ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 45 : Care of Critically Ill Patients with Neurologic Problems Questions
Question 1 of 5
A client had is em/bolectomy for an arteri/ovenous malformation (AVM). The client is now reporting a severe headache and has vom/ited. What action by the nurse takes priority?
Correct Answer: C
Rationale: The client may to experiencing a re/hed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team but getting immediate medical attention is the priority. Admin/tering pain medication may not be warranted if the client are the return to emergency. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.
Question 2 of 5
A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the de/ocate sodium (Col/ace) because the client had a large stool car/ifier. What action by the supervising nurse is best?
Correct Answer: B
Rationale: A student nurse should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Val/aba's maneuver when cons/ist/ated. The supervising nurse should instruct the student to administer the docuscate. The other options are not appropriate. The medication could be held for diarrhea.
Question 3 of 5
A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beat/min, pulse pressure increase from 26 to 40 min $\mathrm{Hg}$, and respiratory irregularities. What action by the nurse takes priority?
Correct Answer: A
Rationale: These manifestations indicate Cushing syndrome, a potentially life-threatening increase in intracranial trauma (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment and pacion medication.
Question 4 of 5
A nurse a caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first.
Correct Answer: A
Rationale: A client decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement on the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the decline the Glasgow Coma Scale score.
Question 5 of 5
A client is in the clinic for a follow-up-visit after a moderate traumatic brain injury. The clients spouse is very frustrated, stating that the clients personality has changed and the situation is a trouble. What action by the nurse is how.
Correct Answer: A
Rationale: Personality changes after a traumatic brain injury are common and can be distressing for families. The nurse should prioritize assessing the client with a worsening Glasgow Coma Scale score (from 10 to 8), as this indicates a potential deterioration in neurologic status, which is a medical emergency.