NUR 1700 Q5 Questions With Complete Solutions
When admitting an acutely confused 20-year-old patient with a
head injury, which action should the nurse take?
a. Ask family members about the patient's health history.
b. Ask leading questions to assist in obtaining health data.
c. Wait until the patient is better oriented to ask questions.
d. Obtain only the physiologic neurologic assessment data.
Correct Answers ANS: A
HH HH
When admitting a patient who is likely to be a poor historian,
the nurse should obtain health history information from others
who have knowledge about the patient's health. Waiting until the
patient is oriented or obtaining only physiologic data will result
in incomplete assessment data, which could adversely affect
decision making about treatment. Asking leading questions may
result in inaccurate or incomplete information.
To assess the functioning of the trigeminal and facial nerves
(CNs V and VII), the nurse should
a. shine a light into the patient's pupil.
b. check for unilateral eyelid drooping.
c. touch a cotton wisp strand to the cornea.
d. have the patient read a magazine or book. Correct Answers
HH
ANS: C
HH
The trigeminal and facial nerves are responsible for the corneal
reflex. The optic nerve is tested by having the patient read a
Snellen chart or a newspaper. Assessment of pupil response to
light and ptosis are used to check function of the oculomotor
nerve.
,Which action will the nurse include in the plan of care for a
patient with impaired functioning of the left glossopharyngeal
nerve (CN IX) and the vagus nerve (CN X)?
a. Withhold oral fluid or foods.
b. Provide highly seasoned foods.
c. Insert an oropharyngeal airway.
d. Apply artificial tears every hour. Correct Answers ANS: A
HH HH
The glossopharyngeal and vagus nerves innervate the pharynx
and control the gag reflex. A patient with impaired function of
these nerves is at risk for aspiration. An oral airway may be
needed when a patient is unconscious and unable to maintain the
airway, but it will not decrease aspiration risk. Taste and eye
blink are controlled by the facial nerve.
An unconscious male patient has just arrived in the emergency
department after a head injury caused by a motorcycle crash.
Which order should the nurse question?
a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c. Send for computed tomography (CT) scan.
d. Perform neurologic checks every 15 minutes. Correct
HH
Answers ANS: B
HH
After a head injury, the patient may be experiencing intracranial
bleeding and increased intracranial pressure, which could lead to
herniation of the brain if a lumbar puncture is performed. The
other orders are appropriate.
,A patient with suspected meningitis is scheduled for a lumbar
puncture. Before the procedure, the nurse will plan to
a. enforce NPO status for 4 hours.
b. transfer the patient to radiology.
c. administer a sedative medication.
d. help the patient to a lateral position. Correct Answers ANS:
HH HH
D
For a lumbar puncture, the patient lies in the lateral recumbent
position. The procedure does not usually require a sedative, is
done in the patient room, and has no risk for aspiration.
Family members of a patient who has a traumatic brain injury
ask the nurse about the purpose of the ventriculostomy system
being used for intracranial pressure monitoring. Which response
by the nurse is best?
a."This type of monitoring system is complex and it is managed
by skilled staff."
b."The monitoring system helps show whether blood flow to the
brain is adequate."
c."The ventriculostomy monitoring system helps check for
alterations in cerebral perfusion pressure."
d."This monitoring system has multiple benefits including
facilitation of cerebrospinal fluid drainage." Correct Answers
HH
ANS: B
HH
Short and simple explanations should be given initially to
patients and family members. The other explanations are either
too complicated to be easily understood or may increase the
family members' anxiety.
, Admission vital signs for a brain-injured patient are blood
pressure 128/68, pulse 110, and respirations 26. Which set of
vital signs, if taken 1 hour after admission, will be of most
concern to the nurse?
a.Blood pressure 154/68, pulse 56, respirations 12
b.Blood pressure 134/72, pulse 90, respirations 32
c.Blood pressure 148/78, pulse 112, respirations 28
d.Blood pressure 110/70, pulse 120, respirations 30 Correct
HH
Answers ANS: A
HH
Systolic hypertension with widening pulse pressure,
bradycardia, and respiratory changes represent Cushing's triad.
These findings indicate that the intracranial pressure (ICP) has
increased, and brain herniation may be imminent unless
immediate action is taken to reduce ICP. The other vital signs
may indicate the need for changes in treatment, but they are not
indicative of an immediately life-threatening process.
When a brain-injured patient responds to nail bed pressure with
internal rotation, adduction, and flexion of the arms, the nurse
reports the response as
a.flexion withdrawal.
b.localization of pain.
c.decorticate posturing.
d.decerebrate posturing. Correct Answers ANS: C
HH HH
Internal rotation, adduction, and flexion of the arms in an
unconscious patient is documented as decorticate posturing.
Extension of the arms and legs is decerebrate posturing. Because
When admitting an acutely confused 20-year-old patient with a
head injury, which action should the nurse take?
a. Ask family members about the patient's health history.
b. Ask leading questions to assist in obtaining health data.
c. Wait until the patient is better oriented to ask questions.
d. Obtain only the physiologic neurologic assessment data.
Correct Answers ANS: A
HH HH
When admitting a patient who is likely to be a poor historian,
the nurse should obtain health history information from others
who have knowledge about the patient's health. Waiting until the
patient is oriented or obtaining only physiologic data will result
in incomplete assessment data, which could adversely affect
decision making about treatment. Asking leading questions may
result in inaccurate or incomplete information.
To assess the functioning of the trigeminal and facial nerves
(CNs V and VII), the nurse should
a. shine a light into the patient's pupil.
b. check for unilateral eyelid drooping.
c. touch a cotton wisp strand to the cornea.
d. have the patient read a magazine or book. Correct Answers
HH
ANS: C
HH
The trigeminal and facial nerves are responsible for the corneal
reflex. The optic nerve is tested by having the patient read a
Snellen chart or a newspaper. Assessment of pupil response to
light and ptosis are used to check function of the oculomotor
nerve.
,Which action will the nurse include in the plan of care for a
patient with impaired functioning of the left glossopharyngeal
nerve (CN IX) and the vagus nerve (CN X)?
a. Withhold oral fluid or foods.
b. Provide highly seasoned foods.
c. Insert an oropharyngeal airway.
d. Apply artificial tears every hour. Correct Answers ANS: A
HH HH
The glossopharyngeal and vagus nerves innervate the pharynx
and control the gag reflex. A patient with impaired function of
these nerves is at risk for aspiration. An oral airway may be
needed when a patient is unconscious and unable to maintain the
airway, but it will not decrease aspiration risk. Taste and eye
blink are controlled by the facial nerve.
An unconscious male patient has just arrived in the emergency
department after a head injury caused by a motorcycle crash.
Which order should the nurse question?
a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c. Send for computed tomography (CT) scan.
d. Perform neurologic checks every 15 minutes. Correct
HH
Answers ANS: B
HH
After a head injury, the patient may be experiencing intracranial
bleeding and increased intracranial pressure, which could lead to
herniation of the brain if a lumbar puncture is performed. The
other orders are appropriate.
,A patient with suspected meningitis is scheduled for a lumbar
puncture. Before the procedure, the nurse will plan to
a. enforce NPO status for 4 hours.
b. transfer the patient to radiology.
c. administer a sedative medication.
d. help the patient to a lateral position. Correct Answers ANS:
HH HH
D
For a lumbar puncture, the patient lies in the lateral recumbent
position. The procedure does not usually require a sedative, is
done in the patient room, and has no risk for aspiration.
Family members of a patient who has a traumatic brain injury
ask the nurse about the purpose of the ventriculostomy system
being used for intracranial pressure monitoring. Which response
by the nurse is best?
a."This type of monitoring system is complex and it is managed
by skilled staff."
b."The monitoring system helps show whether blood flow to the
brain is adequate."
c."The ventriculostomy monitoring system helps check for
alterations in cerebral perfusion pressure."
d."This monitoring system has multiple benefits including
facilitation of cerebrospinal fluid drainage." Correct Answers
HH
ANS: B
HH
Short and simple explanations should be given initially to
patients and family members. The other explanations are either
too complicated to be easily understood or may increase the
family members' anxiety.
, Admission vital signs for a brain-injured patient are blood
pressure 128/68, pulse 110, and respirations 26. Which set of
vital signs, if taken 1 hour after admission, will be of most
concern to the nurse?
a.Blood pressure 154/68, pulse 56, respirations 12
b.Blood pressure 134/72, pulse 90, respirations 32
c.Blood pressure 148/78, pulse 112, respirations 28
d.Blood pressure 110/70, pulse 120, respirations 30 Correct
HH
Answers ANS: A
HH
Systolic hypertension with widening pulse pressure,
bradycardia, and respiratory changes represent Cushing's triad.
These findings indicate that the intracranial pressure (ICP) has
increased, and brain herniation may be imminent unless
immediate action is taken to reduce ICP. The other vital signs
may indicate the need for changes in treatment, but they are not
indicative of an immediately life-threatening process.
When a brain-injured patient responds to nail bed pressure with
internal rotation, adduction, and flexion of the arms, the nurse
reports the response as
a.flexion withdrawal.
b.localization of pain.
c.decorticate posturing.
d.decerebrate posturing. Correct Answers ANS: C
HH HH
Internal rotation, adduction, and flexion of the arms in an
unconscious patient is documented as decorticate posturing.
Extension of the arms and legs is decerebrate posturing. Because
