DRILL-NCMB418

Which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid?

Oxygen administration

Pentobarbital (Nembutal)

Mannitol (Osmitrol) (25%)

Dexamethasone (Decadron)

How are the metabolic and nutritional needs of the patient with increased ICP best met?

Enteral feedings that are low in sodium

Simple glucose available in D5W IV solutions

Fluid restriction that promotes a moderate dehydration

Balanced, essential nutrition in a form that the patient can tolerate

An early sign of increased ICP that the nurse should assess for is

Cushing's triad

Decreasing level of consciousness (LOC).

Unexpected vomiting.

Dilated pupil with sluggish response to light.

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?

Nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?

Hyperreflexia

Positive reflexes

Flaccid paralysis

Reflex emptying of the bladder

A patient has a ventriculostomy. Which finding would you immediately report to the doctor?

Temperature 98.4 'F

CPP 70 mmHg

ICP 24 mmHg

PaCO2 35

A pediatric client is admitted to the neuro ICU with a closed-head injury sustained after falling out of a tree house. The mechanisms of injury this young client most likely sustained would be

Acceleration

Penetrating

Rotational

Deceleration

A client has been in the ICU for 6 weeks for treatment of a traumatic head injury. Brain death has just been declared. Which assessment findings would the nurse anticipate? Select all that apply.

The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other?

Awaken the client every two (2) hours.

Monitor for increased intracranial pressure.

Observe frequently for hypervigilance.

Offer the client food every three (3) to four (4) hours.

The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question?

A subcutaneous anticoagulant.

An intravenous osmotic diuretic.

An oral anticonvulsant.

An oral proton pump inhibitor.

The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead". Which data support That the client is brain dead?

When the client's head is turned to the right, the eyes turn to the right.

The EEG has identifiable waveforms.

There is no Eye activity when the cold caloric test is performed.

The client assumes decorticate posturing when painful stimuli are applied.

A client recovering from a craniotomy complains of a "runny nose". Which of the following nursing actions should be immediately implemented?

Notify the physician

Provide the client with soft tissues

Monitor the client for signs of a cold

Tell the client to use soft tissues to soak up the drainage

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. Which action should the nurse take first?

Request that the client's spouse sit in the waiting room.

Ask the spouse if he wishes to be present during the resuscitation.

Suggest that the spouse begin to pray for the client.

Refer the client's spouse to the hospital's crisis team

A seven year old male who fell from the top of a jungle gym is awake and neurologically intact in all four extremities. When you ask what happens, he tells you he fell and then he tells you about his dog.

Tito Vince works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last.

1. A 50-year-old female with moderate abdominal pain and occasional vomiting.
2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity.
3. An ambulatory dazed 25-year-old male with a bandaged head wound.
4. An irritable infant with a fever, petechiae, and nuchal rigidity.

1, 2, 3, 4

2, 3, 4, 1

3, 4, 1, 2

4, 3, 1, 2

A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can't move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to?

Black

Green

Red

Yellow

Nurse Peps is assigned to telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action the nurse should direct the client to perform?

Removing the stinger by scraping it.

Applying a cold compress.

Taking an oral antihistamine.

Calling 911.

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take?

Irregular pulse.

Ecchymosis in the flank area.

A deviated trachea.

Unequal pupils.

Nurse Kelly Clarkson. A triage nurse encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority?

Complete history taking.

Put the client on ECG monitoring.

Notify the physician.

Administer oxygen therapy via nasal cannula.

An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first?

A 30-year-old distraught mother holding her crying child

A 65-year-old conscious male with a head laceration

A 26-year-old male who has pale, cool, clammy skin

A 48 year old with a simple fracture of the lower leg

You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients.
1. An ambulatory, dazed 25-year-old male with a bandaged head wound
2. An irritable infant with a fever, petechiae, and nuchal rigidity
3. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
4. A 50-year-old female with moderate abdominal pain and occasional vomiting

I, II, IV, III

II, I, IV, III

III, IV, II, I

III, II, I, IV

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