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
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?
Correct Answer: D
Rationale: A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow/ Com Scale score of 12, a PaCOO of 36, and cerebral perfusion pressure of 72 mm Hg all desired outcomes.
Question 2 of 5
A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?
Correct Answer: B
Rationale: In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near normal core temperature, 3) normal systolic blood pressure, and 4) a least one mentioned assessment. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client who is found unresponsive.
Question 3 of 5
A client is the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
Correct Answer: D
Rationale: This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead is hesitation. Informed consent is needed for an LP. but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure/relation (or other preprocedure/mediations) should not be given as the LP will most likely be canceled.
Question 4 of 5
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 m/mr. What action by the nurse is best?
Correct Answer: B
Rationale: This client has manifestations of hypermatremia, which is a possible complication after craniotomy. The nurse should assess the clients serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessment/inursing records.
Question 5 of 5
A client has a brain abscess and is receiving phenyton [Dilantin]. The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?
Correct Answer: A
Rationale: Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenystion is need to a prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.