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A nurse is caring for a client who experienced a traumatic head injury
and has an intraventricular catheter (Ventriculostomy) for ICP
monitoring. The nurse should monitor the client for which of the following
complications related to the ventriculostomy?:
a. Headache
b. Infection
c. Aphasia
d. Hypertension - ANSWER ✔✔b. Infection
,Monitor for infection and use strict asepsis to avoid life-threatening
meningitis.
A nurse is providing education to a client who is to undergo an EEG the
next day. Which of the following info should the nurse include in the
teaching?
a. "Do not wash your hair the morning of the procedure."
b. "Try and stay awake most of the night prior to the procedure."
c. "The procedure will take approximately 15 mins."
d. "You will need to lie flat for 4 hours after the procedure." -
ANSWER ✔✔b. "Try and stay awake most of the night prior to the
procedure."
Tell the client to remain awake to provide cranial stress and increase the
possibility of abnormal electrical activity
A nurse is caring for a client who is postprocedural following a lumbar
puncture and reports a throbbing headache when sitting upright. Which
of the following actions should the nurse take? SATA.
,a. Use the GCS scale to assess the client
b. Assist the client into a supine position
c. Administer an opioid analgesic
d. Encourage the client to increase PO fluid intake
e. Instruct the client to perform coughing and deep breathing -
ANSWER ✔✔B, D
A nurse is caring for a client who has continuous bladder irrigation
following a transurethral resection of the prostate (TURP). Which of the
following findings should the nurse report to the provider?
a Output equal to the instilled irrigate
b. Client reports bladder spasms
c. Viscous urinary output with clots
d. Reports of strong urge to urinate - ANSWER ✔✔c. Viscous urinary
output with clots
Urine that is bright red with clots is an indication of arterial bleeding.
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, A nurse is monitoring the ECG of a client who has hypocalcemia. Which
of the following findings should the nurse expect?
a. Flattened T waves
b. Prolonged QT intervals
c. Shortened QT intervals
d Widened QRS complexes - ANSWER ✔✔b. Prolonged QT intervals
Manifestations of hypocalcemia include tingling, numbness, tetany,
seizures, prolonged QT intervals, and laryngospasm.
A nurse is preparing a client who has a brain tumor for a CT scan. Which
of the following factors affects the manner in which the nurse will prepare
the client for the scan?
a. No food or fluids consumed for 4 hours
b. Difficulty recalling recent events
c. Development of hives while eating shrimp
d. Paresthesia in both hands - ANSWER ✔✔c. Development of hives
while eating shrimp