Exam 2 questions

A nurse is caring for a client with increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

A. Blood pressure 118/72 mm Hg

B. Heart rate 44/min and irregular respirations

C. Temperature 37.4°C (99.3°F)

D. Pain rating 4/10

B. Heart rate 44/min and irregular respirations (This suggests Cushing's triad and impending brain herniation.)

A nurse is caring for a client with a head injury. Which intervention should the nurse include in the plan of care to decrease ICP?

A. Place the client in Trendelenburg position

B. Flex the client's hips 90 degrees

C. Elevate the head of the bed 30 degrees

D. Encourage coughing every hour

C. Elevate the head of the bed 30 degrees (Promotes venous drainage and decreases ICP.)

Which manifestations are associated with increased intracranial pressure? (Select all that apply)

A. Projectile vomiting

B. Decreased level of consciousness

C. Bradycardia

D. Hypotension

E. Pupillary changes

A, B, C, E (Hypotension is not typically associated with ICP.)

A nurse is calculating cerebral perfusion pressure (CPP). Which CPP value indicates adequate cerebral perfusion?

A. 30 mm Hg

B. 45 mm Hg

C. 75 mm Hg

D. 50 mm Hg

C. 75 mm Hg (Normal CPP is 60–100 mm Hg.)

A nurse is caring for a client who suddenly develops right-sided weakness and expressive aphasia. Which cerebral hemisphere is most likely affected?

A. Right hemisphere

B. Left hemisphere

C. Cerebellum

D. Brainstem

B. Left hemisphere (Language centers are usually located in the left hemisphere.)

A nurse is caring for a client experiencing an acute ischemic stroke. Which action should the nurse take first?

A. Obtain a complete health history

B. Assess airway patency

C. Administer aspirin

D. Initiate physical therapy

B. Assess airway patency (ABCs take priority.)

Which finding would contraindicate administration of alteplase (tPA)?

A. Blood glucose 110 mg/dL

B. Symptom onset 1 hour ago

C. Active internal bleeding

D. Age 70 years

C. Active internal bleeding (Major contraindication to thrombolytic therapy.)

A nurse is caring for a client receiving alteplase. Which finding requires immediate intervention?

A. Mild nausea

B. Headache and decreased LOC

C. Fatigue

D. Dry mouth

B. Headache and decreased LOC (Possible intracranial hemorrhage.)

A nurse is teaching a client with dysphagia following a stroke. Which statement indicates understanding?

A. "I will drink liquids through a straw."

B. "I will lie flat after meals."

C. "I will tuck my chin when swallowing."

D. "I will eat quickly to avoid fatigue."

C. "I will tuck my chin when swallowing." (Reduces aspiration risk.)

Which assessment findings are commonly associated with right-sided stroke? (Select all that apply)

A. Impulsive behavior

B. Left-sided weakness

C. Aphasia

D. Poor judgment

E. Spatial-perceptual deficits

A, B, D, E (Aphasia is more common with left-sided stroke.)

A nurse witnesses a tonic-clonic seizure. What is the priority nursing intervention?

A. Insert an oral airway

B. Restrain the client

C. Protect the client from injury

D. Administer lorazepam immediately

C. Protect the client from injury (Safety is priority.)

Which interventions are appropriate during a seizure? (Select all that apply)

A. Turn the client to the side

B. Protect the head

C. Restrain extremities

D. Loosen restrictive clothing

E. Insert a tongue blade

A, B, D (Never restrain or place objects in the mouth.)

What equipment should be available at the bedside for a client on seizure precautions? (Select all that apply)