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 D

Explanation

A. The head tilt chin lift method should be avoided due to the risk of aggravating a spinal injury; the jaw-thrust maneuver is safer if airway management is necessary.

B. While controlling bleeding is important, cervical spine stabilization takes priority in trauma with suspected spinal injury.

C. Not moving the victim is appropriate, but stabilizing the cervical spine provides active support to avoid further injury.

D. Stabilizing the cervical spine is crucial to prevent potential spinal cord damage in an unconscious trauma victim, particularly in a motor vehicle accident. This action helps prevent exacerbation of any spinal injury.

A. Frequent passive range of motion B. Coughing and deep breathing exercises once per shift C. Turn patient every 4 hours D. Ambulate patient twice per shift

Correct Answer is A

Explanation

A. Frequent passive range of motion exercises are crucial for preventing complications of immobility, such as contractures and pressure ulcers, and to promote circulation in patients with spinal cord injuries.

B. While coughing and deep breathing exercises are important for respiratory health, they should be performed more frequently than once per shift in patients with reduced mobility to prevent respiratory complications.

C. Turning the patient every 4 hours may not be adequate to prevent pressure ulcers; typically, patients should be turned at least every 2 hours.

D. Patients with a complete spinal cord injury at C7 typically lack the ability to ambulate, making this intervention inappropriate.

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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 is the first person on the scene of a motor vehicle crash. The victim was the driver and is in the driver's seat unconscious. The driver is breathing, has a pulse, and has minor lacerations on the head and face. What action should the nurse implement first?

Correct Answer is D

Explanation

The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?

Correct Answer is A

Explanation

The nurse is caring for a patient diagnosed with unstable angina who is prescribed metoprolol. The patient asks the nurse, "Why do I have to take this medication?" What response by the nurse is most accurate?

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