Medical-Surgical Nursing Exam 18

1. Which of the following conditions of the inner ear is associated with normal hearing?

1. Vestibular neuronitis
   Vestibular neuronitis is a disorder of the vestibular nerve characterized by severe vertigo with normal hearing.
2. Meniere’s disease
   Meniere’s disease is associated with progressive sensorineural hearing loss.
3. Labyrinthitis
   Labyrinthitis is associated with varying degrees of hearing loss.
4. Endolymphatic hydrops
   Endolymphatic hydrops refers to dilation in the endolymmphatic space associated with Meniere’s disease.

2. Of the following terms, which refers to the progressive hearing loss associated with aging?

1. Presbycusis
   Both middle and inner ear age-related changes result in hearing loss.
2. Exostoses
   Exostoses refers to small, hard, bony protrusions in the lower posterior bony portion of the ear canal.
3. Otalgia
   Otalgia refers to a sensation of fullness or pain in the ear.
4. Sensorineural hearing loss
   Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.

3. Which of the following statements describes benign paroxysmal positional vertigo (BPPV)?

1. The vertigo is usually accompanied by nausea and vomiting; however hearing impairment does not generally occur.
   BPPV is a brief period of incapacitating vertigo that occurs when the position of the patient’s head is changed with respect to gravity. The vertigo is usually accompanied by nausea and vomiting; however hearing impairment does not generally occur.
2. The onset of BPPV is gradual.
   The onset of BPPV is sudden and followed by a predisposition for positional vertigo, usually for hours to weeks but occasionally for months or years.
3. BPPV is caused by tympanic membrane infection.
   BPPV is speculated to be caused by the disruption of debris within the semi circular canal. This debris is formed from small crystals of calcium carbonate from the inner ear structure, the utricle.
4. BPPV is stimulated by the use of certain medication such as acetaminophen.
   BPPV is frequently stimulated by head trauma, infection, or other events.

4. Nursing management of the patient with acute symptoms of benign paroxysmal positional vertigo includes which of the following?

1. Bed rest
   Bed rest is recommended for patients with acute symptoms. Canalith repositioning procedures (CRP) may be used to provide resolution of vertigo, and patients with acute vertigo may be medicated with meclizine for 1-2 weeks.
2. The Epley repositioning procedure
   The Epley procedure is not recommended for patients with acute vertigo.
3. Meclizine for 2-4 weeks
   Patients with acute vertigo may be medicated with meclizine for 1-2 weeks.
4. The Dix-Hallpike procedure.
   The Dix-Hallpike test is an assessment test used to evaluate for BPPV.

5. Which of the following terms refers to the inability to recognize objects through a particular sensory system?

1. Agnosia
   Agnosia may be visual, auditory, or tactile.
2. Dementia
   Dementia refers to organic loss of intellectual function.
3. Ataxia
   Ataxia refers to the inability to coordinate muscle movements.
4. Aphasia
   Aphasia refers to loss of the ability to express oneself or to understand language.

6. Which of the following terms refers to weakness of both legs and the lower part of the trunk?

1. Paraparesis
   Paraparesis is a frequent manifestation of degenerative neurologic disorders.
2. Hemiplegia
   Hemiplegia refers to paralysis of one side of the body or a part of it due to an injury to the motor areas of the brain.
3. Quadriparesis
   Quadriparesis refers to weakness that involves all four extremities.
4. Paraplegia
   Paraplegia refers to paralysis of both legs and the lower trunk.

7. Of the following neurotransmitters, which demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?

1. Serotonin
   The sources of serotonin are the brain stem, hypothalamus, and dorsal horn of the spinal cord.
2. Enkephalin
   Enkephalin is excitatory and associated with pleasurable sensations.
3. Norepinephrine
   Norepinephrine is usually excitatory and affects mood and overall activity.
4. Acetylcholine
   Acetylcholine is usually excitatory, but the parasympathetic effects are sometimes inhibitory.

8. The lobe of the brain that contains the auditory receptive areas is the ____________ lobe.

1. temporal
   The temporal lobe plays the most dominant role of any area of the cortex in cerebration.
2. frontal
   The frontal lobe, the largest lobe, controls concentration, abstract thought, information storage or memory, and motor function.
3. parietal
   The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas.
4. occipital
   The occipital lobe is responsible for visual interpretation.

9. The lobe of the brain that is the largest and controls abstract thought is the ____________ lobe.

1. frontal
   The frontal lobe also controls information storage or memory and motor function.
2. temporal
   The temporal lobe contains the auditory receptive area.
3. parietal
   The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas.
4. occipital
   The occipital lobe is responsible for visual interpretation.

10. Which of the following terms is used to describe the fibrous connective tissue that covers the brain and spinal cord?

1. Meninges
   The meninges have three layers, the dura mater, arachnoid mater, and pia mater.
2. Dura mater
   The dura mater is the outmost layer of the protective covering of the brain and spinal cord.
3. Arachnoid mater
   The arachnoid is the middle membrane of the protective covering of the brain and spinal cord.
4. Pia mater                                                                                                                                        The pia mater is the innermost membrane of the protective covering of the brain and spinal cord.

11. The cranial nerve that is responsible for salivation, tearing, taste, and sensation in the ear is the _____________________ nerve.

1. vestibulocochlear
   The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium.
2. oculomotor
   The oculomotor (III) cranial nerve is responsible for the muscles that move the eye and lid, pupillary constriction, and lens accommodation.
3. trigeminal
   The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication.
4. facial
   The facial (VII) nerve controls facial expression and muscle movement.

12. The cranial nerve that is responsible for muscles that move the eye and lid is the _____________________ nerve.

1. oculomotor
   The oculomotor (III) cranial nerve is also responsible for pupillary constriction and lens accommodation.
2. trigeminal
   The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication.
3. vestibulocochlear
   The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium.
4. facial
   The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.

13. The cranial nerve that is responsible for facial sensation and corneal reflex is the _____________________ nerve.

1. trigeminal
   The trigeminal (V) cranial nerve is also responsible for mastication.
2. oculomotor
   The oculomotor (III) cranial nerve is responsible for the muscles that move the eye and lid, pupillary constriction, and lens accommodation.
3. vestibulocochlear
   The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium.
4. facial
   The facial nerve is responsible for salivation, tearing, taste, and sensation in the ear.

14. Upper motor neuron lesions cause

1. no muscle atrophy.
   Upper motor neuron lesions do not cause muscle atrophy but do cause loss of voluntary control.
2. decreased muscle tone.
   Lower motor neuron lesions cause decreased muscle tone.
3. flaccid paralysis.
   Lower motor neuron lesions cause flaccid paralysis.
4. absent or decreased reflexes.
   Lower motor neuron lesions cause absent or decreased reflexes.

15. Lower motor neuron lesions cause

1. flaccid muscle paralysis.
   Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control.
2. increased muscle tone.
   Upper motor neuron lesions cause increased muscle tone.
3. no muscle atrophy.
   Upper motor neuron lesions cause no muscle atrophy.
4. hyperactive and abnormal reflexes.
   Upper motor neuron lesions cause hyperactive and abnormal reflexes.

16. The percentage of patients over the age of 70 admitted to the hospital with delirium is about

1. 25%.
   About 25% of patients over the age of 70 admitted to the hospital have delirium. The cause is often reversible and treatable (as in drug toxicity, vitamin B12 deficiency or thyroid disease) or chronic and irreversible. Depression may produce impairment of attention and memory.
2. 10%.
   About 25% of patients over the age of 70 admitted to the hospital have delirium.
3. 40%.
   About 25% of patients over the age of 70 admitted to the hospital have delirium.
4. 50%.
   About 25% of patients over the age of 70 admitted to the hospital have delirium.

17. Structural and motor changes related to aging that may be assessed in geriatric patients during an examination of neurologic function include which of the following?

1. Decreased or absent deep tendon reflexes
   Structural and motor changes related to aging that may be assessed in geriatric patients include decreased or absent deep tendon reflexes.
2. Increased pupillary responses
   Pupillary responses are reduced or may not appear at all in the presence of cataracts
3. Increased autonomic nervous system responses.
   There is an overall slowing of autonomic nervous system responses
4. Enhanced reaction and movement times
   Strength and agility are diminished and reaction and movement times are decreased.

18. What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

1. Ensure that no patient care equipment containing metal enters the room where the MRI is located.
   For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles towards the magnet.
2. Securely fasten the patient’s portable oxygen tank to the bottom of the MRI table after the patient has been positioned on the top of the MRI table.
   For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located.
3. Check the patient’s oxygen saturation level using a pulse oximeter after the patient has been placed on the MRI table.
   For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located.
4. No special safety actions need to be taken.
   For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located.

19. Which of the following terms refer to a method of recording, in graphic form, the electrical activity of the muscle?

1. Electromyogram
   Electromyogram is a method of recording, in graphic form, the electrical activity of the muscle.
2. Electroencephalogram
   Electroencephalogram is a method of recording, in graphic form, the electrical activity of the brain.
3. Electrocardiography
   Electrocardiography is performed to assess the electrical activity of the heart.
4. Electrogastrography
   Electrogastrography is an electrophysiologic study performed to assess gastric motility disturbances.

20. Which of the following are sympathetic effects of the nervous system?

1. Dilated pupils
   Dilated pupils are a sympathetic effect of the nervous system. Constricted pupils are a parasympathetic effect.
2. Decreased blood pressure
   Decreased blood pressure is a parasympathetic effect. Increased blood pressure is a sympathetic effect.
3. Increased peristalsis
   Increased peristalsis is a parasympathetic effect. Decreased peristalsis is a sympathetic effect.
4. Decreased respiratory rate                                                                                                              Decreased respiratory rate is a parasympathetic effect. Increased respiratory rate is a sympathetic effect.

21. Lesions in the temporal lobe may result in which of the following types of agnosia?

1. Auditory
   Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia.
2. Visual
   Lesions in the occipital lobe may result in visual agnosia.
3. Tactile
   Lesions in the parietal lobe may result in tactile agnosia.
4. Relationship
   Lesions in the parietal lobe (posteroinferior regions) may result in relationship and body part agnosia.

22. When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient’s posturing as

1. decerebrate.
   Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.
2. normal.
   The described posturing results from cerebral trauma and is not normal.
3. flaccid.
   The patient has no motor function, is limp, and lacks motor tone with flaccid posturing.
4. decorticate.
   In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

23. Monro-Kellie hypothesis refers to

1. the dynamic equilibrium of cranial contents.
   The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others.
2. unresponsiveness to the environment.
   Akinetic mutism is the phrase used to refer to unresponsiveness to the environment.
3. the brain’s attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure.
   Cushing’s response is the phrase used to refer to the brain’s attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure.
4. a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function.
   Persistent vegetative state is the phrase used to describe a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function.

24. A patient who demonstrates an obtunded level of consciousness

1. sleeps almost constantly but can be aroused and can follow simple commands.
   An obtunded patient stays awake only with persistent stimulation.
2. has difficulty following commands, and may be agitated or irritable.
   A confused patient has difficulty following commands, and may be agitated or irritable.
3. sleeps often and shows slowed speech and thought processes.
   A patient who sleeps often and shows slowed speech and thought processes is described as lethargic.
4. does not respond to environmental stimuli.
   A comatose patient does not respond to environmental stimuli.

25. An osmotic diuretic, such as Mannitol, is given to the patient with increased intracranial pressure (IICP) in order to

1. dehydrate the brain and reduce cerebral edema.
   Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.
2. control fever.
   Antipyretics and a cooling blanket are used to control fever in the patient with IICP.
3. control shivering.
   Chloropromazine (Thorazine) may be prescribed to control shivering in the patient with IICP.
4. reduce cellular metabolic demands.
   Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.

26. Which of the following positions are employed to help reduce intracranial pressure (ICP)?

1. Avoiding flexion of the neck with use of a cervical collar
   Use of a cervical collar promotes venous drainage and prevents jugular vein distortion that will increase ICP.
2. Keeping the head flat with use of no pillow
   Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed.
3. Rotating the neck to the far right with neck support
   Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP.
4. Extreme hip flexion supported by pillows
   Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

27. Which of the following insults or abnormalities most commonly causes ischemic stroke?

1. Cocaine use
   Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual’s first unprescribed use of the drug.
2. Arteriovenous malformation
   Arteriovenous malformations are associated with hemorrhagic strokes.
3. Trauma
   Trauma is associated with hemorrhagic strokes.
4. Intracerebral aneurysm rupture
   Intracerebral aneurysm rupture is associated with hemorrhagic strokes.

28. When the patient is diagnosed as having global aphasia, the nurse recognizes that the patient will

1. be unable to form words that are understandable or comprehend the spoken word.
   Global aphasia is a combination of expressive and receptive aphasia and presents tremendous challenge to the nurse to effectively communicate with the patient.
2. be unable to comprehend the spoken word.
   In receptive aphasia, the patient is unable to form words that are understandable.
3. be unable to form words that are understandable.
   In expressive aphasia, the patient is unable to form words that are understandable.
4. be unable to speak at all.
   The patient who is unable to speak at all is referred to as mute.

29. Which of the following terms related to aphasia refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?

1. Apraxia
   Verbal apraxia refers to difficulty in forming and organizing intelligible words although the musculature is intact.
2. Agnosia
   Agnosia is failure to recognize familiar objects perceived by the senses.
3. Agraphia
   Agraphia refers to disturbances in writing intelligible words.
4. Perseveration
   Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate.

30. Which of the following terms related to aphasia refers to the failure to recognize familiar objects perceived by the senses?

1. Agnosia
   Auditory agnosia is failure to recognize significance of sounds.
2. Agraphia
   Agraphia refers to disturbances in writing intelligible words.
3. Apraxia
   Apraxia refers to inability to perform previously learned purposeful motor acts on a voluntary basis.
4. Perseveration                                                                                                                              Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.

31. Which of the following terms related to aphasia refers to difficulty reading?

1. Alexia
   Alexia or dyslexia may occur in the absence of aphasia.
2. Agnosia
   Agnosia is failure to recognize familiar objects perceived by the senses.
3. Agraphia
   Agraphia refers to disturbances in writing intelligible words.
4. Perseveration
   Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.

32. Which of the following terms related to aphasia refers to difficulty in selecting appropriate words, particularly nouns?

1. Anomia
   Anomia is also termed dysnomia.
2. Acalculia
   Acalculia refers to difficulty in dealing with mathematical processes or numerical symbols in general.
3. Dysarthria
   Dysarthria refers to defects of articulation due to neurologic causes.
4. Paraphasia
   Paraphasia refers to using wrong words, word substitutions, and faults in word usage in both oral and written language.

33. A patient has had neurologic deficits lasting for more than 24 hours, and now the symptoms are resolving. The nurse concludes that the patient has had which type of stroke?

1. Reversible ischemic neurologic deficit
   With a reversible ischemic neurologic deficit, the patient has more pronounced signs and symptoms that last more than 24 hours; symptoms resolve in a matter of days without any permanent neurologic deficit.
2. Transient ischemic attack (TIA)
   With a TIA, the patient has a temporary episode of neurologic dysfunction that may last a few seconds or minutes but not longer than 24 hours.
3. Stroke in evolution
   With a stroke in evolution the patient experiences a worsening of neurological signs and symptoms over several minutes or hours; it is a progressing stroke.
4. Completed stroke
   With a completed stroke, the patient’s neurological signs and symptoms have stabilized with no indication of further progression of the hypoxic insult to the brain.

34. Which of the following is a modifiable risk factor for transient ischemic attacks and ischemic strokes?

1. History of smoking.
   Modifiable risk factors for TIAs and ischemic stroke include hypertension, Type 1 diabetes, cardiac disease, history of smoking, and chronic alcoholism.
2. Thyroid disease
   Hypertension, Type 1 diabetes, and cardiac disease are modifiable risk factors for TIAs and ischemic stroke.
3. Social drinking
   Chronic alcoholism is a modifiable risk factor for TIAs and ischemic stroke.
4. Advanced age
   Advanced age, gender, and race are non-modifiable risk factors for stroke.

35. A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken together with warfarin

1. can greatly increase the international normalization ratio (INR) and therefore increase the risk of bleeding.
   Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.
2. have no drug-drug interactions and therefore may be taken together.
   Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.
3. can cause platelet aggregation and therefore increase the risk of blood clotting.
   Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.
4. may increase cerebral blood flow causing migraine headaches.
   Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

36. Later signs of increased intracranial pressure (ICP) later include which of the following?

1. Projectile vomiting
   Projectile vomiting may occur with increased pressure on the reflex center in the medulla.
2. Increased pulse rate
   As ICP increases, the pulse rate decreases.
3. Decreased blood pressure
   As ICP increases, the blood pressure increases.
4. Narrowed pulse pressure
   As ICP increases, the pulse pressure (the difference between the systolic and the diastolic pressure) widens.

37. Bleeding between the dura mater and arachnoid membrane is termed

1. subdural hematoma.
   A subdural hematoma is bleeding between the dura mater and arachnoid membrane.
2. intracerebral hemorrhage.
   Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures.
3. epidural hematoma.
   An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath.
4. extradural hematoma.
   An extradural hematoma is another name for an epidural hematoma.

38. Which of the following statements reflect nursing management of the patient with expressive aphasia?

1. Encourage the patient to repeat sounds of the alphabet.
   Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet.
2. Speak clearly and in simple sentences; use gestures or pictures when able.
   Nursing management of the patient with global aphasia includes speaking clearly and in simple sentences and using gestures or pictures when able.
3. Speak slowly and clearly to assist the patient in forming the sounds.
   Nursing management of the patient with receptive aphasia includes speaking slowing and clearly to assist the patient in forming the sounds.
4. Frequently reorient the patient to time, place, and situation.
   Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation.

39. Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including

1. a low fat, low cholesterol diet, and increasing exercise.
   Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including a low fat, low cholesterol diet, and increasing exercise.
2. eating fish no more than once a month.
   Recent evidence suggests that eating fish two or more times per week reduces the risk of thrombotic stroke for women
3. a high protein diet and increasing weight-bearing exercise.
   Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including a low fat, low cholesterol diet, and increasing exercise.
4. a low cholesterol, low protein diet, and decreasing aerobic exercise.
   Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including a low fat, low cholesterol diet, and increasing exercise.

40. Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or return to the ED if the patient

1. vomits.
   Vomiting is a sign of increasing intracranial pressure and should be reported immediately.
2. complains of headache.
   In general, the finding of headache in the patient with a concussion is an expected abnormal observation. However, severe headache should be reported or treated immediately.
3. complains of generalized weakness.
   Weakness of one side of the body should be reported or treated immediately.
4. sleeps for short periods of time.                                                                                                        Difficulty in waking the patient should be reported or treated immediately.

41. When the nurse reviews the physician’s progress notes for the patient who has sustained a head injury and sees that the physician observed Battle’s sign when the patient was in the Emergency Department, the nurse knows that the physician observed

1. an area of bruising over the mastoid bone.
   Battle‘s sign may indicate skull fracture.
2. a bloodstain surrounded by a yellowish stain on the head dressing.
   A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a cerebrospinal fluid leak.
3. escape of cerebrospinal fluid (CSF) from the patient’s ear.
   Escape of CSF from the patient’s ear is termed otorrhea.
4. escape of cerebrospinal fluid (CSF) from the patient’s nose.
   Escape of CSF from the patient’s nose is termed rhinorrhea.

42. Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)?

1. Widened pulse pressure
   Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature.
2. Increased pulse
   Bradycardia, slowing of the pulse, is an indication of increasing ICP in the head-injured patient.
3. Decreased respirations
   Rapid respiration is an indication of increasing ICP in the head-injured patient.
4. Decreased body temperature
   A rapid rise in body temperature is regarded as unfavorable because hyperthermia may indicate brain stem damage, a poor prognostic sign.

43. Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient?

1. Supply oxygen therapy to keep blood gas values within normal range.
   The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.
2. Do not elevate the head of the bed.
   In general, the head of the bed is elevated about 30 degrees to decrease intracranial venous pressure.
3. Encourage the patient to cough every 2 hours.
   Coughing should not be encouraged because it increases intracranial pressure.
4. Use restraints if the patient becomes agitated.
   Restraints should be avoided because straining against them can increase intracranial pressure. Use of padded side rails and application of mitts are the appropriate interventions in the agitated head-injured patient.

44. Of the following stimuli, which is known to trigger an episode of autonomic hyperreflexia in the patient who has suffered a spinal cord injury?

1. Applying a blanket over the patient
   An object on the skin or skin pressure may precipitate an autonomic hyperreflexic episode.
2. Diarrhea
   In general, constipation or fecal impaction triggers autonomic hyperreflexia.
3. Placing the patient in a sitting position
   When the patient is observed to be demonstrating signs of autonomic hyperreflexia, he is placed in a sitting position immediately to lower blood pressure.
4. Voiding
   The most common cause of autonomic hyperreflexia is a distended bladder.

45. Risk factors that increase the likelihood of post-traumatic seizures following a head injury include which of the following?

1. Age over 65 years
   Risk factors that increase the likelihood of post-traumatic seizures following a head injury include brain contusion with subdural hematoma, skull fracture, loss of consciousness or amnesia of 1 day or more, and age over 65 years.
2. Loss of consciousness for less than 1 day
   Loss of consciousness or amnesia of 1 day or more is a risk factor that increases the likelihood of post-traumatic seizures following a head injury
3. Glasgow Coma Scale (GCS) score less than 10
   The GCS assesses level of consciousness; a score of 10 or less indicates the need for emergency attention. It is not a risk factor for post-traumatic seizures.
4. Epidural hematoma
   Brain contusion with subdural hematoma is a risk factor that increases the likelihood of post-traumatic seizures following a head injury

46. A post-traumatic seizure classified as early occurs

1. within 1-7 days of injury.
   Posttraumatic seizures are classified as immediate (occurring within 24 hours of injury), early, (occurring within 1-7 days of injury) or late, occurring more than 7 days following injury.
2. within 4 hours of injury.
   Posttraumatic seizures are classified as immediate (occurring within 24 hours of injury), early, (occurring within 1-7 days of injury) or late, occurring more than 7 days following injury.
3. within 24 hours of injury.
   Posttraumatic seizures occurring within 24 hours of injury are classified as immediate seizures.
4. more than 7 days following surgery.
   Posttraumatic seizures occurring more than 7 days following surgery are classified as late seizures.

47. The nurse assesses the dressing of a patient with a basal skull fracture and sees the halo sign – a blood stain surrounded by a yellowish stain. The nurse knows that this sign

1. is highly suggestive of a cerebrospinal fluid (CSF) leak.
   The halo sign – a blood stain surrounded by a yellowish stain is highly suggestive of a cerebrospinal fluid (CSF) leak.
2. may indicate a subdural hematoma..
   The halo sign is highly suggestive of a cerebrospinal fluid (CSF) leak.
3. is highly suggestive of a cerebral contusion.
   The halo sign is highly suggestive of a cerebrospinal fluid (CSF) leak.
4. normally occurs within 24 hours following a basal skull fracture.
   The halo sign is highly suggestive of a cerebrospinal fluid (CSF) leak.

48. A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as

1. coma.
   The Glasgow Coma Scale (GCS) is a tool for assessing a patient’s response to stimuli. A score of 7 or less is generally interpreted as coma.
2. a need for emergency attention.
   A GCS score of 10 or less indicates a need for emergency attention.
3. least responsive.
   A GCS score of 3 is interpreted as least responsive.
4. most responsive.
   A GCS score of 15 is interpreted as most responsive.

49. Which of the following terms refers to muscular hypertonicity with increased resistance to stretch?

1. Spasticity
   Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes.
2. Akathesia
   Akathesia refers to a restless, urgent need to move around and agitation.
3. Ataxia
   Ataxia refers to impaired ability to coordinate movement.
4. Myclonus
   Myoclonus refers to spasm of a single muscle or group of muscles.

50. Of the following terms, which refers to blindness in the right or left halves of the visual fields of both eyes?

1. Homonymous hemianopsia
   Homonymous hemianopsia occurs with occipital lobe tumors.
2. Scotoma
   Scotoma refers to a defect in vision in a specific area in one or both eyes.
3. Diplopia
   Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes.
4. Nystagmus                                                                                                                                                                       Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.