NURS 404: MEDSURG HEAD INJURY Q & A
1. The client has sustained a severe closed head injury and the neurosurgeon is determining
if the client is “brain dead.” Which data support that the client is brain dead?
1. When the client’s head is turned to the right, the eyes turn to the right.
2. The electroencephalogram (EEG) has identifiable waveforms.
3. There is no eye activity when the cold caloric test is
performed.
4. The client assumes decorticate posturing when painful stimuli are applied.
2. The client is admitted to the medical floor with a diagnosis of closed head
injury. Which nursing intervention has priority?
1. Assess neurological status.
2. Monitor pulse, respiration, and blood pressure.
3. Initiate an intravenous access.
4. Maintain an adequate airway.
3. The client diagnosed with a closed head injury is admitted to the
rehabilitation department. Which medication order would the nurse question?
1. A subcutaneous anticoagulant.
2. An intravenous osmotic
diuretic.
3. An oral anticonvulsant.
4. An oral proton pump inhibitor.
4. The client diagnosed with a gunshot wound to the head assumes decorticate
posturing when the nurse applies painful stimuli. Which assessment data
obtained three (3) hours later would indicate the client is improving?
1. Purposeless movement in response to painful stimuli.
2. Flaccid paralysis in all four extremities.
3. Decerebrate posturing when painful stimuli are applied.
,4. Pupils that are 6 mm in size and nonreactive on painful stimuli.
5. The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing
interventions should the nurse implement? Select all that apply.
1. Maintain the head of the bed at 60 degrees of elevation.
2. Administer stool softeners daily.
3. Ensure that pulse oximeter reading is higher than 93%.
4. Perform deep nasal suction every two (2) hours.
5. Administer mild sedatives.
6. The client with a closed head injury has clear fluid draining from the nose.
Which action should the nurse implement first?
1. Notify the health-care provider immediately.
2. Prepare to administer an antihistamine.
3. Test the drainage for presence of
glucose.
4. Place 2 × 2 gauze under the nose to collect drainage
, 22. The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp.
The water skier is in the water not responding to verbal stimuli. The nurse is the
first health-care provider to respond to the accident. Which intervention should be
implemented first?
1. Assess the client’s level of consciousness.
2. Organize onlookers to remove the client from the lake.
3. Perform a head-to-toe assessment to determine injuries.
4. Stabilize the client’s cervical spine.
23. The client is diagnosed with a closed head injury and is in a coma. The nurse writes
the client problem as “high risk for immobility complications.” Which intervention
would be included in the plan of care?
1. Position the client with the head of the bed elevated at intervals.
2. Perform active range-of-motion exercises every four (4) hours.
3. Turn the client every shift and massage bony prominences.
4. Explain all procedures to the client before performing them.
24. The 29-year-old client who was employed as a forklift operator sustains a traumatic
brain injury secondary to a motor-vehicle accident. The client is being discharged
from the rehabilitation unit after three (3) months and has cognitive deficits. Which
goal would be most realistic for this client?
1. The client will return to work within six (6) months.
2. The client is able to focus and stay on task for 10 minutes.
3. The client will be able to dress self without assistance.
4. The client will regain bowel and bladder control
Seizures
37. The male client is sitting in the chair and his entire body is rigid with his arms and
legs contracting and relaxing. The client is not aware of what is going on and is
making guttural sounds. Which action should the nurse implement first?
1. Push aside any furniture.
2. Place the client on his side.
3. Assess the client’s vital
signs. 4. Ease the client to the
1. The client has sustained a severe closed head injury and the neurosurgeon is determining
if the client is “brain dead.” Which data support that the client is brain dead?
1. When the client’s head is turned to the right, the eyes turn to the right.
2. The electroencephalogram (EEG) has identifiable waveforms.
3. There is no eye activity when the cold caloric test is
performed.
4. The client assumes decorticate posturing when painful stimuli are applied.
2. The client is admitted to the medical floor with a diagnosis of closed head
injury. Which nursing intervention has priority?
1. Assess neurological status.
2. Monitor pulse, respiration, and blood pressure.
3. Initiate an intravenous access.
4. Maintain an adequate airway.
3. The client diagnosed with a closed head injury is admitted to the
rehabilitation department. Which medication order would the nurse question?
1. A subcutaneous anticoagulant.
2. An intravenous osmotic
diuretic.
3. An oral anticonvulsant.
4. An oral proton pump inhibitor.
4. The client diagnosed with a gunshot wound to the head assumes decorticate
posturing when the nurse applies painful stimuli. Which assessment data
obtained three (3) hours later would indicate the client is improving?
1. Purposeless movement in response to painful stimuli.
2. Flaccid paralysis in all four extremities.
3. Decerebrate posturing when painful stimuli are applied.
,4. Pupils that are 6 mm in size and nonreactive on painful stimuli.
5. The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing
interventions should the nurse implement? Select all that apply.
1. Maintain the head of the bed at 60 degrees of elevation.
2. Administer stool softeners daily.
3. Ensure that pulse oximeter reading is higher than 93%.
4. Perform deep nasal suction every two (2) hours.
5. Administer mild sedatives.
6. The client with a closed head injury has clear fluid draining from the nose.
Which action should the nurse implement first?
1. Notify the health-care provider immediately.
2. Prepare to administer an antihistamine.
3. Test the drainage for presence of
glucose.
4. Place 2 × 2 gauze under the nose to collect drainage
, 22. The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp.
The water skier is in the water not responding to verbal stimuli. The nurse is the
first health-care provider to respond to the accident. Which intervention should be
implemented first?
1. Assess the client’s level of consciousness.
2. Organize onlookers to remove the client from the lake.
3. Perform a head-to-toe assessment to determine injuries.
4. Stabilize the client’s cervical spine.
23. The client is diagnosed with a closed head injury and is in a coma. The nurse writes
the client problem as “high risk for immobility complications.” Which intervention
would be included in the plan of care?
1. Position the client with the head of the bed elevated at intervals.
2. Perform active range-of-motion exercises every four (4) hours.
3. Turn the client every shift and massage bony prominences.
4. Explain all procedures to the client before performing them.
24. The 29-year-old client who was employed as a forklift operator sustains a traumatic
brain injury secondary to a motor-vehicle accident. The client is being discharged
from the rehabilitation unit after three (3) months and has cognitive deficits. Which
goal would be most realistic for this client?
1. The client will return to work within six (6) months.
2. The client is able to focus and stay on task for 10 minutes.
3. The client will be able to dress self without assistance.
4. The client will regain bowel and bladder control
Seizures
37. The male client is sitting in the chair and his entire body is rigid with his arms and
legs contracting and relaxing. The client is not aware of what is going on and is
making guttural sounds. Which action should the nurse implement first?
1. Push aside any furniture.
2. Place the client on his side.
3. Assess the client’s vital
signs. 4. Ease the client to the
