1. An 18-year-old client is admitted with a closed head injury sustained
in a MVA. His intracranial pressure (ICP) shows an upward trend.
Which intervention should the nurse perform first?
Reposition the client to avoid neck flexion
Administer 1 g Mannitol IV as ordered
Increase the ventilator’s respiratory rate to 20 breaths/minute
Administer 100 mg of pentobarbital IV as ordered.
2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg
loading dose of Dilantin IV. Which consideration is most important
when administering this dose?
1. Therapeutic drug levels should be maintained between 20 to
30 mg/ml. 2. Rapid Dilantin administration can cause cardiac
arrhythmias.
Dilantin should be mixed in dextrose in water before
administration.
• Dilantin should be administered through an IV catheter in
the client’s hand.
3
While in the ER, a client with C8 tetraplegia develops
a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects
which of the following conditions?
1. Autonomic dysreflexia
2. Hemorrhagic
shock 3.
Neurogenic shock
4. Pulmonary embolism
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?
Appropriate; lowering carbon dioxide (CO2) reduces intracranial
pressure (ICP).
Emergent; the client is poorly oxygenated.
Normal
Significant; the client has alveolar hypoventilation.
A client who had a transsphenoidal hypophysectomy should be
watched carefully for hemorrhage, which may be shown by which of the
following signs?
Bloody drainage from the
ears 2. Frequent
swallowing
Guaiac-positive stools
Hematuria
6. After a hypophysectomy, vasopressin is given IM for which of the
following reasons?
To treat growth failure
To prevent syndrome of inappropriate antidiuretic hormone
(SIADH)
To reduce cerebral edema and lower intracranial pressure
To replace antidiuretic hormone (ADH) normally secreted by the
pituitary.
7. A client comes into the ER after hitting his head in an MVA. He’s
alert and oriented. Which of the following nursing interventions should
be done first?
Assess full ROM to determine extent of injuries
Call for an immediate chest x-ray
Immobilize the client’s head and neck
Open the airway with the head-tilt-chin-lift maneuver
8. A client with a C6 spinal injury would most likely have which of the
following symptoms?
Aphasia
Hemiparesis
Paraplegi
a 4.
Tetraplegia
9. . A client with a T1 spinal cord injury arrives at the emergency
department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis
of the lower extremities. Which of the following conditions would most
likely be suspected?
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