NURS 618 Saunders Med Surg Neuro Revised 2023
Saunders Med Surg Neuro
1. The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain?
1. Sternal rub
2. Nail bed pressure
...
A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and blood pressure and decreasing pulse and
respirations. Respiratory irregularities also may occur.
3. A client recovering from a head injury is participating in care. The nurse determines
that the client understands measures to prevent elevations in intracranial pressure if the
nurse observes the client doing which activity?
1. Blowing the nose
2. Isometric exercises
3. Coughing vigorously
4. Exhaling during repositioning
,Answer:
4. Exhaling during repositioning
Rationale:
Activities that increase intrathoracic and intraabdominal pressures cause an indirect
elevation of the intracranial pressure. Some of these activities include isometric
exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling
during activities such as repositioning or pulling up in bed opens the glottis, which
prevents intrathoracic pressure from rising.
4. A client has clear fluid leaking from the nose following a basilar skull fracture. Which
finding would alert the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
3. Fluid clumps together on the dressing and has a pH of 7.
4. Fluid separates into concentric rings and tests positive for glucose.
Answer:
4. Fluid separates into concentric rings and tests positive for glucose.
Rationale:
Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull
fracture. CSF can be distinguished from other body fluids because the drainage will
, separate into bloody and yellow concentric rings on dressing material, called a halo sign.
The fluid also tests positive for glucose.
5. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The
nurse should include which measures in the plan of care to minimize the risk of
occurrence? Select all that apply.
1. Keeping the linens wrinkle-free under the client
2. Preventing unnecessary pressure on the lower limbs
3. Limiting bladder catheterization to once every 12 hours
4. Turning and repositioning the client at least every 2 hours
5. Ensuring that the client has a bowel movement at least once a week
Answers:
1. Keeping the linens wrinkle-free under the client
2. Preventing unnecessary pressure on the lower limbs
4. Turning and repositioning the client at least every 2 hours
Rationale:
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too
infrequent), and urinary catheters should be checked frequently to prevent kinks in the
tubing. Constipation and fecal impaction are other causes, so maintaining bowel
regularity is important. Ensuring a bowel movement once a week is much too
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