ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 66 : Management of Patients with Neurologic Dysfunction Questions
Question 1 of 5
A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?
Correct Answer: D
Rationale: Loss of brain stem reflexes (e.g., pupillary, corneal) signals impending death in severe head injury. Hemiplegia, dry membranes, and bleeding are not specific to this outcome.
Question 2 of 5
A patient has experienced a seizure in which she became rigid and then experienced alternating spasms and relaxation. What type of seizure does the nurse recognize?
Correct Answer: C
Rationale: Generalized tonic-clonic seizures involve rigidity followed by spasms and relaxation. Absence seizures involve staring, focal seizures are localized, and unclassified seizures lack specific patterns.
Question 3 of 5
When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH?
Correct Answer: A
Rationale: SIADH causes fluid overload, requiring fluid restriction and electrolyte monitoring. Platelet or plasma transfusions and electrolyte restriction are not indicated.
Question 4 of 5
The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patients admission orders? Select all that apply.
Correct Answer: A,B,C
Rationale: CT, MRI, cerebral angiography, and transcranial Doppler assess brain masses. Cranial radiography and EMG are not diagnostic for intracranial masses.
Question 5 of 5
A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate?
Correct Answer: A
Rationale: Severe post-craniotomy headache warrants morphine administration. Prone positioning increases ICP, hot packs may worsen pain, and distraction is inadequate for severe pain.