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Exam Prep Questions

1.A client is admitted with a head injury. Which vital sign assessment is most indicative of increased intracranial pressure?

A.BP 120/80, pulse 120, respirations 20

B.BP 180/98, pulse 50, temperature 102° F

C.BP 98/60, pulse 132, temperature 97.6° F

D.BP 170/90, pulse 80, respirations 24


2.The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse’s best action?

A.Notify the charge nurse.

B.Record the reading as the only action.

C.Turn the client and recheck the reading.

D.Place the client supine.


3.A client has developed diabetes insipidus after removal of a pituitary tumor. Which finding would the nurse expect?

A.Polyuria

B.Hypertension

C.Polyphagia

D.Hyperkalemia


4.The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by reversing dilation of cerebral blood vessels. Which physician prescription would the nurse expect to accomplish this?

A.Hyperventilation per mechanical ventilation

B.Insertion of a ventricular shunt

C.Furosemide (Lasix)

D.Solu medrol


5.A client is admitted with Parkinson’s disease. The client has been taking Carbidopa/levodopa (Sinemet) for 1 year. Which clinical manifestation would be the most important to report?

A.Dry mouth

B.Spasmodic eye winking

C.Dark urine

D.Dizziness


6.The nurse caring for a client with myasthenia gravis is reviewing the nursing care plan. Which is recognized as the priority nursing diagnosis?

A.Risk for injury

B.Acute pain

C.Ineffective airway clearance

D.Impaired mobility


7.A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?

A.Notify the RN.

B.Assess the client for a distended bladder.

C.Apply oxygen at 3 L/min.

D.Increase the IV fluids.


8.The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?

A.Epistaxis

B.Abdominal distention

C.Nausea

D.Hyperactivity


9.Which assessment finding is most indicative of increased ICP in a client admitted with a basilar skull fracture?

A.Nausea and vomiting

B.Headache

C.Dizziness

D.Papilledema


10.A client with angina is experiencing migraine headaches. The physician has prescribed sumatriptan succinate (Imitrex). Which nursing action is most appropriate?

A.Consult with the RN before administration.

B.Try to obtain samples for the client to take home.

C.Perform discharge teaching regarding this drug.

D.Consult social services for financial assistance with obtaining the drug.


Answer Rationales

1.Answer B is correct. Vital signs correlating with increased intracranial pressure are an elevated BP with a widening pulse pressure, a slow pulse rate, and an elevated temperature with involvement of the hypothalamus. Answer C relates to hypovolemia, so it is incorrect. Answers A and D do not relate to increased intracranial pressure and are therefore incorrect.
2.Answer A is correct. Normal ICP is less than 15. 66 is a high reading, and the RN and the physician should be notified. Answer B would be the action if the reading was normal, so it is incorrect. Answers C and D would not be appropriate actions, so they are wrong.
3.Answer A is correct. Clients with diabetes insipidus have excessive urinary output due to a lack of antidiuretic hormone. Answers B, C, and D are not exhibited with diabetes insipidus, so they are incorrect.
4.Answer A is correct. Hyperventilation is utilized to decrease the PCO2 to 27–30, producing cerebral blood vessel constriction. Answers B, C, and D can decrease cerebral edema, but not by constriction of cerebral blood vessels; therefore, they are wrong.
5.Answer B is correct. Spasmodic eye winking could indicate a toxicity or overdose and should be reported to the physician. Other signs of toxicity include involuntary twitching of muscles, facial grimaces, and severe tongue protrusion. Answers A, C, and D are incorrect because they are side effects of the drug.
6.Answer C is correct. Clients with myasthenia gravis have problems with the muscular activity of breathing. Answers A, B, and D are not the priority, so they are wrong.
7.Answer B is correct. The client is experiencing autonomic hyperreflexia, which can be caused by a full bowel or bladder. Answer A is not the appropriate action before the assessment of the bladder, so it is incorrect. There is no evidence in the stem to support the need for oxygen, so answer C is incorrect. Answer D is not appropriate at this time and might serve to further increase the BP, making it wrong.
8.Answer A is correct. Plavix is an antiplatelet. Bleeding could indicate a severe effect. Answers B, C, and D are not associated with Plavix’s undesired effects, so they are incorrect.
9.Answer D is correct. Papilledema is a hallmark symptom of increased intracranial pressure. Answers A, B, and C are not as conclusive as papilledema, so they are wrong.
10.Answer A is correct. Imitrex results in cranial vasoconstriction to reduce pain, but it can also cause vasoconstrictive effects systemically. This drug is contraindicated in clients with angina, and the RN and the physician should be notified. Answers B and D are incorrect because they are inappropriate actions from the information given. Answer C is appropriate, but answer A is most appropriate.


  

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