Knowing is not enough; we must apply.

Willing is not enough; we must do.

~ Johann Wolfgang von Goethe

4. Dilantin should be administered through an IV catheter in the clients

hand.

3. A client with head trauma develops a urine output of 300 ml/hr,

Topics

dry skin, and dry mucous membranes. Which of the following

Included topics in this practice quiz are:

nursing interventions is the most appropriate to perform initially?

1. Evaluate urine specific gravity

Autonomic Dysreflexia

Cerebral Hemorrhage

Craniotomy

Epidural Hematoma

Headache

Head Trauma

Intracranial Pressure

Quadriplegia

Seizures

1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial

Spinal Cord Injury

pressure (ICP).

Spinal Shock

2. Emergent; the client is poorly oxygenated.

Subarachnoid Hemorrhage

3. Normal

Transsphenoidal Hypophysectomy

4. Significant; the client has alveolar hypoventilation.

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?

1. Reposition the client to avoid neck flexion

2. Administer 1 g Mannitol IV as ordered
3. Increase the ventilators respiratory rate to 20 breaths/minute
4. Administer 100 mg of pentobarbital IV as ordered.

2. A client with a subarachnoid hemorrhage is prescribed a 1,000mg 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.
3. Dilantin should be mixed in dextrose in water before administration.

2. Anticipate treatment for renal failure

3. Provide emollients to the skin to prevent breakdown
4. Slow down the IV fluids and notify the physician

4. 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?

5. A client who had a transsphenoidal hypophysectomy should be

watched carefully for hemorrhage, which may be shown by which
of the following signs?

1. Bloody drainage from the ears

2. Frequent swallowing
3. Guaiac-positive stools
4. Hematuria

6. After a hypophysectomy, vasopressin is given IM for which of

the following reasons?

1. To treat growth failure

2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH)
3. To reduce cerebral edema and lower intracranial pressure
4. To replace antidiuretic hormone (ADH) normally secreted by the
pituitary.

7. A client comes into the ER after hitting his head in an MVA.

3. Methylprednisolone (Solu-Medrol)

Hes alert and oriented. Which of the following nursing

4. Sodium bicarbonate

interventions should be done first?

12. A 22-year-old client with quadriplegia is apprehensive and
1. Assess full ROM to determine extent of injuries

flushed, with a blood pressure of 210/100 and a heart rate of 50

2. Call for an immediate chest x-ray

bpm. Which of the following nursing interventions should be

3. Immobilize the clients head and neck

done first?

4. Open the airway with the head-tilt-chin-lift maneuver

1. Place the client flat in bed
8. A client with a C6 spinal injury would most likely have which of

2. Assess patency of the indwelling urinary catheter

the following symptoms?

3. Give one SL nitroglycerin tablet

4. Raise the head of the bed immediately to 90 degrees

1. Aphasia
2. Hemiparesis

13. A client with a cervical spine injury has Gardner-Wells tongs

3. Paraplegia

inserted for which of the following reasons?

4. Tetraplegia
1. To hasten wound healing
9. A 30-year-old was admitted to the progressive care unit with a

2. To immobilize the cervical spine

C5 fracture from a motorcycle accident. Which of the following

3. To prevent autonomic dysreflexia

assessments would take priority?

4. To hold bony fragments of the skull together

1. Bladder distension

14. Which of the following interventions describes an appropriate

2. Neurological deficit

bladder program for a client in rehabilitation for spinal cord

3. Pulse ox readings

injury?

4. The clients feelings about the injury

1. Insert an indwelling urinary catheter to straight drainage
10. While in the ER, a client with C8 tetraplegia develops a blood

2. Schedule intermittent catheterization every 2 to 4 hours

pressure of 80/40, pulse 48, and RR of 18. The nurse suspects

3. Perform a straight catheterization every 8 hours while awake

which of the following conditions?

4. Perform Credes maneuver to the lower abdomen before the client

voids.

1. Autonomic dysreflexia
2. Hemorrhagic shock

15. A client is admitted to the ER for head trauma is diagnosed

3. Neurogenic shock

with an epidural hematoma. The underlying cause of epidural

4. Pulmonary embolism

hematoma is usually related to which of the following conditions?

11. A client is admitted with a spinal cord injury at the level of

1. Laceration of the middle meningeal artery

T12. He has limited movement of his upper extremities. Which of

2. Rupture of the carotid artery

the following medications would be used to control edema of the

3. Thromboembolism from a carotid artery

spinal cord?

4. Venous bleeding from the arachnoid space

1. Acetazolamide (Diamox)

16. A 23-year-old client has been hit on the head with a baseball

2. Furosemide (Lasix)

bat. The nurse notes clear fluid draining from his ears and nose.

Which of the following nursing interventions should be done

21. During an episode of autonomic dysreflexia in which the client

first?

becomes hypertensive, the nurse should perform which of the

following interventions?

1. Position the client flat in bed

2. Check the fluid for dextrose with a dipstick

1. Elevate the clients legs

3. Suction the nose to maintain airway patency

2. Put the client flat in bed

4. Insert nasal and ear packing with sterile gauze

3. Put the client in the Trendelenburgs position

4. Put the client in the high-Fowlers position

17. When discharging a client from the ER after a head trauma,

the nurse teaches the guardian to observe for a lucid interval.

22. A client with a T1 spinal cord injury arrives at the emergency

Which of the following statements best described a lucid interval?

department with a BP of 82/40, pulse 34, dry skin, and flaccid

paralysis of the lower extremities. Which of the following

1. An interval when the clients speech is garbled

conditions would most likely be suspected?

2. An interval when the client is alert but cant recall recent events
3. An interval when the client is oriented but then becomes somnolent

1. Autonomic dysreflexia

4. An interval when the client has a warning symptom, such as an

2. Hypervolemia

odor or visual disturbance.

3. Neurogenic shock
4. Sepsis

18. Which of the following clients on the rehab unit is most likely
to develop autonomic dysreflexia?

23. A client has a cervical spine injury at the level of C5. Which of
the following conditions would the nurse anticipate during

1. A client with a brain injury

the acute phase?

2. A client with a herniated nucleus pulposus

3. A client with a high cervical spine injury

1. Absent corneal reflex

4. A client with a stroke

2. Decerebrate posturing
3. Movement of only the right or left half of the body

19. Which of the following conditions indicates that spinal shock

4. The need for mechanical ventilation

is resolving in a client with C7 quadriplegia?

24. A client with C7 quadriplegia is flushed and anxious and
1. Absence of pain sensation in chest

complains of a pounding headache. Which of the following

2. Spasticity

symptoms would also be anticipated?

3. Spontaneous respirations
4. Urinary continence

1. Decreased urine output or oliguria

2. Hypertension and bradycardia

20. A nurse assesses a client who has episodes of autonomic

dysreflexia. Which of the following conditions can cause

3. Respiratory depression
4. Symptoms of shock

autonomic dysreflexia?
25. A 40-year-old paraplegic must perform
1. Headache

intermittent catheterization of the bladder. Which of the following

2. Lumbar spinal cord injury

instructions should be given?

3. Neurogenic shock
4. Noxious stimuli

1. Clean the meatus from back to front.

3. Epidural hematoma

2. Measure the quantity of urine.

4. Contusion

3. Gently rotate the catheter during removal.

4. Clean the meatus with soap and water.

30. After falling 20, a 36-year-old man sustains a C6 fracture with

spinal cord transaction. Which other findings should the nurse

26. An 18-year-old client was hit in the head with a baseball during

expect?

practice. When discharging him to the care of his mother, the

nurse gives which of the following instructions?

1. Quadriplegia with gross arm movement and diaphragmatic breathing

2. Quadriplegia and loss of respiratory function

1. Watch him for keyhole pupil the next 24 hours.

3. Paraplegia with intercostal muscle loss

2. Expect profuse vomiting for 24 hours after the injury.

4. Loss of bowel and bladder control

3. Wake him every hour and assess his orientation to person, time,
and place.
4. Notify the physician immediately if he has a headache.

31. A 20-year-old client who fell approximately 30 is unresponsive

and breathless. A cervical spine injury is suspected. How should
the first-responder open the clients airway for rescue breathing?

27. Which neurotransmitter is responsible for may of the

functions of the frontal lobe?

1. By inserting a nasopharyngeal airway

2. By inserting a oropharyngeal airway

1. Dopamine

3. By performing a jaw-thrust maneuver

2. GABA

4. By performing the head-tilt, chin-lift maneuver

3. Histamine
4. Norepinephrine

32. The nurse is caring for a client with a T5 complete spinal cord
injury. Upon assessment, the nurse notes flushed skin,

28. The nurse is discussing the purpose of an

diaphoresis above the T5, and a blood pressure of 162/96. The

electroencephalogram (EEG) with the family of a client with

client reports a severe, pounding headache. Which of the

massive cerebral hemorrhage and loss of consciousness. It

following nursing interventions would be appropriate for this

would be most accurate for the nurse to tell family members that

client? Select all that apply.

the test measures which of the following conditions?

1. Elevate the HOB to 90 degrees
1. Extent of intracranial bleeding

2. Loosen constrictive clothing

2. Sites of brain injury

3. Use a fan to reduce diaphoresis

3. Activity of the brain

4. Assess for bladder distention and bowel impaction

4. Percent of functional brain tissue

5. Administer antihypertensive medication

6. Place the client in a supine position with legs elevated

29. A client arrives at the ER after slipping on a patch of ice and

hitting her head. A CT scan of the head shows a collection of

33. The client with a head injury has been urinating copious

blood between the skull and dura mater. Which type of head

amounts of dilute urine through the Foley catheter. The clients

injury does this finding suggest?

urine output for the previous shift was 3000 ml. The nurse
implements a new physician order to administer:

1. Subdural hematoma
2. Subarachnoid hemorrhage

1. Desmopressin (DDAVP, Stimate)

3. Moving the client quickly as one unit

2. Dexamethasone (Decadron)

4. Applying Teds or compression stockings.

3. Ethacrynic acid (Edecrin)

4. Mannitol (Osmitrol)

38. The nurse is caring for a client admitted with spinal cord
injury. The nurse minimizes the risk of compounding the injury

34. The nurse is caring for the client in the ER following a head

most effectively by:

injury. The client momentarily lost consciousness at the time of

the injury and then regained it. The client now has lost

1. Keeping the client on a stretcher

consciousness again. The nurse takes quick action, knowing this

2. Logrolling the client on a firm mattress

is compatible with:

3. Logrolling the client on a soft mattress

4. Placing the client on a Stryker frame

1. Skull fracture
2. Concussion
3. Subdural hematoma
4. Epidural hematoma

39. The nurse is evaluating neurological signs of the male client in

spinal shock following spinal cord injury. Which of the following
observations by the nurse indicates that spinal shock persists?

35. The nurse is caring for a client who suffered a spinal cord

1. Positive reflexes

injury 48 hours ago. The nurse monitors for GI complications by

2. Hyperreflexia

assessing for:

3. Inability to elicit a Babinskis reflex

4. Reflex emptying of the bladder

1. A flattened abdomen
2. Hematest positive nasogastric tube drainage
3. Hyperactive bowel sounds
4. A history of diarrhea

40. A client with a spinal cord injury suddenly experiences an

episode of autonomic dysreflexia. After checking the clients vital
signs, list in order of priority, the nurses actions (Number 1 being
the first priority and number 5 being the last priority).

36. A client with a spinal cord injury is prone to experiencing

autonomic dysreflexia. The nurse would avoid which of the

1. Check for bladder distention

following measures to minimize the risk of recurrence?

2. Raise the head of the bed

3. Contact the physician

1. Strict adherence to a bowel retraining program

4. Loosen tight clothing on the client

2. Limiting bladder catheterization to once every 12 hours

5. Administer an antihypertensive medication

3. Keeping the linen wrinkle-free under the client

4. Preventing unnecessary pressure on the lower limbs

41. A client is at risk for increased ICP. Which of the following

would be a priority for the nurse to monitor?

37. The nurse is planning care for the client in spinal shock.
Which of the following actions would be least helpful in

1. Unequal pupil size

minimizing the effects of vasodilation below the level of the

2. Decreasing systolic blood pressure

injury?

3. Tachycardia
4. Decreasing body temperature

1. Monitoring vital signs before and during position changes

2. Using vasopressor medications as prescribed

42. Which of the following respiratory patterns indicate increasing

ICP in the brain stem?

1. Slow, irregular respirations

47. A client receiving vent-assisted mode ventilation begins to

2. Rapid, shallow respirations

experience cluster breathing after recent intracranial

3. Asymmetric chest expansion

occipital bleeding. Which action would be most appropriate?

4. Nasal flaring
1. Count the rate to be sure the ventilations are deep enough to be
43. Which of the following nursing interventions is appropriate for

sufficient

a client with an ICP of 20 mm Hg?

2. Call the physician while another nurse checks the vital signs and
ascertains the patients Glasgow Coma score.

1. Give the client a warming blanket

3. Call the physician to adjust the ventilator settings.

2. Administer low-dose barbiturate

4. Check deep tendon reflexes to determine the best motor response

3. Encourage the client to hyperventilate

4. Restrict fluids

48. In planning the care for a client who has had a posterior fossa
(infratentorial) craniotomy, which of the following

44. A client has signs of increased ICP. Which of the following is

is contraindicated when positioning the client?

an early indicator of deterioration in the clients condition?

1. Keeping the client flat on one side or the other
1. Widening pulse pressure

2. Elevating the head of the bed to 30 degrees

2. Decrease in the pulse rate

3. Log rolling or turning as a unit when turning

3. Dilated, fixed pupil

4. Keeping the head in neutral position

4. Decrease in LOC
49. A client has been pronounced brain dead. Which findings
45. A client who is regaining consciousness after a craniotomy

would the nurse assess? Check all that apply.

becomes restless and attempts to pull out her IV line. Which

nursing intervention protects the client without increasing her

1. Decerebrate posturing

ICP?

2. Dilated nonreactive pupils

3. Deep tendon reflexes

1. Place her in a jacket restraint

4. Absent corneal reflex

2. Wrap her hands in soft mitten restraints

3. Tuck her arms and hands under the draw sheet

50. A 23-year-old patient with a recent history of encephalitis is

4. Apply a wrist restraint to each arm

admitted to the medical unit with new onset generalized tonicclonic seizures. Which nursing activities included in the patients

46. Which of the following describes decerebrate posturing?

1. Internal rotation and adduction of arms with flexion of elbows, wrists,

care will be best to delegate to an LPN/LVN whom you are

supervising?

and fingers

1. Document the onset time, nature of seizure activity, and postictal

2. Back hunched over, rigid flexion of all four extremities with

behaviors for all seizures.

supination of arms and plantar flexion of the feet

2. Administer phenytoin (Dilantin) 200 mg PO daily.

3. Supination of arms, dorsiflexion of feet

3. Teach patient about the need for good oral hygiene.

4. Back arched; rigid extension of all four extremities.

4. Develop a discharge plan, including physician visits and referral to

the Epilepsy Foundation.