When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). B. Emergent; the client is poorly oxygenated. C. Normal D. Significant; the… Read More »
Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis? A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination D. Risk for injury Correct Answer: B. Ineffective airway clearance In Parkinson’s crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client.… Read More »
The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? A. Head midline B. Head turned to the side C. Neck in neutral position D. Head of bed elevated 30 to 45 degrees Correct Answer: B. Head… Read More »
The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: A. Wrinkle the forehead, blow out the cheeks, and whistle. B. Massage the face… Read More »
A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: A. Is clear and tests negative for glucose. B. Is grossly bloody in appearance and has a pH of 6. C. Clumps together on the dressing… Read More »
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia D. Decreasing body temperature Correct Answer: A. Unequal pupil size Increasing ICP causes unequal pupils… Read More »
A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of: A. Seizures or trauma to the brain. B. Meningitis during the last five (5 years). C. Back injury or trauma to the spinal… Read More »
A male client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program. B. Keeping the linen wrinkle-free under the client. C. Preventing unnecessary pressure on the lower… Read More »
Which of the following respiratory patterns indicate increasing ICP in the brain stem? A. Slow, irregular respirations B. Rapid, shallow respirations C. Asymmetric chest expansion D. Nasal flaring Correct Answer: A. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure… Read More »
A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? A. Giving the client full control over care decisions and restricting visitors. B. Providing positive… Read More »