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The nurse is caring for a patient who suttered massive head trauma, and suspected increased intracranial pres- sure (ICP) from an automobile accident. Which cranial nerves are most appropriate to check at this time? A. CN I and CN II B. CN II and CN III C. CN III and CN IV D .CN IV and CN V When increased ICP is suspected, the nurse performs a complete neurologic assessment. What does the pupillary response indicate? A. High pressure can cause blurred vision. B. Hemorrhage can cause visual impairment. C. Pupil dilation is the first sign of increased ICP. D. Pupil changes can be caused by pressure on the ocular nerve. When rating a patient using the Glasgow Coma Scale, what would be appropriate for the LPN/LVN to ask the pa- tient to do in order to test the patient's motor response? A. Roll his eyes in a circle. B. Take a deep breath and exhale. C. Describe the view from his window. D. Touch his nose with his left index finger. The nurse is assessing a patient who has a brain tumor. What assessment finding is most indicative of increased ICP in this patient? A. Decreasing level of consciousness (LOC) B. Elevated temperature C. Agitation and hostility D. Increasing blood pressure (BP) B. CN II and CN III D. Pupil changes can be caused by pressure on the ocular nerve. D. Touch his nose with his left index finger. A. Decreasing level of consciousness (LOC)
The nurse is assessing the patient's patellar reflex. The patient asks what the purpose of this exam is. Which response by the nurse is correct? A. "I am checking the conscious nerve response in your leg." B. "This assessment determines your hand-eye coordina- tion." C. "Checking this reflex assesses involuntary muscular contractions." D. "The patellar reflex demonstrates large voluntary mus- cle coordination." The nurse is performing a "neuro check" on a patient who has demonstrated a decreased LOC. What is the best way to assess the patient's neuromuscular status? A. Measure the patient's vital signs. B. Test the reaction of the patient's pupils to light. C. Check the patient's response to the stimulus of pinch- ing. D. Determine whether the patient is able to move his legs and arms A patient who is to have computed tomography (CT scan) of the brain voices concern about the procedure. The LPN/LVN can best allay the patient's fears by making which statement? A. "CT scans use only a small amount of radioactive ma- terial injected into your brain." B. "The procedure is safe and painless; you will hear a clicking noise as the CT machine rotates." C. "You will probably be given something to make you drowsy and deaden the pain during the CT scan." C. "CT scanning is a new procedure, and since it involves C. "Checking this reflex assesses involuntary muscular contractions." D. Determine whether the patient is able to move his legs and arms B. "The procedure is safe and painless; you will hear a clicking noise as the CT machine rotates."
The nurse suspects that a 36-year-old patient recover- ing from a hypophysectomy (removal of the pituitary gland) has developed diabetes insipidus (DI). What sign or symptom is most indicative of DI? A. Polyuria B. Polyphagia C. Hypertension D. Hyperkalemia The patient who had a laminectomy following a herni- ated lumbar disk is preparing to be discharged. Which statement by the patient indicates a need for additional discharge instructions? A. "I should try to maintain a normal weight." B. "It is best for me to do my back exercises twice a day." C. "I need to be sure not to twist or bend at the waist when lifting things." D. "I can take a four hour car ride, as long as I stay perfectly still. A 13 - year-old female patient has been seen in a walk-in clinic following a blow to the head from a fall during bas- ketball practice. Which statement by the parent indicates the need for further discharge teaching? A. "I need to wake her up every 2 or 3 hours for the first 24 hours." B. "I need to apply ice to the bump on her head for 20 minutes every hour for 72 hours." C. "I need to check her pupils frequently with a flashlight to be sure her pupils constrict." D. "I need to watch for any changes in the level of con- sciousness or vomiting for 48 hours." A. Polyuria D. "I can take a four hour car ride, as long as I stay perfectly still. B. "I need to apply ice to the bump on her head for 20 minutes every hour for 72 hours."
Which patient is the nurse most concerned with develop- ing a subdural hematoma following an injury that resulted with a blow to the head? A. The 76 - year-old patient who is taking an anticoagulant B. The 16-year-old football player who suttered a concus- sion C. The 36-year-old patient who has a history of migraine headaches D. The 56-year-old patient who is taking an antihyperten- sive medication The student nurse is assisting the nurse in turning a pa- tient who is in cervical traction. What is most important for the LPN/LVN to instruct the student to do when assisting in turning the patient? A. Flex the knees and hips before turning the patient. B. Support the patient's head with a pillow so that his neck is flexed. C. Turn the patient slowly and as one unit to avoid twisting the spine. D. Place the patient's back in traction so that the spine will be kept slightly flexed. Which of the following conditions can increase the risk for torn vessels and contusion on the brain if an accident that involves brain injury occurs? A. Brain atrophy B. Hydrocephalus C. Heterotopic ossification D. Increased intracranial pressure (ICP) After a head injury, the patient begins to have drainage from the nose. The nurse assesses the drainage by which method? A. The 76 - year-old patient who is taking an anticoagulant C. Turn the patient slowly and as one unit to avoid twisting the spine. A. Brain atrophy
of the disorder. Which response by the nurse is correct? A. "It is best if you speak with your physician about this condition." B. "Unfortunately, there is little you can do to prevent future episodes of pain." C. "Drinking very cold or hot liquids is frequently a trigger, so you should avoid both." D. "Surgery is the only form of treatment that will prevent this condition from recurring." A patient is admitted to a rehabilitation facility following a brain injury that has resulted in dysphagia. While observ- ing the patient and his wife, the nurse determines further instruction is necessary if which activity is performed? A. The patient sips from a cup rather than using a straw. B. The patient sits in his chair for 45 minutes after each meal. C. The patient tilts his head back when trying to swallow solid foods. D. The patient's wife places a teaspoon of food in the patient's mouth at a time. The nurse who is caring for a patient following a stroke performs passive range-of-motion exercises on the pa- tient. The patient asks why these exercises are so impor- tant. Which response by the nurse is accurate? A. "This helps the patient believe she is making some progress." B. "This helps overcome mood swings and crying spells." C. "This helps prevent fatigue from worsening." D. "This helps to strengthen and retrain muscles." The nurse is providing patient teaching to a 23-year-old female who has recently been diagnosed with epilepsy. C. "Drinking very cold or hot liquids is frequently a trigger, so you should avoid both." C. The patient tilts his head back when trying to swallow solid foods. D. "This helps to strengthen and retrain muscles "
The nurse should educate the patient that seizures are most likely to occur at which time in the patient's men- strual cycle? A. At the time of ovulation B. 1 week after menstruation C. At the time of menstruation D. 1 week before menstruation A patient who has epilepsy is to take phenytoin (Dilantin). What is an important teaching point that the LPN/LVN should include regarding this medication? A. The patient should have periodic drug levels drawn. B. The patient should regulate the dosage according to need. C. The patient should take the medication with juice containing vitamin C. D. The patient should take an extra dose of the medication before exercising. A patient has had a left-sided cerebrovascular accident (CVA). Which condition does the nurse expect the patient to have as a result of the CVA? A. Ataxia B. Aphasia C. Dyslexia D. Quadriplegia A patient has been diagnosed with a cerebral neoplasm. What are the symptoms of a cerebral neoplasm? A. Long-term memory loss and paralysis B. Loss of muscle strength and paresthesia C. Grand mal seizure activity and facial paralysis D. Severe headache that wakes patient and visual prob- lems C. At the time of menstruation A. The patient should have periodic drug levels drawn. B. Aphasia D. Severe headache that wakes patient and visual prob- lems
During the advanced stages of amyotrophic lateral scle- rosis (ALS), which service would be most beneficial to the family and patient? A. Hospice services B. In-home physical therapy C. Pulmonary rehabilitation program D. Nursing visits from a home health care agency When teaching the patient with multiple sclerosis (MS) about how to best manage his disease, the nurse de- termines the patient requires further instruction when making which statement? A. "It is important that I attend all of my physical therapy sessions." B. "I should eat adequate fiber to prevent constipation." C. "It is a good idea for me to take a hot shower in the morning to relax my muscles." D. "The injections of interferon beta-1b (Betaseron) will help manage my symptoms." A patient has recently been diagnosed with MS. The family asks the nurse about the common manifestations of the disease. The nurse is correct by identifying which as the most common clinical manifestation of the disease? A. Urinary incontinence B. Weakness of the limbs C. A loss of the sense of smell D. Decreased intellectual function Following a viral respiratory infection, a patient devel- ops symptoms of Guillain-Barré syndrome. What is most closely associated with this disorder? A. Emotional lability B. Hyperactive deep tendon reflexes A. Hospice Services C. "It is a good idea for me to take a hot shower in the morning to relax my muscles." B. Weakness of the limbs D. Paresthesia and weakness of the lower extremities
C. Flapping tremors of the hands and feet D. Paresthesia and weakness of the lower extremities Interventions to prevent which problem are the priority for a patient with myasthenia gravis (MG)? A. Accidental injury B. Uncontrolled pain C. Inability to maintain own airway D. Decreased functional ability and mobility Why should the nurse check with the physician to be sure that she knows a patient has MG when prescribing medications? A. Because the patient needs sublingual medications due to excessive salivation. B. Because when the patient is in remission, certain drugs should not be prescribed. C. Because the myasthenic patient can sutter from exag- gerated and bizarre ettects from a variety of drugs. D. Because the patient's MG medication, selegiline (El- depryl), needs to be carefully monitored for patient reac- tions. For which condition would a patient most need to have medical alert identification? A. Poliomyelitis B. MS C. MG D. Cerebrovascular accident (CVA) During the acute stage of Guillain-Barré syndrome, what is the priority goal of nursing and medical treatment? A. Sustenance of life B. Promotion of rest C. Inability to maintain own airway C. Because the myasthenic patient can sutter from exag- gerated and bizarre ettects from a variety of drugs. C. MG A. Sustenance of life
The client has just undergone computed tomography ( CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of the post procedure care? A. " I should drink extra fluids for the remainder of the day." B. " I should not take any medications for atleast 4 hours." C. "I should eat lightly for the remainder of the day." D. " I should rest quietly for the remainder of the day." The nurse is caring for a client with an increased intracra- nial pressure. ( ICP) Which change in vital signs would occur is ICP is rising? A. increasing temperature, increasing pulse, increasing respirations, and decreasing BP B. decreasing temperature, decreasing pulse, increasing respirations, decreasing BP C. decreasing temperature, increasing pulse, decreasing respirations, increasing BP D. increasing temperature, decreasing pulse, decreasing respirations, increasing BP The nurse observes the unlicensed assistive personnel positioning the client with increased intracranial pressure. Which position would require intervention by the nurse? A. Head midline B. Head turned to the side C. neck in neutral position D. head of bed elevated to 30 to 45 degrees The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracra- A. " I should drink extra fluids for the remainder of the day." D. increasing temperature, decreasing pulse, decreasing respirations, increasing BP B. Head turned to the side
nial pressure if the nurse observes the client doing which of the following? A. Blowing the nose B. isometric exercises C. coughing vigorously D. exhaling during repositioning The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that is is cere- brospinal fluid ( CSF) if the fluid meets which criteria? A. Is grossly bloody in appearance and has a pH of 6 B. Clumps together on the dressing and has a pH of 7 C. Is clear in appearance and tests negative for glucose D. separates into concentric rings and tests positive for glucose The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? A. The client is taken for spinal x-rays B. The family comes to visit after surgery C. The nurse needs to provide physical care D. The health care provider reviews the x-rays The client was seen and treated in the ER for a concus- sion. Before discharge, the nurse explains the signs and symptoms of worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign and symptom? A. Vomiting B. Minor headache D. exhaling during respostioning D. separates into concentric rings and tests positive for glucose D. The health care provider reviews the x-rays B. Minor headache
and symptoms of autonomic dysreflexia and suspects this complication if which sign and symptoms is noted? A. sudden tachycardia B. Pallor of face and neck C. Severe, throbbing headache D. Severe and sudden hypotension The client with a spinal cord injury is prone to experienc- ing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? A. Strictly adhering to a bowel retraining program B. Keeping the linen wrinkle-free under the client C. Avoiding unnecessary pressure on the lower limbs D. Limiting bladder catherization to once every 12 hours The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the vital signs, which immediate action should the nurse take? A. raise the head of bed and removed the noxious stimu- lus B. lower the head of bed and remove the noxious stimu- lus C. lower the head of bed and administer an antihyperten- sive agent D. remove the noxious stimulus and administer an antihy- pertensive agent The client is having a lumbar puncture preformed. The nurse should place the client in which position for the procedure? A. Supine, in semi-fowlers B. Prone, in slight Trendelenburg C. Severe, throbbing headache D. Limiting bladder catherization to once every 12 hours A. raise the head of bed and removed the noxious stimulus D. Side- laying with legs pulled up and chin to the chest
