The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the patient diagnosed with a brain injury and their family. The nurse states, "The ventriculostomy is placed:

after the client has an electroencephalogram (EEG)."

due to having minimal risk for infection."

by threading it through the femoral artery to the brain."

to monitor intracranial pressure (ICP) and drain the cerebral spinal fluid."

Answer and Explanation

The Correct Answer is D

A. EEG is a monitoring tool for brain activity, but it is not a prerequisite for ventriculostomy placement.

B. While the procedure is carefully managed to reduce infection risk, ventriculostomy does have an infection risk due to its invasive nature.

C. Ventriculostomy is not inserted via the femoral artery; it is placed directly in the brain’s ventricles.

D. A ventriculostomy is used to monitor ICP and allows for the drainage of cerebrospinal fluid, which helps in managing elevated ICP in patients with brain injuries.

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Correct Answer is A

Explanation

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

A. Scheduled voiding B. Intermittent catheterization C. Indwelling urinary catheter D. External catheter

Correct Answer is B

Explanation

A. Scheduled voiding is less effective in patients with a flaccid bladder because there is no voluntary control of bladder function.

B. Intermittent catheterization is the preferred management technique for a flaccid or atonic bladder, allowing the bladder to empty at regular intervals and reducing the risk of infection associated with continuous catheters.

C. An indwelling catheter is usually avoided for long-term use due to a higher risk of infection.

D. An external catheter is generally not effective for flaccid or atonic bladder management in spinal cord injuries as it doesn’t actively empty the bladder.

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The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the patient diagnosed with a brain injury and their family. The nurse states, "The ventriculostomy is placed:

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Naxlex Comprehensive Predictor Exams

The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Correct Answer is A

Explanation

The nurse is caring for a patient with a spinal cord injury who has a flaccid or atonic bladder. The nurse would provide discharge education to the patient and family regarding which bladder management technique?

Correct Answer is B

Explanation

The nurse anticipates which antibiotic class, due to the lack of ototoxicity, will be ordered for a patient diagnosed with tympanic membrane rupture?

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this injury?

The nurse is caring for several patients with eye disorders. Which assessment finding correlates with each diagnosis? Note: each column must have one response option selected. Note: Each category must have at least 1 response option selected.

The nurse is caring for a patient diagnosed with a brain injury to the cerebellum. Which nursing intervention is priority?

The nurse is caring for a patient diagnosed with epilepsy who is prescribed antiepileptic medications. The nurse would identify the need for further teaching when the patient states:

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