward

Answer: 1. Signs of meningeal irritation

escaping from the source of pain.

compatible with meningitis include nuchal

Variations in individuals tolerance and

rigidity, positive Brudzinskis sign, and

perception of pain are apparent only in

positive Kernigs sign. Nuchal rigidity is

conscious clients, and only conscious

characterized by a stiff neck and

clients are able to employ distraction to

soreness, which is especially noticeable

help relieve pain.

when the neck is fixed. Kernigs sign is

positive when the client feels pain and
spasm of the hamstring muscles when the
knee and thigh are extended from a
flexed-right angle position. Brudzinskis
sign is positive when the client flexes the
hips and knees in response to the nurse
gently flexing the head and neck onto the
chest. A Glascow Coma Scale of 15 is a
perfect score and indicates the client is
awake and alert with no neurological
deficits.
14. A client is arousing from a coma
and keeps saying, Just stop the pain.
The nurse responds based on the
knowledge that the human body
typically and automatically responds to
pain first with attempts to:
1. Tolerate the pain
2. Decrease the perception of pain

a.c.b.e.l.

15. During the acute stage of

meningitis, a 3-year-old child is
restless and irritable. Which of the
following would be most appropriate to
institute?
1. Limiting conversation with the child
2. Keeping extraneous noise to a
minimum
3. Allowing the child to play in the bathtub
4. Performing treatments quickly
Answer: 2. A child in the acute stage of
meningitis is irritable and hypersensitive to
loud noise and light. Therefore,
extraneous noise should be minimized
and bright lights avoided as much as
possible. There is no need to limit
conversations with the child. However, the
nurse should speak in a calm, gentle,
reassuring voice. The child needs gentle

and calm bathing. Because of the

17. When interviewing the parents of a

acuteness of the infection, sponge baths

2-year-old child, a history of which of

would be more appropriate than tub baths.

the following illnesses would lead the

Although treatments need to be

nurse to suspect pneumococcal

completed as quickly as possible to

meningitis?

prevent overstressing the child, any

treatments should be performed carefully
and at a pace that avoids sudden
movements to prevent startling the child
and subsequently increasing intracranial
pressure.
16. Which of the following would lead
the nurse to suspect that a child with
meningitis has developed
disseminated intravascular
coagulation?

1. Bladder infection
2. Middle ear infection
3. Fractured clavicle
4. Septic arthritis
Answer: 2. Organisms that cause bacterial
meningitis, such as pneumococci or
meningococci, are commonly spread in
the body by vascular dissemination from a
middle ear infection. The meningitis may
also be a direct extension from the
paranasal and mastoid sinuses. The

1. Hemorrhagic skin rash

causative organism is a pneumococcus. A

2. Edema

chronically draining ear is frequently also

3. Cyanosis

found.

4. Dyspnea on exertion

18. The nurse is assessing a child

Answer: 1. DIC is characterized by skin

diagnosed with a brain tumor. Which of

petechiae and a purpuric skin rash caused

the following signs and symptoms

by spontaneous bleeding into the tissues.

would the nurse expect the child to

An abnormal coagulation phenomenon

demonstrate? Select all that apply.

causes the condition.

1. Head tilt
2. Vomiting
3. Polydipsia
4. Lethargy

a.c.b.e.l.

5. Increased appetite

20. A nurse is planning care for a child

6. Increased pulse

with acute bacterial meningitis. Based

Answer: 1, 2, 4. Head tilt, vomiting, and

lethargy are classic signs assessed in a
child with a brain tumor. Clinical

on the mode of transmission of this

infection, which of the following would
be included in the plan of care?

manifestations are the result of location

1. No precautions are required as long as

and size of the tumor.

antibiotics have been started

19. A lumbar puncture is performed on

a child suspected of having bacterial
meningitis. CSF is obtained for
analysis. A nurse reviews the results of
the CSF analysis and determines that

2. Maintain enteric precautions

3. Maintain respiratory isolation
precautions for at least 24 hours after the
initiation of antibiotics
4. Maintain neutropenic precautions

which of the following results would

Answer: 3. A major priority of nursing care

verify the diagnosis?

for a child suspected of having meningitis

1. Cloudy CSF, decreased protein, and

decreased glucose
2. Cloudy CSF, elevated protein, and
decreased glucose
3. Clear CSF, elevated protein, and

is to administer the prescribed antibiotic

as soon as it is ordered. The child is also
placed on respiratory isolation for at least
24 hours while culture results are obtained
and the antibiotic is having an effect.

decreased glucose

21. A nurse is reviewing the record of a

4. Clear CSF, decreased pressure, and

child with increased ICP and notes that

elevated protein

the child has exhibited signs of

Answer: 2. A diagnosis of meningitis is

made by testing CSF obtained by lumbar
puncture. In the case of bacterial
meningitis, findings usually include an

decerebrate posturing. On assessment

of the child, the nurse would expect to
note which of the following if this type
of posturing was present?

elevated pressure, turbid or cloudy CSF,

1. Abnormal flexion of the upper

elevated leukocytes, elevated protein, and

extremities and extension of the lower

decreased glucose levels.

extremities

a.c.b.e.l.

2. Rigid extension and pronation of the

1. Congenital anatomic abnormality of the

arms and legs

meninges

3. Rigid pronation of all extremities

2. Lack of acquired resistance to the

4. Flaccid paralysis of all extremities

various etiologic organisms

Answer: 2. Decerebrate posturing is

characterized by the rigid extension and
pronation of the arms and legs.
22. Which of the following assessment
data indicated nuchal rigidity?
1. Positive Kernigs sign
2. Negative Brudzinskis sign
3. Positive homans sign
4. Negative Kernigs sign
Answer: 1. A positive Kernigs sign
indicated nuchal rigidity, caused by an
irritative lesion of the subarachnoid space.
Brudzinskis sign is also indicative of the
condition.
23. Meningitis occurs as an extension
of a variety of bacterial infections due
to which of the following conditions?

3. Occlusion or narrowing of the CSF

pathway
4. Natural affinity of the CNS to certain
pathogens
Answer: 2. Extension of a variety of
bacterial infections is a major causative
factor of meningitis and occurs as a result
of a lack of acquired resistance to the
etiologic organisms. Preexisting CNS
anomalies are factors that contribute to
susceptibility.
24. Which of the following pathologic
processes is often associated with
aseptic meningitis?
1. Ischemic infarction of cerebral tissue
2. Childhood diseases of viral causation
such as mumps
3. Brain abscesses caused by a variety of
pyogenic organisms
4. Cerebral ventricular irritation from a
traumatic brain injury
Answer: 2. Aseptic meningitis is caused
principally by viruses and is often
associated with other diseases such as
measles, mumps, herpes, and leukemia.

a.c.b.e.l.

Incidences of brain abscess are high in

MVA. His intracranial pressure (ICP)

bacterial meningitis, and ischemic

shows an upward trend. Which

infarction of cerebral tissue can occur with

intervention should the nurse perform

tubercular meningitis. Traumatic brain

first?

injury could lead to bacterial (not viral)

meningitis.

1. Reposition the client to avoid neck

flexion

25. You are preparing to admit a patient

2. Administer 1 g Mannitol IV as ordered

with a seizure disorder. Which of the

3. Increase the ventilators respiratory rate

following actions can you delegate to

to 20 breaths/minute

LPN/LVN?

4. Administer 100 mg of pentobarbital IV

1. Complete admission assessment.

as ordered.

2. Set up oxygen and suction equipment.

Answer: 1. The nurse should first attempt

3. Place a padded tongue blade at

nursing interventions, such as

bedside.

repositioning the client to avoid neck

4. Pad the side rails before patient arrives.

flexion, which increases venous return

Answer: 2 The LPN/LVN can set up the

equipment for oxygen and suctioning. The
RN should perform the complete initial
assessment. Padded side rails are

and lowers ICP. If nursing measures prove

ineffective, notify the physician, who may
prescribe mannitol, pentobarbital, or
hyperventilation therapy.

controversial in terms of whether they

2. A client with a subarachnoid

actually provide safety and ay embarrass

hemorrhage is prescribed a 1,000-mg

the patient and family. Tongue blades

loading dose of Dilantin IV. Which

should not be at the bedside and should

consideration is most important when

never be inserted into the patients mouth

administering this dose?

after a seizure begins. Focus:

Delegation/supervision.

1. Therapeutic drug levels should be

maintained between 20 to 30 mg/ml.
2. Rapid dilantin administration can cause

1. An 18-year-old client is admitted with

a closed head injury sustained in a

a.c.b.e.l.

cardiac arrhythmias.
3. Dilantin should be mixed in dextrose in

water before administration.

diuretic hormone. This may occur with

4. Dilantin should be administered through

increased intracranial pressure and head

an IV catheter in the clients hand.

trauma; the nurse evaluates for low urine

Answer: 2. Dilantin IV shouldnt be given

at a rate exceeding 50 mg/minute. Rapid
administration can depress the
myocardium, causing arrhythmias.
Therapeutic drug levels range from 10 to
20 mg/ml. Dilantin shouldnt be mixed in
solution for administration. However,
because its compatible with normal saline
solution, it can be injected through an IV

specific gravity, increased serum

osmolarity, and dehydration. Theres no
evidence that the client is experiencing
renal failure. Providing emollients to
prevent skin breakdown is important, but
doesnt need to be performed
immediately. Slowing the rate of IV fluid
would contribute to dehydration when
polyuria is present.

line containing normal saline. When given

4. When evaluating an ABG from a

through an IV catheter hand, dilantin may

client with a subdural hematoma, the

cause purple glove syndrome.

nurse notes the PaCO2 is 30 mm Hg.

3. A client with head trauma develops a

urine output of 300 ml/hr, dry skin, and

Which of the following responses best

describes this result?

dry mucous membranes. Which of the

1. Appropriate; lowering carbon dioxide

following nursing interventions is the

(CO2) reduces intracranial pressure (ICP).

most appropriate to perform initially?

2. Emergent; the client is poorly

1. Evaluate urine specific gravity

2. Anticipate treatment for renal failure
3. Provide emollients to the skin to prevent
breakdown

oxygenated.
3. Normal
4. Significant; the client has alveolar
hypoventilation.

4. Slow down the IV fluids and notify the

Answer: 1. A normal PaCO2 value is 35 to

physician

45 mm Hg. CO2 has vasodilating

Answer: 1. Urine output of 300 ml/hr may

indicate diabetes insipidus, which is a
failure of the pituitary to produce anti-

a.c.b.e.l.

properties; therefore, lowering PaCO2

through hyperventilation will lower ICP
caused by dilated cerebral vessels.
Oxygenation is evaluated through PaO2

and oxygen saturation. Alveolar

Answer: 4. After hypophysectomy, or

hypoventilation would be reflected in an

removal of the pituitary gland, the body

increased PaCO2.

cant synthesize ADH. Somatropin or

5. A client who had a transsphenoidal

hypophysectomy should be watched
carefully for hemorrhage, which may
be shown by which of the following
signs?
1. Bloody drainage from the ears
2. Frequent swallowing
3. Guaiac-positive stools
4. Hematuria
Answer: 2. Frequent swallowing after
brain surgery may indicate fluid or blood
leaking from the sinuses into the
oropharynx. Blood or fluid draining from
the ear may indicate a basilar skull
fracture.
6. After a hypophysectomy,
vasopressin is given IM for which of
the following reasons?
1. To treat growth failure
2. To prevent syndrome of inappropriate
antidiuretic hormone (SIADH)
3. To reduce cerebral edema and lower
intracranial pressure
4. To replace antidiuretic hormone (ADH)
normally secreted by the pituitary.

a.c.b.e.l.

growth hormone, not vasopressin is used

to treat growth failure. SIADH results from
excessive ADH secretion. Mannitol or
corticosteroids are used to decrease
cerebral edema.
7. A client comes into the ER after
hitting his head in an MVA. Hes alert
and oriented. Which of the following
nursing interventions should be done
first?
1. Assess full ROM to determine extent of
injuries
2. Call for an immediate chest x-ray
3. Immobilize the clients head and neck
4. Open the airway with the head-tilt chinlift maneuver
Answer: 3. All clients with a head injury
are treated as if a cervical spine injury is
present until x-rays confirm their absence.
ROM would be contraindicated at this
time. There is no indication that the client
needs a chest x-ray. The airway doesnt
need to be opened since the client
appears alert and not in respiratory
distress. In addition, the head-tilt chin-lift
maneuver wouldnt be used until the
cervical spine injury is ruled out.

8. A client with a C6 spinal injury would

10. While in the ER, a client with C8

most likely have which of the following

tetraplegia develops a blood pressure

symptoms?

of 80/40, pulse 48, and RR of 18. The

1. Aphasia
2. Hemiparesis

nurse suspects which of the following

conditions?

3. Paraplegia

1. Autonomic dysreflexia

4. Tetraplegia

2. Hemorrhagic shock

Answer: 4. Tetraplegia occurs as a result

of cervical spine injuries. Paraplegia

3. Neurogenic shock
4. Pulmonary embolism

occurs as a result of injury to the thoracic

Answer: 3. Symptoms of neurogenic

cord and below.

shock include hypotension, bradycardia,

9. 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?
1. Bladder distension
2. Neurological deficit
3. Pulse ox readings

and warm, dry skin due to the loss of

adrenergic stimulation below the level of
the lesion. Hypertension, bradycardia,
flushing, and sweating of the skin are
seen with autonomic dysreflexia.
Hemorrhagic shock presents with anxiety,
tachycardia, and hypotension; this
wouldnt be suspected without an injury.
Pulmonary embolism presents with chest

4. The clients feelings about the injury

pain, hypotension, hypoxemia,

Answer: 3. After a spinal cord injury,

a later complication of spinal cord injury

ascending cord edema may cause a

higher level of injury. The diaphragm is
innervated at the level of C4, so
assessment of adequate oxygenation and
ventilation is necessary. Although the
other options would be necessary at a
later time, observation for respiratory
failure is the priority.

a.c.b.e.l.

tachycardia, and hemoptysis; this may be

due to immobility.
11. 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?

1. Acetazolamide (Diamox)

more. The indwelling urinary catheter

2. Furosemide (Lasix)

should be assessed immediately after the

3. Methylprednisolone (Solu-Medrol)

HOB is raised. Nitroglycerin is given to

4. Sodium bicarbonate

reduce chest pain and reduce preload; it

Answer: 3. High doses of Solu-Medrol are

isnt used for hypertension or dysreflexia.

used within 24 hours of spinal injury to

13. A client with a cervical spine injury

reduce cord swelling and limit neurological

has Gardner-Wells tongs inserted for

deficit. The other drugs arent indicated in

which of the following reasons?

this circumstance.

1. To hasten wound healing

12. A 22-year-old client with

2. To immobilize the cervical spine

quadriplegia is apprehensive and

3. To prevent autonomic dysreflexia

flushed, with a blood pressure of

4. To hold bony fragments of the skull

210/100 and a heart rate of 50 bpm.

together

Which of the following nursing

interventions should be done first?
1. Place the client flat in bed
2. Assess patency of the indwelling
urinary catheter
3. Give one SL nitroglycerin tablet
4. Raise the head of the bed immediately
to 90 degrees
Answer: 4. Anxiety, flushing above the
level of the lesion, piloerection,
hypertension, and bradycardia are
symptoms of autonomic dysreflexia,
typically caused by such noxious stimuli
such as a full bladder, fecal impaction, or
decubitus ulcer. Putting the client flat will
cause the blood pressure to increase even

a.c.b.e.l.

Answer: 2. Gardner-Wells, Vinke, and

Crutchfield tongs immobilize the spine
until surgical stabilization is accomplished.
14. Which of the following
interventions describes an appropriate
bladder program for a client in
rehabilitation for spinal cord injury?
1. Insert an indwelling urinary catheter to
straight drainage
2. Schedule intermittent catheterization
every 2 to 4 hours
3. Perform a straight catheterization every
8 hours while awake
4. Perform Credes maneuver to the lower
abdomen before the client voids.

Answer: 2. Intermittent catherization

16. A 23-year-old client has been hit on

should begin every 2 to 4 hours early in

the head with a baseball bat. The nurse

the treatment. When residual volume is

notes clear fluid draining from his ears

less than 400 ml, the schedule may

and nose. Which of the following

advance to every 4 to 6 hours. Indwelling

nursing interventions should be done

catheters may predispose the client to

first?

infection and are removed as soon as

possible. Credes maneuver is not used
on people with spinal cord injury.

1. Position the client flat in bed

2. Check the fluid for dextrose with a
dipstick

15. A client is admitted to the ER for

3. Suction the nose to maintain airway

head trauma is diagnosed with an

patency

epidural hematoma. The underlying

4. Insert nasal and ear packing with sterile

cause of epidural hematoma is usually

gauze

related to which of the following

conditions?

Answer: 2. Clear fluid from the nose or ear

can be determined to be cerebral spinal

1. Laceration of the middle meningeal

fluid or mucous by the presence of

artery

dextrose. Placing the client flat in bed may

2. Rupture of the carotid artery

increase ICP and promote pulmonary

3. Thromboembolism from a carotid artery

aspiration. The nose wouldnt be

4. Venous bleeding from the arachnoid

suctioned because of the risk for

space

suctioning brain tissue through the

Answer: 1. Epidural hematoma or

extradural hematoma is usually caused by
laceration of the middle meningeal artery.

sinuses. Nothing is inserted into the ears

or nose of a client with a skull fracture
because of the risk of infection.

An embolic stroke is a thromboembolism

17. When discharging a client from the

from a carotid artery that ruptures. Venous

ER after a head trauma, the nurse

bleeding from the arachnoid space is

teaches the guardian to observe for a

usually observed with subdural

lucid interval. Which of the following

hematoma.

statements best described a lucid

interval?

a.c.b.e.l.

1. An interval when the clients speech is

T10. The other clients arent prone to

garbled

dysreflexia.

2. An interval when the client is alert but

cant recall recent events
3. An interval when the client is oriented
but then becomes somnolent
4. An interval when the client has a
warning symptom, such as an odor or
visual disturbance.
Answer: 3. A lucid interval is described as
a brief period of unconsciousness
followed by alertness; after several hours,
the client again loses consciousness.
Garbled speech is known as dysarthria.
An interval in which the client is alert but
cant recall recent events is known as
amnesia. Warning symptoms or auras
typically occur before seizures.
18. Which of the following clients on
the rehab unit is most likely to develop
autonomic dysreflexia?
1. A client with a brain injury
2. A client with a herniated nucleus
pulposus
3. A client with a high cervical spine injury
4. A client with a stroke
Answer: 3. Autonomic dysreflexia refers to
uninhibited sympathetic outflow in clients
with spinal cord injuries about the level of

a.c.b.e.l.

19. Which of the following conditions

indicates that spinal shock is resolving
in a client with C7 quadriplegia?
1. Absence of pain sensation in chest
2. Spasticity
3. Spontaneous respirations
4. Urinary continence
Answer: 2. Spasticity, the return of
reflexes, is a sign of resolving shock.
Spinal or neurogenic shock is
characterized by hypotension,
bradycardia, dry skin, flaccid paralysis, or
the absence of reflexes below the level of
injury. The absence of pain sensation in
the chest doesnt apply to spinal shock.
Spinal shock descends from the injury,
and respiratory difficulties occur at C4 and
above.
20. A nurse assesses a client who has
episodes of autonomic dysreflexia.
Which of the following conditions can
cause autonomic dysreflexia?
1. Headache
2. Lumbar spinal cord injury
3. Neurogenic shock
4. Noxious stimuli

Answer: 4. Noxious stimuli, such as a full

with a BP of 82/40, pulse 34, dry skin,

bladder, fecal impaction, or a decub ulcer,

and flaccid paralysis of the lower

may cause autonomic dysreflexia. A

extremities. Which of the following

headache is a symptom of autonomic

conditions would most likely be

dysreflexia, not a cause. Autonomic

suspected?

dysreflexia is most commonly seen with

injuries at T10 or above. Neurogenic
shock isnt a cause of dysreflexia.
21. During an episode of autonomic
dysreflexia in which the client becomes
hypertensive, the nurse should
perform which of the following
interventions?

1. Autonomic dysreflexia
2. Hypervolemia
3. Neurogenic shock
4. Sepsis
Answer: 3. Loss of sympathetic control
and unopposed vagal stimulation below
the level of injury typically cause
hypotension, bradycardia, pallor, flaccid

1. Elevate the clients legs

paralysis, and warm, dry skin in the client

2. Put the client flat in bed

in neurogenic shock. Hypervolemia is

3. Put the client in the Trendelenburgs

indicated by rapid and bounding pulse and

position

edema. Autonomic dysreflexia occurs

4. Put the client in the high-Fowlers

after neurogenic shock abates. Signs of

position

sepsis would include elevated

Answer: 4. Putting the client in the highFowlers position will decrease cerebral

temperature, increased heart rate, and

increased respiratory rate.

blood flow, decreasing hypertension.

23. A client has a cervical spine injury

Elevating the clients legs, putting the

at the level of C5. Which of the

client flat in bed, or putting the bed in the

following conditions would the nurse

Trendelenburgs position places the client

anticipate during the acute phase?

in positions that improve cerebral blood

flow, worsening hypertension.
22. A client with a T1 spinal cord injury
arrives at the emergency department

a.c.b.e.l.

1. Absent corneal reflex

2. Decerebrate posturing
3. Movement of only the right or left half of

the body

1. Clean the meatus from back to front.

4. The need for mechanical ventilation

2. Measure the quantity of urine.

Answer: 4. The diaphragm is stimulated

by nerves at the level of C4. Initially, this
client may need mechanical ventilation
due to cord edema. This may resolve in

3. Gently rotate the catheter during

removal.
4. Clean the meatus with soap and
water.

time. Absent corneal reflexes, decerebrate

Answer: 4. Intermittent catheterization

posturing, and hemiplegia occur with brain

may be performed chronically with clean

injuries, not spinal cord injuries.

technique, using soap and water to clean

24. A client with C7 quadriplegia is

flushed and anxious and complains of
a pounding headache. Which of the
following symptoms would also be
anticipated?
1. Decreased urine output or oliguria
2. Hypertension and bradycardia
3. Respiratory depression
4. Symptoms of shock
Answer: 2. Hypertension, bradycardia,
anxiety, blurred vision, and flushing above
the lesion occur with autonomic
dysreflexia due to uninhibited sympathetic
nervous system discharge. The other
options are incorrect.
25. A 40-year-old paraplegic must
perform intermittent catheterization of
the bladder. Which of the following
instructions should be given?

a.c.b.e.l.

the urinary meatus. The meatus is always

cleaned from front to back in a woman, or
in expanding circles working outward from
the meatus in a man. It isnt necessary to
measure the urine. The catheter doesnt
need to be rotated during removal.
26. 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?
1. Watch him for keyhole pupil the next
24 hours.
2. Expect profuse vomiting for 24 hours
after the injury.
3. Wake him every hour and assess his
orientation to person, time, and place.
4. Notify the physician immediately if he
has a headache.

Answer: 3. Changes in LOC may indicate

accurate for the nurse to tell family

expanding lesions such as subdural

members that the test measures which

hematoma; orientation and LOC are

of the following conditions?

assessed frequently for 24 hours. A

keyhole pupil is found after iridectomy.
Profuse or projectile vomiting is a
symptom of increased ICP and should be
reported immediately. A slight headache
may last for several days after
concussion; severe or worsening
headaches should be reported.
27. Which neurotransmitter is
responsible for may of the functions of
the frontal lobe?
1. Dopamine
2. GABA
3. Histamine
4. Norepinephrine
Answer: 1. The frontal lobe primarily
functions to regulate thinking, planning,
and affect. Dopamine is known to circulate
widely throughout this lobe, which is why
its such an important neurotransmitter in
schizophrenia.
28. 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

a.c.b.e.l.

1. Extent of intracranial bleeding

2. Sites of brain injury
3. Activity of the brain
4. Percent of functional brain tissue
Answer: 3. An EEG measures the
electrical activity of the brain. Extent of
intracranial bleeding and location of the
injury site would be determined by CT or
MRI. Percent of functional brain tissue
would be determined by a series of tests.
29. 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?
1. Subdural hematoma
2. Subarachnoid hemorrhage
3. Epidural hematoma
4. Contusion
Answer: 3. An epidural hematoma occurs
when blood collects between the skull and
the dura mater. In a subdural hematoma,
venous blood collects between the dura
mater and the arachnoid mater. In a
subarachnoid hemorrhage, blood collects

between the pia mater and arachnoid

1. By inserting a nasopharyngeal airway

membrane. A contusion is a bruise on the

2. By inserting a oropharyngeal airway

brains surface.

3. By performing a jaw-thrust maneuver

30. After falling 20, a 36-year-old man

sustains a C6 fracture with spinal cord

4. By performing the head-tilt, chin-lift

maneuver

transaction. Which other findings

Answer: 3. If the client has a suspected

should the nurse expect?

cervical spine injury, a jaw-thrust

1. Quadriplegia with gross arm movement

and diaphragmatic breathing
2. Quadriplegia and loss of respiratory
function
3. Paraplegia with intercostal muscle loss
4. Loss of bowel and bladder control
Answer: 1. A client with a spinal cord
injury at levels C5 to C6 has quadriplegia
with gross arm movement and
diaphragmatic breathing. Injury levels C1
to C4 leads to quadriplegia with total loss
of respiratory function. Paraplegia with
intercostal muscle loss occurs with injuries
at T1 to L2. Injuries below L2 cause
paraplegia and loss of bowel and bladder
control.
31. A 20-year-old client who fell
approximately 30 is unresponsive and
breathless. A cervical spine injury is
suspected. How should the firstresponder open the clients airway for
rescue breathing?

a.c.b.e.l.

maneuver should be used to open the

airway. If the tongue or relaxed throat
muscles are obstructing the airway, a
nasopharyngeal or oropharyngeal airway
can be inserted; however, the client must
have spontaneous respirations when the
airway is open. The head-tilt, chin-lift
maneuver requires neck hyperextension,
which can worsen the cervical spine
injury.
32. 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.
1. Elevate the HOB to 90 degrees
2. Loosen constrictive clothing
3. Use a fan to reduce diaphoresis
4. Assess for bladder distention and bowel

impaction

33. The client with a head injury has

5. Administer antihypertensive medication

been urinating copious amounts of

6. Place the client in a supine position with

dilute urine through the Foley catheter.

legs elevated

The clients urine output for the

Answer: 1, 2, 4, 5. The client has signs

and symptoms of autonomic dysreflexia.
The potentially life-threatening condition is

previous shift was 3000 ml. The nurse

implements a new physician order to
administer:

caused by an uninhibited response from

1. Desmopressin (DDAVP, stimate)

the sympathetic nervous system resulting

2. Dexamethasone (Decadron)

from a lack of control over the autonomic

3. Ethacrynic acid (Edecrin)

nervous system. The nurse should

4. Mannitol (Osmitrol)

immediately elevate the HOB to 90

degrees and place extremities
dependently to decrease venous return to
the heart and increase venous return from
the brain. Because tactile stimuli can
trigger autonomic dysreflexia, any
constrictive clothing should be loosened.
The nurse should also assess for
distended bladder and bowel impaction,
which may trigger autonomic dysreflexia,
and correct any problems. Elevated blood
pressure is the most life-threatening
complication of autonomic dysreflexia
because it can cause stroke, MI, or
seizures. If removing the triggering event
doesnt reduce the clients blood pressure,
IV antihypertensives should be
administered. A fan shouldnt be used
because cold drafts may trigger
autonomic dysreflexia.

a.c.b.e.l.

Answer: 1. A complication of a head injury

is diabetes insipidus, which can occur with
insult to the hypothalamus, the antidiuretic
storage vesicles, or the posterior pituitary
gland. Urine output that exceeds 9 L per
day generally requires treatment with
desmopressin. Dexamethasone, a
glucocorticoid, is administered to treat
cerebral edema. This medication may be
ordered for the head injured patient.
Ethacrynic acid and mannitol are diuretics,
which would be contraindicated.
34. 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

Answer: 2. After spinal cord injury, the

compatible with:

client can develop paralytic ileus, which is

1. Skull fracture
2. Concussion
3. Subdural hematoma
4. Epidural hematoma
Answer: 4. The changes in neurological
signs from an epidural hematoma begin
with a loss of consciousness as arterial
blood collects in the epidural space and
exerts pressure. The client regains
consciousness as the cerebral spinal fluid
is reabsorbed rapidly to compensate for

characterized by the absence of bowel

sounds and abdominal distention.
Development of a stress ulcer can be
detected by hematest positive NG tube
aspirate or stool. A history of diarrhea is
irrelevant.
36. 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?

the rising intracranial pressure. As the

1. Strict adherence to a bowel retraining

compensatory mechanisms fail, even

program

small amounts of additional blood can

2. Limiting bladder catheterization to once

cause the intracranial pressure to rise

every 12 hours

rapidly, and the clients neurological status

3. Keeping the linen wrinkle-free under the

deteriorates quickly.

client

35. The nurse is caring for a client who

suffered a spinal cord injury 48 hours

4. Preventing unnecessary pressure on

the lower limbs

ago. The nurse monitors for GI

Answer: 2. The most frequent cause of

complications by assessing for:

autonomic dysreflexia is a distended

1. A flattened abdomen
2. Hematest positive nasogastric tube
drainage
3. Hyperactive bowel sounds
4. A history of diarrhea

bladder. Straight catherization should be

done every 4 to 6 hours, and Foley
catheters should be checked frequently to
prevent kinks in the tubing. Constipation
and fecal impaction are other causes, so
maintaining bowel regularity is important.
Other causes include stimulation of the

a.c.b.e.l.

skin from tactile, thermal, or painful

38. The nurse is caring for a client

stimuli. The nurse administers care to

admitted with spinal cord injury. The

minimize risk in these areas.

nurse minimizes the risk of

37. The nurse is planning care for the

client in spinal shock. Which of the

compounding the injury most

effectively by:

following actions would be least

1. Keeping the client on a stretcher

helpful in minimizing the effects of

2. Logrolling the client on a firm mattress

vasodilation below the level of the

3. Logrolling the client on a soft mattress

injury?

4. Placing the client on a Stryker frame

1. Monitoring vital signs before and during

Answer: 4. Spinal immobilization is

position changes

necessary after spinal cord injury to

2. Using vasopressor medications as

prevent further damage and insult to the

prescribed

spinal cord. Whenever possible, the client

3. Moving the client quickly as one unit

is placed on a Stryker frame, which allows

4. Applying Teds or compression

the nurse to turn the client to prevent

stockings.

complications of immobility, while

Answer: 3. Reflex vasodilation below the

level of the spinal cord injury places the
client at risk for orthostatic hypotension,
which may be profound. Measures to

maintaining alignment of the spine. If a

Stryker frame is not available, a firm
mattress with a bed board should be
used.

minimize this include measuring vital

39. The nurse is evaluating

signs before and during position changes,

neurological signs of the male client in

use of a tilt-table with early mobilization,

spinal shock following spinal cord

and changing the clients position slowly.

injury. Which of the following

Venous pooling can be reduced by using

observations by the nurse indicates

Teds (compression stockings) or

that spinal shock persists?

pneumatic boots. Vasopressor

medications are administered per
protocol.

a.c.b.e.l.

1. Positive reflexes
2. Hyperreflexia

3. Inability to elicit a Babinskis reflex

emergency and must be treated promptly

4. Reflex emptying of the bladder

to prevent a hypertensive stroke.

Answer: 3. Resolution of spinal shock is

occurring when there is a return of
reflexes (especially flexors to noxious
cutaneous stimuli), a state of hyperreflexia
rather than flaccidity, reflex emptying of
the bladder, and a positive Babinskis
reflex.
40. A client with a spinal cord injury
suddenly experiences an episode of
autonomic dysreflexia. After checking
the clients vital signs, list in order of
priority, the nurses actions (Number 1
being the first priority and number 5
being the last priority).
1. Check for bladder distention
2. Raise the head of the bed
3. Contact the physician
4. Loosen tight clothing on the client
5. Administer an antihypertensive
medication
Answer: 2, 4, 1, 3, 5. Autonomic
dysreflexia is characterized by severe
hypertension, bradycardia, severe
headache, nasal stuffiness, and flushing.
The cause is a noxious stimulus, most
often a distended bladder or constipation.
Autonomic dysreflexia is a neurological

a.c.b.e.l.

Immediate nursing actions are to sit the

client up in bed in a high-Fowlers position
and remove the noxious stimulus. The
nurse should loosen any tight clothing and
then check for bladder distention. If the
client has a foley catheter, the nurse
should check for kinks in the tubing. The
nurse also would check for a fecal
impaction and disimpact if necessary. The
physician is contacted especially if these
actions do not relieve the signs and
symptoms. Antihypertensive medications
may be prescribed by the physician to
minimize cerebral hypertension.
41. A client is at risk for increased ICP.
Which of the following would be a
priority for the nurse to monitor?
1. Unequal pupil size
2. Decreasing systolic blood pressure
3. Tachycardia
4. Decreasing body temperature
Answer: 1. Increasing ICP causes
unequal pupils as a result of pressure on
the third cranial nerve. Increasing ICP
causes an increase in the systolic
pressure, which reflects the additional
pressure needed to perfuse the brain. It
increases the pressure on the vagus

nerve, which produces bradycardia, and it

blood volume, two important factors for

causes an increase in body temperature

reducing a sustained ICP of 20 mm Hg. A

from hypothalamic damage.

cooling blanket is used to control the

42. Which of the following respiratory

patterns indicate increasing ICP in the
brain stem?
1. Slow, irregular respirations
2. Rapid, shallow respirations
3. Asymmetric chest expansion

elevation of temperature because a fever

increases the metabolic rate, which in turn
increases ICP. High doses of barbiturates
may be used to reduce the increased
cellular metabolic demands. Fluid volume
and inotropic drugs are used to maintain
cerebral perfusion by supporting the

4. Nasal flaring

cardiac output and keeping the cerebral

Answer: 1. Neural control of respiration

Hg.

takes place in the brain stem.

Deterioration and pressure produce
irregular respiratory patterns. Rapid,
shallow respirations, asymmetric chest
movements, and nasal flaring are more
characteristic of respiratory distress or
hypoxia.
43. Which of the following nursing
interventions is appropriate for a client
with an ICP of 20 mm Hg?
1. Give the client a warming blanket
2. Administer low-dose barbiturate
3. Encourage the client to hyperventilate

perfusion pressure greater than 80 mm

44. A client has signs of increased ICP.

Which of the following is
an early indicator of deterioration in
the clients condition?
1. Widening pulse pressure
2. Decrease in the pulse rate
3. Dilated, fixed pupil
4. Decrease in LOC
Answer: 4. A decrease in the clients LOC
is an early indicator of deterioration of the
clients neurological status. Changes in
LOC, such as restlessness and irritability,

4. Restrict fluids

may be subtle. Widening of the pulse

Answer: 3. Normal ICP is 15 mm Hg or

dilated, fixed pupils occur later if the

less. Hyperventilation causes

vasoconstriction, which reduces CSF and

a.c.b.e.l.

pressure, decrease in the pulse rate, and

increased ICP is not treated.

45. A client who is regaining

4. Back arched; rigid extension of all four

consciousness after a craniotomy

extremities.

becomes restless and attempts to pull

out her IV line. Which nursing
intervention protects the client without
increasing her ICP?

Answer: 4. Decerebrate posturing occurs

in patients with damage to the upper brain
stem, midbrain, or pons and is
demonstrated clinically by arching of the

1. Place her in a jacket restraint

back, rigid extension of the extremities,

2. Wrap her hands in soft mitten

pronation of the arms, and plantar flexion

restraints

of the feet. Internal rotation and adduction

3. Tuck her arms and hands under the

of arms with flexion of the elbows, wrists,

draw sheet

and fingers described decorticate

4. Apply a wrist restraint to each arm

posturing, which indicates damage to

Answer: 2. It is best for the client to wear

mitts which help prevent the client from

corticospinal tracts and cerebral

hemispheres.

pulling on the IV without causing

47. A client receiving vent-assisted

additional agitation. Using a jacket or wrist

mode ventilation begins to experience

restraint or tucking the clients arms and

cluster breathing after recent

hands under the draw sheet restrict

intracranial occipital bleeding. Which

movement and add to feelings of being

action would be most appropriate?

confined, all of which would increase her

agitation and increase ICP.

1. Count the rate to be sure the

ventilations are deep enough to be

46. Which of the following describes

sufficient

decerebrate posturing?

2. Call the physician while another nurse

1. Internal rotation and adduction of arms

with flexion of elbows, wrists, and fingers
2. Back hunched over, rigid flexion of all
four extremities with supination of arms
and plantar flexion of the feet
3. Supination of arms, dorsiflexion of feet

a.c.b.e.l.

checks the vital signs and ascertains the

patients Glasgow Coma score.
3. Call the physician to adjust the
ventilator settings.
4. Check deep tendon reflexes to
determine the best motor response

Answer: 2. Cluster breathing consists of

Answer: 2. Elevating the HOB to 30

clusters of irregular breaths followed by

degrees is contraindicated for

periods of apnea on an irregular basis. A

infratentorial craniotomies because it

lesion in the upper medulla or lower pons

could cause herniation of the brain down

is usually the cause of cluster breathing.

onto the brainstem and spinal cord,

Because the client had a bleed in the

resulting in sudden death. Elevation of the

occipital lobe, which is superior and

head of the bed to 30 degrees with the

posterior to the pons and medulla, clinical

head turned to the side opposite of the

manifestations that indicate a new lesion

incision, if not contraindicated by the ICP;

are monitored very closely in case another

is used for supratentorial craniotomies.

bleed ensues. The physician is notified

immediately so that treatment can begin
before respirations cease. Another nurse
needs to assess vital signs and score the
client according to the GCS, but time is
also of the essence. Checking deep
tendon reflexes is one part of the GCS
analysis.
48. 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?
1. Keeping the client flat on one side or
the other
2. Elevating the head of the bed to 30
degrees
3. Log rolling or turning as a unit when
turning
4. Keeping the head in neutral position

a.c.b.e.l.

49. A client has been pronounced brain

dead. Which findings would the nurse
assess? Check all that apply.
1. Decerebrate posturing
2. Dilated nonreactive pupils
3. Deep tendon reflexes
4. Absent corneal reflex
Answer: 2, 3, 4. A client who is brain dead
typically demonstrates nonreactive dilated
pupils and nonreactive or absent corneal
and gag reflexes. The client may still have
spinal reflexes such as deep tendon and
Babinski reflexes in brain death.
Decerebrate or decorticate posturing
would not be seen.
50. 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

nursing measures is inappropriate

the patients care will be best to

when providing oral hygiene?

delegate to an LPN/LVN whom you are

supervising? (Choose all that apply).

1. Placing the client on the back with a

small pillow under the head.

1. Document the onset time, nature of

2. Keeping portable suctioning equipment

seizure activity, and postictal behaviors for

at the bedside.

all seizures.

3. Opening the clients mouth with a

2. Administer phenytoin (Dilantin) 200 mg

padded tongue blade.

PO daily.

4. Cleaning the clients mouth and teeth

3. Teach patient about the need for good

with a toothbrush.

oral hygiene.
4. Develop a discharge plan, including
physician visits and referral to the
Epilepsy Foundation.

Answer: 1. A helpless client should be

positioned on the side, not on the back.
This lateral position helps secretions
escape from the throat and mouth,

Answer: 2 Administration of medications

minimizing the risk of aspiration. It may be

is included in LPN education and scope of

necessary to suction, so having suction

practice. Collection of data about the

equipment at the bedside is necessary.

seizure activity may be accomplished by

Padded tongue blades are safe to use. A

an LPN/LVN who observes initial seizure

toothbrush is appropriate to use.

activity. An LPN/LVN would know to call

the supervising RN immediately if a
patient started to seize. Documentation of
the seizure, patient teaching, and planning
of care are complex activities that require
RN level education and scope of practice.

2. A 78 year old client is admitted to the

emergency department with numbness
and weakness of the left arm and
slurred speech. Which nursing
intervention is priority?
1. Prepare to administer recombinant
tissue plasminogen activator (rt-PA).

1. Regular oral hygiene is an essential

2. Discuss the precipitating factors that

intervention for the client who has had

caused the symptoms.

a stroke. Which of the following

3. Schedule for A STAT computer

a.c.b.e.l.

tomography (CT) scan of the head.

Answer: 3. The time of onset of a stroke to

4. Notify the speech pathologist for an

t-PA administration is critical.

emergency consult.

Administration within 3 hours has better

Answer: 3. A CT scan will determine if the

client is having a stroke or has a brain
tumor or another neurological disorder.
This would also determine if it is a
hemorrhagic or ischemic accident and
guide the treatment, because only an

outcomes. A complete history is not

possible in emergency care. Upcoming
surgical procedures will need to be delay if
t-PA is administered. Current medications
are relevant, but onset of current stroke
takes priority.

ischemic stroke can use rt-PA. This would

4. During the first 24 hours after

make (1) not the priority since if a stroke

thrombolytic therapy for ischemic

was determined to be hemorrhagic, rt-PA

stroke, the primary goal is to control

is contraindicated. Discuss the

the clients:

precipitating factors for teaching would not

be a priority and slurred speech would as
indicate interference for teaching.
Referring the client for speech therapy
would be an intervention after the CVA
emergency treatment is administered
according to protocol.
3. A client arrives in the emergency
department with an ischemic stroke
and receives tissue plasminogen
activator (t-PA) administration. Which
is the priority nursing assessment?

1. Pulse
2. Respirations
3. Blood pressure
4. Temperature
Answer: 3. Controlling the blood pressure
is critical because an intracerebral
hemorrhage is the major adverse effect of
thrombolytic therapy. Blood pressure
should be maintained according to
physician and is specific to the clients
ischemic tissue needs and risks of
bleeding from treatment. Other vital signs

1. Current medications.

are monitored, but the priority is blood

2. Complete physical and history.

pressure.

3. Time of onset of current stroke.

4. Upcoming surgical procedures.

a.c.b.e.l.

5. What is a priority nursing

assessment in the first 24 hours after

admission of the client with a

ischemic attack (TIA). Which

thrombotic stroke?

medication would the nurse anticipate

1. Cholesterol level
2. Pupil size and pupillary response

being ordered for the client on

discharge?

3. Bowel sounds

1. An oral anticoagulant medication.

4. Echocardiogram

2. A beta-blocker medication.

Answer: 2. It is crucial to monitor the pupil

size and pupillary response to indicate

3. An anti-hyperuricemic medication.
4. A thrombolytic medication.

changes around the cranial nerves.

Answer: 1. Thrombi form secondary to

Cholesterol level is an assessment to be

atrial fibrillation, therefore, an

addressed for long-term healthy lifestyle

anticoagulant would be anticipated to

rehabilitation. Bowel sounds need to be

prevent thrombi formation; and oral

assessed because an ileus or constipation

(warfarin [Coumadin]) at discharge verses

can develop, but is not a priority in the first

intravenous. Beta blockers slow the heart

24 hours. An echocardiogram is not

rate and lower the blood pressure. Anti-

needed for the client with a thrombotic

hyperuricemic medication is given to

stroke.

clients with gout. Thrombolytic medication

6. What is the expected outcome of

thrombolytic drug therapy?
1. Increased vascular permeability.
2. Vasoconstriction.
3. Dissolved emboli.
4. Prevention of hemorrhage
Answer: 3. Thrombolytic therapy is use to
dissolve emboli and reestablish cerebral
perfusion.
7. The client diagnosed with atrial
fibrillation has experienced a transient

a.c.b.e.l.

might have been given at initial

presentation but would not be a drug
prescribed at discharge.
8. Which client would the nurse identify
as being most at risk for experiencing
a CVA?
1. A 55-year-old African American male.
2. An 84-year-old Japanese female.
3. A 67-year-old Caucasian male.
4. A 39-year-old pregnant female.
Answer: 1. Africana Americans have twice
the rate of CVAs as Caucasians; males

are more likely to have strokes than

10. The nurse and unlicensed assistive

females except in advanced years.

personnel (UAP) are caring for a client

Orientals have a lower risk, possibly due

with right-sided paralysis. Which

to their high omega-3 fatty acids.

action by the UAP requires the nurse to

Pregnancy is a minimal risk factor for

intervene?

CVA.

1. The assistant places a gait belt around

9. Which assessment data would

the clients waist prior to ambulating.

indicate to the nurse that the client

2. The assistant places the client on the

would be at risk for a hemorrhagic

back with the clients head to the side.

stroke?

3. The assistant places her hand under

1. A blood glucose level of 480 mg/dl.

2. A right-sided carotid bruit.
3. A blood pressure of 220/120 mmHg.
4. The presence of bronchogenic
carcinoma.
Answer: 3. Uncontrolled hypertension is a
risk factor for hemorrhagic stroke, which is
a rupture blood vessel in the cranium. A
bruit in the carotid artery would
predispose a client to an embolic or
ischemic stroke. High blood glucose levels
could predispose a patient to ischemic
stroke, but not hemorrhagic. Cancer is not
a precursor to stroke.

a.c.b.e.l.

the clients right axilla to help him/her

move up in bed.
4. The assistant praises the client for
attempting to perform ADLs
independently.
Answer: 3. This action is inappropriate
and would require intervention by the
nurse because pulling on a flaccid
shoulder joint could cause shoulder
dislocation; as always use a lift sheet for
the client and nurse safety. All the other
actions are appropriate.