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
Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patients current LOC?
Correct Answer: C
Rationale: Coma patients may exhibit nonpurposeful movements to stimuli. Verbal sounds are rare, comas are not permanent, and spontaneous respirations may persist.
Question 2 of 5
The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should be prioritized?
Correct Answer: A
Rationale: Maximizing function is the primary goal for neurologic impairment, encompassing quality of life and family/community involvement. Quantity of life is less relevant.
Question 3 of 5
The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
Correct Answer: D
Rationale: Documenting pre-seizure activities helps identify triggers. Patients cannot follow instructions or explain seizures during or postictally, and restraint is contraindicated.
Question 4 of 5
The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurses first action when assessing this patient?
Correct Answer: A
Rationale: Verbal response assessment, via orientation to time, person, and place, is the initial step in evaluating altered LOC. Other assessments follow based on findings.
Question 5 of 5
The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Immobility in a vegetative state increases risks for contractures, pressure ulcers, DVT, and pneumonia. Hemorrhage is not a common complication of decreased LOC.