ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 66 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
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
Correct Answer: D
Rationale: Loosening restrictive clothing prevents injury during a seizure. Restraining or inserting an airway can cause harm, and high Fowlers is inappropriate during a seizure.
Question 3 of 5
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patients injury is causing increased intracranial pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool?
Correct Answer: B
Rationale: The Glasgow Coma Scale assesses LOC via eye, verbal, and motor responses, making it ideal for monitoring ICP-related changes. Other options are not specific to LOC assessment.
Question 4 of 5
A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety?
Correct Answer: B
Rationale: A side-lying position prevents aspiration of secretions post-seizure. Padding rails, antianxiety drugs, or reassurance are secondary to airway safety.
Question 5 of 5
A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patients care, the nurse would expect to administer what priority medication?
Correct Answer: C
Rationale: Mannitol, an osmotic diuretic, reduces cerebral edema by dehydrating brain tissue. Other diuretics like hydrochlorothiazide, furosemide, and spirolactone are not typically used for increased ICP.