Intracranial Regulation

The nurse is teaching a patient how to walk with a cane following a cerebrovascular accident that left the patient with right-sided weakness. Which action by the patient indicates the teaching was effective?

Which patient must be treated first in the emergency department following a mass shooting?

Which exercise is appropriate for the patient who has a Glasgow Coma Scale of 4?

The patient presents to the emergency department after having a metal beam fall on his head at a work site. He was wearing a helmet which broke with the impact. He was unconscious at the scene but is awake now, and his initial assessment is completely benign. Which finding upon reassessment 30 minutes later is most concerning?

A patient who has severe depression asks if electroconvulsive therapy (ECT) could help his depression. Which response is most appropriate?

The patient with advanced dementia accuses the nurse of trying to poison him with his scheduled medications. Which nursing intervention is most appropriate?

Release of which neurotransmitters in the brain and spinal cord leads to increased nociception? Select all that apply.

The patient is experiencing syndrome of inappropriate antidiuretic hormone. The nurse recognizes malfunction of which structure is responsible for this disorder?

Following brain surgery, the patient is producing massive volumes of dilute urine. The nurse suspects which structure was inadvertently harmed during the surgery?

The patient complains of cold intolerance, weight gain, and hair loss. The nurse notes periorbital and generalized, non-pitting edema. The patient’s blood pressure is 98/64 mmHg and heart rate is 48 bpm. The nurse anticipates which lab result?

The patient receiving thyroid supplementation for hypothyroidism reports insomnia, fatigue, tachycardia, and headache. Which statement by the nurse is appropriate?

The 6-month-old infant is admitted to the pediatric intensive care unit with a diffuse purpuric rash and prolonged bleeding. The nurse notes the fingers on the right hand are pale and cool to the touch. Which question asked of the parents will be the most helpful in diagnosing this patient’s condition?

The patient with increased intracranial pressure has been administered mannitol. Which patient symptom indicates the drug is having its intended effect?

The patient is brought to the emergency department following a serious motor vehicular accident (MVA). List the assessments the nurse performs in order from highest to lowest priority.

The emergency department nurse is assessing the unconscious patient following a fall from the ladder while he was doing home improvement work. Which assessment is performed first?

The nurse is the first responder to a motor vehicular accident involving the injury of a 40-year-old male. Which action is the highest priority?

The patient with malignant hypertension has suffered from a transient ischemic attack. He asks the nurse if he can continue taking his St. John’s wort for depression. Which answer by the nurse is most appropriate?

Which patient is triaged as first to be treated following a hurricane?

The patient is brought to the emergency room by her husband with slurred speech and facial drooping. Which question does the nurse ask first?

The nurse instructs parents on which type of diet to decrease the risk for lead poisoning in their children? 

The older adult patient is brought to the emergency department with sudden onset confusion, agitation, and hallucinations. The patient's past medical history is significant for type 2 diabetes managed with glyburide, anxiety managed with lorazepam, and insomnia managed with zolpidem. Upon assessment, the patient's heart rate and rhythm are regular, lungs are clear to auscultation, and bowel sounds are present. Vital signs are normal, with exception of a slightly elevated heart rate. Which is the most likely cause of the patient's symptoms?

The elderly patient is at risk for falls related to urinary incontinence. Which intervention is appropriate?

The patient is scheduled for bariatric surgery in one month. During the preoperative physical, the nurse notes the patient takes St. John's wort. The nurse instructs the patient to stop taking St. John's wort 5 days prior to the surgery for which reason?  

The nurse is helping the nursing student to relate patient findings to pathophysiological concepts. Which findings, if selected by the nursing student as characteristics that prompt the kidneys to release renin, indicates a need for further teaching?

The 7-year-old child with pica is brought to the emergency room (ER) with decreased level of consciousness after ingesting lead paint. His blood lead level (BLL) is determined to be 72 mcg/dL. The nurse prepares to administer which medication?

Which initiative is a primary strategy to prevent lead toxicity?

Which neurologic alteration is associated with acute rheumatic fever?

A patient with epilepsy asks whether he will know if a seizure is coming on. The nurse replies with which statement?

Which medication is used to treat epilepsy?

Which instruction does the nurse give the patient with epilepsy who is 6 weeks pregnant?

Which medication is an anxiolytic?

There are four patients with hyperglycemia in the emergency department triage. One treatment room has become available. The patient with which additional symptom is moved into the available room first?

The patient with a history of epilepsy has a seizure in the emergency department. He has stopped convulsing, but cannot be aroused. Once the patient is admitted to a room, the patient then starts convulsing again. Which action by the nurse is appropriate?

The nurse receives report from the operating room regarding a postoperative craniotomy patient and recognizes the patient is at risk for which complications? Select all that apply.

The nurse anticipates administering which medications to the patient with meningitis? Select all that apply.

The patient in the intensive care unit is being weaned off of a continuous morphine infusion after being extubated 6 hours ago. Which assessments indicate the patient is failing to tolerate the treatment plan? Select all that apply.

The nonverbal patient is improving in the intensive care unit following a motor vehicle accident; as such, the continuous hydromorphone infusion is being weaned according to a schedule. The nurse provides education to the patient’s guardian about which signs and symptoms that the pain medicine is being weaned too quickly? Select all that apply.

The 14-year-old patient was admitted following surgical reduction of an open femur fracture. The patient, who has reported good pain control with the patient-controlled analgesia (PCA) pump, is sleeping peacefully. During hourly rounding, the nurse observes the parent press the button to administer the bolus of pain medication. Which action by the nurse is appropriate?

The patient receiving patient-controlled analgesia (PCA) with morphine is found to be sleeping deeply and minimally responsive. Which action does the nurse take first?

The physician writes an order for diphenhydramine 250 mg PRN for sleep. Which part of the order does the nurse question?

The unconscious patient presents with the following respiratory pattern: The nurse anticipates further testing will reveal which condition?

The patient who has severely elevated intracranial pressure following a traumatic brain injury is intubated, sedated, and chemically paralyzed. Which intervention does the nurse include in the plan of care?

The nurse questions the order for an infusion of 0.45% NaCl in the patient with which condition?

Fentanyl must be used with caution in which patient?

Which statement describes the mechanism of action of erenumab (Aimovig)?

The patient with arteriovenous malformation who takes a monoamine oxidase inhibitor for depression develops an upper respiratory infection. The nurse requests a prescription for which medication?

The patient with migraines undergoes an MRI and is found to have a cerebral aneurysm in the Circle of Willis. The nurse is vigilant for which symptoms that would indicate the patient is experiencing a life-threatening complication of the cerebral aneurysm? Select all that apply.

The patient presents to the emergency department (ED) with flu-like symptoms and mucocutaneous erythematous rash and bullae formation over 38% of the body. The nurse asks the patient if which medications had been taken in the last month? Select all that apply.

The nurse has received orders for the patient admitted following a hemorrhagic stroke and clarifies orders for which medications? Select all that apply.

The nurse is visiting the home of a patient who recently underwent a trabeculectomy. Which statement improves patient safety?