SOLVED

 Question 11 A nurse is assisting with a patient’s oculocephalic and oculovestibular reflex assessment. How should the nurse prepare for this testing? 1. Prepare for oculocephalic testing to be done after oculovestibular testing. 2. Ensure that cervical spine injury has been ruled out. 3. Obtain cold water and a syringe 4. Be certain there is no perforation of the tympanic membrane in the side being tested. 5. Tell the patient he will be asked to report any feeling of numbness or vertigo. Question 12 A patient with a head injury is being monitored with an intraventricular catheter. The nurse would design interventions based upon which priority nursing diagnosis (NDX)? 1. Risk for Injury 2. Decreased Intracranial Adaptive Capacity 3. Altered Comfort, Acute Pain 4. Risk for Infection Question 13 A patient with an intraventricular catheter for the assessment of increased intracranial pressure is demonstrating is demonstrating A waves. The nurse would assess for which other findings? 1. Decreasing level of consciousness 2. Pupillary changes 3. Posturing 4. Variations in blood pressure 5. Changes in the wave associated with respiration Question 14 A patient who sustained a traumatic brain injury is being sent for a CT scan. Which nursing statements would help the patient’s spouse understand the rationale for a CT scan rather than an MRI? 1. “CT scans are easier for patients with head injuries because movement is allowed.” 2. “We can get results from a CT scan quicker than from an MRI.” 3. “MRIs are more costly so the least expensive test is always done first.” 4. “CT scans are noninvasive.” 5. “CT scans show more detail than an MRI.” Question 15 The family of a comatose patient asks the nurse if there is any way to know if their loved one will ever “wake up.” The nurse should consider which test when formulating a response to this concern? 1. Evoked potentials 2. CT scan 3. Electroencephalogram 4. Lumbar puncture Question 16 A patient was the unrestrained driver of a car that was struck head on by another vehicle. During initial assessment the nurse observes another nurse using supraorbital pressure to assess for response. What nursing intervention is indicated? 1. Hold the patient’s head still so that the test will be valid. 2. Stop the procedure. 3. Ask the nurse to repeat the procedure on the other orbit. 4. Document the response as 1+, 2+, 3+, or 4+. Question 17 A nurse is preparing to conduct a neurological assessment on a patient who is not suspected for having neurological impairment. Which tests should the nurse perform? 1. Observation for level of consciousness 2. Checking pupillary response to light 3. Ability to count by serial 7s 4. Assessing the blood pressure 5. Visual acuity Question 18 Following a stroke a patient is diagnosed with expressive aphasia. What nursing intervention is indicated? 1. Speak slowly and face the patient directly when speaking. 2. Speak at a slightly louder volume. 3. Watch the patient carefully for behavioral clues. 4. Decrease environmental stimuli before attempting to communicate with the patient. Question 19 A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the patient extends his legs and demonstrates extreme plantar flexion. What action should be taken by the nurse? 1. Document the presence of decorticate posturing. 2. Immediately stop the attempt at intravenous insertion and obtain a blood pressure reading. 3. Assess the position of the patient’s arms. 4. Administer intravenous sedation as quickly as possible after access is obtained. Question 20 A nurse is assisting with a patient’s oculocephalic and oculovestibular reflex assessment. How should the nurse prepare for this testing? 1. Prepare for oculocephalic testing to be done after oculovestibular testing. 2. Ensure that cervical spine injury has been ruled out. 3. Obtain cold water and a syringe 4. Be certain there is no perforation of the tympanic membrane in the side being tested. 5. Tell the patient he will be asked to report any feeling of numbness or vertigo.