An 80-year-old patient is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?

1
An 80-year-old patient is admitted to the
emergency department with numbness and weakness
of the left arm and slurred speech. Which
nursing intervention is priority?

1. Prepare to administer recombinant tissue
   plasminogen activator.
2. Scheduled for a stat computed tomography scan of
   head
3. Discuss the precipitating factors that cause the
   symptoms.
4. Notify the speech pathologist for an emergency
   consult.

2
The nurse is assessing a patient experiencing
motor loss as a result of a left-sided
cerebrovascular accident. Which clinical
manifestation with the nurse document?

1. Hemiparesis of the patients left arm and
   apraxia.
2. Paralysis of the right side of the body and
   ataxia.
3. Homonymous hemianopsia and diplopia.
4. Impulsive behavior and hostility toward family.

3
The nurse is planning care for patients
experiencing agnosia secondary to a
cerebrovascular accident. Which collaborative
intervention will be included in the plan of care?

1. Observing the patient swallowing for possible
   aspiration.
2. Positioning the patient in a semi-Fowlers
   position when sleeping.
3. Placing a suction set up on the patients bedside
   during meals.
4. Referring the patient to an occupational
   therapist for evaluation.

4
The patient diagnosed with atrial fibrillation
has experience a transient ischemic attack.
Which medication with the nurse anticipate being
ordered for the patient on discharge?

1. An oral anticoagulant medication.
2. A beta blocker medication.
3. An anti-hyperuricemic Medication
4. A thrombolytic medication

5
The 78-year-old patient diagnosed with a stroke
is complaining of a severe headache. Which
intervention should the nurse implement first?

1. Administer a nonnarcotic analgesic.
2. Prepare for a stat MRI.
3. Start an intravenous line with D5W at 100
   mL/hour.
4. Complete a neurological assessment.

6
A patient diagnosed with a subarachnoid
hemorrhage has undergone a craniotomy for repair
of a ruptured aneurysm. Which intervention will
the intensive care nurse implement?

1. Administer a stool softener BID.
2. Encourage the patient to cough hourly.
3. Monitored neurological status every shift.
4. Maintain the dopamine drip to keep blood pressure
   at 160/90.

7
The nurse is caring for the following patients.
Which patient with the nurse assess first after
receiving the shift report?

1. The 22-year-old male patient diagnosed with a
   concussion who is complaining someone is waking
   him up every two hours.
2. The 36-year-old female patient admitted with
   complaints of left-sided weakness who is
   scheduled for a magnetic resonance imaging scan.
3. The 45-year-old patient admitted with blunt
   trauma to the head after a motorcycle accident
   who has a Glasgow coma scale score 6.
4. The 62-year-old patient diagnosed with a
   cerebrovascular accident who has expressive
   aphasia.

8
The patient has sustained a severe closed head
injury and the neurosurgeon is determining if the
patient is brain dead. Which data support
that the patient could be brain dead?

1. When the patients head is turned to the side,
   the eyes turn to the right.
2. The EEG has identifiable waveforms.
3. There is no eye activity when the cold caloric
   test is performed.
4. The patient assumes decorticate posturing when
   painful stimuli are applied.

9
The patient diagnosed with a gunshot wound to the
head assumes decorticate posturing when the nurse
applies painful stimuli. Which assessment data
obtained three hours later would indicate the
patient is improving?

1. Purposeless movement in response to painful
   stimuli.
2. Flaccid paralysis in all four extremities.
3. Decerebrate posturing when painful stimuli are
   applied.
4. Pupils that are 6 mm in size and nonreactive on
   painful stimuli.

10
In assessing a patient with the T-12 spinal cord
injury, which clinical manifestation with the
nurse expect to find to support the diagnosis of
spinal shock?

1. No reflex activity below the waist.
2. Inability to move upper extremities.
3. Complaints of a pounding headache.
4. Hypertension and bradycardia.

11
The patient with a C-6 spinal cord injury is
admitted to the emergency Department complaining
of a severe pounding headache and has a blood
pressure of 180/110. Which intervention to the
emergency department nurse implement?

1. Keep the patient flat in bed.
2. Dim the lights in the room.
3. Assess for bladder distention.
4. Administer a narcotic analgesic.

12
The patient with a cervical fracture is being
discharged in a halo device. Which teaching
instruction should the nurse discuss with the
patient?

1. Discuss how to remove insertion pins correctly.
2. Instruct the patient to report reddened or
   irritated skin areas.
3. Inform the patient that the vest liner cannot be
   changed.
4. Encourage the patient to remain in the recliner
   as much as possible.

13
The intensive care nurse is caring for a patient
with a T-1 spinal cord injury. When the nurse
elevates the head of the bed 30, the patient
complains of lightheadedness and dizziness. The
patients vital signs are temperature 99.2F,
pulse-98, respirations-24, and blood pressure
84/40. Which action should the nurse implement?

1. Notify the health care provider ASAP.
2. Calm the patient down by talking therapeutically.
3. Increase the IV rate by 50 mL/hour
4. Lower the head of the bed immediately.

14
The male patient is sitting in the chair in his
entire body is rigid with his arms and legs
contracting and relaxing. The patient is not
aware of what is going on and is making guttural
sounds. Which action should the nurse implement
first?

1. Push aside any furniture.
2. Place the patient on his side.
3. Assess the vital signs.
4. Ease the patient to the floor.

15
The patient is scheduled for an
electroencephalogram (EEG) to help diagnose a
seizure disorder. Which preprocedural teaching
should the nurse implement?

1. Tell the patient to take any routine antiseizure
   medication prior to the EEG.
2. Tell the patient not to eat anything for eight
   hours prior to the procedure.
3. Instruct the patient to stay awake 24 hours prior
   to the EEG.
4. Explained to the patient that there will be some
   discomfort during the procedure.

16
The nurse enters the room as the patient is
beginning to have a tonic clonic seizure. What
action should the nurse implement first?

1. Note the first thing the patient does in the
   seizure.
2. Assess the size of the patients pupils.
3. Determine if the patient is incontinent of urine
   or stool.
4. Provide the patient with privacy during the
   seizure.

17
The nurse is caring for a patient diagnosed with
an epidural hematoma. Which nursing intervention
should the nurse implement? Select all that
apply.

1. Maintain the head of the bed at 60 of elevation.
2. Administer stool softeners daily.
3. Ensure that pulse oximeter reading is higher than
   93.
4. Perform deep nasal suction every two hours.
5. Administer mild sedatives.

18
The nurse in the neurointensive care unit is
caring for a patient with a new C-6 spinal cord
injury who is breathing independently. Which
nursing intervention should be implemented?
Select all that apply.

1. Monitor the pulse oximetry reading.
2. Provide pureed food six times a day.
3. Encourage coughing and deep breathing.
4. Assess for autonomic dysreflexia.
5. Administer intravenously corticosteroids.

19
Flumazenil (Romazicon) has been ordered for a
male patient who has overdosed on oxazepam
(Serax). Before administering the medication, The
nurse should be prepared for which common adverse
effect?

1. Seizures
2. Shivering
3. Anxiety
4. Chest pain

20
A patient is diagnosed with bulimia. The most
appropriate initial goal for a patient diagnosed
with bulimia is to

1. avoid shopping for large amounts of food
2. control eating impulses
3. identify anxiety-causing situations
4. eat only three meals per day

21
A female patient who is at high risk for suicide
needs close supervision. To best ensure the
patients safety, the RN should

1. check the patient frequently at irregular
   intervals throughout the night
2. assure the patient that the nurse will hold in
   confidence anything the patient says
3. repeatedly discuss previous suicide attempts with
   the patient
4. disregard decreased communication by the patient
   because this is common in suicidal patients

22
Which of the following drugs should the RN
prepare to administer to a patient with lead
poisoning?

1. deferoxamine mesylate (Desferal)
2. succimer (Chemet)
3. Flumazenil (Romazicon)
4. acetylcysteine (Mucomyst)

23
A male patient is admitted to the substance abuse
unit for alcohol detoxification. Which of the
following medications is nurse Apple most likely
to administer to reduce the symptoms of alcohol
withdrawal?

1. naloxone (Narcan)
2. haloperidol (Haldol)
3. magnesium sulfate
4. chlordiazepoxide (Librium)

24
RN is caring for a patient being treated for
alcoholism. Before initiating therapy with
disulfiram (Antabuse), the nurse teaches the
patient that he must read labels carefully on
which of the following products?

1. Carbonated beverages
2. Aftershave lotion
3. Toothpaste
4. Cheese

25
A male patient is hospitalized with fractures of
the right femur and right humerus sustained in a
motorcycle accident. Police suspect the patient
was intoxicated at the time of the accident.
Laboratory tests reveal a blood alcohol level of
0.2 (200 mg/dl). The patient later admits to
drinking heavily for years. During
hospitalization, the patient periodically
complains of tingling and numbness in the hands
and feet. The RN realizes that these symptoms
probably result from

1. acetate accumulation
2. thiamine deficiency
3. triglyceride buildup.
4. a below-normal serum potassium level