Which of the following describes decerebrate posturing? A. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers. B. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet. C. Supination of arms, dorsiflexion of feet. D. Back arched;… Read More »
A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client’s blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? A. Loosen tight clothing… Read More »
Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? A. Speaking to the client at a slower rate. B. Allowing plenty of time for the client to respond. C. Completing the sentences that… Read More »
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? A. Count the rate to be sure the ventilations are deep enough to be sufficient. B. Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score.… Read More »
A client who had a stroke is seen bumping into things on the side and is having difficulty picking up the beginning of the next line of what he is reading. The client is experiencing which of the following conditions? A. Visual neglect B. Astigmatism C. Blepharitis D. Homonymous Hemianopsia … Read More »
A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: A. Getting too little exercise. B. Taking excess medication. C. Omitting doses of medication. D. Increasing intake of fatty foods. Correct Answer: C. Omitting doses… Read More »
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? A. Keeping the client flat on one side or the other. B. Elevating the head of the bed to 30 degrees. C. Logrolling or turning as a… Read More »
A client has been pronounced brain dead. Which findings would the nurse assess? Select all that apply. A. Decerebrate posturing B. Dilated nonreactive pupils C. Deep tendon reflexes D. Absent corneal reflex Correct Answer: B, C, & D A client who is brain dead typically demonstrates nonreactive dilated… Read More »
Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except? A. acetaminophen (Tylenol) B. dexamethasone (Decadron) C. mannitol (Osmitrol) D. phenytoin (Dilantin) E. nitroglycerin (Nitrostat) Correct Answer: E. nitroglycerin (Nitrostat) Decreasing blood pressure is essential to… Read More »
The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. The nurse tells the client that this is most effectively done by: A. Eating large, well-balanced meals. B. Doing muscle-strengthening exercises. C. Doing all chores early in the day while less fatigued. D.… Read More »