I NEED ANSWERS TO THESE QUESTIONS. Head

I NEED ANSWERS TO THESE QUESTIONS. Head Injury 1. The client has sustained a traumatic brain injury (TBI) secondary to a motor vehicle accident. Which signs/symptoms would the emergency department (ED) nurse expect the client to exhibit? a. Blurred vision, nausea, and right-sided hemiparesis. b. Increased urinary output, negative Babinski, andptosis. c. Autonomic dysreflexia, positive Brudzinski, and hyperpyrexia. d. Negative dextrostik, nuchal rigidity, and nystagmus. 2. The intensive care nurse is caring for a client diagnosed with a closed head injury. Which data would warrant immediate intervention? a. The client refuses to cough and deep-breathe. b. The client’s Glasgow Coma Scale goes from 13 to 7. c. The client complains of a frontal headache. d. The client’s Mini-Mental Status Exam (MMSE) is 30. 3. The rehabilitation nurse is caring for the client with a closed head injury. Which cognitive goal would be most appropriate for this client? 1. The client will be able to feed himself/herself independently. 2. The client will attend therapy sessions 3 hours a day. 3. The client will interact appropriately with staff members. 4. The client will be able to stay on task for 15 minutes. 4. The intensive care nurse is caring for a client diagnosed with a TBI who is exhibiting decorticates posturing. Three hours later the client has flaccid posturing. Which action should the nurse implement first? 1. Notify the client’s health-care provider (HCP) immediately. 2. Prepare to administer mannitol (Osmitrol), an osmotic diuretic. 3. do a thorough neurological assessment on the client. 4. Reassess the client in 1 hour, including calculating the Glasgow Coma Scale. 5. The emergency department nurse is entering the room of a client who was at a baseball game and was hit in the head with a bat. Which intervention should the nurse implement first? 1. Assess the client’s orientation to date, time, and place. 2. Ask the client to squeeze the nurse’s fingers. 3. Determine the client’s reaction to the door opening. 4. Request the client to move his lower legs. 6. The nurse is preparing the client diagnosed with a head injury for a magnetic resonance imaging (MRI). Which interventions should the nurse implement? Select all that apply. 1. Ask the client if he/she is claustrophobic. 2. Have the client sign a procedural permit. 3. Determine if the client is allergic to shellfish. 4. Check if the client has any prosthetic devices. 5. Ask the client to empty his/her bladder. 7. The client with increased intracranial pressure is receiving mannitol (Osmitrol), an osmotic diuretic. Which intervention should the nurse implement? 1. Monitor the client’s complete blood cell (CBC) count. 2. Do not administer the drug if the client’s apical pulse is less than 60. 3. Ensure that the client’s cardiac status is monitored by telemetry. 4. Use a filter needle when administering the medication. 8. The male client is being discharged from the ED after sustaining a minor head injury. Which statement indicates the wife understands the discharge teaching? 1. “My husband will be hard to wake up for a couple of days.” 2. “He doesn’t need any pain medication because have some at home.” 3. “I should not give my husband anything to eat or drink for 12 hours.” 4. “I will bring my husband back to the emergency room if he starts vomiting.” 9. The nurse is discussing the TBI Act at a support group meeting. Which statement best explains the act? 1. It is a federal act that provides public policy regarding community living for clients with a TBI. 2. It ensures that all public buildings must have access for physically challenged clients. 3. This act ensures that all clients with a TBI have access to rehabilitation services. 4. It is a national policy that establishes guidelines for neurological rehabilitation centers. 10. The nurse is caring for a female client who sustained a closed head injury 8 days ago due to a motor vehicle accident. Which signs/symptoms would alert the nurse to a complication of the head injury? 1. The client reports having trouble sleeping due to having nightmares about the wreck. 2. The client tells the nurse she has a stuffy nose and green nasal drainage. 3. The client complains of extreme thirst and has an increased urine output. 4. The client informs the nurse that she has started her menstrual period. SPINAL CORD INJURY 11. Which clinical manifestation would the nurse assess in the client with a T-12 spinal cord injury (SCI) who is experiencing spinal shock? 1. Flaccid paralysis below the waist. 2. Lower extremity spasticity. 3. Complaints of a pounding headache. 4. Hypertension and bradycardia. 12. The nurse is caring for a client who has a C-6 vertebral fracture and is using Crutchfield tongs with 2-pound weights. Which data would the nurse expect the client to exhibit? 1. The client is on controlled mechanical ventilation at 12 respirations a minute. 2. The client has no movement of the lower extremities. 3. The client has 2ï€«ï€ deep tendon reflexes in the lower extremities. 4. The client has loss of sensation below the C-6 vertebral fracture. 13. The rehabilitation nurse caring for the young client with a T-12 SCI is developing the nursing care plan. Which priority intervention should the nurse implement? 1. Monitor the client’s indwelling urinary catheter. 2. Insert a rectal stimulant at the same time every morning. 3. Encourage active lower extremity range of motion (ROM) exercises. 4. Refer the client to a vocational training assistance program. 14. The nurse is caring for a client with a C-6 SCI in the neurological intensive care unit. Which nursing intervention should be implemented? 1. Monitor the client’s heparin drip. 2. Assess the neurological status every shift. 3. Maintain the client’s ice saline infusion. 4. Administer corticosteroids intrathecally. 15. The male client with a C-6 SCI tells the home health nurse he has had a severe pounding headache for the last 2 hours. Which intervention should the clinic nurse implement? 1. Determine when and how much the client last urinated. 2. Ask the client if he has taken any medication for the headache. 3. Inquire when the client had his last bowel movement. 4. Check the client’s respiratory rate reading immediately. 16. The client with a T-1 SCI complains of lightheadedness and dizziness when the head of the bed is elevated. The client’s B/P is 84/40. Which action should the nurse implement first? 1. Increase the client’s intravenous (IV) rate by 50 mL/hr. 2. Administer dopamine, a vasopressor, via an IV pump. 3. Notify the HCP immediately. 4. Lower the client’s head of bed immediately. 17. The nurse caring for a client with a C-6 SCI determines the client has no plantar reflexes. Which area on the stick figure should the nurse document this finding? 18. The nurse on the rehabilitation unit is caring for the following clients with SCIs. Which client should the nurse assess first after receiving the change-of-shift report? 1. The client with a C-6 SCI who has a warm, reddened edematous gastrocnemius muscle. 2. The client with an L-4 SCI who is concerned about being able to live independently. 3. The client with an L-2 SCI who is complaining of a headache and nausea. 4. The client with a T-4 SCI who is unable to move the lower extremities. 19. The nurse is caring for clients on a rehabilitation unit. Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Ask the UAP to hold the urinal while the client performs the Credé maneuver. 2. Discuss the proper method of administering tube feedings to the family member. 3. Assist with bowel training by inserting a suppository into the client’s rectum. 4. Observe the client demonstrating self-catheterization technique. 20. The 25-year-old client with an SCI is sharing with the nurse that he is worried about how his family will be able to survive financially until he can go back to work. Which intervention should the nurse implement? 1. Refer the client to the American Spinal Injury Association. 2. Refer the client to the state rehabilitation commission. 3. Refer the client to the social worker about applying for disability. 4. Refer the client to an occupational therapist for life skills training. SEIZURES 21. The nurse walks into the room and notes the male client is lying supine, and the entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? 1. Loosen constrictive clothing. 2. Place padding on the side rails. 3. Assess the client’s vital signs. 4. Turn the client on his side. 22. The client newly diagnosed with epilepsy who works in an office asks the nurse, “What can I do to prevent having seizures?” Which statement is the nurse’s best response? 1. “I recommend getting about 4 hours of sleep a night.” 2. “Ask your supervisor to have someone else make copies.” 3. “Request your employer to provide a work area with dim lighting.” 4. “You should get your serum blood level checked every month.” 23. The nurse observes a client having a tonic-clonic seizure. Which information should the nurse document in the client’s chart? Select all that apply. 1. Determine if the client is incontinent of urine or stool. 2. Document the client had privacy during the seizure. 3. Note the time and where the movement or stiffness began. 4. Note the circumstances before the client’s seizure activity began. 5. Note the results of a complete neurological assessment. 24. The UAP is holding the arms of a client who is having a tonic-clonic seizure. Which action should the nurse implement? 1. Help the UAP restrain the client’s upper extremities. 2. Instruct the UAP to release the client’s arms immediately. 3. Take no action because the assistant is handling the situation. 4. Notify the charge nurse of the situation immediately. 25. The client diagnosed with a seizure disorder is prescribed phenytoin (Dilantin), an anticonvulsant. Which statement indicates the client needs more teaching concerning this medication? 1. “I will brush my teeth after every meal.” 2. “I will get my Dilantin level checked regularly.” 3. “My urine will turn orange while on Dilantin.” 4. “This medication will help prevent my seizures.” 26. The client is admitted to the intensive care unit (ICU) experiencing status epilepiticus. Which intervention should the nurse anticipate implementing first? 1. Assess the client’s neurological status frequently. 2. Monitor the client’s heart rhythm via telemetry. 3. Administer diazepam (Valium), a benzodiazepine. 4. Prepare to administer anticonvulsant medication. 27. The client is admitted to the ED after experiencing a partial seizure. Which would be most appropriate the nurse to ask the client? 1. “Do you know if you lost consciousness during the seizure?” 2. “Are you feeling sleepy or very tired at this time?” 3. “When did you last take your seizure medication?” 4. “Were you feeling jittery or irritable prior to the seizure?” 28. Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? 1. “I should not take birth control pills to prevent pregnancy.” 2. “I need to limit my intake of dairy products.” 3. “I should not participate in any contact sports.” 4. “My menstrual cycle may affect my seizure disorder.” 29. The clinic nurse is checking diagnostic test results. Which diagnostic test result would warrant notifying the client immediately? 1. The female client who is taking an anticonvulsant who has a low bone density scan. 2. The client who is diagnosed with epilepsy who has a phenytoin (Dilantin) level of 28 mcg/dL. 3. The client with a seizure disorder who has a carbamazepine (Tegretol) of 10 mcg/mL. 4. The client who has partial seizures who has a serum sodium level of 143 mEq/L. 30. The mother of a child who had a febrile seizure tells the pediatric clinic nurse, “I am so upset because now my child has epilepsy.” Which statement is the clinic nurse’s best response? 1. “Your child had a seizure due to a high fever, not due to epilepsy.” 2. “You are upset about your child having epilepsy. Let’s talk.” 3. “The Epilepsy Foundation of America provides good information.” 4. “I would recommend you attend the local epilepsy support group.” CEREBROVASCULAR ACCIDENT (STROKE, BRAIN ATTACK) 31. The 88-year-old client is admitted to the ED with numbness and weakness of the left arm and slurred speech. The computed tomography (CT) scan was negative for bleeding. Which nursing intervention is priority? 1. Prepare to administer tissue plasminogen activator (TPA). 2. Discuss the precipitating factors that caused the symptoms. 3. Determine the exact time the symptoms occurred. 4. Notify the speech pathologist for an emergency consult. 32. The nurse is assessing the client experiencing a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse expect the client to exhibit? 1. Hemiparesis of the left arm and apraxia. 2. Paralysis of the right side of the body and aphasia. 3. Inability to recognize and use familiar objects. 4. Impulsive behavior and hostility toward family. 33. The HCP has discussed a carotid endarterectomy with the client who has experienced two transient ischemic attacks (TIAs). The client tells the nurse, “I really don’t understand why I need this procedure, and I don’t want to have it.” Which scientific rationale would support the nurse’s response? 1. This surgery is indicated for clients with symptoms of a TIA due to carotid artery stenosis. 2. This surgical procedure will ensure the client does not have a cerebrovascular accident. 3. This surgery will remove all atherosclerotic plaque from the carotid arteries. 4. This surgical procedure will increase the elasticity of the carotid arterial wall. 34. Which client would the nurse identify as being least at risk for experiencing a CVA? 1. A 55 year-old African-American male who is obese. 2. A 73-year-old Japanese female who has essential hypertension. 3. A 67-year-old Caucasian male whose cholesterol level is below 200 mg/dL. 4. A 39-year-old female who is taking oral contraceptives. 35. The client diagnosed with a right-sided CVA is admitted to the rehabilitation unit. Which intervention should be included in the nursing care plan? 1. Turn and reposition the client every shift. 2. Place a small pillow under the client’s left shoulder. 3. Have the client perform quadriceps exercises three times a day. 4. Instruct the client to hold fingers in a fist. 36. The nurse is planning care for the client experiencing dysphagia secondary to a CVA. Which intervention should be included in the plan of care? 1. Evaluate the client during mealtime. 2. Position the client in a semi-Fowler position. 3. Administer oxygen during meals. 4. Refer the client to a physical therapist. 37. The nurse and a UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The UAP places the gait belt under the client’s axilla prior to ambulating. 2. The UAP places the client on the abdomen with the client’s head to the side. 3. The UAP uses a lift sheet when moving the client up in the bed. 4. The UAP praises the client for attempting to perform activities of daily life (ADLs) independently. 38. The client diagnosed with chronic atrial fibrillation has experienced a transient TIA. Which discharge instruction should the nurse implement? 1. Keep nitroglycerin tablets in a dark-colored bottle. 2. Check the radial pulse prior to all medications. 3. Obtain International Normalized Ratio (INR) routinely. 4. Take over-the-counter vitamin K tablets daily. 39. The client diagnosed with a CVA has hemiparesis. Which problem would be priority for the client? 1. Impaired skin integrity. 2. Fluid volume overload. 3. High risk for aspiration. 4. High risk for injury. 40. The nurse has received the morning shift report. Which client should the nurse assess first? 1. The client who is complaining of a headache at a 3 on a scale of 1-10. 2. The client who has an apical pulse of 56 and a blood pressure of 210/116. 3. The client who is reporting not having a bowel movement in 3 days. 4. The client who is angry because the call light was not for 1 hour. BRAIN TUMORS 41. The client is being admitted with rule-out (R/O) brain tumor. Which signs/symptoms support the diagnosis of a brain tumor? l 1. Widening pulse pressure, hypertension, and bradycardia. l 2. Headache, vomiting, and diplopia. l 3. Hypotension, tachycardia, and tachypnea. l 4. Abrupt loss of motor function, diarrhea, and changes in taste. 42. The client is diagnosed with a frontal lobe brain tumor. Which sign/symptom would the nurse expect the client to exhibit? l 1. Ataxia. l 2. Decreased visual acuity. l 3. Scanning speech. l 4. Personality changes. 43. The male client diagnosed with a brain tumor is having a closed magnetic resonance imaging (MRI) scan in 1 hour. The client tells the radiology nurse, “I don’t like small enclosed spaces.” Which action should the nurse implement? l 1. Allow the client to express his feelings. l 2. Discuss the procedure with the client. l 3. Obtain an order for an anti-anxiety medication. l 4. Reschedule the procedure for another day. 44. The client diagnosed with lung cancer has developed metastasis to the brain. Which problem would be priority for this client? l 1. Anticipatory grieving. l 2. Impaired gas exchange. l 3. Altered nutritional status. l 4. Alteration in comfort. 45. The client diagnosed with a brain tumor was admitted to the ICU with decorticate posturing. Which indicates that the client’s condition is improving? l 1. The client has purposeful movement with painful stimuli. l 2. The client assumes adduction of the upper extremities. l 3. The client assumes the decerebrate posture upon painful stimuli. l 4. The client has become flaccid and does not respond to stimuli. 46. The intensive care nurse is caring for a client following an infratentorial craniotomy. Which interventions should the nurse implement? Select all that apply. l 1. Keep the head of the bed elevated at 30 degrees. l 2. Keep a humidifier in the client’s room. l 3. Do not put anything in the client’s mouth. l 4. Provide the client with a clear liquid diet. l 5. Assess the client’s respiratory status every hour. 47. The client is diagnosed with a pituitary tumor and is scheduled for a transsphenoidal hypophysectomy. Which postoperative instruction is important to discuss with the client? l 1. Demonstrate to a family member how to change a turban dressing. l 2. Explain to the client how to monitor urine output at home. l 3. Tell the client not to blow his nose for 2 weeks after surgery. l 4. Tell the client he will have to lie flat for 24 hours following the surgery. 48. The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery? l 1. The client complains of a headache at a 3-4 on a 1-10 scale. l 2. The client has a urinary output of 250 mL over the last 24 hours. l 3. The client has a serum sodium level of 137 mEq/L. l 4. The client experiences dizziness when trying to get up too quickly. 49. The client diagnosed with a brain tumor is prescribed intravenous dexamethasone (Decadron), a steroid. Which intervention should the nurse implement when administering this medication? l 1. Administer medication with normal saline only. l 2. Check the client’s white blood cell (WBC) count. l 3. Determine if the client has oral candidiasis. l 4. Monitor the client’s glucose level. 50. The male client is scheduled for gamma knife stereotactic surgery for a brain tumor. Which preoperative instruction should the nurse discuss with the client? l 1. Instruct the client to avoid bright lights and wear sunscreen. l 2. Tell the client he must sleep with the head of the bed elevated. l 3. Explain there are no activity limitations after this procedure. l 4. Encourage the client to take off at least 2 weeks from work. Meningitis 51. The nurse is assessing the client diagnosed with bacterial meningitis. In addition to nuchal rigidity, which clinical manifestations would the nurse assess? l 1. Positive Cushing sign and ascending paralysis. l 2. Negative Kernig sign and facial tingling. l 3. Positive Brudzinski sign and photophobia. l 4. Negative Trousseau sign and descending paralysis. 52. The nurse is admitting a client diagnosed with meningococcal meningitis and notes lesions over the face and extremities. Which priority intervention should the nurse implement? l 1. Initiate the intravenous antibiotics stat. l 2. Obtain a skin biopsy for culture and sensitivity. l 3. Perform a complete neurological assessment. l 4. Close all the curtains in the room and turn off lights. SECTION ONE Neurological Disorders 31 53. Which type of precautions should the nurse implement for the client diagnosed with aseptic meningitis? 1. Standard precautions. 2. Airborne precautions. 3. Contact precautions. 4. Droplet precautions. 54. A college student came to the university health clinic and was diagnosed with bacterial meningitis and admitted to a local hospital. Which intervention should the university health clinic nurse implement? 1. Place the client’s dormitory under strict respiratory isolation. 2. Notify the parents of all students about the meningitis outbreak. 3. Arrange for students to receive the meningococcal vaccination. 4. Ensure dormitory roommates receive chemoprophylaxis using rifampin. 55. The nurse is preparing for a lumbar puncture for the client diagnosed with R/O meningitis. Which interventions should the nurse implement? Select all that apply. 1. Determine if the client has any allergies to iodine. 2. Do not let the client urinate 2 hours before the procedure. 3. Place the client in a prone position with the face turned to the side. 4. Instruct the client to take slow deep breaths during the procedure. 5. Label the specimen and send to the laboratory for cultures. 56. The client diagnosed with septic meningitis is admitted to the medical floor at 1200. Which HCP’s order would the nurse implement first? 1. Administer intravenous antibiotic. 2. Start the client’s intravenous line. 3. Provide a quiet, calm dark room. 4. Initiate seizure precautions. 57. The nurse asks the UAP to help admit the client diagnosed with bacterial meningitis. Which nursing task is priority? 1. Take the client’s vital signs. 2. Obtain the client’s height and weight. 3. Prepare the room for respiratory isolation. 4. Pull the drapes and make sure the room is dim. 58. The 18-year-old client is admitted to the medical floor with a diagnosis of meningitis. Which priority intervention should the nurse assess? 1. Assess the client’s neurovascular status. 2. Assess the client’s cranial nerve IX function. 3. Assess the client’s brachioradialis reflex. 4. Assess the client’s neurological status. 59. The nurse is developing a plan of care for a client diagnosed with septic meningitis. Which client goal would be most appropriate for the client problem of “altered thermoregulation”? 1. The client will have no injury from using the hypothermia blanket. 2. The client will be protected from injury if seizure activity occurs. 3. The client will be afebrile for 48 hours prior to discharge. 4. The client will have serum electrolytes within normal limits. 60. The nurse is admitting a client diagnosed with meningitis who has AIDS. Which signs/symptoms would the nurse expect the client to exhibit? 1. A positive Babinski sign. 2. Diplopia and blurred vision. 3. Auditory deficits. 4. The client may be asymptomatic.

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