Question 1

The nurse is completing a Glasgow Coma Scale reassessment of a client who fell down a flight of stairs 8 hours ago. On admission, the client displayed spontaneous eye opening. The nurse does not see this response at this time and knows to do which to know if the client responds at the next level of eye opening?
A)Provide painful stimuli to evoke eye opening.
B)Request the client speak his own name.
C)Tell the client to "open his eyes" or to look at the nurse.
D)Ask the client to squeeze the nurse's hand.

Accepted Answer

If the client doesn't spontaneously open his eyes, the nurse should ask the client to open his eyes.

Question 2

The charge nurse in a long-term care facility is called to assess an older adult client diagnosed with Alzheimer disease who has fallen and has a head laceration. The nurse is aware that the Glasgow Coma Scale is not an accurate tool to assess this client's level of consciousness because of which reason?
A)The client is in a long-term care facility.
B)The client is an older adult.
C)The client has a head laceration.
D)The client has been diagnosed with Alzheimer disease.

Accepted Answer

The client's Alzheimer disease hampers the nurse's ability to fully assess the client's responses on the Glasgow Coma Scale.

Question 3

Prior to beginning to assist a healthcare provider with a lumbar puncture on an adult client, the nurse asks another nurse to also assist in the procedure for what reason?
A)To administer pain medication to the client
B)To encourage the client to lie as still as possible
C)To ensure that the healthcare provider maintains sterile technique
D)To take over holding the client when the first nurse gets tired

Accepted Answer

Providing encouragement to the client helps the client hold still, which is necessary for safety in the procedure.

Question 4

The nurse instructs the UAP to hold the infant in a side-lying position in preparation for a lumbar puncture. The nurse shows the UAP how to flex the infant so that the spine is exposed and curved. Which explanation is the BEST to help the UAP understand why this position must be maintained?
A)"This position decreases pain for the infant while this procedure is performed."
B)"This position must be maintained because it gives the healthcare provider the best access to the infant's spinal column."
C)"This is the position in which the healthcare provider requested that the infant be placed."
D)"This position prevents contamination of the lumbar puncture site if the infant urinates or defecates during the procedure."

Accepted Answer

Flexing the infant's spine by holding the neck and the legs is the best way to ensure that the healthcare provider has the best and safest access to the infant's spinal column.

Question 5

The nurse working in the emergency department is preparing to determine the level of consciousness on a client who was involved in a motor vehicle accident with a possible head injury. Which client precondition would prevent the nurse from using the Glasgow Coma Score?
A)The client is blind.
B)The client is deaf.
C)The client had a previous brain attack.
D)The client has diabetes mellitus.

Accepted Answer

It would be very difficult for the nurse to use the GCS in a client who is deaf because the tool requires the client to hear the nurse and respond.

Question 6

The charge nurse is preparing to assign a staff member to assist the healthcare provider planning to perform a lumbar puncture on a 9-month-old infant who is irritable and has an elevated temperature. Which staff member would be the best one to assist in this procedure?
A)An RN who graduated from nursing school 6 weeks ago
B)A UAP with 9 years of experience in caring for elderly clients
C)A UAP with 2 years of experience on a pediatric unit
D)An LPN who has been licensed for 4 years but has only worked on the unit for 2 weeks

Accepted Answer

The UAP has 2 years of experience working with infants and children and would be the best choice for holding the infant during the procedure.

Question 7

The nurse enters a client's room with a suspected head injury in preparation for completing a neurological assessment that includes a Glasgow Coma Score (GCS). Upon entering the room and turning on a light, the nurse notes that the client doesn't open his eyes immediately. Which is the nurse's next action?
A)Complete the client's vital signs and recheck the client in 30 minutes.
B)Gently touch the client's arm to see if the client spontaneously awakens.
C)Turn the light off, leave the room, and document that the client is sleeping.
D)Vigorously rub the client's sternum to determine if the client responds to painful stimuli.

Accepted Answer

The nurse should first attempt to gently awaken the client because it is the normal sleeping time. If the client awakens with this, the nurse would continue with the GCS and neuro check.

Question 8

The nurse is caring for a client with a diagnosed closed head injury that requires intracranial pressure monitoring. Which signs/symptoms indicate that the client's intracranial pressure is rising? Select all that apply.
A)The nurse notes "Doll's eyes" when assessing the client's pupils.
B)The nurse documents eupnea in respect to respiratory effort.
C)The nurse finds that all extremities are flaccid.
D)The nurse notes that blood pressure is stable.
E)The nurse documents that the client is in a comatose state.

Accepted Answer

Doll's eyes is a pupillary sign that indicates a worsening ICP.
Flaccid extremities are a sign of worsening ICP.
A comatose state indicates worsening ICP.

Question 9

The nurse is caring for an older adult client who sustained a closed head injury approximately 4 hours ago. At the time of the injury, the client denied any pain or other symptoms. Which statement by the client would cause the MOST concern to the nurse?
A)"Who are you? Why do you keep asking me my name?"
B)"I wish the nurses would stop coming in and shining a light in my eyes. It's annoying."
C)"This is so silly. I really don't see why all of this is necessary."
D)"Please let me go home. I will come back if I have any problems."

Accepted Answer

A very early sign of increased ICP is a slight change in level of consciousness. The client does not appear to recognize the nurse or understand why the assessments are being done.

Question 10

The nurse is talking to parents of a 6-month-old infant who will have a lumbar puncture to rule out meningitis. The mother tells the nurse that she refuses to leave the baby and that no one will touch her child unless she is there. Which is the nurse's BEST response to this mother?
A)"We can't take the chance that you will faint during the procedure. We are here to care for your child, not you."
B)"I realize that you are upset, but this is a sterile procedure and there is an increased chance your child will get an infection if you insist on staying in the room."
C)"I know this must be stressful with your child so sick. Would you like to help hold her in the correct position or would you just like to talk quietly to her during the procedure?"
D)"Our facility's policy is that no one can be in the room except for medical personnel. Besides, you don't want your baby to blame you for all of this."

Accepted Answer

If the parent would like to be present, the nurse should give the parent the choice of what he or she would like to do to assist with the procedure.

Question 11

The nurse is caring for a client diagnosed with diabetic ketoacidosis and notes that the client's level of consciousness appears to be deteriorating. The nurse is aware that which assessments are a component of both the Glasgow Coma Score and the Full Outline of Un-Responsiveness (FOUR Score)Coma Scale? Select all that apply.
A)Brainstem reflexes
B)Ability to follow verbal commands
C)Abnormal breathing patterns
D)Pupil size
E)Types of motor responses

Accepted Answer

Both the FOUR Coma Scale and the GCS use the client's ability to follow commands as a component of the assessment.
Motor response is a component of both the GCS and the FOUR Coma Scale.

Question 12

The nurse is instructing a UAP in the technique of assisting a client to stay in the proper position for a lumbar puncture. The nurse will know that the UAP is doing it correctly if the UAP holds which parts of the client's body immediately before the procedure begins?
A)Behind the client's neck and knees
B)Behind the client's neck and feet
C)Under the client's arms and knees
D)Around the client's neck and behind the knees

Accepted Answer

The UAP stands in front of the client and places the hands behind the client's neck and knees with the client in a fetal position.

Question 13

The nurse notes that an elderly resident of a long-term care facility has fallen and the client is unable to say whether or not he hit his head. Which are the first signs that the nurse will note if this client has sustained a closed head injury? Select all that apply.
A)Spontaneous vomiting
B)Bradycardia
C)Vertigo
D)Headache
E)Widened pulse pressure

Accepted Answer

Vomiting without nausea is an early sign of ICP.
Vertigo is an early sign of ICP.
Headache is an early sign of ICP.

Question 14

While holding a 2-year-old child in a flexed position for a lumbar puncture, the nurse monitors which vital sign to detect any abnormality caused by the child's position?
A)Temperature
B)Heart rate
C)Respirations
D)Blood pressure

Accepted Answer

Respirations may be affected because the child's flexed position may impair the ability to adequately breathe.

Question 15

The healthcare provider is preparing to perform a lumbar puncture on a 5-year-old child and requests that the child be placed in a sitting position. How will the nurse assist the child to maintain this position?
A)Tell the child to curl up in a ball and grab onto his feet and hold very still.
B)Inform the healthcare provider that the child is too young to do the procedure in a sitting position and that the procedure must be performed with the child lying down.
C)Assist the child to curl the body over a pillow and help the child stay in this position by stabilizing the child's neck with one hand and the child's knees with another hand.
D)Request another nurse assist so that one nurse can hold the child's neck and head in the curved position and the other nurse can assist the child to hold the knees steady.

Accepted Answer

For a child to be assisted to maintain the seated position for a lumbar puncture, it requires at least two people: one to help the child hold still at the head and the other to help the child hold still at the knees.

Question 16

The intensive care unit nurse is preparing to assess the level of consciousness of a client who is intubated and has both hands restrained to prevent the client from pulling out the endotracheal tube. The client's injury occurred due to a stabbing incident that ultimately caused the client to fall and hit his head. Which item related to the client will cause the nurse to report an incomplete Glasgow Coma Score (GCS)?
A)The client is intubated.
B)The client's hands are restrained.
C)The client was stabbed.
D)The client fell and hit his head.

Accepted Answer

Because the client is intubated, the nurse will be unable to get a verbal response, which is a part of the GCS.

Question 17

The nurse is caring for an older adult client who has been diagnosed with a closed head injury. The healthcare provider decides to monitor the client's intracranial pressure (ICP)using an ICP transducer system. The nurse will place the client in which position to prevent compromise of the client's condition?
A)Left lateral, bed flat
B)Supine, head midline, head of bed elevated 30 degrees
C)Right lateral, head of bed elevated 60 degrees
D)Supine, head midline, bed in Trendelenburg

Accepted Answer

The best position for the client who has an ICP transducer system to monitor the client's intracranial pressure is supine, head midline, and the head of the bed elevated 15 to 30 degrees. This position prevents compression of blood vessels in the neck and obstruction of venous blood flow.

Question 18

The nurse is assisting with a lumbar puncture of an infant who is irritable and feverish. The manometer indicates increased intracranial pressure and the cerebral spinal fluid appears cloudy. The nurse will institute which interventions as a result of these findings?
A)Prepare to send the infant for a CT scan to look for an area of bleeding.
B)Assess the infant's anterior fontanel for any bulging.
C)Place the child in respiratory isolation because of possible meningitis.
D)Administer an antipyretic and prepare to send the infant home.

Accepted Answer

The presence of cloudy fluid is indicative of infection, so the child should be placed in isolation until the type of infection can be determined.

Question 19

The nurse is caring for an older adult client who is being observed after sustaining a minor head injury. The client's only complaints related to the head injury are headache and dizziness. Which interventions would be most helpful to this client in preventing a possible increase in intracranial pressure?
A)Place the client in a room near the nurse's station.
B)Encourage the client to visit with friends and family to prevent boredom.
C)Dim the lights in the room and encourage the client to rest.
D)Place the client in a supine position with both legs elevated slightly.

Accepted Answer

The client should be encouraged to rest and the environment should encourage that rest.

Question 20

The nurse is caring for a client with a diagnosed head injury who has an ICP transducer system to monitor the client's intracranial pressure. Which sign on the ICP monitor indicates that the client's condition is worsening?
A)Narrow amplitude waveform
B)Appearance of plateau waveforms
C)Increased ICP for 2 minutes
D)ICP pressure of 4-20

Accepted Answer

The appearance of plateau waveforms is indicative of a worsening condition of the client.

Quiz 58: Intracranial Regulation

Prior to beginning to assist a healthcare provider with a lumbar puncture on an adult client, the nurse asks another nurse to also assist in the procedure for what reason?

The nurse instructs the UAP to hold the infant in a side-lying position in preparation for a lumbar puncture. The nurse shows the UAP how to flex the infant so that the spine is exposed and curved. Which explanation is the BEST to help the UAP understand why this position must be maintained?

The nurse working in the emergency department is preparing to determine the level of consciousness on a client who was involved in a motor vehicle accident with a possible head injury. Which client precondition would prevent the nurse from using the Glasgow Coma Score?

The charge nurse is preparing to assign a staff member to assist the healthcare provider planning to perform a lumbar puncture on a 9-month-old infant who is irritable and has an elevated temperature. Which staff member would be the best one to assist in this procedure?

The nurse is caring for a client with a diagnosed closed head injury that requires intracranial pressure monitoring. Which signs/symptoms indicate that the client's intracranial pressure is rising? Select all that apply.

The nurse is caring for an older adult client who sustained a closed head injury approximately 4 hours ago. At the time of the injury, the client denied any pain or other symptoms. Which statement by the client would cause the MOST concern to the nurse?

The nurse is talking to parents of a 6-month-old infant who will have a lumbar puncture to rule out meningitis. The mother tells the nurse that she refuses to leave the baby and that no one will touch her child unless she is there. Which is the nurse's BEST response to this mother?

The nurse is instructing a UAP in the technique of assisting a client to stay in the proper position for a lumbar puncture. The nurse will know that the UAP is doing it correctly if the UAP holds which parts of the client's body immediately before the procedure begins?

The nurse notes that an elderly resident of a long-term care facility has fallen and the client is unable to say whether or not he hit his head. Which are the first signs that the nurse will note if this client has sustained a closed head injury? Select all that apply.

While holding a 2-year-old child in a flexed position for a lumbar puncture, the nurse monitors which vital sign to detect any abnormality caused by the child's position?

The healthcare provider is preparing to perform a lumbar puncture on a 5-year-old child and requests that the child be placed in a sitting position. How will the nurse assist the child to maintain this position?

The nurse is assisting with a lumbar puncture of an infant who is irritable and feverish. The manometer indicates increased intracranial pressure and the cerebral spinal fluid appears cloudy. The nurse will institute which interventions as a result of these findings?

The nurse is caring for a client with a diagnosed head injury who has an ICP transducer system to monitor the client's intracranial pressure. Which sign on the ICP monitor indicates that the client's condition is worsening?