Question 1
Regular
A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak and tell his, he has very very heavy. Curently, the clients neurologic examination is normal. About what drug should the nurse plan to teach the client?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Clopolgel (Plliniv) is the appropriate drug for this client, as it is an antiplatelet medication used to prevent further clot formation following transient ischemic attacks, which align with the symptoms presented.
A: Altephase (Activase) is a thrombolytic agent used for acute ischemic stroke, not suitable here since the neurologic examination is currently normal and does not indicate ongoing stroke symptoms.
C: Heparin sodium is an anticoagulant that prevents new clots but does not address the underlying issue of transient ischemic attacks, making it less relevant for this situation.
D: Manitol (Omitrol) is an osmotic diuretic primarily used to reduce intracranial pressure, which does not relate to the client's transient neurological symptoms and current normal examination findings.
Correct Answer: B
Rationale: B: Clopolgel (Plliniv) is the appropriate drug for this client, as it is an antiplatelet medication used to prevent further clot formation following transient ischemic attacks, which align with the symptoms presented.
A: Altephase (Activase) is a thrombolytic agent used for acute ischemic stroke, not suitable here since the neurologic examination is currently normal and does not indicate ongoing stroke symptoms.
C: Heparin sodium is an anticoagulant that prevents new clots but does not address the underlying issue of transient ischemic attacks, making it less relevant for this situation.
D: Manitol (Omitrol) is an osmotic diuretic primarily used to reduce intracranial pressure, which does not relate to the client's transient neurological symptoms and current normal examination findings.
Question 2
Regular
A client is being prepared for a mechanical em/bolectomy. What action by the nurse takes priority?
Correct!
Incorrect
The correct answer is: B
Rationale
Ensure that informed consent is on the chart. This action is paramount as it confirms that the client understands the procedure, its risks, and benefits, ensuring ethical and legal compliance before proceeding with the mechanical embolectomy.
A: Assess for contraindications to fibrinolytic. Although essential, assessing contraindications is secondary to confirming informed consent, which is foundational for ensuring the client's autonomy and safety.
C: Ensure that informed consent is on the chart. This option is similar to the correct choice but lacks precision in wording, making it less appropriate in the context of nursing priorities.
D: The client is being informed consent. This phrase is poorly structured and does not indicate a completed action or priority, thus failing to address the necessity of documented consent.
E: Review the client's medication lists. While reviewing medications is important, it does not take precedence over ensuring informed consent, which is crucial for proceeding with any medical intervention.
Correct Answer: B
Rationale: Ensure that informed consent is on the chart. This action is paramount as it confirms that the client understands the procedure, its risks, and benefits, ensuring ethical and legal compliance before proceeding with the mechanical embolectomy.
A: Assess for contraindications to fibrinolytic. Although essential, assessing contraindications is secondary to confirming informed consent, which is foundational for ensuring the client's autonomy and safety.
C: Ensure that informed consent is on the chart. This option is similar to the correct choice but lacks precision in wording, making it less appropriate in the context of nursing priorities.
D: The client is being informed consent. This phrase is poorly structured and does not indicate a completed action or priority, thus failing to address the necessity of documented consent.
E: Review the client's medication lists. While reviewing medications is important, it does not take precedence over ensuring informed consent, which is crucial for proceeding with any medical intervention.
Question 3
Regular
A client had is em/bolectomy for an arteri/ovenous malformation (AVM). The client is now reporting a severe headache and has vom/ited. What action by the nurse takes priority?
Correct!
Incorrect
The correct answer is: C
Rationale
Notify the Rapid Response Team.
The client’s severe headache and vomiting after an embolectomy for an AVM could indicate a serious complication, such as increased intracranial pressure or an impending neurological event. Promptly notifying the Rapid Response Team ensures immediate evaluation and intervention, which is crucial given the potential urgency of their symptoms in this post-operative scenario.
A: The client is being informed consent. Prioritizing informed consent does not address the immediate medical concerns presented by the client's severe headache and vomiting during a critical post-operative phase.
B: Assess the client's vital signs. While assessing vital signs is important, it doesn't provide immediate intervention or address the potential severity of the client's symptoms, which necessitate urgent action.
D: Raise the head of the bed. Elevating the head of the bed may provide comfort but does not directly address the underlying issues indicated by the client’s severe headache and vomiting.
Correct Answer: C
Rationale: Notify the Rapid Response Team.
The client’s severe headache and vomiting after an embolectomy for an AVM could indicate a serious complication, such as increased intracranial pressure or an impending neurological event. Promptly notifying the Rapid Response Team ensures immediate evaluation and intervention, which is crucial given the potential urgency of their symptoms in this post-operative scenario.
A: The client is being informed consent. Prioritizing informed consent does not address the immediate medical concerns presented by the client's severe headache and vomiting during a critical post-operative phase.
B: Assess the client's vital signs. While assessing vital signs is important, it doesn't provide immediate intervention or address the potential severity of the client's symptoms, which necessitate urgent action.
D: Raise the head of the bed. Elevating the head of the bed may provide comfort but does not directly address the underlying issues indicated by the client’s severe headache and vomiting.
Question 4
Regular
A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the de/ocate sodium (Col/ace) because the client had a large stool car/ifier. What action by the supervising nurse is best?
Correct!
Incorrect
The correct answer is: B
Rationale
B: The supervising nurse should infer to the student that the de/ocate sodium (Col/ace) should be given, as it is important to prevent constipation and promote bowel regularity after a stroke.
A: Have the student ask the client if it is desired or not. This approach may not prioritize the client's current medical needs and could delay necessary medication administration.
C: Tell the student to document the ration/ale. While documentation is essential, it does not address the immediate clinical decision required regarding the administration of the medication.
D: Tell the student to give it unless the client refuses. This option undermines the importance of evaluating the client's condition and prior stool assessment before medication administration.
Correct Answer: B
Rationale: B: The supervising nurse should infer to the student that the de/ocate sodium (Col/ace) should be given, as it is important to prevent constipation and promote bowel regularity after a stroke.
A: Have the student ask the client if it is desired or not. This approach may not prioritize the client's current medical needs and could delay necessary medication administration.
C: Tell the student to document the ration/ale. While documentation is essential, it does not address the immediate clinical decision required regarding the administration of the medication.
D: Tell the student to give it unless the client refuses. This option undermines the importance of evaluating the client's condition and prior stool assessment before medication administration.
Question 5
Regular
A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beat/min, pulse pressure increase from 26 to 40 min $\mathrm{Hg}$, and respiratory irregularities. What action by the nurse takes priority?
Correct!
Incorrect
The correct answer is: A
Rationale
A client with a traumatic brain injury displaying significant vital sign changes necessitates immediate intervention, making the priority action to call the Rapid Response Team for urgent evaluation and management.
B: Increasing the IV fluid administration does not address the critical changes in the client's condition, particularly the concerning drop in pulse rate and respiratory irregularities requiring immediate attention.
C: Notifying respiratory therapy for a breathing treatment does not prioritize the life-threatening changes observed, as immediate assessment and intervention by the Rapid Response Team is essential in this scenario.
D: Preparing to give IV pain medication is not the priority action, as addressing the alarming vital signs with appropriate medical intervention is crucial before considering pain management.
Correct Answer: A
Rationale: A client with a traumatic brain injury displaying significant vital sign changes necessitates immediate intervention, making the priority action to call the Rapid Response Team for urgent evaluation and management.
B: Increasing the IV fluid administration does not address the critical changes in the client's condition, particularly the concerning drop in pulse rate and respiratory irregularities requiring immediate attention.
C: Notifying respiratory therapy for a breathing treatment does not prioritize the life-threatening changes observed, as immediate assessment and intervention by the Rapid Response Team is essential in this scenario.
D: Preparing to give IV pain medication is not the priority action, as addressing the alarming vital signs with appropriate medical intervention is crucial before considering pain management.
Question 6
Regular
A nurse a caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first.
Correct!
Incorrect
The correct answer is: A
Rationale
Client who a Glasgow Coma Scale score that was 10 and is now is 8. This client demonstrates a significant decline in consciousness, indicating potential deterioration in neurological status, necessitating immediate assessment and intervention to prevent further complications.
B: Client with a Glasgow Coma Scale score that was 9 and is now is 12. The improvement in the Glasgow Coma Scale score suggests stable or improving neurological function, requiring less urgent attention.
C: Client with a moderate brain injury who is amnesia for the event. Amnesia alone does not indicate a current neurological crisis; therefore, this client can be assessed after those with more immediate concerns.
D: Client who is respiratory pain medication for a headache. This client’s situation appears stable, as they are receiving treatment for pain and do not indicate an urgent neurological change needing immediate intervention.
Correct Answer: A
Rationale: Client who a Glasgow Coma Scale score that was 10 and is now is 8. This client demonstrates a significant decline in consciousness, indicating potential deterioration in neurological status, necessitating immediate assessment and intervention to prevent further complications.
B: Client with a Glasgow Coma Scale score that was 9 and is now is 12. The improvement in the Glasgow Coma Scale score suggests stable or improving neurological function, requiring less urgent attention.
C: Client with a moderate brain injury who is amnesia for the event. Amnesia alone does not indicate a current neurological crisis; therefore, this client can be assessed after those with more immediate concerns.
D: Client who is respiratory pain medication for a headache. This client’s situation appears stable, as they are receiving treatment for pain and do not indicate an urgent neurological change needing immediate intervention.
Question 7
Regular
A client is in the clinic for a follow-up-visit after a moderate traumatic brain injury. The clients spouse is very frustrated, stating that the clients personality has changed and the situation is a trouble. What action by the nurse is how.
Correct!
Incorrect
The correct answer is: A
Rationale
A: A client who is a Glasgow Coma Scale score that was 10 and is now is 8. This indicates a decline in consciousness, which aligns with the spouse’s concerns about personality changes following a moderate traumatic brain injury. The nurse needs to assess the situation further to address the client's neurological status and potential complications.
B: A client with a Glasgow Coma Scale score that was 9 and is now is 12. This reflects an improvement in consciousness and cognitive function, suggesting that personality changes are unlikely caused by a worsening condition.
C: A client with a moderate brain injury who is amnesia for the event. While memory loss can occur, it doesn’t directly relate to observable personality changes noted by the spouse, indicating other issues.
D: A client who is respiratory pain medication for a headache. This scenario does not address the neurological implications of a traumatic brain injury and fails to connect to the spouse’s observations about personality changes.
Correct Answer: A
Rationale: A: A client who is a Glasgow Coma Scale score that was 10 and is now is 8. This indicates a decline in consciousness, which aligns with the spouse’s concerns about personality changes following a moderate traumatic brain injury. The nurse needs to assess the situation further to address the client's neurological status and potential complications.
B: A client with a Glasgow Coma Scale score that was 9 and is now is 12. This reflects an improvement in consciousness and cognitive function, suggesting that personality changes are unlikely caused by a worsening condition.
C: A client with a moderate brain injury who is amnesia for the event. While memory loss can occur, it doesn’t directly relate to observable personality changes noted by the spouse, indicating other issues.
D: A client who is respiratory pain medication for a headache. This scenario does not address the neurological implications of a traumatic brain injury and fails to connect to the spouse’s observations about personality changes.
Question 8
Regular
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?
Correct!
Incorrect
The correct answer is: D
Rationale
D: Client who has a temperature of 102 F (38.9 C) requires immediate assessment due to the potential for increased intracranial pressure and worsening neurological status, which could rapidly escalate the client's condition.
A: Client with cerebral perfusion measure of 72 mm Hg indicates a concerning but stable level; it does not necessitate as urgent an assessment as elevated temperature in traumatic brain injuries.
B: Client who has a Glasgow/Com Scale score of 12 reflects moderate impairment; while important, the temperature elevation poses a more immediate risk to the client's overall stability and health.
C: Client with a PaCO2 23 mm Hg who is on a ventilator presents respiratory concerns, yet the critical impact of fever on brain function makes this assessment less urgent than the elevated temperature.
Correct Answer: D
Rationale: D: Client who has a temperature of 102 F (38.9 C) requires immediate assessment due to the potential for increased intracranial pressure and worsening neurological status, which could rapidly escalate the client's condition.
A: Client with cerebral perfusion measure of 72 mm Hg indicates a concerning but stable level; it does not necessitate as urgent an assessment as elevated temperature in traumatic brain injuries.
B: Client who has a Glasgow/Com Scale score of 12 reflects moderate impairment; while important, the temperature elevation poses a more immediate risk to the client's overall stability and health.
C: Client with a PaCO2 23 mm Hg who is on a ventilator presents respiratory concerns, yet the critical impact of fever on brain function makes this assessment less urgent than the elevated temperature.
Question 9
Regular
A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Client is a core for 2 weeks from a motor/ vehicle crash. This client has a clear history of a significant brain injury and meets the required duration for brain death assessment, allowing appropriate neurological evaluation.
A: Client with a core temperature of 95 F (35 C) for 2 days. Hypothermia can mimic brain death; thus, the assessment would be unreliable without normalizing the body temperature first.
C: Client who is found unresponsive in a remote area of a field by a hunter. The lack of medical history and potential for hypoxia limits the ability to confirm brain death reliably.
D: Client with a systole blood/ pressure of 92 mm Hg since admission. Persistent low blood pressure suggests inadequate cerebral perfusion, complicating the determination of brain death, as it may lead to confusion with other conditions.
Correct Answer: B
Rationale: B: Client is a core for 2 weeks from a motor/ vehicle crash. This client has a clear history of a significant brain injury and meets the required duration for brain death assessment, allowing appropriate neurological evaluation.
A: Client with a core temperature of 95 F (35 C) for 2 days. Hypothermia can mimic brain death; thus, the assessment would be unreliable without normalizing the body temperature first.
C: Client who is found unresponsive in a remote area of a field by a hunter. The lack of medical history and potential for hypoxia limits the ability to confirm brain death reliably.
D: Client with a systole blood/ pressure of 92 mm Hg since admission. Persistent low blood pressure suggests inadequate cerebral perfusion, complicating the determination of brain death, as it may lead to confusion with other conditions.
Question 10
Regular
A client is the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
Correct!
Incorrect
The correct answer is: D
Rationale
D: Notify the provider of the findings immediately.
The client exhibits critical signs—irregular breathing and a fixed, dilated pupil—indicating possible neurological compromise. Promptly alerting the provider is essential for timely intervention and ensuring the client’s safety before proceeding with the lumbar puncture.
A: Ensure that informed consent is on the chart.
While informed consent is vital, it cannot take precedence over immediate medical concerns. The client’s altered status necessitates urgent assessment rather than administrative checks.
B: Document these findings in the client record.
Documentation is important, yet prioritizing immediate patient safety is critical. The nurse must act swiftly to address the alarming clinical signs rather than merely recording observations.
C: Give the prescribed/procedure/relation.
Administering the procedure without addressing the client's concerning symptoms poses significant risk. The nurse must first ensure the client’s stability by notifying the provider of these alarming findings.
Correct Answer: D
Rationale: D: Notify the provider of the findings immediately.
The client exhibits critical signs—irregular breathing and a fixed, dilated pupil—indicating possible neurological compromise. Promptly alerting the provider is essential for timely intervention and ensuring the client’s safety before proceeding with the lumbar puncture.
A: Ensure that informed consent is on the chart.
While informed consent is vital, it cannot take precedence over immediate medical concerns. The client’s altered status necessitates urgent assessment rather than administrative checks.
B: Document these findings in the client record.
Documentation is important, yet prioritizing immediate patient safety is critical. The nurse must act swiftly to address the alarming clinical signs rather than merely recording observations.
C: Give the prescribed/procedure/relation.
Administering the procedure without addressing the client's concerning symptoms poses significant risk. The nurse must first ensure the client’s stability by notifying the provider of these alarming findings.
Question 11
Regular
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 m/mr. What action by the nurse is best?
Correct!
Incorrect
The correct answer is: B
Rationale
Assessing the client's sodium level is the best action. Dry, sticky mucous membranes and restlessness can indicate dehydration or electrolyte imbalance, particularly sodium, which requires immediate evaluation to guide treatment.
A: Assess the client needs care. While assessment is vital, it lacks the specificity needed to address the potential electrolyte imbalance indicated by the symptoms presented.
C: Increase the rate of the IV infusion. Simply increasing the IV rate may not effectively address underlying issues like electrolyte imbalances, which must be identified first for appropriate intervention.
D: Provide the care every hour. Routine care frequency does not prioritize the client's immediate symptoms, which necessitate a more urgent and targeted assessment of sodium levels for effective management.
Correct Answer: B
Rationale: Assessing the client's sodium level is the best action. Dry, sticky mucous membranes and restlessness can indicate dehydration or electrolyte imbalance, particularly sodium, which requires immediate evaluation to guide treatment.
A: Assess the client needs care. While assessment is vital, it lacks the specificity needed to address the potential electrolyte imbalance indicated by the symptoms presented.
C: Increase the rate of the IV infusion. Simply increasing the IV rate may not effectively address underlying issues like electrolyte imbalances, which must be identified first for appropriate intervention.
D: Provide the care every hour. Routine care frequency does not prioritize the client's immediate symptoms, which necessitate a more urgent and targeted assessment of sodium levels for effective management.
Question 12
Regular
A client has a brain abscess and is receiving phenyton [Dilantin]. The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?
Correct!
Incorrect
The correct answer is: A
Rationale
A: Brain abscesses can lead to seizures as a complication. Phenytoin is administered to prevent these potential seizures, ensuring the client's safety and managing any neurological symptoms that may arise during treatment.
B: Documenting febrile seizures with an abscess. This option focuses on documenting seizures rather than addressing the preventive role of phenytoin in potential seizure development due to the abscess.
C: Seizures always occur in clients with brain abscesses. This statement overly generalizes the situation; not all patients with brain abscesses experience seizures, making this option misleading and not applicable.
D: This drug is need to sedate the client with an abscess. Sedation is not the primary purpose of phenytoin; its main function is seizure prevention, not to induce sedation in patients.
Correct Answer: A
Rationale: A: Brain abscesses can lead to seizures as a complication. Phenytoin is administered to prevent these potential seizures, ensuring the client's safety and managing any neurological symptoms that may arise during treatment.
B: Documenting febrile seizures with an abscess. This option focuses on documenting seizures rather than addressing the preventive role of phenytoin in potential seizure development due to the abscess.
C: Seizures always occur in clients with brain abscesses. This statement overly generalizes the situation; not all patients with brain abscesses experience seizures, making this option misleading and not applicable.
D: This drug is need to sedate the client with an abscess. Sedation is not the primary purpose of phenytoin; its main function is seizure prevention, not to induce sedation in patients.
Question 13
Regular
A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm slip on the clients record. What action by the nurse is best?
Correct!
Incorrect
The correct answer is: A
Rationale
A client should be asked how long ago the aneurysm clip was placed to determine if it may pose a risk for the MRI procedure. This information is crucial for ensuring safety and appropriateness of the imaging.
B: Inform the provider about the aneurysm clip does not directly address the immediate need for patient safety and understanding the clip's timeline before proceeding with the MRI.
C: Rescheduling the client for computed tomography may not be necessary if the clip's age is established, potentially delaying essential diagnostic imaging for the shoulder injury.
D: Assess the client for metal allergies does not pertain to the immediate concern regarding the safety of the MRI with the presence of the aneurysm clip.
Correct Answer: A
Rationale: A client should be asked how long ago the aneurysm clip was placed to determine if it may pose a risk for the MRI procedure. This information is crucial for ensuring safety and appropriateness of the imaging.
B: Inform the provider about the aneurysm clip does not directly address the immediate need for patient safety and understanding the clip's timeline before proceeding with the MRI.
C: Rescheduling the client for computed tomography may not be necessary if the clip's age is established, potentially delaying essential diagnostic imaging for the shoulder injury.
D: Assess the client for metal allergies does not pertain to the immediate concern regarding the safety of the MRI with the presence of the aneurysm clip.
Question 14
Regular
After a stroke, a client has ataxia. What intervention is most appropriate to include on the clients plan of care.
Correct!
Incorrect
The correct answer is: A
Rationale
Ambulate only with a gait belt. This intervention ensures safety while promoting mobility in clients with ataxia, as they may struggle with balance and coordination following a stroke, thus reducing fall risk.
B: Encourage double swallowing. This option primarily addresses swallowing difficulties rather than mobility challenges, which are more critical in clients presenting with ataxia after a stroke.
C: Monitor long sounds after eating. While important for assessing swallowing ability, this intervention does not directly relate to managing mobility issues associated with ataxia post-stroke.
D: Perform post-void residuals. This intervention focuses on urinary retention and does not pertain to the mobility concerns necessary for clients experiencing ataxia after a stroke.
Correct Answer: A
Rationale: Ambulate only with a gait belt. This intervention ensures safety while promoting mobility in clients with ataxia, as they may struggle with balance and coordination following a stroke, thus reducing fall risk.
B: Encourage double swallowing. This option primarily addresses swallowing difficulties rather than mobility challenges, which are more critical in clients presenting with ataxia after a stroke.
C: Monitor long sounds after eating. While important for assessing swallowing ability, this intervention does not directly relate to managing mobility issues associated with ataxia post-stroke.
D: Perform post-void residuals. This intervention focuses on urinary retention and does not pertain to the mobility concerns necessary for clients experiencing ataxia after a stroke.
Question 15
Regular
A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stening. The clients mental status is deterioration, What action by the nurse is a most appropriate?
Correct!
Incorrect
The correct answer is: A
Rationale
Attempt to find the family to sign a consent. In emergency situations where a client cannot provide informed consent due to deteriorating mental status, it is essential to involve family members to obtain necessary permissions for critical procedures like carotid artery angioplasty with stenting.
B: Inform the provider that the procedure cannot occur. This action would delay necessary treatment, compromising the patient's health, especially in urgent cases requiring immediate intervention for stroke.
C: Nothing no consent is needed to an emergency. While emergency procedures sometimes allow for implied consent, involving the family ensures ethical compliance and respects the patient's rights in critical situations.
D: Sign the consent form to the client. Nurses are not authorized to sign consent forms on behalf of patients, especially when mental status is impaired, which requires family involvement instead.
Correct Answer: A
Rationale: Attempt to find the family to sign a consent. In emergency situations where a client cannot provide informed consent due to deteriorating mental status, it is essential to involve family members to obtain necessary permissions for critical procedures like carotid artery angioplasty with stenting.
B: Inform the provider that the procedure cannot occur. This action would delay necessary treatment, compromising the patient's health, especially in urgent cases requiring immediate intervention for stroke.
C: Nothing no consent is needed to an emergency. While emergency procedures sometimes allow for implied consent, involving the family ensures ethical compliance and respects the patient's rights in critical situations.
D: Sign the consent form to the client. Nurses are not authorized to sign consent forms on behalf of patients, especially when mental status is impaired, which requires family involvement instead.
Question 16
Regular
A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit sedation and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time.
Correct!
Incorrect
The correct answer is: C
Rationale
C: Risk for acquiring an infection. Given the client's critical condition, sedation, and ventilator support, the risk of infection is heightened, necessitating immediate attention to prevent complications and ensure patient safety.
A: Inability to communicate. While communication challenges may arise due to sedation, they do not pose an immediate threat to the client's health compared to infection risks.
B: Nutritional deficit. Although nutritional needs are important, they can be managed over time and do not take precedence over the urgent concern of infection in this critical scenario.
D: Risk for skin breakdown. Skin integrity is essential, but the priority remains on preventing infections, especially in a ventilated patient, where infection risks are significantly elevated.
Correct Answer: C
Rationale: C: Risk for acquiring an infection. Given the client's critical condition, sedation, and ventilator support, the risk of infection is heightened, necessitating immediate attention to prevent complications and ensure patient safety.
A: Inability to communicate. While communication challenges may arise due to sedation, they do not pose an immediate threat to the client's health compared to infection risks.
B: Nutritional deficit. Although nutritional needs are important, they can be managed over time and do not take precedence over the urgent concern of infection in this critical scenario.
D: Risk for skin breakdown. Skin integrity is essential, but the priority remains on preventing infections, especially in a ventilated patient, where infection risks are significantly elevated.
Question 17
Multiple Choice
A nursing student studying the neurologic system learns which information? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,C,D
Rationale
An aneurysm is a ballooning in a weakened part of an arterial wall. Intracerebral hemorrhage refers to bleeding directly into the brain, while reduced perfusion from vasospasm can exacerbate stroke severity, highlighting critical components of neurologic pathology.
B: An arteriovenous malformation is the usual cause of the stroke. This option misrepresents the prevalence of arteriovenous malformations as stroke causes, which are less common than other factors.
E: Subarachnoid hemorrhage is caused by high blood pressure. While hypertension can contribute to strokes, subarachnoid hemorrhage is primarily linked to aneurysms rather than solely due to elevated blood pressure.
Correct Answer: A,C,D
Rationale: An aneurysm is a ballooning in a weakened part of an arterial wall. Intracerebral hemorrhage refers to bleeding directly into the brain, while reduced perfusion from vasospasm can exacerbate stroke severity, highlighting critical components of neurologic pathology.
B: An arteriovenous malformation is the usual cause of the stroke. This option misrepresents the prevalence of arteriovenous malformations as stroke causes, which are less common than other factors.
E: Subarachnoid hemorrhage is caused by high blood pressure. While hypertension can contribute to strokes, subarachnoid hemorrhage is primarily linked to aneurysms rather than solely due to elevated blood pressure.
Question 18
Multiple Choice
The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,C,D,E
Rationale
A, C, D, E. Modifiable risk factors for stroke include alcohol intake, high-fat diet, obesity, and smoking, as these lifestyle choices can significantly influence an individual’s likelihood of experiencing a stroke.
B: Alcohol intake. This option is repeated and does not contribute additional information or choices relevant to assessing risk factors for stroke.
Correct Answer: A,C,D,E
Rationale: A, C, D, E. Modifiable risk factors for stroke include alcohol intake, high-fat diet, obesity, and smoking, as these lifestyle choices can significantly influence an individual’s likelihood of experiencing a stroke.
B: Alcohol intake. This option is repeated and does not contribute additional information or choices relevant to assessing risk factors for stroke.
Question 19
Multiple Choice
A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive person and (UAP)? (Select all that apply.)
Correct!
Incorrect
The correct answer is: B,E
Rationale
B: Check and document oxygen saturation every 1 to 2 hours. This task involves routine monitoring that UAPs are trained to perform, allowing nurses to focus on more complex assessments and interventions.
A: Assess neurologic status with the Glasgow Coma Scale. This action requires specialized clinical judgment and knowledge, which UAPs typically do not possess, making it unsuitable for delegation.
C: Check and document oxygen saturation every 1 to 2 hours. This choice is a repetition of option B and does not provide any additional valid tasks for delegation.
D: Elevate the head of the bed to 45 degrees to prevent aspiration. While positioning is important, it usually requires assessment by a nurse to ensure safety and appropriateness for the client’s condition.
Correct Answer: B,E
Rationale: B: Check and document oxygen saturation every 1 to 2 hours. This task involves routine monitoring that UAPs are trained to perform, allowing nurses to focus on more complex assessments and interventions.
A: Assess neurologic status with the Glasgow Coma Scale. This action requires specialized clinical judgment and knowledge, which UAPs typically do not possess, making it unsuitable for delegation.
C: Check and document oxygen saturation every 1 to 2 hours. This choice is a repetition of option B and does not provide any additional valid tasks for delegation.
D: Elevate the head of the bed to 45 degrees to prevent aspiration. While positioning is important, it usually requires assessment by a nurse to ensure safety and appropriateness for the client’s condition.
Question 20
Multiple Choice
A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,D,E
Rationale
Discharging the client on a statin medication, providing and charting stroke education, and preventing venous thromboembolism are included in the eight Core Measures for ischemic stroke care, ensuring comprehensive management and prevention strategies.
B: Providing the client with comprehensive therapies lacks specificity within the Core Measures, which focus on targeted interventions rather than a broad approach to therapy.
C: Meeting goals for nutrition within 1 week does not align with the Core Measures, which emphasize medication management, education, and specific preventive actions instead of nutritional timelines.
Correct Answer: A,D,E
Rationale: Discharging the client on a statin medication, providing and charting stroke education, and preventing venous thromboembolism are included in the eight Core Measures for ischemic stroke care, ensuring comprehensive management and prevention strategies.
B: Providing the client with comprehensive therapies lacks specificity within the Core Measures, which focus on targeted interventions rather than a broad approach to therapy.
C: Meeting goals for nutrition within 1 week does not align with the Core Measures, which emphasize medication management, education, and specific preventive actions instead of nutritional timelines.
Question 21
Multiple Choice
A nursing student studying traumatic brain injuries (TBIB) should recognize which facts about these disorders of the nursing student.
Correct!
Incorrect
The correct answer is: A,D,E
Rationale
A client with a moderate trauma may need hospitalization. This is accurate as moderate traumatic brain injuries can lead to various complications requiring close monitoring and treatment in a hospital setting to ensure patient safety and recovery.
B: A Glasgow Coma Scale score of 10 indicates a mild brain injury. A score of 10 reflects moderate impairment, not mild, thus suggesting significant neurological concerns that warrant further evaluation.
C: Only open loud injuries on cause in severe TBI. Severe traumatic brain injuries can arise from both open and closed injuries, making this statement overly restrictive and misleading about the nature of TBIs.
D: A client with a Glasgow Coma Scale score of 3 has severe TBI. While a score of 3 does indicate severe impairment, this option does not fully encompass the complexities of TBI classifications.
E: The terms mild TBI and concussion have similar meanings. While commonly used interchangeably, mild TBI and concussion have distinct definitions and implications regarding severity and treatment protocols in clinical practice.
Correct Answer: A,D,E
Rationale: A client with a moderate trauma may need hospitalization. This is accurate as moderate traumatic brain injuries can lead to various complications requiring close monitoring and treatment in a hospital setting to ensure patient safety and recovery.
B: A Glasgow Coma Scale score of 10 indicates a mild brain injury. A score of 10 reflects moderate impairment, not mild, thus suggesting significant neurological concerns that warrant further evaluation.
C: Only open loud injuries on cause in severe TBI. Severe traumatic brain injuries can arise from both open and closed injuries, making this statement overly restrictive and misleading about the nature of TBIs.
D: A client with a Glasgow Coma Scale score of 3 has severe TBI. While a score of 3 does indicate severe impairment, this option does not fully encompass the complexities of TBI classifications.
E: The terms mild TBI and concussion have similar meanings. While commonly used interchangeably, mild TBI and concussion have distinct definitions and implications regarding severity and treatment protocols in clinical practice.
Question 22
Multiple Choice
A nurse cares for older clients who have traumatic brain injury. What should be nurse understand about this population? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,C,D
Rationale
A client with a moderate brain injury, nursing mechanisms for older clients. Understanding that older adults often have unique needs and vulnerabilities is crucial for effective care in traumatic brain injury scenarios.
B: Alcohol is typically involved in more traumatic brain injuries for this age group. While substance use can impact injuries, it is not the primary concern for all older clients with TBI.
E: Very few traumatic brain injuries occur in this age group. Contrary to this statement, older adults frequently experience TBIs, particularly due to falls, making it a significant health issue.
Correct Answer: A,C,D
Rationale: A client with a moderate brain injury, nursing mechanisms for older clients. Understanding that older adults often have unique needs and vulnerabilities is crucial for effective care in traumatic brain injury scenarios.
B: Alcohol is typically involved in more traumatic brain injuries for this age group. While substance use can impact injuries, it is not the primary concern for all older clients with TBI.
E: Very few traumatic brain injuries occur in this age group. Contrary to this statement, older adults frequently experience TBIs, particularly due to falls, making it a significant health issue.
Question 23
Multiple Choice
A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (NAP) (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,B,C,D
Rationale
A cool washcloth on the head, assisting in positioning for comfort, softening voices, and maintaining low lighting are all appropriate comfort measures that NAP can perform for a meningitis patient.
A: Applying a cool washcloth to the head. This task involves basic hygiene and comfort, which NAP are trained to handle effectively without needing specialized nursing skills.
E: Providing antipyretics for fever. Administering medication requires nursing judgment and assessment, ensuring safe dosage and monitoring for potential side effects, which NAP are not qualified to perform.
Correct Answer: A,B,C,D
Rationale: A cool washcloth on the head, assisting in positioning for comfort, softening voices, and maintaining low lighting are all appropriate comfort measures that NAP can perform for a meningitis patient.
A: Applying a cool washcloth to the head. This task involves basic hygiene and comfort, which NAP are trained to handle effectively without needing specialized nursing skills.
E: Providing antipyretics for fever. Administering medication requires nursing judgment and assessment, ensuring safe dosage and monitoring for potential side effects, which NAP are not qualified to perform.
Question 24
Multiple Choice
A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,B,D,E
Rationale
Clients A, B, D, and E should be referred to a mental health provider on discharge due to their significant psychological or neurological needs that may affect their recovery and overall well-being.
A: Client with an initial neurological (all health) presents potential ongoing cognitive issues, warranting mental health support to address any emotional or psychological ramifications of their condition.
C: Client with mild forgetfulness and a slight limp may not demonstrate sufficient psychological distress or severe cognitive impairment requiring mental health intervention at this time.
D: Client who has a past hospitalization for all suicide attempt needs mental health support due to the history of suicidal behavior, indicating a high risk for future crises.
E: Client who is unable to wait or eat 1 week post-stroke indicates significant physical impairment but does not specifically denote psychological issues needing immediate mental health assessment.
Correct Answer: A,B,D,E
Rationale: Clients A, B, D, and E should be referred to a mental health provider on discharge due to their significant psychological or neurological needs that may affect their recovery and overall well-being.
A: Client with an initial neurological (all health) presents potential ongoing cognitive issues, warranting mental health support to address any emotional or psychological ramifications of their condition.
C: Client with mild forgetfulness and a slight limp may not demonstrate sufficient psychological distress or severe cognitive impairment requiring mental health intervention at this time.
D: Client who has a past hospitalization for all suicide attempt needs mental health support due to the history of suicidal behavior, indicating a high risk for future crises.
E: Client who is unable to wait or eat 1 week post-stroke indicates significant physical impairment but does not specifically denote psychological issues needing immediate mental health assessment.
Question 25
Multiple Choice
A client has a small-bore feeding tube (Dobboff tube) inserted for continuous external feedings while recovering from a traumatic serious injury. What actions should the nurse include to the clients care? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,B,C,D
Rationale
Assess tube placement per agency policy, keep the head of the bed elevated at least 30 degrees, and run continuous feedings on a feeding pump.
Correct Option Explanation: These actions are essential for ensuring the safety and effectiveness of feeding through a small-bore tube. Assessing tube placement prevents complications, elevating the head minimizes aspiration risk, and using a feeding pump ensures controlled delivery of nutrition.
C: Keep the head of the bed elevated at least 30 degrees. This option is repeated and emphasizes the importance of maintaining elevation to reduce aspiration risk during feedings.
E: Run continuous feedings on a feeding pump. This option reiterates the need for a feeding pump to provide consistent nutrition, which is crucial for a patient recovering from a significant injury.
Correct Answer: A,B,C,D
Rationale: Assess tube placement per agency policy, keep the head of the bed elevated at least 30 degrees, and run continuous feedings on a feeding pump.
Correct Option Explanation: These actions are essential for ensuring the safety and effectiveness of feeding through a small-bore tube. Assessing tube placement prevents complications, elevating the head minimizes aspiration risk, and using a feeding pump ensures controlled delivery of nutrition.
C: Keep the head of the bed elevated at least 30 degrees. This option is repeated and emphasizes the importance of maintaining elevation to reduce aspiration risk during feedings.
E: Run continuous feedings on a feeding pump. This option reiterates the need for a feeding pump to provide consistent nutrition, which is crucial for a patient recovering from a significant injury.
Question 26
Multiple Choice
A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,B
Rationale
Clients A and B require more teaching as they demonstrate misunderstandings about their conditions. Client A incorrectly believes there is no chance of recurrence, and Client B underestimates the importance of follow-up care after a surgical procedure.
C: Client who underwent a flow diversion procedure 3 months ago is correctly managing constipation, indicating understanding of post-operative care.
D: Client who underwent surgical aneurysm ligation seems to be aware of their health status, indicating no immediate need for additional education regarding travel plans.
Correct Answer: A,B
Rationale: Clients A and B require more teaching as they demonstrate misunderstandings about their conditions. Client A incorrectly believes there is no chance of recurrence, and Client B underestimates the importance of follow-up care after a surgical procedure.
C: Client who underwent a flow diversion procedure 3 months ago is correctly managing constipation, indicating understanding of post-operative care.
D: Client who underwent surgical aneurysm ligation seems to be aware of their health status, indicating no immediate need for additional education regarding travel plans.
Question 27
Multiple Choice
A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management (Select all that apply.)
Correct!
Incorrect
The correct answer is: B,D,E
Rationale
A: Does not want to purchase a thermometer
The client’s reluctance to buy a thermometer indicates a lack of willingness to monitor their health, which is crucial for self-management following a brain injury.
C: Laughing, says Sermous? (Whats that)
The client’s confusion suggests cognitive impairment, undermining their ability to understand self-management instructions crucial for their recovery process after the injury.
E: A client needs category: Physiological Integrity
This option does not represent a barrier to self-management; instead, it highlights the overall concern for the client's physiological state following the injury.
Correct Answer: B,D,E
Rationale: A: Does not want to purchase a thermometer
The client’s reluctance to buy a thermometer indicates a lack of willingness to monitor their health, which is crucial for self-management following a brain injury.
C: Laughing, says Sermous? (Whats that)
The client’s confusion suggests cognitive impairment, undermining their ability to understand self-management instructions crucial for their recovery process after the injury.
E: A client needs category: Physiological Integrity
This option does not represent a barrier to self-management; instead, it highlights the overall concern for the client's physiological state following the injury.
Question 28
Regular
A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activity (t-PA) alphaing (Activase). The client weight is 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) mg
Correct!
Incorrect
The correct answer is: A
Rationale
A: 90 mg
The client will receive 90 mg of t-PA based on their weight of 146 pounds. The standard dosing protocol for t-PA is 0.9 mg/kg, resulting in a total dose of 90 mg for this patient.
B: 100 mg
Calculating the t-PA dose based on weight, 100 mg exceeds the recommended 0.9 mg/kg calculation for a 146-pound client, indicating an overestimation of the dosage.
C: 80 mg
An 80 mg dosage falls short of the calculated requirement for a 146-pound patient, which should be closer to 90 mg according to the established dosing guidelines.
D: 110 mg
A dosage of 110 mg is an overcalculation for this patient's weight; the appropriate amount, derived from the weight-based formula, should be 90 mg, not exceeding that limit.
Correct Answer: A
Rationale: A: 90 mg
The client will receive 90 mg of t-PA based on their weight of 146 pounds. The standard dosing protocol for t-PA is 0.9 mg/kg, resulting in a total dose of 90 mg for this patient.
B: 100 mg
Calculating the t-PA dose based on weight, 100 mg exceeds the recommended 0.9 mg/kg calculation for a 146-pound client, indicating an overestimation of the dosage.
C: 80 mg
An 80 mg dosage falls short of the calculated requirement for a 146-pound patient, which should be closer to 90 mg according to the established dosing guidelines.
D: 110 mg
A dosage of 110 mg is an overcalculation for this patient's weight; the appropriate amount, derived from the weight-based formula, should be 90 mg, not exceeding that limit.
Question 29
Regular
A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-PA, at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.) mL/hr
Correct!
Incorrect
The correct answer is: B
Rationale
The IV pump should be set at 1.4 mL/hr. This rate is calculated based on the dosage guidelines for t-PA administration, which depend on the patient's weight and ensure safe and effective thrombolytic therapy.
A: 1.2 mL/hr This rate falls below the recommended dosage range for a patient weighing 225 pounds, potentially leading to suboptimal treatment outcomes during stroke management.
C: 1.6 mL/hr This dosage exceeds the appropriate administration rate for t-PA, risking complications and adverse effects that could arise from delivering too high a volume of the medication.
D: 1.8 mL/hr This rate is higher than the established guidelines, which could cause increased risk of bleeding or other serious side effects associated with t-PA therapy in stroke patients.
Correct Answer: B
Rationale: The IV pump should be set at 1.4 mL/hr. This rate is calculated based on the dosage guidelines for t-PA administration, which depend on the patient's weight and ensure safe and effective thrombolytic therapy.
A: 1.2 mL/hr This rate falls below the recommended dosage range for a patient weighing 225 pounds, potentially leading to suboptimal treatment outcomes during stroke management.
C: 1.6 mL/hr This dosage exceeds the appropriate administration rate for t-PA, risking complications and adverse effects that could arise from delivering too high a volume of the medication.
D: 1.8 mL/hr This rate is higher than the established guidelines, which could cause increased risk of bleeding or other serious side effects associated with t-PA therapy in stroke patients.
Quiz Complete!
Care of Critically Ill Patients with Neurologic Problems
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