Download NUR 445-Exam 3: Neurological Disorders and Critical Care QUESTIONS AND ANSWERS 2025/2026 E and more Exams Nursing in PDF only on Docsity!
NUR 445-Exam 3
A client is hospitalized in ICU after a drug overdose. Which statement would the nurse interpret as indicating the client has normal mentation? (Select all that apply.)
- "Which part of the hospital am I in?"
- "I just want to die."
- "I should have swallowed the pills with bourbon."
- "Get that cat out of here."
- "My feet are cold." Answer: 1, 2, 3, 5 A client reports feeling very anxious and not being able to sleep. The nurse anticipates initially administering a drug from which class to treat these disorders?
- Opiate narcotics
- Benzodiazepines
- Antidepressants
- Neuromuscular blockers Answer: 2 Which characteristics would the nurse attribute to delirium rather than dementia? (Select all that apply.)
- The client's mentation was clear until he was hospitalized last week.
- The client does not recognize his children.
- The client has periods of clarity that alternate with confusion.
- The client's family reports his confusion has become steadily more pronounced over the last year
- The client continually tries to get out of bed stating, "I've got to get off this Answer: 1, 3
A nurse is concerned that a hospitalized client may be developing delirium. Which interventions are indicated? (Select all that apply.)
- Ask the family to bring the client's eyeglasses from home.
- Turn room lights down at night to encourage sleep.
- Maintain bed rest until mentation improves.
- Remove the television from the room.
- Review the client's medication list. Answer: 1, 2, 5 The nurse discovers a client having a seizure. What should be the nurse's initial action?
- Roll the client onto his or her side.
- Intubate the client immediately.
- Administer pentobarbital.
- Establish an IV line. Answer: 1 A client experiencing continued seizure activity is to be given propofol. The nurse should prepare for which other intervention?
- Administration of insulin
- Mechanical ventilation
- Placement of an oral airway
- Administration of a neuromuscular blocking agent Answer: 2 A client experienced an episode of vision loss and right-side weakness that lasted 4 hours before totally resolving. What information should the nurse provide to this client?
A patient who had a stroke has decreased level of consciousness, headache, and is vomiting. Using this information, which nursing diagnosis should the nurse assign?
- Impaired Skin Integrity
- Acute Pain
- Decreased Intracranial Adaptive Capacity
- Activity Intolerance Answer: 3 A client is receiving an infusion of tPA for treatment of acute ischemic stroke. The nurse would immediately discontinue this infusion if the client manifested which assessment finding? (Select all that apply.)
- Nausea
- Severe headache
- Elevation of blood pressure to 180/
- Atrial fibrillation
- Decrease in pedal pulse amplitude Answer: 1, 2, 3, 5 A client being treated for an ischemic stroke has vital signs of temperature: 39.0°C (102.2°F), blood pressure 160/90 mmHg, heart rate 98 bpm, and respirations 16 bpm. What action should the nurse take? (Select all that apply.)
- Continue to monitor
- Treat the temperature according to protocol
- STAT page the provider regarding the blood pressure
- Increase the client's oxygen delivery
- Accept these vital signs as normal for the client after ischemic stroke
Answer: 1, 2 The wife of a client who had a stroke says, "I'll never be able to care for him at home unless he can help me. When will therapy start to help him with walking?" Which answer, made by the nurse, is most appropriate?
- "Most stroke clients don't rebuild enough strength to help with their care."
- "The physical therapist will make that determination, and I'm certain they will talk with you about it then."
- "When he has some leg strength and balance back, we will start helping him learn to walk again."
- "As soon as his vital signs are stable, we will start walking therapy." Answer: 3 A client was just admitted for treatment of stroke. Assessment reveals a well-nourished 63-year-old male with left-sided weakness, a weak gag reflex, and difficulty swallowing. The nurse would anticipate initiating nutritional support for this client if he is unable to take oral nourishment by which time?
- Within 24 hours of discontinuation of IV therapy
- Within 2 days of return of gag reflex
- Within 5 days of admission
- Within 12 hours of diagnosis Answer: 3 The nurse is caring for a client who has right-sided weakness and Broca's aphasia following a stroke that occurred 36 hours ago. Which assessment instruction should the nurse use with this client?
- "Tell me what you were doing immediately before your illness."
- "Can you see anything at all out of your bad eye?"
- "Lift your unaffected arm up as much as you can."
- "Describe the sensations you have in your good leg." Answer: 3
A client sustained a brain injury when struck by a falling tree limb. Upon admission to the emergency department (ED) the client's Glasgow Coma Score was 10. What interventions will the ED nurse expect to manage? (Select all that apply.)
- Explanation of brain injury surveillance as discharge instructions
- Skull x-rays
- CT scan
- Hospital admission
- Placement of an indwelling urinary catheter Answer: 2, 3, 4 A client has an expanding epidural hematoma and is taken to the OR to have it evacuated. The client returns to the ICU ventilated and with an intraventricular catheter in place. According to Brain Trauma Foundation Guidelines, what is the minimal cerebral perfusion pressure (CPP) desired to reduce secondary injury in this client?
- 50 mm Hg
- 60 mm Hg
- 70 mm Hg
- 80 mm Hg Answer: 2 A client who sustained a traumatic brain injury develops abrupt hypertension, bradycardia, and an irregular breathing pattern. The nurse immediately collaborates with the healthcare provider for which reason?
- The client needs additional pain medication.
- Anxiety is building that may cause additional problems.
- Herniation may be occurring.
- Brain death is occurring. Answer: 3
A client in the ICU who sustained a traumatic brain injury is being mechanically ventilated. Which nursing interventions should be implemented to manage increased intracranial pressure? (Select all that apply.)
- Position the client supine with head of bed flat.
- Preoxygenate the client if suctioning is needed.
- Keep the client's neck in a neutral position.
- Elevate the head of the bed by 30 degrees.
- Provide pain medication. Answer: 2, 3, 4, 5 The nurse has attempted to control a client's increased intracranial pressure with level one interventions, but the attempt has failed. The nurse discusses this situation with the neurosurgeon and anticipates which order?
- Preparing the client for an emergent decompressive craniotomy
- Administering hypertonic saline by IV bolus
- Administering DDAVP
- Aggressively hyperventilating the client Answer: 2 A 16-year-old football player sustained a mild concussion and was brought to the ED. Loss of consciousness lasted about five minutes. Which interventions would the nurse plan to provide for this client? (Select all that apply.)
- Observing the client in the ED for 1-2 hours
- Providing the parents with brain injury observations instructions before discharge
- Providing the nurse on the unit with a detailed client report when admitting the client to the hospital
- Discussing the possibility of postconcussive syndrome with the client and parents
- Tetraplegia
- No impairment Answer: 1 A patient has sustained a spinal cord injury. The nurse asks the patient to close her eyes while the nurse moves the big toe up and down, having the patient state the direction in which the toe moves. What is the nurse assessing with this technique?
- Priapism
- Proprioception
- Dermatomes
- Sensation Answer: 2 A patient who sustained a C4-5 fracture subluxation has been placed in Gardner-Well tong traction with 20 pounds of weight. The patient is alert and oriented and complaining of neck pain and spasms. Which nursing intervention should be implemented?
- Remove 10 pounds of weight from the traction apparatus.
- Administer PRN muscle relaxants.
- Report this unusual finding to the surgeon immediately.
- Place a pillow under the patient's neck with ice bags to the side. Answer: 2 A patient sustained a C4 spinal cord injury 3 weeks ago. This morning the patient's BP is 204/110, heart rate is 45, and the patient is complaining of a headache. What should the nurse do? (Select all that apply.)
- Administer antihypertensive medications immediately.
- Encourage the patient to rest and plan to recheck blood pressure in 30 minutes.
- Elevate the head of the bed.
- Check for a source of noxious stimuli.
- Order a stat 12-lead ECG. Answer: 3, 4 A patient is diagnosed with a lower motor neuron lesion. The nurse uses this information to plan care for which condition?
- Permanent loss of bladder function
- Flaccid paralysis
- Contralateral motor weakness
- Spastic paralysis Answer: 2 A patient who has a spinal cord injury has been admitted to the ICU. Which factors, associated with the development of decreased cardiac output, are essential for the nurse to monitor? (Select all that apply.)
- Orthostatic hypotension
- Neurogenic shock
- Venous pooling
- Bradycardia
- Atelectasis Answer: 1, 2, 3, 4 A patient sustained an injury to the right side of the neck 3 years ago that resulted in Brown- Séquard syndrome. The nurse admitting the patient to the hospital for an elective surgery would expect which assessment findings? (Select all that apply.)
- Loss of voluntary motor movement on the right
- Loss of temperature sensation on the left
- Prepare a chest tube drainage tray. Answer: 2 A patient has experienced blunt trauma in a motor vehicle crash. The ED nurse would consider which forces while discussing mechanism of injury with the paramedic team? (Select all that apply.)
- Acceleration
- Axial loading
- Deceleration
- Mass
- Shearing Answer: 1, 3, 5 A patient admitted after a motor vehicle crash is 36 weeks pregnant. After spinal injury has been ruled out, how should the nurse position the patient?
- Supine with head of bed flat
- Prone
- Supine with head of bed raised 30 degrees
- Left lateral decubitus Answer: 4 A patient, admitted after falling, is unconscious and has open fractures to both femurs. Initial assessment reveals diminished breath sounds bilaterally despite chest wall movements of breathing. What is the nurse's priority intervention?
- Roll the patient to the left side.
- Tilt the patient's head back to open the airway.
- Do a blind finger sweep of the oral pharynx.
- Perform a modified jaw thrust maneuver.
Answer: 4 Paramedics report that a patient was the restrained driver of a vehicle that struck a bridge abutment. Time of injury was approximately 30 minutes ago. Which assessment findings would alert the nurse to the possibility of a ruptured spleen? (Select all that apply.)
- Decreased lung sounds on the right side
- Hypotension with no obvious hemorrhage
- Presence of seat belt abrasions
- Distention of the abdomen
- Patient is unconscious Answer: 2, 3, 4 A patient who was admitted to the emergency department after a gunshot wound to the chest is hemorrhaging. What interventions should the nurse anticipate? (Select all that apply.)
- Initiation of IV access with two large-bore catheters
- Administration of IV vasopressors
- Administration of packed red blood cells
- Rapid administration of IV fluid
- Open resuscitative thoracotomy Answer: 1, 3, 4, 5 A patient has been admitted with multiple trauma injury. What assessments should make the nurse suspect that a posttrauma complication has occurred? (Select all that apply.)
- Warm, dry skin
- Decreased urine output
- Decreased white blood cell count
- "You may experience belching and a bloated feeling for a few hours after you get home."
- "Call the healthcare provider's office if you have any fever." Answer: 2, 4, 5 A patient presents to the emergency department with complaints of fatigue. Testing reveals anemia secondary to a gastrointestinal bleed. The patient says, "How could that be true? I have never seen blood in my stools." What is the nurse's best response? (Select all that apply.)
- "You must just have not noticed it."
- "Sometimes the blood is occult, which means you can't see it."
- "The blood may have made your stools black, not red."
- "The stools have to be tested to determine if blood is present."
- "If your stools are dark and sticky, it may be due to the presence of blood." Answer: 2, 3, 5 Answer: 2, 3, 5 A 45-year-old man is diagnosed with a duodenal ulcer. He asks, "Now that I have an ulcer, what comes next?" What is the nurse's best response?
- "Most peptic ulcers heal with medical treatment."
- "People who have gastric ulcers have to accept that they will have pain when they eat."
- "Early surgery is usually advised, especially for duodenal ulcers."
- "If ulcers are untreated, cancer of the stomach will develop." Answer: 1 A patient who has history of ulcerative colitis has been hospitalized for repair of a fractured humerus. A combination of which findings would prompt the nurse to collaborate with the healthcare provider regarding a transfer to the ICU? (Select all that apply.)
- The patient vomits coffee-ground material.
- The patient's BUN drops.
- The patient's stool is hemoccult positive.
- The patient is tachycardic.
- The patient is hypotensive. Answer: 1, 3, 4 A patient who has a history of esophageal varices is vomiting blood. Which initial intervention does the nurse anticipate?
- Administration of an antiemetic
- Endotracheal intubation
- Laboratory analysis of the emesis
- STAT chest x-ray Answer: 2 A patient has been diagnosed with a bowel obstruction. Which nursing intervention is indicated?
- Rapid initiation of parenteral feeding
- STAT soapsuds enema
- Insertion of a nasogastric tube
- Digital evacuation of stool mass Answer: 3 A patient has developed intraabdominal hypertension (IAH). The nurse monitors for findings associated with which complication?
- Bacterial translocation
- Increased peristalsis
- Increased production of mucus
Answer: 3 A patient is receiving lactulose (Cephulac). Which findings would the nurse evaluate as indicating this medication is having the desired effects? (Select all that apply.)
- The patient's serum ammonia level is dropping.
- The patient is having two to four soft stools daily.
- The patient's hemoglobin level has stabilized.
- The patient has stopped vomiting.
- The patient's urine output has increased to above 45 mL/hr. Answer: 1, 2 A 48-year-old woman has just been diagnosed with hemorrhagic pancreatitis. Which statement by the nurse is most accurate?
- "You will be over this problem in less than a week."
- "You will get well very quickly once the correct antibiotics are prescribed."
- "You may feel sick for a month or more, but no one dies from this disorder."
- "A common cause of this problem in women is gallbladder disease." Answer: 4 A patient has experienced intermittent abdominal pain for the last 6 months and is being evaluated for possible pancreatitis. The nurse would expect serial serum lipase levels to be drawn rather than serum amylase levels for which reason?
- Serum lipase levels are more accurate.
- Serum lipase is more sensitive to pancreatitis.
- Serum lipase remains elevated for a longer period.
- Serum lipase requires no special analysis technique. Answer: 3
A patient is being admitted to the hospital for treatment of hemorrhagic pancreatitis. The emergency department report indicates that the patient has a positive Cullen's sign. The nurse admitting the patient would look for which manifestation?
- Decreased bowel sounds in the left upper quadrant
- Bruising over the high epigastric area
- Bluish discoloration around the umbilicus
- Decreased deep tendon reflexes in the lower extremities Answer: 3 The nurse is writing a plan of care for a patient who was just admitted with acute pancreatitis. The nurse would include monitoring for which major pulmonary complications? (Select all that apply.)
- Influenza
- Pleural effusion
- Hypoxia
- Respiratory failure
- Pneumonia Answer: 2, 3, 4, 5 The nurse closely observes a patient admitted with acute pancreatitis for respiratory complications related to ineffectiveness of breathing pattern. Which situations will increase the patient's risk for this problem? (Select all that apply.)
- The patient's abdominal pain is severe and difficult to manage.
- The patient has a history of hepatitis C.
- The patient is taking opioids for pain relief.
- The patient's diaphragmatic excursion is diminished.
- The patient's position of comfort is sitting up in bed.
