NCLEX-style questions: Intracranial regulation

NCLEX-style questions: Intracranial regulation

Leave the first rating Students also studied Terms in this set (20) Collin County Community College DistrictRNSG 1216 Save ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview Seizures NCLEX 12 terms murkacatPreview ICP/head injury NCLEX style questio...50 terms Alix_VanderWiele Preview Spinal C 53 terms Ma What pathophysiological changes should the nurse expect to see in a client with increased intracranial​ pressure?

• Removal of fluid from interstitial spaces reducing

excess body fluid

• Transmission of sensory and motor impulses to the

cerebrum for interpretation

• Alteration of electrical discharges in the brain to cause

involuntary movement

• An oxygen deficit that leads to changes in​ personality,

memory, and judgment

• An oxygen deficit that leads to changes in​ personality, memory, and judgment

The nurse assesses a client -admitted​ post-head trauma and notes small reactive​ pupils, an intact oculocephalic​ reflex, decorticate​ posturing, and respirations. The nurse should suspect that damage has progressed to which area of the​ brain?

• Midbrain
• Diencephalon
• Pons
• Medulla
• Diencephalon

The nurse is reviewing the intracranial pressure​ (ICP) readings for a child with a brain tumor. Which reading should the nurse interpret as normal for the​ child?

• 12 mmHg
• 3 mmHg
• 8 mmHg
• 1 mmHg
• 3 mmHg

The nurse is providing a​ community-based teaching course to a group of high school parents concerning brain injury. Which participant statement indicates accurate understanding of the population most at risk for traumatic brain injury​ (TBI)?

• ​"TBIs most commonly occur in men between the ages

of 18 and 25 years of​ age."

• ​"TBIs are common across the​ lifespan, affecting men

and women fairly​ equally."

• ​"They are most common in the very young ​ (0 -4 ​years)

or old​ (65 years and​ above)."

• ​"Due to their age and the high number of falls and​

injuries, toddlers and children have higher levels of​ TBIs."

• ​"They are most common in the very young ​ (0 -4 ​years) or old​ (65 years and​

above)." The nurse is providing discharge teaching to an older adult. Which information should the nurse include in the session to help the older adult avoid development of​ IICP?

• ​"With any early signs of​ infection, be sure to call your

healthcare​ provider."

• ​"Make sure to use your walker as we​ discussed."
• ​"Be sure to check your blood sugar more frequently

than previously to manage your​ diabetes."

• ​"You should stop driving and exchange your license

for a​ non-driver identification​ card."

• ​"Make sure to use your walker as we​ discussed."

A client with a minor head injury has a Glasgow Coma Scale score of 15 out of 15. What does this score indicate to the​ nurse? (Select all that​ apply.)

• Client withdraws to touch.
• Client uses appropriate words and phrases.
• Client spontaneously opens the eyes.
• Client is oriented to​ person, place, and time.
• Client withdraws to pain.
• Client uses appropriate words and phrases.
• Client spontaneously opens the eyes.
• Client is oriented to​ person, place, and time.

The nurse is preparing to conduct a neurologic assessment interview with a client. Which general question should the nurse ask when conducting this​ assessment? (Select all that​ apply.)

• ​"Are you having any problems with your​ memory?"
• ​"Do you have any problems with balance or​

coordination?"

• ​"Are you experiencing any​ pain?"
• ​"How many fingers am I holding up at this​ time?"
• ​"Do you have a history of seizures or​ fainting?"
• ​"Are you having any problems with your​ memory?"
• ​"Do you have any problems with balance or​ coordination?"
• ​"Are you experiencing any​ pain?"
• ​"Do you have a history of seizures or​ fainting?"

The nurse notes that a client has muscle fasciculations of both bicep muscles. Which additional information should the nurse​ assess? (Select all that​ apply.)

• Urine output
• Last solid food intake
• Blood pressure and pulse
• Body temperature
• List of medications taken
• Urine output
• Body temperature
• List of medications taken

The nurse is caring for a client with an altered level of consciousness. To assess the level of​ consciousness, the nurse administers the Glasgow Coma Scale. Which response does this scale​ measure? (Select all that​ apply.)

• Cerebellar function
• Eye opening
• Verbal response
• Corneal reflex
• Motor response
• Eye opening
• Verbal response
• Motor response

During a neurologic assessment of a​ client, the nurse received an affirmative response to the​ question, "Have you ever been diagnosed with a neurologic​ illness?" Which​ follow-up question would be most important for the nurse to ask this​ client?

• ​"Are you experiencing​ pain?"
• ​"When was your last blood work​ done?"
• ​"What helped the​ problem? What made it​ worse?"
• ​"Do you have noticeable​ tremors? Do you feel you are​

clumsier

• ​"What helped the​ problem? What made it​ worse?"

A client with a traumatic brain injury is intubated and placed on mechanical ventilation. Which measurement should the nurse use to evaluate the effectiveness of these respiratory​ interventions?

• Glasgow Coma Scale score
• Cranial nerve function
• Arterial blood gas results
• Motor and sensory function
• Arterial blood gas results

The nurse is assessing a client with a recent head injury.Upon previous​ assessment, the​ client's vital signs were blood pressure​ 140/90 mmHg, pulse 74​ beats/min, and respirations 22​ breaths/min and irregular. Upon this​ assessment, the nurse notes a blood pressure of​ 152/70 mmHg, pulse of 48​ beats/min, and more irregular respirations. Which condition does the nurse suspect is​ occurring?

• Cushing triad
• Autonomic dysreflexia
• Decreasing intracranial pressure​ (ICP)
• Epidural hematoma
• Cushing triad

The nurse is caring for a client with increased intracranial pressure secondary to a brain tumor. Which position should the nurse place the client in to help decrease intracranial​ pressure?

• ​Semi-Fowler
• Left lateral recumbent
• Fowler
• High Fowler
• ​Semi-Fowler

Which intervention should the nurse initiate secondary to a change in level of consciousness​ (LOC) for a client experiencing increased intracranial pressure​ (IICP)?(Select all that​ apply.)

• Maintain the head of the bed at 30 degrees
• Assess​ LOC, pupillary​ response, and neurologic status
• Encourage family to visit and keep client engaged in

normal activities as possible

• Implement deep vein thrombosis prophylaxis
• Monitor​ ICP/cerebral perfusion pres
• Maintain the head of the bed at 30 degrees
• Assess​ LOC, pupillary​ response, and neurologic status
• Implement deep vein thrombosis prophylaxis
• Monitor​ ICP/cerebral perfusion pres

The nurse is monitoring a client with increased intracranial pressure who is experiencing status epilepticus. Which intervention has the highest priority for this​ client?

• Establishing and maintaining an airway
• Administering a solution of​ 50% dextrose
• Administering diazepam intravenously
• Contacting the provider for orders
• Establishing and maintaining an airway

A client with increased intracranial pressure​ (IICP) is also hyponatremic. Which intravenous medication should the nurse anticipate administering to address fluid​ removal?

• Osmotic diuretic
• Antiepileptic
• Corticosteroid
• Proton pump inhibitor
• Osmotic diuretic

​Rationale: Osmotic diuretics are used in clients with IICP to promote water

excretion and to address hyponatremia The nurse is discussing the multiple medications with the family of a client diagnosed with increased intracranial pressure​ (IICP). The family member asks why the client is being given a gastric acid reducer. Which response by the nurse provides the correct ​explanation?

• ​"We use a gastric acid reducer to adhere to ulcer sites

and protect them from​ acids, bile​ salts, and​ enzymes."

• ​"Since they are not​ eating, we use a gastric acid

reducer to neutralize the acid in their​ stomach."

• ​"A gastric acid reducer helps to protect the inner lining

of the stomach from​ ulcer-producing effects."

• ​"There is a higher risk for stress​ ulcers; therefore, we

use an acid reducer to block gastric​ secretion."

• ​"There is a higher risk for stress​ ulcers; therefore, we use an acid reducer to

block gastric​ secretion." When caring for an older adult experiencing problems with intracranial​ regulation, which change noted by the nurse during care would be attributed to normal​ age- associated changes versus those indicative of issues requiring​ attention? (Select all that​ apply.)

• Some decline in mental status
• Alterations in​ long-term memory
• Slower fine finger movements
• Slower impulse transmission and reaction to stimuli
• Decreased perception of temperature sensation
• Slower fine finger movements
• Slower impulse transmission and reaction to stimuli
• Decreased perception of temperature sensation