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Nur 336 ICR practice questions with complete solutions
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Nur 336 ICR practice questions with complete solutions
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Nur 336 ICR practice questions with complete solutions6. Which patient below is at MOST risk for increased
intracranial pressure?
A. A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brain injury.
C. A patient who recently experienced a myocardial infarction.
D. A patient post-op from eye surgery. Correct Answers B. A
patient who is admitted with a traumatic brain injury.
A 5-year-old girl sustained a concussion when she fell out of a
tree. In preparation for discharge, the nurse is discussing home
care with her mother. Which statement made by the mother
indicates a correct understanding of the teaching?
a. I should expect my child to have a few episodes of vomiting.
b. If I notice sleep disturbances, I should contact the physician
immediately.
c. I should expect my child to have some behavioral changes
after the accident.
d. If I notice diplopia, I will have my child rest for 1 hour.
Correct Answers c. I should expect my child to have some
behavioral changes after the accident.
A client admitted to the hospital with a subarachnoid
hemorrhage has complaints of severe headache, nuchal rigidity,
and projectile vomiting. The nurse knows lumbar puncture (LP)
would be contraindicated in this client in which of the following
circumstances?
A. Vomiting continues.
B. Intracranial pressure (ICP) is increased.
C. The client needs mechanical ventilation.
,D. Blood is anticipated in the cerebrospinal fluid (CSF).
Correct Answers B. Intracranial pressure (ICP) is increased.
A client arrives in the emergency department with an ischemic
stroke and receives tissue plasminogen activator (t-PA)
administration. Which is the priority nursing assessment?
A. Time of onset of current stroke
B. Complete physical and history
C. Current medications
D. Upcoming surgical procedures Correct Answers A. Time of
onset of current stroke
A client in the emergency department is having a stroke and the
provider has prescribed the tissue plasminogen activator (t-PA)
alteplase (Activase). The client weighs 146 pounds. How much
medication will this client receive? (Record your answer using a
whole number.) _____ mg Correct Answers 60
A client in the emergency department is having a stroke. The
client weighs 225 pounds. After the initial bolus of t-Pa, at what
rate should the nurse set the IV pump? (Record your answer
using a decimal rounded to the nearest tenth.) ____ mL/hr
Correct Answers 1.4ml/hr
A client with a minor head injury has a Glasgow Coma Scale
score of 15 out of 15. What does this score indicate to the nurse?
(Select all that apply.)
A. Client withdraws to touch.
B. Client uses appropriate words and phrases.
C. Client spontaneously opens the eyes.
D. Client is oriented to person, place, and time.
,E. Client withdraws to pain. Correct Answers B. Client uses
appropriate words and phrases.
C. Client spontaneously opens the eyes.
D. Client is oriented to person, place, and time.
A client with a traumatic brain injury is intubated and placed on
mechanical ventilation. Which measurement should the nurse
use to evaluate the effectiveness of these respiratory
interventions?
A. Glasgow Coma Scale score
B. Cranial nerve function
C. Arterial blood gas results
D. Motor and sensory function Correct Answers C. Arterial
blood gas results
A client with subdural hematoma was given mannitol to
decrease intracranial pressure (ICP). Which of the following
results would best show the mannitol was effective?
A. Urine output increases.
B. Pupils are 8 mm and nonreactive.
C. Systolic blood pressure remains at 150 mm Hg.
D. BUN and creatinine levels return to normal. Correct
Answers A. Urine output increases.
A nurse assesses a client with the National Institutes of Health
(NIH) Stroke Scale and determines the clients score to be 36.
How should the nurse plan care for this client?
a. The client will need near-total care.
b. The client will need cuing only.
c. The client will need safety precautions.
, d. The client will be discharged home. Correct Answers a. The
client will need near-total care.
A nurse at a rehabilitation center is planning care for a client
who had a left hemispheric stroke 3 weeks ago. Which of the
following goals should the nurse include int he client's rehab
program?
a. Establish the ability to communicate effectively
b. Compensate for loss of depth perception
c. Learn to control impulsive behavior
d. Improve left-side motor function Correct Answers Establish
the ability to communicate effectively
A nurse cares for older clients who have traumatic brain injury.
What should the nurse understand about this population? (Select
all that apply.)
a. Admission can overwhelm the coping mechanisms for older
clients
b. Alcohol is typically involved in most traumatic brain injuries
for this age group.
c. These clients are more susceptible to systemic and wound
infections
d. Other medical conditions can complicate treatment for these
clients
e. Very few traumatic brain injuries occur in this age group.
Correct Answers a. Admission can overwhelm the coping
mechanisms for older clients
c. These clients are more susceptible to systemic and wound
infections
d. Other medical conditions can complicate treatment for these
clients
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