A client presents with a headache and complaining of vision difficulties. Which cranial nerve might be defective in this client?
A) VIII
... [Show More] (Vestibulocochlear) B) VII (Facial) C) XI (Accessory) D) III (Oculomotor) - Answer: D
A client presents to the ED with loss of consciousness. The RN evaluates the client using the Glasgow Coma Scale. The results are as follows:
Eyes open to speech Abnormal flexion of extremities Use of inappropriate words
What would the RN estimate this client's GCS score to be?
A) 13 B) 9 C) 7 D) 4 - Answer: B
Eyes open to speech = 3 Abnormal flexion = 3 Inappropriate words = 3
The RN is receiving report from the night-shift nurse about a patient on the neuro unit. The night-shift nurse states that the client has had decreased proprioception throughout the night. The RN knows tthis means that
A) The client has difficulty sensing their position and posture. B) The client's pupils are different sizes. C) The client' has the inability to perform purposeful movements. D) The client is exhibiting symptoms on the opposite side of the body from the brain injury. - Answer: A
The RN is caring for a client on a neuro unit who has sustained a head injury. The RN knows that if the pressure of either the brain, CSF, or blood goes up, the other two intracranial components must go down to compensate. This is known as the
A) Orem's Self-Care Deficit theory
B) Monroe-Kellie hypothesis C) Kolcaba's hypothesis D) Peplau's Neurological Compensation theory - Answer: B
Which of the following can lead to cytotoxic edema? (SELECT ALL THAT APPLY)
A) Ischemia B) Hyperglycemia C) Hyponatremia D) SIADH E) Cardiac arrest F) Cushing's triad - Answer: A, C, D, E
*Anything involving decreased oxygenation can lead to cytotoxic edema.
The RN is taking care of a patient on the neuro unit. The night-shift nurse indicates in the morning report that the client has sustained a right midline shift during the night. The RN interprets this to mean that the client
A) Has fluid accumulating on the right side of the brain. B) Has had a brain herniation through the foramen magnum. C) Has experienced right-sided vasogenic cerebral edema. D) Has fluid accumulating on the left side of the brain. - Answer: D
*A "midline shift" simply means that fluid is putting pressure on one side of the brain, pushing it in the opposite direction toward the "midline".
EX: A patient with a right-sided subdural hematoma will have a left midline shift.
Which of the following is an early indication of a central herniation?
A) Coma B) Decreased level of consciousness C) Temperature >100.4 degrees Fahrenheit D) Decorticate posturing - Answer: B [Show Less]