Question

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

Answer 1

Correct Answers:

Mannitol 25%

Rationale :

✅ Mannitol 25% is an osmotic diuretic used to lower increased intracranial pressure (ICP) by pulling fluid from swollen brain tissue into the bloodstream.

✅ This helps reduce cerebral edema, improve cerebral perfusion, and decrease worsening neurological deterioration linked with Cushing’s Triad (late sign of rising ICP).

✅ Mannitol also reduces blood viscosity briefly, which can improve cerebral blood flow and oxygen delivery.

✅ The nurse must monitor serum osmolality, electrolytes, urine output, and blood pressure because mannitol can cause fluid shifts and dehydration.

✅ It is commonly used in acute neuro emergencies when rapid ICP reduction is needed while definitive treatment is underway.

Hydroxyethyl glucose

✅This is a volume-expanding IV solution, not a standard medication for lowering ICP.

✅It can worsen fluid overload and does not pull fluid from brain tissue to reduce swelling.

Dextran 70

✅This is a plasma expander used for volume support, not for treating elevated ICP.

✅It can increase circulating volume and does not directly decrease cerebral edema.

Albumin 25%

✅Although hyperoncotic, it is primarily used for volume expansion and specific hypoalbuminemia-related needs, not first-line ICP reduction.

✅In neuro injury, aggressive colloids may increase intravascular volume without reliably correcting brain swelling.

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Answer 2

Correct Answers:

Gait belt

Rationale :

♦ A gait belt provides the nurse with a secure handhold to steady the client and prevent falls during ambulation.

♦ It supports safe transfers and walking by allowing controlled assistance if the client becomes unsteady.

♦ This is especially important for older adults with intermittent balance loss because the nurse can quickly correct posture and reduce the risk of injury.

♦ A gait belt improves client safety while promoting mobility, rather than restricting movement.

♦ Proper use includes placing it snugly over clothing at the waist and maintaining a supportive stance during walking.

Cane

♦ A cane is an assistive device the client uses independently and requires correct fitting and training.

♦ It is not the primary safety tool the nurse uses to physically support an unsteady client during ambulation.

Four-wheel walker

♦ This device provides mobility support but requires coordination, brake use, and safe technique.

♦ It does not replace the nurse’s need for a gait belt when the client may suddenly lose balance.

Jacket harness

♦ This is not a standard first-line ambulation safety device in routine care and is more restrictive.

♦ It can pose discomfort and is not typically used for basic assisted ambulation.

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Answer 3

Correct Answers:

Smokes 1 pack of cigarettes per day

Rationale :

💎 Cigarette smoking is a major risk factor for osteoporosis because it decreases bone mineral density.

💎 Nicotine negatively affects osteoblast activity (bone formation) and can increase bone breakdown over time.

💎 Smoking is also linked to lower estrogen levels, which accelerates bone loss—especially in older adults and postmenopausal clients.

💎 It contributes to poorer calcium absorption and reduced blood supply to bone tissue.

💎 Long-term smoking increases the risk of fragility fractures (hip, vertebrae, wrist).

Large body stature

💎Larger body mass is generally protective because it increases mechanical load on bones and often correlates with higher estrogen levels.

💎This tends to support higher bone density rather than bone loss.

Drinks one alcoholic beverage per day

💎Light or occasional alcohol intake is not typically the strongest osteoporosis risk factor compared to heavy chronic use.

💎Osteoporosis risk rises more with excess alcohol due to impaired bone formation and falls risk.

History of bone fracture during childhood

💎Childhood fractures are commonly related to trauma and do not automatically indicate low bone density.

💎Osteoporosis risk is more associated with adult fragility fractures and long-term metabolic factors.

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Answer 4

Correct Answers:

"Your pain will gradually become less severe."

Rationale :

🟣 Phantom limb pain is a real neurologic pain experience that often decreases in intensity over time.

🟣 It results from continued signaling and re-mapping in the peripheral nerves, spinal cord, and brain, not from imagination.

🟣 Teaching that pain may lessen prepares the client realistically while validating that pain can occur and can be treated.

🟣 The nurse should also emphasize that management may include medications (e.g., analgesics, anticonvulsants), mirror therapy, and nonpharmacologic techniques.

🟣 Providing accurate expectations reduces anxiety and supports coping during recovery.

“It’s likely that you will have only a tingling sensation.”

🟣Phantom sensations vary widely and can include severe pain, burning, cramping, or stabbing.

🟣Minimizing it can leave the client unprepared for real postoperative pain experiences.

“Phantom pain never lasts long.”

🟣Phantom pain can persist for months or longer in some clients and may fluctuate.

🟣Saying it never lasts long is inaccurate and dismissive.

“Phantom pain is mostly psychological.”

🟣Phantom limb pain has a physiologic neurologic basis and is not “mostly psychological.”

🟣 Labeling it that way can increase stigma and reduce the likelihood the client reports symptoms.

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Answer 5

Correct Answers:

Apply lubricating eye drops.

Rationale :

🔷 Loss of the corneal reflex prevents normal blinking, which increases the risk for corneal drying and injury.

🔷 Lubricating drops protect the cornea by maintaining moisture and preventing breakdown of the corneal surface.

🔷 This intervention reduces risk of corneal abrasions, ulceration, and infection, which can occur quickly in unconscious clients.

🔷 Eye protection is a priority because the client cannot self-report discomfort or protect the eyes.

🔷 The nurse should also ensure eyelids are gently closed as appropriate and follow facility protocols for eye care.

Keep the room darkened.

🔷Darkening the room may reduce light irritation but does not address the primary issue of corneal drying.

🔷The injury risk remains without lubrication.

Alternate warm saline compresses to the eyes.

🔷Warm compresses are not the primary prevention for exposure keratopathy and may introduce moisture inconsistently.

🔷Lubrication is more appropriate for ongoing protection.

Clean the eyes with a mild soap.

🔷Soap can irritate ocular tissue and is unsafe for routine eye care.

🔷Eye cleansing should be done with appropriate sterile solutions, not soap.

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Answer 6

Correct Answers:

Increase fluid intake.

Rationale :

🔶 A post–lumbar puncture headache is commonly caused by cerebrospinal fluid (CSF) leakage and decreased CSF pressure.

🔶 Increasing fluids supports rehydration and can help the body restore CSF volume, easing the headache.

🔶 Hydration (often paired with caffeine per provider orders) is a first-line nursing measure to promote symptom improvement.

🔶 The headache typically worsens when upright, so restoring volume helps reduce traction on pain-sensitive structures.

🔶 The nurse should also monitor severity and report persistent headache because a blood patch may be needed if it does not resolve.

Darken the client’s room and close the door.

🔶This may reduce discomfort from light sensitivity but does not correct low CSF pressure.

🔶The underlying cause remains.

Elevate the head of the bed to 30°.

🔶Post-LP headaches usually improve when lying flat, not with head elevation.

🔶Elevation can worsen symptoms by further reducing CSF pressure at the brain.

Administer pain medication.

🔶Analgesics may provide temporary relief but do not treat the cause of CSF leak/low pressure.

🔶Nursing interventions should prioritize measures that support CSF restoration.

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Answer 7

Correct Answers:

Avoid driving until effects are known.

Rationale :

🔵 Cyclobenzaprine is a centrally acting skeletal muscle relaxant that commonly causes drowsiness and dizziness.

🔵 Because it can impair alertness, coordination, and reaction time, clients should avoid driving or operating machinery until they know how it affects them.

🔵 This teaching reduces risk of injury from sedation-related accidents, especially when starting therapy.

🔵 The nurse should also reinforce avoiding alcohol or other CNS depressants that increase sedation.

🔵 Safety teaching is essential because the medication’s therapeutic effect is related to central nervous system depression.

Expect urine to turn orange.

🔵Orange urine is more associated with certain medications like phenazopyridine or rifampin, not cyclobenzaprine.

🔵This statement is inaccurate teaching for this drug.

Discontinue medication if nausea occurs.

🔵Mild nausea can occur with many medications and is not an automatic stop indication.

🔵The client should report persistent or severe effects, but abrupt discontinuation is not routine teaching for mild nausea.

Monitor for increased muscle spasms.

🔵Cyclobenzaprine is intended to reduce muscle spasm, and increased spasms are not the expected monitoring focus.

🔵Safety concerns like sedation are more clinically relevant for teaching.

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Answer 8

Correct Answers:

"Normal bone growth can be affected."

Rationale :

⚫ The epiphyseal plate is the growth plate, and injury can disrupt normal longitudinal bone growth.

⚫ A fracture in this area can lead to growth arrest, limb-length discrepancy, or angular deformity depending on severity and healing.

⚫ Teaching should emphasize careful follow-up because growth plate injuries may require monitoring over time as the child grows.

⚫ Early recognition and proper alignment/immobilization are crucial to protect future bone development.

⚫ This statement accurately prepares the parent for why adherence to treatment and follow-up imaging is important.

“Bone marrow can be lost though the fracture.”

⚫Bone marrow loss is not a typical teaching point for epiphyseal plate fractures.

⚫The primary concern is growth disruption, not marrow loss.

“The younger the child the longer the healing process will take.”

⚫Children generally heal faster than adults due to better bone remodeling capacity.

⚫Younger age does not usually mean longer healing time.

“The blood supply to the bone is disrupted.”

⚫While vascular compromise can occur with some fractures, it is not the key defining risk of epiphyseal plate fractures.

⚫The central issue is potential growth disturbance.

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Answer 9

Correct Answers:

Monitor the client for an elevated temperature.

Rationale :

🟡 Halo fixation uses pins that penetrate the skull, creating a risk for infection at pin sites.

🟡 Monitoring for elevated temperature helps detect systemic infection early, which can progress if pin-site care is inadequate.

🟡 Fever may indicate complications such as pin-site infection or osteomyelitis, requiring prompt intervention.

🟡 Ongoing assessment should include pin-site inspection, drainage monitoring, and reinforcement of prescribed pin care.

🟡 Early identification of infection supports safer healing and reduces the risk of serious neurologic complications.

Provide range of motion to the client’s neck.

🟡Halo fixation is designed to immobilize the cervical spine.

🟡Neck ROM can compromise alignment and safety.

Check that the halo jacket is snug against the client’s skin.

🟡The vest should be secure but not overly tight against the skin because pressure increases risk of skin breakdown.

🟡Fit and skin checks are important, but “snug against skin” is not the safe phrasing.

Remove the vest daily to inspect the client’s skin integrity.

🟡The vest should not be removed routinely because it maintains spinal stabilization.

🟡Skin integrity is assessed around accessible areas without removing the device unless prescribed by the provider.

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Answer 10

Correct Answers:

"Take the medication with milk."

Rationale :

✅ Betamethasone is a corticosteroid that can irritate the gastric mucosa and increase the risk for GI upset or ulceration.

✅ Taking it with milk or food helps protect the stomach lining and improves tolerance.

✅ Corticosteroids can also increase gastric acid secretion, making stomach protection an important teaching point.

✅ Clients should take it exactly as prescribed and not stop abruptly, because sudden withdrawal can cause adrenal insufficiency.

✅ This teaching supports adherence while reducing common adverse effects like nausea, epigastric pain, and dyspepsia.

“Take the medication on an empty stomach.”

✅Taking corticosteroids on an empty stomach increases risk for GI irritation and discomfort.

✅This can worsen nausea and raise ulcer risk in susceptible clients.

“Take the medication between meals.”

✅Between meals does not reliably reduce gastric irritation the way taking with food/milk does.

✅The priority is stomach protection, especially for long-term steroid therapy.

“Take the medication with orange juice.”

✅Orange juice is acidic and may worsen gastric irritation in some clients.

✅Milk/food is the preferred option for GI protection.

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☑️ATI Custom Unit V Neuromuscular 0526

No.

1 :
A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

2 :
A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?

3 :
A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

4 :
A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. What preoperative teaching should the nurse include, considering the possibility of an amputation procedure, regarding the potential for phantom limb pain?

5 :
A nurse is caring for an unconscious client who has a loss of the corneal reflex. Which of the following actions should the nurse take?

6 :
A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

7 :
A nurse is teaching a client who has a new prescription for cyclobenzaprine. Which of the following information should the nurse include in the teaching?

8 :
A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make?

9 :
A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

10 :
A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?

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☑️ATI Custom Unit V Neuromuscular 0526

No.

1 : A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

2 : A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?

3 : A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

4 : A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. What preoperative teaching should the nurse include, considering the possibility of an amputation procedure, regarding the potential for phantom limb pain?

5 : A nurse is caring for an unconscious client who has a loss of the corneal reflex. Which of the following actions should the nurse take?

6 : A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

7 : A nurse is teaching a client who has a new prescription for cyclobenzaprine. Which of the following information should the nurse include in the teaching?

8 : A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make?

9 : A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

10 : A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?

1 :
A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

2 :
A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?

3 :
A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

4 :
A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. What preoperative teaching should the nurse include, considering the possibility of an amputation procedure, regarding the potential for phantom limb pain?

5 :
A nurse is caring for an unconscious client who has a loss of the corneal reflex. Which of the following actions should the nurse take?

6 :
A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

7 :
A nurse is teaching a client who has a new prescription for cyclobenzaprine. Which of the following information should the nurse include in the teaching?

8 :
A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make?

9 :
A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

10 :
A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?