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Test Bank for Neuroscience, 6th Edition by Laurie Lundy-Ekman 2024
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Test Bank for Neuroscience, 6th Edition by Laurie Lundy-Ekman 2024
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Test Bank for Neuroscience, 6th Edition byLaurie Lundy-Ekman 2024
A 39-year-old patient with a suspected herniated intervertebral disc is scheduled for a
myelogram. Which information is most important for the nurse to communicate to the
health care provider before the procedure?
a. The patient is anxious about the test.
b. The patient has an allergy to shellfish.
c. The patient has back pain when lying flat.
d. The patient drank apple juice 4 hours earlier. - b. The patient has an allergy to
shellfish.
Iodine-containing contrast medium is injected into the subarachnoid space during a
myelogram. The health care provider may need to modify the postmyelogram orders to
prevent back pain, but this can be done after the procedure. Clear liquids are usually
considered safe up to 4 hours before a diagnostic or surgical procedure. The patients
anxiety should be addressed, but this is not as important as the iodine allergy.
The priority nursing assessment for a 72-year-old patient being admitted with a
brainstem infarction is
a. reflex reaction time.
b. pupil reaction to light.
c. level of consciousness.
d. respiratory rate and rhythm. - d. respiratory rate and rhythm.
Vital centers that control respiration are located in the medulla, and these are the
priority assessments because changes in respiratory function may be life threatening.
The other information will also be collected by the nurse, but it is not as urgent.
Several patients have been hospitalized for diagnosis of neurologic problems. Which
patient will the nurse assess first?
a. Patient with a transient ischemic attack (TIA) returning from carotid duplex studies
b. Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram
c. Patient with a seizure disorder who has just completed an electroencephalogram
(EEG)
d. Patient prepared for a lumbar puncture whose health care provider is waiting for
assistance - b. Patient with a brain tumor who has just arrived on the unit after a
cerebral angiogram
,Because cerebral angiograms require insertion of a catheter into the femoral artery,
bleeding is a possible complication. The nurse will need to check the pulse, blood
pressure, and the catheter insertion site in the groin as soon as the patient arrives.
Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the
lumbar puncture as soon as possible, but monitoring for hemorrhage after cerebral
angiogram has a higher priority.
Which assessments will the nurse make to monitor a patients cerebellar function (select
all that apply)?
a. Assess for graphesthesia.
b. Observe arm swing with gait.
c. Perform the finger-to-nose test.
d. Check ability to push against resistance.
e. Determine ability to sense heat and cold. - b. Observe arm swing with gait.
c. Perform the finger-to-nose test.
The cerebellum is responsible for coordination and is assessed by looking at the
patients gait and the finger-to-nose test. The other assessments will be used for other
parts of the neurologic assessment.
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. - b. The monitoring system helps show whether blood flow to the brain is
adequate.
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 - a. Blood pressure 154/68, pulse
56, respirations 12
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory
changes represent Cushings 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. - c. decorticate posturing.
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 the flexion is generalized, it does not indicate localization of pain or
flexion withdrawal.
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious
patient. Which parameter should the nurse monitor to determine the medications
effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit - c. Intracranial pressure
Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial
pressure. It may initially reduce hematocrit and increase blood pressure, but these are
not the best parameters for evaluation of the effectiveness of the drug. Oxygen
saturation will not directly improve as a result of mannitol administration.
A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses
when stimulated, and does not respond to a verbal command to move but attempts to
push away a painful stimulus. The nurse records the patients Glasgow Coma Scale
score as
a. 9.
b. 11.
c. 13.
d. 15. - b. 11.
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best
motor response.
An unconscious 39-year-old male patient is admitted to the emergency department (ED)
with a head injury. The patients spouse and teenage children stay at the patients side
and ask many questions about the treatment being given. What action is best for the
nurse to take?
a. Ask the family to stay in the waiting room until the initial assessment is completed.
, b. Allow the family to stay with the patient and briefly explain all procedures to them.
c. Refer the family members to the hospital counseling service to deal with their anxiety.
d. Call the familys pastor or spiritual advisor to take them to the chapel while care is
given. - b. Allow the family to stay with the patient and briefly explain all procedures to
them.
The need for information about the diagnosis and care is very high in family members of
acutely ill patients. The nurse should allow the family to observe care and explain the
procedures unless they interfere with emergent care needs. A pastor or counseling
service can offer some support, but research supports information as being more
effective. Asking the family to stay in the waiting room will increase their anxiety.
A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral
tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be
included in the plan of care?
a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods. - c. Keep the head of the bed
elevated to 30 degrees.
The patient with increased intracranial pressure (ICP) should be maintained in the head-
up position to help reduce ICP. Extreme flexion of the hips and knees increases
abdominal pressure, which increases ICP. Because the stimulation associated with
nursing interventions increases ICP, clustering interventions will progressively elevate
ICP.
A 20-year-old male patient is admitted with a head injury after a collision while playing
football. After noting that the patient has developed clear nasal drainage, which action
should the nurse take?
a. Have the patient gently blow the nose.
b. Check the drainage for glucose content.
c. Teach the patient that rhinorrhea is expected after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity. - b. Check the
drainage for glucose content.
Clear nasal drainage in a patient with a head injury suggests a dural tear and
cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose.
Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will
not be useful. Blowing the nose is avoided to prevent CSF leakage.
Which action will the emergency department nurse anticipate for a patient diagnosed
with a concussion who did not lose consciousness?
a. Coordinate the transfer of the patient to the operating room.
b. Provide discharge instructions about monitoring neurologic status.
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