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
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 2 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.
Question 3 of 5
The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor?
Correct Answer: C
Rationale: Dexamethasone reduces edema around brain tumors. Solumedrol is less specific, furosemide is not ideal, and dextromethorphan is for cough suppression.
Question 4 of 5
The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response?
Correct Answer: A
Rationale: Increased respiratory effort may indicate rising ICP, requiring immediate team notification and further assessment. Bronchodilators, bed elevation, or saline are inappropriate initial actions.
Question 5 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.