1…A nurse is reviewing the medical history of a client who is scheduled for a magnetic
resonance imaging (MRI) examination of the cervical vertebra. Which of the following
pieces of information in the client’s history is a contraindication to this procedure?
Correct answer: The client has a pacemaker.
Explanation: An MRI uses strong magnets and radio waves that are evaluated using
computer technology to view 3-dimensional images of the body. Since an MRI is
magnetically generated, it is not indicated for use in the presence of certain medical
implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal
defibrillators cannot undergo an MRI because the strong magnetic force can interfere
with these devices and obscure surrounding anatomical structures.
2….A nurse responds to a call from an assistive personnel that a client just had a seizure
and is unconscious. Which of the following assessments is the nurse’s priority?
Correct answer: Check airway patency.
Explanation: The nurse should apply the ABC priority-setting framework, which
emphasizes the basic core of human functioning: having an open airway, being able to
breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via
the blood. An alteration in any of these areas can indicate a threat to life and is the
nurse’s priority concern. When applying the ABC priority-setting framework, airway is
always the highest priority because the airway must be clear for oxygen exchange to
occur. Breathing is the second-highest priority because adequate ventilatory effort is
essential in order for oxygen exchange to occur. Circulation is the third-highest priority
because the delivery of oxygen to critical organs only occurs if the heart and blood
vessels are capable of efficiently carrying oxygen to them. The priority assessment the
nurse should make is to check the client's airway patency. The nurse should establish
and maintain the client’s airway to prevent respiratory arrest and hypoxia.
3….A nurse is caring for a client who has a brainstem injury. Which of the following
physiological functions should the nurse monitor?
Correct answer: Respiratory effort.
Explanation: The nurse should monitor the respiratory effort of a client who has an
injury to the brainstem. The medulla in the brainstem controls the respiratory center.
, 4….A nurse is providing teaching to a client who has a history of tonic-clonic seizures and
is scheduled for a standard electroencephalogram (EEG). Which of the following
instructions should the nurse include in the teaching?
Correct answer: Thoroughly shampoo her hair prior to the EEG.
Explanation: The nurse should instruct the client to thoroughly wash her hair prior to
the EEG because hairsprays, oils, and other hair preparations interfere with recording
results of the EEG.
5….A nurse is assessing a client who sustained a recent head injury. Which of the
following findings should the nurse recognize as a manifestation of increased intracranial
pressure?
Correct answer: (A) Widened pulse pressure.
Explanation: A widening of the pulse pressure (i.e. the difference between the systolic
and diastolic pressure) is a manifestation of increased intracranial pressure. Other
manifestations include pupil changes, change in the level of consciousness, and nausea
and vomiting.
6….A nurse is providing discharge teaching to the family of a client who has a new
diagnosis of a seizure disorder. The nurse should instruct the client’s family to take which
of the following actions first in the event of a seizure?
Correct answer: Protect the client’s head.
Explanation: The nurse should apply the safety and risk reduction priority-setting
framework, which assigns priority to the factor or situation posing the greatest safety
risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow’s Hierarchy of
Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which
risk poses the greatest threat to the client. This client is at greatest risk for injury from
hitting his head; therefore, the first action is to protect the client’s head from injury.
7….A nurse is preparing a client who has a brain tumor for computed tomography (CT).
Which of the following factors affects the manner in which the nurse will prepare the
client for the scan?
Correct answer: Development of hives when eating shrimp.
Explanation: An allergy to shellfish is a contraindication for the use of contrast media
during a CT scan. The nurse should inform the provider and explain to the client that this
factor might alter how the technician performs the CT scan.
resonance imaging (MRI) examination of the cervical vertebra. Which of the following
pieces of information in the client’s history is a contraindication to this procedure?
Correct answer: The client has a pacemaker.
Explanation: An MRI uses strong magnets and radio waves that are evaluated using
computer technology to view 3-dimensional images of the body. Since an MRI is
magnetically generated, it is not indicated for use in the presence of certain medical
implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal
defibrillators cannot undergo an MRI because the strong magnetic force can interfere
with these devices and obscure surrounding anatomical structures.
2….A nurse responds to a call from an assistive personnel that a client just had a seizure
and is unconscious. Which of the following assessments is the nurse’s priority?
Correct answer: Check airway patency.
Explanation: The nurse should apply the ABC priority-setting framework, which
emphasizes the basic core of human functioning: having an open airway, being able to
breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via
the blood. An alteration in any of these areas can indicate a threat to life and is the
nurse’s priority concern. When applying the ABC priority-setting framework, airway is
always the highest priority because the airway must be clear for oxygen exchange to
occur. Breathing is the second-highest priority because adequate ventilatory effort is
essential in order for oxygen exchange to occur. Circulation is the third-highest priority
because the delivery of oxygen to critical organs only occurs if the heart and blood
vessels are capable of efficiently carrying oxygen to them. The priority assessment the
nurse should make is to check the client's airway patency. The nurse should establish
and maintain the client’s airway to prevent respiratory arrest and hypoxia.
3….A nurse is caring for a client who has a brainstem injury. Which of the following
physiological functions should the nurse monitor?
Correct answer: Respiratory effort.
Explanation: The nurse should monitor the respiratory effort of a client who has an
injury to the brainstem. The medulla in the brainstem controls the respiratory center.
, 4….A nurse is providing teaching to a client who has a history of tonic-clonic seizures and
is scheduled for a standard electroencephalogram (EEG). Which of the following
instructions should the nurse include in the teaching?
Correct answer: Thoroughly shampoo her hair prior to the EEG.
Explanation: The nurse should instruct the client to thoroughly wash her hair prior to
the EEG because hairsprays, oils, and other hair preparations interfere with recording
results of the EEG.
5….A nurse is assessing a client who sustained a recent head injury. Which of the
following findings should the nurse recognize as a manifestation of increased intracranial
pressure?
Correct answer: (A) Widened pulse pressure.
Explanation: A widening of the pulse pressure (i.e. the difference between the systolic
and diastolic pressure) is a manifestation of increased intracranial pressure. Other
manifestations include pupil changes, change in the level of consciousness, and nausea
and vomiting.
6….A nurse is providing discharge teaching to the family of a client who has a new
diagnosis of a seizure disorder. The nurse should instruct the client’s family to take which
of the following actions first in the event of a seizure?
Correct answer: Protect the client’s head.
Explanation: The nurse should apply the safety and risk reduction priority-setting
framework, which assigns priority to the factor or situation posing the greatest safety
risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow’s Hierarchy of
Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which
risk poses the greatest threat to the client. This client is at greatest risk for injury from
hitting his head; therefore, the first action is to protect the client’s head from injury.
7….A nurse is preparing a client who has a brain tumor for computed tomography (CT).
Which of the following factors affects the manner in which the nurse will prepare the
client for the scan?
Correct answer: Development of hives when eating shrimp.
Explanation: An allergy to shellfish is a contraindication for the use of contrast media
during a CT scan. The nurse should inform the provider and explain to the client that this
factor might alter how the technician performs the CT scan.
