Exam 3: TBI (NCLEX) Graded A 2023

1. Patient with head injury. Which of the following are manifestations of Increased ICP? SELECT ALL THAT APPLY A.Headache. B.Tachycardia C.Hypotension D.Pupillary changes. E.Abnormal posturing. - ADE 2. Abnormal extension (Decerebrate) posturing is characterized by which of the following? A.Extension of extremities and pronation of the arms B.Flexion of extremities and pronation of arms C.Upper extremity flexion with lower extremity extension D.Upper extremity extension with lower extremity flexion. - D 3. A client with increased ICP is prescribed the following tests. The nurse would clarify which test with the physician? A. MRI B. LP C. CT Scan. D. Cerebral angiography - B 4. Client sustained closed head injury. Nurse assesses for which early sign of impending neurological deterioration? A.Loss of corneal reflex B.Increased visual acuity C.Bilateral pupil equality and reactivity D.Ipsilateral pupil dilation. - D 5. Client with diagnosis of SIADH. The nurse would expect to see what laboratory finding? A.Serum sodium 125. B.Serum potassium 2.7 C.Serum glucose 250 D.Serum chloride 110 - A 6. The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? select all that apply. A. systolic blood pressure B. urine output C. breath sounds D. cerebral perfusion pressure - AD 7. Which activity should the nurse encourage the patient to avoid when there is a risk for intracranial pressure(ICP)? A. deep breathing B. turning C. coughing D. passive range-of-motion exercises - C 8. the nurse is caring for the client with increased intracranial pressure. the nurse would note which trend in vital sings if the intracranial pressure is rising? A. increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B. increasing temperature, decreasing pulse, decreasing respirations. increasing blood pressure C. decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure - B 9. a client recovering from a head injury is participating in care. the nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? A. blowing the nose B. isometric exercises C. coughing vigorously D. exhaling during repositioning - D 10. a client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurses the cerebrospinal fluid is present? A. fluid is clear and tests negative for glucose B. fluid is grossly bloody in appearance and has a pH of 6 C. fluid clumps together on the dressing and has a pH of 7 D. fluid separates into concentric rings and tests positive for glucose - D 11. the nurse is assessing the motor function of an unconscious client. the nurse should plan to use which techniques to test the clients peripheral response to pain? A. sternal rub B. nail bed pressure C. pressure on the orbital rim D. squeezing of the sternocleidomastoid muscle - B 12. in which of the following positions should the nurse place a client following a craniotomy for evacuation of a subdural hematoma of the frontal lobe? A. supine B. Prone C. semi-fowlers D. sims - C 13. an unconscious client assumes a decerebrate posture in response to any noxious stimuli. when drawing a blood sample, the nurse should expect the client to: A. rigidly extend all four extremities B. internally flex the arms and extend the legs C. tightly curl into a fetal position D. internally rotate the arms and legs - A 14. a nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. which of the following is the priority assessment? A. glasgow coma scale B. cranial nerve function C. oxygen saturation D. pupillary response - C 15. a nurse is caring for a client who has a closed had injury with ICp readings ranging from 16-22 mmH of the following actions should the nurse take to decrease the potential for raising the clients ICP (select all that apply) A. suction the endotracheal tube frequently B. decrease the noise level in the clients room C. elevate the clients head on two pillow D. administer stool softener - D