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A client admitted with a cerebral contusion is confused, disoriented, and restless.
Which nursing diagnosis takes the highest priority?
• Disturbed sensory perception (visual) related to neurologic trauma
• Feeding self-care deficit related to neurologic trauma
• Impaired verbal communication related to confusion
• Risk for injury related to neurologic deficit
The nurse working on the neurological unit is caring for a client with a basilar
skull fracture. During the assessment, the nurse expects to observe Battle's sign,
which is a sign of basilar skull fracture. Which of the following correctly describes
Battle's sign?
• Drainage of cerebrospinal fluid from the ears
• Ecchymosis over the mastoid
• Bruising under the eyes
• Drainage of cerebrospinal fluid from the nose
A client in the emergency department has bruising over the mastoid bone and
rhinorrhea. The triage nurse suspects the client has which type of skull fracture?
• Linear
• Simple
• Basilar
• Comminuted
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The earliest sign of serious impairment of brain circulation related to increased ICP
is:
• A bounding pulse.
• Hypertension.
• A change in consciousness.
• Bradycardia.
While snowboarding, a client fell and sustained a blow to the head, resulting in
a loss of consciousness. The client regained consciousness within an hour after
arrival at the ED, was admitted for 24-hour observation, and was discharged
without neurologic impairment. What would the nurse expect this client's
diagnosis to be?
• concussion
• skull fracture
• laceration
• contusion
Which condition occurs when blood collects between the dura mater and arachnoid
membrane?
• Extradural hematoma
• Epidural hematoma
• Intracerebral hemorrhage
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• Subdural hematoma
The nurse is caring for a client following a spinal cord injury who has a halo device
in place. The client is preparing for discharge. Which statement by the client
indicates the need for further instruction?
• “I will change the vest liner periodically.”
• “I can apply powder under the liner to help with sweating.”
• “If a pin becomes detached, I’ll notify the surgeon.”
• “I’ll check under the liner for blisters and redness.”
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical
finding, observed during the reassessment of the client, causes the nurse the
most concern?
• Heart rate decrease from 100 to 90 bpm
• Urinary output increase from 40 to 55 mL/hr
• Pulse oximetry decrease from 99% to 97% room air
• Temperature increase from 98.0°F to 99.6°F
Family members of a client with traumatic brain injury are extremely distressed
about their loved one. How can the nurse best assist the family to cope during this
acute phase?
• Reassure them that progress will be made, but it takes time.
• Allow family members distance and space to deal with the changes to the
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client.
• Wait for the family members to approach with questions.
• Provide factual information and emotional support.
Which of the following types of hematoma results from venous bleeding with
blood gradually accumulating in the space below the dura?
• Subdural
• Epidural
• Intracerebral
• Cerebral
The nursing instructor is teaching about hematomas to a pre-nursing
pathophysiology class. What would the nursing instructor describe as an
arterial bleed with rapid neurologic deterioration?
• Intracranial hematoma
• Epidural hematoma
• Extradural hematoma
• Subdural hematoma
When the nurse observes that the patient has extension and external rotation of the
arms and wrists, and extension, plantar flexion, and internal rotation of the feet,
she records the patient’s posturing as which of the following?
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A client admitted with a cerebral contusion is confused, disoriented, and restless.
Which nursing diagnosis takes the highest priority?
• Disturbed sensory perception (visual) related to neurologic trauma
• Feeding self-care deficit related to neurologic trauma
• Impaired verbal communication related to confusion
• Risk for injury related to neurologic deficit
The nurse working on the neurological unit is caring for a client with a basilar
skull fracture. During the assessment, the nurse expects to observe Battle's sign,
which is a sign of basilar skull fracture. Which of the following correctly describes
Battle's sign?
• Drainage of cerebrospinal fluid from the ears
• Ecchymosis over the mastoid
• Bruising under the eyes
• Drainage of cerebrospinal fluid from the nose
A client in the emergency department has bruising over the mastoid bone and
rhinorrhea. The triage nurse suspects the client has which type of skull fracture?
• Linear
• Simple
• Basilar
• Comminuted
NURS 140 EXAM Questions And Answers
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The earliest sign of serious impairment of brain circulation related to increased ICP
is:
• A bounding pulse.
• Hypertension.
• A change in consciousness.
• Bradycardia.
While snowboarding, a client fell and sustained a blow to the head, resulting in
a loss of consciousness. The client regained consciousness within an hour after
arrival at the ED, was admitted for 24-hour observation, and was discharged
without neurologic impairment. What would the nurse expect this client's
diagnosis to be?
• concussion
• skull fracture
• laceration
• contusion
Which condition occurs when blood collects between the dura mater and arachnoid
membrane?
• Extradural hematoma
• Epidural hematoma
• Intracerebral hemorrhage
NURS 140 EXAM Questions And Answers
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,NURS 140 EXAM Questions And Answers
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• Subdural hematoma
The nurse is caring for a client following a spinal cord injury who has a halo device
in place. The client is preparing for discharge. Which statement by the client
indicates the need for further instruction?
• “I will change the vest liner periodically.”
• “I can apply powder under the liner to help with sweating.”
• “If a pin becomes detached, I’ll notify the surgeon.”
• “I’ll check under the liner for blisters and redness.”
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical
finding, observed during the reassessment of the client, causes the nurse the
most concern?
• Heart rate decrease from 100 to 90 bpm
• Urinary output increase from 40 to 55 mL/hr
• Pulse oximetry decrease from 99% to 97% room air
• Temperature increase from 98.0°F to 99.6°F
Family members of a client with traumatic brain injury are extremely distressed
about their loved one. How can the nurse best assist the family to cope during this
acute phase?
• Reassure them that progress will be made, but it takes time.
• Allow family members distance and space to deal with the changes to the
NURS 140 EXAM Questions And Answers
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client.
• Wait for the family members to approach with questions.
• Provide factual information and emotional support.
Which of the following types of hematoma results from venous bleeding with
blood gradually accumulating in the space below the dura?
• Subdural
• Epidural
• Intracerebral
• Cerebral
The nursing instructor is teaching about hematomas to a pre-nursing
pathophysiology class. What would the nursing instructor describe as an
arterial bleed with rapid neurologic deterioration?
• Intracranial hematoma
• Epidural hematoma
• Extradural hematoma
• Subdural hematoma
When the nurse observes that the patient has extension and external rotation of the
arms and wrists, and extension, plantar flexion, and internal rotation of the feet,
she records the patient’s posturing as which of the following?
NURS 140 EXAM Questions And Answers
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