Referencing Styles : Harvard 1. Prior to performing the doll’s eyes (oculocephalic) reflex on a patient, the nurse must verify: a. Absence of cervical injury 2. With an abnormal oculocephalic reflex the: b. Patient’s eyes move in the opposite direction to the movement of the patient’s head 3. A patient is admitted to the Neuro ICU with a subdural hematoma. Upon assessment, you find that she has BP of 220/90 with widening pulse pressures and HR 40. These clinical manifestations are representative of: c. Cushing’s Triad 4. Your patient has ICP 50. All of the following treatments are appropriate except: c. Phosphenytoin 5. A 29-year-old patient is admitted to you with worst headache of her life. You are concerned the patient may have a meningitis because the assessment also reveals: d. Nuchal rigidity and N/V 6. Your patient’s ICP reading is 26 for 5 minutes. You would do all of the following except: a. Manually hyperventilate the patient with an Ambu-bag 7. Which of the following spinal cord injuries would most likely require mechanical ventilation? c. C3 fracture 8. A patient was brought to the ED with a hemorrhagic stroke and is very lethargic and difficult to arouse. Which of the following should be performed first? d. Perform a neurological check 9. A patient is in the intensive care unit following a motor vehicle crash. The patient is oriented to person, place, and time; can move all extremities; and follows commands. Current pulse is 75 beats/min, blood pressure is 120/70 mm Hg, and respirations are 18 breaths/min and regular. Which assessment finding by the nurse would best indicate the earliest finding that the patient’s intracranial pressure is increasing? b. Flexion posturing 10. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. BP is 144/90 mm Hg with a mean arterial pressure (MAP) of 108 mm Hg. What is the cerebral perfusion pressure (CPP)? c. 90 mm Hg 11. The nurse is caring for a patient with a sustained ICP of 18mm Hg for the past 30 minutes during the morning assessment and hygiene interventions. What is the best nursing action? b. Change ventriculostomy dressing using strict aseptic technique 12. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly, but on arrival to the emergency department, he was conscious with a GCS score of 15. One hour later, the nurse assesses a GCS score of 8. What is the best nursing action? d. Support airway and breathing then call for medical assistance 13. An awake, alert patient arrives at the ED following a fall down a flight of stairs. The physician suspects a basilar skull fracture. Which assessment findings should the nurse anticipate? b. Rhinorrhea and raccoon eyes 14. With the above patient, you should avoid which of the following: d. Placement of a 16 French orogastric tube 15. 15. A patient on the ER exhibits the following symptoms: weakness to the left side, facial droop, and slurred speech. You expect which of the following diagnostics tests to be ordered? a. CT of the head 16. Based on the diagnosis for the previous patient, you expect which of the following assessments is of highest priority? a. History of smoking and alcohol usage, childhood illnesses, and cardiac history 17. In preparation for TPA administration, you know that which of the following must be accomplished prior to administration? a. IV access, SBP controlled and less than 185, must start within three hours of symptom onset 18. All of the following are common medications to control seizures except: d. Mannitol 19. To treat SAH, nurses administer which of the following medications? d. Digoxin 20. When zeroing the ICP monitor, the transducer should be leveled at the: a. Phlebostatic axis 21. Which of the following injuries to the brain are considered to be diffuse? b. Axonal 22. A neuro trauma patient is in the ICU has maintained a BP of 175/100 with increasing ICP despite treatment. In order for the brain to maintain CPP you understand that the vessels within the brain will? 23. An patient sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED: a. Includes cervical spine x-ray study to determine the presence of a fracture 24. A patient with multiple traumatic injuries receives fluid to maintain a systolic blood pressure at 90 mm Hg. Despite the administration of 3 L of crystalloids, the systolic blood pressure is in the 80s and is very labile. A focused assessment with sonography for trauma (FAST) test identifies peritoneal hemorrhage. What action is anticipated at this time? b. Administration of a vasoactive drip, such as a dopamine drip 25. 25 You are caring for a patient who sustained rib fractures after hitting the steering wheel of his car. The patient is spontaneously breathing and receiving oxygen via a face mask. Current oxygen saturation is 95%. During your assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/50 mm Hg. You do not auscultate any breath sounds on the left side of the chest and notice tracheal deviation. You notify the physician and anticipate: c. Endotracheal intubation and mechanical ventilation