uworld NCLEX Questions

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110 terms kandykat1012Preview Neuro/Spinal Cord Injury 27 terms lauren_baillyPreview NCLEX 423 term em The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

• Increasing temperature, increasing pulse, increasing

respirations, decreasing blood pressure

• Increasing temperature, decreasing pulse, decreasing

respirations, decreasing blood pressure

• Decreasing temperature, decreasing pulse, increasing

respirations, decreasing blood pressure

• Decreasing temperature, increasing pulse, decreasing

respirations, increasing blood pressure

• Increasing temperature, decreasing pulse, decreasing respirations, increasing

blood pressure 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 occur.The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply.

• Encourage the client to cough to expectorate

secretions.

• Elevate the head of the bed 15 - 20 degrees.
• Contact the HCP if ICP is >15 mmHg.
• Monitor neurologic status using the Glasgow Coma

Scale.

• Stimulate the client with active range-of-motion

exercises.

2, 3, 4

The nurse should maintain ICP by elevating the head of the bed 15 - 20 degrees and monitoring neurologic status. An ICP >15 mmHg with 20 to 25 mmHg as upper limits of normal indicates increased ICP, and the nurse should notify the HCP.Coughing and range of motion exercises will increase ICP and should be avoided in the early postoperative stage.

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

• Compress the nares
• Tilt the head back
• Collect the drainage
• Administer an antihistamine for postnasal drip

3 The clear drainage must be analyzed to determine whether it is nasal drainage or CSF. The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

• Fluid is clear and tests negative for glucose.
• Fluid is grossly blood in appearance and has a pH of 6
• Fluid clumps together on the dressing and had a pH of

7 Fluid separates into concentric rings and tests positive for glucose.4 Leakage of cerebrospinal fluid from the ears or nose may accompany basilar skull fractures. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke. Which characteristics are associated with this condition? Select all that apply.

• The client is aphasic.
• The client has weakness on the right side of the body.
• The client has complete bilateral paralysis of the arms

and legs.

• The client has weakness on the right side of the face

and tongue.

• The client has lost the ability to move the right arm but

is able to walk independently

• The client has lost the ability to ambulate

independently, but is able to feed and bathe himself or herself without assistance.

1, 2, 4

Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautions and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.The nurse has instructed the family of a client with stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understand the measures to use when caring for the client?

• We need to discourage him from wearing eyeglasses.
• We need to place objects in his impaired field of vision.
• We need to approach him from the impaired field of

vision.

• We need to remind him to turn his head to scan the

lost visual field.4 Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

What is the expected outcome of thrombolytic drug therapy for stroke?

• Increased vascular permeability
• Vasoconstriction
• Dissolved emboli
• Prevention of hemorrhage

3 Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, this reastablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.

• Maintain a patent airway.
• Record the seizure activity observed.
• Ease the client to the floor.
• Obtain vital signs.

3, 1, 4, 2

To protect the client from falling, the nurse first should ease the client to the floor.It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded.The nurse is instituting seizure precautions for a client who is being admitted from the emergency department.Which measures should the nurse include in planning for the client's safety? Select all that apply.

• Padding the side rails of the bed.
• Placing an airway at the bedside.
• Placing the bed in the high position
• Putting a padded tongue blade at the head of the bed
• Placing oxygen and suction equipment at the bedside
• Flushing the intravenous catheter to ensure that the site

is patent.

1, 2, 5, 6

Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking the patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity.Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively?

• Head of bed flat, head and neck midline.
• Head of bed flat, head turned to the nonoperative side
• Head of bed elevated 30 to 45 degrees, head and

neck midline

• Head of bed elevated 30 to 45 degrees, head turned

to the operative side 3 After a supratentorial surgery, the head is kept at a 30-45 degree angle. The head and neck should not be angled either anteriorly or laterally but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what action first?

• Check for Kernig's and Brudzinski's signs
• Establish IV access
• Place the client on droplet precautions
• Prepare the client for lumbar puncture
• Place the client on droplet precautions.

The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative agent has been identified and appropriate treatment is initiated. Meningococcal meningitis and Haemophilus influenzae type B meningitis are highly transmissible to others, and the client must remain on droplet isolation until these can be ruled out. Precautions can usually be discontinued 24 hours after beginning antibiotic therapy. Viral meningitis and other types of bacterial meningitis (ie, other than meningococcal meningitis) usually do not require droplet precautions.(Option 1) Although assessment is a priority and meningeal signs should be checked, the nurse can only safely perform these assessments once droplet precautions are in place.(Options 2 and 4) A peripheral IV catheter should be inserted to provide fluids.Subsequently, preparation for lumbar puncture is needed. However, placing the client on isolation is a priority to protect the nurse and other clients and care providers.

Educational objective:

The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative agent has been identified and appropriate treatment is initiated.Four children are brought to the emergency department.Which child should be assessed first?

• A 13-month-old who ingested an unknown quantity of

children's multivitamins

• A 15-month-old with a fever of 100.5 F (38.1 C) after

being vaccinated

• A 3-year-old with a forehead laceration and colorless

nasal drainage

• A 4-year-old with enlarged tonsillar lymph nodes who

is crying in pain 3 Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF) leakage (Option 3). When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose.This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in level of consciousness and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics.(Option 1) Iron ingestion is the major concern with vitamin toxicity in children.However, children's formulations contain minimal or no iron. As a result, ingestion of an unknown quantity is unlikely to cause serious toxicity. This child should be seen second.(Option 2) A low-grade fever is common after immunizations; this child can be seen last.(Option 4) Although infection and pain are important, this child can be seen third.

Educational objective:

The child with head trauma who is leaking cerebrospinal fluid (CSF) is at risk for meningitis and intracerebral bleeding. If the drainage is clear, a dextrose test is used to determine if the drainage is CSF. The nurse should assess for signs of bleeding (eg, change in level of consciousness) and infection (eg, increased temperature) and anticipate a CT scan and prophylactic antibiotics.