Nokea
A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms?
- A. Adrenal crisis
- B. Hypothalamic collapse
- C. Sympathetic storm
- D. Cranial nerve deficit
Correct Answer: C
Rationale: Sympathetic storm, triggered by brain injury, causes altered consciousness, elevated vital signs, diaphoresis, and agitation due to sympathetic overstimulation. Other options do not fully explain these symptoms.
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A patient is scheduled for CT scanning of the head because of recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test?
- A. No metal objects can enter the procedure room.
- B. You need to fast for 8 hours prior to the test.
- C. You will need to lie still throughout the procedure.
- D. There will be a lot of noise during the test.
Correct Answer: C
Rationale: Lying still during a CT scan ensures clear images. Metal and noise concerns apply to MRI, and fasting is not required for a head CT.
A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests?
- A. Lumbar puncture
- B. MRI
- C. Cerebral angiography
- D. EEG
Correct Answer: A
Rationale: Myelography involves contrast injection via lumbar puncture, so preparation is similar. MRI, angiography, and EEG have different preparation requirements.
A patient is having a fight or flight response after receiving bad news about his prognosis. What affect will this have on the patients sympathetic nervous system?
- A. Constriction of blood vessels in the heart muscle
- B. Constriction of bronchioles
- C. Increase in the secretion of sweat
- D. Constriction of pupils
Correct Answer: C
Rationale: Sympathetic activation during fight or flight increases sweat secretion, dilates heart muscle vessels, bronchodilates, and dilates pupils.
The nursing students are learning how to assess function of cranial nerve VIII. To assess the function of cranial nerve VIII the students would be correct in completing which of the following assessment techniques?
- A. Have the patient identify familiar odors with the eyes closed.
- B. Assess papillary reflex.
- C. Utilize the Snellen chart.
- D. Test for air and bone conduction (Rinne test).
Correct Answer: D
Rationale: The Rinne test assesses hearing, a function of cranial nerve VIII. Odor identification tests cranial nerve I, pupillary reflex tests III, IV, and VI, and the Snellen chart tests II.
The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit?
- A. Temporal lobe
- B. Parietal-occipital area
- C. Inferior posterior frontal areas
- D. Posterior frontal area
Correct Answer: B
Rationale: Visual-receptive aphasia, involving difficulty copying figures, is linked to the parietal-occipital area, which integrates visual and spatial processing. Temporal lobe damage affects auditory comprehension, and frontal areas impact expressive speech.