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Q 1/19
Score 0
The nurse is caring for a client immediately after receiving a craniotomy with an incision over the middle fossa and notes the client is in a supine position? Which of the following actions would be most appropriate for the nurse to take?
300
Apply pressure to the wound and lower the head of the bed
Head needs to be elevated 30-40 degrees, complete an incident report
Suction any clear drainage from the nares
Administer oral opioids to the client for pain
Q 2/19
Score 0
The nurse is caring for a client with increased intracranial pressure (ICP). The client has a nursing diagnosis of Ineffective cerebral tissue perfusion. Which of the following would be an expected outcome for this client?
300
Obeys commands with appropriate motor responses
Is able to ambulate 600 feet
Has no reports of headache
The client has no nausea or vomiting for a 3 to four hours after injury occurred.
19 questions
Q.
The nurse is caring for a client immediately after receiving a craniotomy with an incision over the middle fossa and notes the client is in a supine position? Which of the following actions would be most appropriate for the nurse to take?
1
300 sec
Q.
The nurse is caring for a client with increased intracranial pressure (ICP). The client has a nursing diagnosis of Ineffective cerebral tissue perfusion. Which of the following would be an expected outcome for this client?
2
300 sec
Q.
The nurse is caring for a client with increased intracranial pressure (ICP). The nurse observes the client’s urine output from the indwelling urethral catheter to be 1,500 milliliters for the last 2 hours. Which of the following should the nurse suspect the client is experiencing?
3
300 sec
Q.
The nurse is caring for a client with a traumatic brain injury (TBI) following a fall. Which of the following medications should the nurse anticipate being prescribed for the client to reduce cerebral edema?
4
300 sec
Q.
The nurse is caring for a client with increased intracranial pressure (ICP) who has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following prescribed interventions should the nurse implement?
5
300 sec
Q.
The nurse is caring for a client that has a ventriculostomy for monitoring increased intracranial pressure (ICP). Which of the following would indicate to the nurse that the client is experiencing a complication of the ventriculostomy?
6
300 sec
Q.
The nurse is admitting a 16-year-old client who returned home early from summer camp with fever, severe headache, and vomiting. Which of the following prescribed interventions should the nurse implement first?
7
300 sec
Q.
The nurse is caring for a client who has been diagnosed with acute subdural hematoma after falling at home. Which of the following findings should indicate to the nurse that the client is experiencing a complication?
8
300 sec
Q.
In outpatient clinic. Assessing client's risk for ischemic stroke. What conditions add to their risk? A. Diabetes mellitus
B. Atrial Fibrillation
C. Carotid stenosis D. vegan diet E. epilepsy
9
300 sec
Q.
The nurse is caring for a client who has aphasia following a stroke. Which of the following would facilitate communication with the client? A. Ask questions the patient can answer with one word
B. Decrease environmental stimuli C. Speaking loudly D. Using repetitive hand gestures
10
300 sec
Q.
The nurse on the neurological care unit is talking with the spouse of a client who had an ischemic stroke and is having an echocardiogram. The family member says, “I do not understand why the heart is being tested when a stroke affects the brain.” Which of the following responses should the nurse make?
11
300 sec
Q.
The nurse is planning care for a client who has homonymous hemianopsia following a right hemispheric stroke. Which of the following interventions should the nurse include in the client’s plan of care?
12
300 sec
Q.
The nurse is caring for a client who had a right hemispheric stroke and has been evaluated by the speech therapist. The client has motor and visual deficits. During the client’s first meal, since having a stroke, which of the following actions should the nurse take?
13
300 sec
Q.
The nurse has provided information about urinary elimination to the spouse of a client who recently had a stroke. Which of the following statements by the client’s spouse would require follow-up by the nurse? A. Limit fluid intake after 7PM
B. Encourage bladder emptying Q2H
C. It's best to have elastic waists
D. Use bedpan at night and set spouse upright E. Initiate a foley catheter is the patient is unable to void.
14
300 sec
Q.
The nurse is observing family members care for a client who has multiple deficits following a stroke 2 weeks ago. The nurse must intervene if a family member is observed doing which of the following?
15
300 sec
Q.
The nurse is providing discharge teaching about post-concussion syndrome for a client and the client’s family. The nurse should include in the teaching that the client might experience which of the following? Select all that apply. A. Headache
B. Decreased short term memory
C. Personality changes D. Urinary Incontinence
16
300 sec
Q.
The nurse on the neurological care unit is conducting a staff education conference about subdural hematoma. Which of the following information should the nurse include in the conference?
17
300 sec
Q.
The nurse on the neurological care unit is planning a staff education conference about conditions that would require intracranial pressure monitoring with a ventriculostomy. Which of the following conditions should the nurse include in the conference? Select all that apply. A. Subdural hematoma
B. Brain tumor C. PE
D. Encephalitis E. Pneumonia
18
300 sec
Q.
The nurse is caring for a client who has a ventriculostomy. Which of the following actions by the nurse would be appropriate?