Nclex Q- Exam 4

A nurse is caring for a patient who sustained a traumatic brain injury. The patient’s current intracranial pressure (ICP) is 22 mmHg and the mean arterial pressure (MAP) is 70 mmHg. Which action should the nurse take first?

• Continue to monitor as these are normal findings.

• Document the cerebral perfusion pressure (CPP) as 92 mmHg.

• Notify the healthcare provider immediately.

• Lower the head of the bed to a flat position.

The nurse is assessing a patient with a suspected increase in intracranial pressure (ICP). Which clinical manifestation should the nurse recognize as the earliest and most sensitive indicator of neurological deterioration?

• Projectile vomiting without preceding nausea.

• A fixed and dilated pupil on the side of the injury.

• Systolic hypertension with a widening pulse pressure.

• Irritability, restlessness, or a shortened attention span.

A patient with a spinal cord injury at the T3 level reports a sudden, pounding headache and nasal stuffiness. The nurse notes the patient is shivering and has a blood pressure of 190/100 mmHg. Which interventions should the nurse implement? (Select All That Apply.)

• Elevate the head of the bed to an upright position.

• Perform a digital rectal exam to check for fecal impaction.

• Check the urinary catheter tubing for kinks or obstruction.

• Administer a prescribed prophylactic anticoagulant.

• Loosen the patient’s restrictive clothing and shoes.

A nurse is preparing to administer Nimodipine to a patient following a subarachnoid hemorrhage (SAH). Which assessment finding would require the nurse to hold the medication and notify the healthcare provider?

• Apical pulse of 58 beats per minute.

• Systolic blood pressure of 110 mmHg.

• Patient report of a thunderclap headache.

• Serum potassium level of 3.6 mEq/L.

The nurse is caring for a patient with a ventriculostomy. Which action is essential to ensure the accuracy of the ICP readings and prevent complications?

• Routinely irrigate the catheter with heparinized saline.

• Ensure the transducer is at the level of the patient’s tragus.

• Maintain the patient in a prone position to promote drainage.

• Use clean technique when assessing the insertion site.

A patient arrives in the emergency department with symptoms of an ischemic stroke that began 2 hours ago. Which diagnostic test is the priority to determine if the patient is a candidate for tissue plasminogen activator (tPA)?

• Carotid ultrasound.

• 12-lead electrocardiogram (ECG).

• Non-contrast CT scan of the head.

• Magnetic resonance angiography (MRA).

A nurse is evaluating a patient using the Glasgow Coma Scale (GCS). The patient opens their eyes only to painful stimuli, utters incomprehensible sounds, and shows abnormal extension (decerebrate posturing) when a nail bed pinch is applied. What is this patient’s GCS score?

• 3

• 5

• 8

• 10

The nurse is caring for a patient who just returned from a CT scan following a cervical spinal cord injury. The patient’s halo vest pins have become displaced. What is the nurse’s priority action?

• Use the halo vest bars to reposition the patient’s head.

• Clean the pin sites with chlorhexidine and water.

• Manually stabilize the patient’s head in a neutral position.

• Call the healthcare provider to tighten the pins immediately.

A nurse is caring for a patient with right-brain damage following a stroke. Which clinical manifestations should the nurse expect to observe? (Select All That Apply.)

• Impulsivity and impaired judgment.

• Slow, cautious behavioral style.

• Left-sided neglect (ignoring the left side of the body).

• Aphasia or total loss of language comprehension.

• Spatial-perceptual deficits.

A patient with a T2 spinal cord injury is experiencing neurogenic shock. Which triad of symptoms should the nurse expect to find during the assessment?

• Hypertension, bradycardia, and irregular respirations.

• Hypotension, bradycardia, and warm, flushed skin.

• Hypotension, tachycardia, and cool, pale skin.

• Hypertension, tachycardia, and pounding headache.