253 - Neuro Questions (51-100 with rationales and strategies)

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client? Select all that apply. 1.Provide oral hygiene after each meal. 2.Assess swallowing ability frequently. 3.Allow the client sufficient time to eat. 4.Maintain a suction machine at the bedside. 5.Provide a full liquid diet for ease in swallowing.

1,2,3,4. A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. The client should be given a sufficient amount of time to eat. Semisoft foods are easiest to swallow and require less chewing. Oral hygiene is necessary after each meal. Suctioning should be available for clients who experience dysphagia and are at risk for aspiration. * Focus on the subject, care of the client with ALS, and note the words severely dysphagic. Think about the complications associated with this disorder. Recall that liquids are most difficult to swallow in the client with dysphagia.

The nurse is developing a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. 1.Thicken liquids. 2.Assist the client with eating. 3.Assess for the presence of a swallow reflex. 4.Place the food on the affected side of the mouth. 5.Provide ample time for the client to chew and swallow.

1,2,3,5. Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking. * Focus on the subject, the client with dysphagia, and recall that the client with dysphagia has difficulty swallowing. Recalling that the client is therefore at risk for aspiration will assist in directing you to the correct options.

A thymectomy accomplished via a median sternotomy approach is performed in a client with a diagnosis of myasthenia gravis. The nurse develops a postoperative plan of care for the client that should include which intervention? 1.Monitor the chest tube drainage. 2.Restrict visitors for 24 hours postoperatively. 3.Maintain intravenous infusion of lactated Ringer's solution. 4.Avoid administering pain medication to prevent respiratory depression.

1. A thymectomy may be used for management of clients with myasthenia gravis. The procedure is performed through a median sternotomy or a transcervical approach. Postoperatively the client will have a chest tube in the mediastinum. Lactated intravenous solutions usually are avoided because they can increase weakness. Pain medication is administered as needed, but the client is monitored closely for respiratory depression. There is no reason to restrict visitors. * Focus on the subject, general postoperative measures. Note the words median sternotomy approach in the question. Think about this anatomical location; this should provide you with a clue that the client will have a chest tube in place after this procedure.

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1.Elevate the head of the bed. 2.Examine the rectum digitally. 3.Assess the client's blood pressure. 4.Place the client in the prone position.

1. Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position. * Note the strategic word initial in the question. Noting that both options 1 and 4 identify a client position will assist in eliminating options 2 and 3 because positioning is a priority. Recalling the pathophysiology of autonomic dysreflexia will direct you to the correct option.

The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse should expect to observe which finding in the client? 1.Facial drooping 2.Periorbital edema 3.Ptosis of the eyelid 4.Twitching on the affected side of the face

1. Bell's palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). Assessment findings include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. Options 2, 3, and 4 are not associated findings in Bell's palsy. * Focus on the subject, manifestations of Bell's palsy. Recalling that Bell's palsy is a type of paralysis will direct you to the correct option. Also noting the word palsy in the question and the word drooping in the correct option will assist in answering correctly.

The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? 1.Blood pressure 2.Motor response 3.Pupillary response 4.Level of consciousness

1. Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. Options 2, 3, and 4 are unrelated to monitoring for Cushing's reflex. * Use knowledge regarding Cushing's reflex and the ABCs-airway, breathing, and circulation-to assist in directing you to the correct option.

The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care? 1.The client's body temperature is 98° F. 2.The client's fingers and toes are cool to touch. 3.The client remains in a fetal position when in bed. 4.The client complains of coolness in the hands and feet only.

1. Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include the following: hands and limbs are warm; body is relaxed and not curled; body temperature is greater than 97° F; the client is not shivering; and the client has no complaints of feeling cold. * Eliminate option 4 first because of the closed-ended word only. Regarding the remaining options, focusing on the subject, a desired outcome to prevent cold discomfort and hypothermia, will direct you to the correct option.

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1.Confusion 2.Bradycardia 3.Sluggish pupils 4.A widened pulse pressure

1. Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern; pupillary sluggishness and dilatation appear in the late stages. * Note the strategic word early in the question. Recalling that the earliest indicator of increased ICP is changes in level of consciousness will direct you to the correct option.

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function by the nurse will yield the best information about these cranial nerves? 1.Eye movements 2.Response to verbal stimuli 3.Affect, feelings, or emotions 4.Insight, judgment, and planning

1. Eye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum. * Focus on the subject, cranial nerves III, IV, and VI. Recalling that these nerves control eye movement will direct you to the correct option.

A client who had a brain attack (stroke) has right-sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem? 1.Teach the client to scan the environment. 2.Place all objects within the left visual field. 3.Place all objects within the right visual field. 4.Ensure that the family brings the client's eyeglasses to hospital.

1. Hemianopsia is blindness in half the visual field. The client with hemianopsia is taught to scan the environment. This allows the client to take in the entirety of the visual field, which is necessary for proper functioning within the environment and helps to prevent injury to the client. Options 2 and 3 will not help the client adapt to this visual impairment. Eyeglasses are useful if the client already wears them, but they will not correct this visual-field deficit. * Note the subject, measures to assist the client experiencing hemianopsia. The correct option teaches the client a response to overcome this visual deficit. Recalling that hemianopsia is blindness in one half of the field of vision will direct you to the correct option.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? 1.The left side of the body 2.The right side of the body 3.Both sides of the body equally 4.Cranial nerves only, such as speech and pupillary response

1. Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits. * Note the strategic word primarily. Eliminate option 4 because of the closed-ended word only. Noting that the injury was on the right side of the head and using knowledge of anatomy and physiology will direct you to the correct option.

The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Dilantin). Which statement, if made by the client, would indicate an understanding of the information about this medication? 1."I need to perform good oral hygiene, including flossing and brushing my teeth." 2."I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." 3."I should take my medication before coming to the laboratory to have a blood level drawn." 4."I should monitor for side effects and adjust my medication dose depending on how severe the side effects are."

1. The client should perform good oral hygiene, including flossing and brushing the teeth. The client also should see a dentist at regularly scheduled times because gingival hyperplasia is a side effect of this medication. The client should avoid alcohol while taking this medication. The client should also be instructed that follow-up serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn. The client should not adjust medication dosages. * Focus on the subject, client understanding about phenytoin. Knowledge that gingival hyperplasia is a side effect of this medication will assist in directing you to the correct option.

A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family hoped. The nurse plans to implement which approach as most helpful to the client and family at this time? 1.Emphasize progress in a realistic manner. 2.Set high goals to give the client something to "aim for." 3.Tell the family to be extremely optimistic with the client. 4.Inform the client and family of standardized goals of care.

1. The most helpful approach by the nurse is to emphasize progress that is being made in a realistic manner. The nurse does not offer false hope but does provide factual information in a clear and positive manner. The nurse encourages the family to be realistic in their expectations and attitudes. The plan of care should be individualized for each client. * Note the strategic word most. Use therapeutic communication techniques to answer this question. Also, noting the word realistic in the correct option will direct you to this one.

The nurse caring for a client with a head injury is monitoring for signs of increased intracranial pressure. The nurse reviews the record and notes that the intracranial pressure (cerebrospinal fluid) is averaging 8 mm Hg. The nurse plans care, knowing that these results are indicative of which condition? 1.Normal condition 2.Increased pressure 3.Borderline situation 4.Compensating condition

1. The normal intracranial pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal range. *Focus on the subject, normal intracranial pressure. Knowledge about normal intracranial pressure is needed to answer this question. Recalling that the normal pressure is 5 to 10 mm Hg will direct you to the correct option.

The nurse is caring for a client who is on bed rest as part of aneurysm precautions. The nurse should avoid doing which action when giving respiratory care to this client? 1.Encourage hourly coughing. 2.Assist with incentive spirometer. 3.Encourage hourly deep breathing. 4.Reposition gently side to side every 2 hours.

1. With aneurysm precautions, any activity that could raise the client's intracranial pressure (ICP) is avoided. For this reason, activities such as straining, coughing, blowing the nose, and even sneezing are avoided whenever possible. The other interventions (repositioning, deep breathing, and incentive spirometry) do not provide added risk of increasing ICP and are beneficial in reducing the respiratory complications of bed rest. * Focus on the subject, the action that should be avoided with a client on aneurysm precautions. Using principles related to increased ICP will direct you to the correct option.

The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions should be included in the plan? Select all that apply. 1.Leave the lights on in the client's room at night. 2.Place a blood pressure cuff at the client's bedside. 3.Close the shades in the client's room during the day. 4.Allow the client to drink one cup of caffeinated coffee a day. 5.Allow the client to ambulate four times a day with assistance.

2,3. Aneurysm precautions include placing the client on bed rest in a quiet setting. The use of lights is kept to a minimum to prevent environmental stimulation. The nurse should monitor the blood pressure and note any changes that could indicate rupture. Any activity, such as pushing, pulling, sneezing, or straining, that increases the blood pressure or impedes venous return from the brain is prohibited. The nurse provides physical care to minimize increases in blood pressure. Visitors, radio, television, and reading materials are restricted or limited. Stimulants, such as nicotine and coffee and other caffeine-containing products, are prohibited. Decaffeinated coffee or tea may be used. * Focus on the client's diagnosis and the subject, measures to prevent aneurysm rupture. Read each option in terms of whether it would cause stimulation or increased intracranial pressure, which can lead to rupture. This will direct you to the correct options.

The nurse is performing an assessment on a client admitted to the nursing unit with a diagnosis of stroke (brain attack). On assessment, the nurse notes that the client is unable to understand spoken language. The nurse plans care, understanding that the client is experiencing impairment of which areas? 1.The occipital lobe 2.The auditory association areas 3.The frontal lobe and optic nerve tracts 4.Concept formation and abstraction areas

2. Auditory association and storage areas are located in the temporal lobe and relate to understanding spoken language. The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation. * Focus on the subject, that the client is unable to understand spoken language. Note the relationship of these words and the words auditory association areas in the correct option.

The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate (Cogentin) orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs? 1.Shuffling gait 2.Inability to urinate 3.Decreased appetite 4.Irregular bowel movements

2. Benztropine mesylate is an anticholinergic, which causes urinary retention as a side effect. The nurse would instruct the client or spouse about the need to monitor for difficulty with urinating, a distended abdomen, infrequent voiding in small amounts, and overflow incontinence. Options 1, 3, and 4 are unrelated to the use of this medication. * Focus on the subject and recall that benztropine mesylate is an anticholinergic and that these types of medications cause urinary retention. This will direct you to the correct option.

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium (Depakote). The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? 1.Electrolyte panel 2.Liver function studies 3.Renal function studies 4.Blood glucose level determination

2. Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determinations. Options 1, 3, and 4 are not studies that are required with the use of this medication. * Focus on the subject, the toxic effects of divalproex sodium. Recalling that divalproex sodium can lead to hepatotoxicity will direct you to the correct option.

The nurse is performing the oculocephalic response (doll's-eyes maneuver) test on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as for the head. How should the nurse document these findings? 1.Normal 2.Abnormal 3.Insignificant 4.Inconclusive

2. In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. * Eliminate options 3 and 4 first because they are comparable or alike findings. Regarding the remaining choices, it is necessary to know that the assessment finding noted in the question is an abnormal response.

At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention? 1.Tightened screws 2.Red skin areas under the jacket 3.Clean and dry lamb's wool jacket lining 4.Finger-width space between the jacket and the skin

2. Red skin areas under the jacket indicate that the jacket is too tight. The resulting pressure could lead to altered skin integrity and needs to be relieved by loosening the jacket. The screws all should be properly tightened. A clean, dry lamb's wool lining should be in place underneath the jacket, and there should be a finger-width space between the jacket and the skin. In addition, the client should wear a clean white cotton T-shirt next to the skin to help prevent itching. * Focus on the subject, care of a halo device. Note the words requires intervention. This phrasing tells you that the correct answer is an option that represents a problem. Noting the word red in the correct option will direct you to this one.

The clinic nurse is reviewing the record of a client scheduled to be seen in the clinic. The nurse notes that the client is taking selegiline hydrochloride (Eldepryl). The nurse suspects that the client has which disorder? 1.Diabetes mellitus 2.Parkinson's disease 3.Alzheimer's disease 4.Coronary artery disease

2. Selegiline hydrochloride is an antiparkinsonian medication. The medication increases dopaminergic action, assisting in the reduction of tremor, akinesia, and the rigidity of parkinsonism. This medication is not used to treat diabetes mellitus, Alzheimer's disease, or coronary artery disease. * Focus on the subject, uses for this medication. Knowledge regarding the action and use of selegiline hydrochloride is required to answer this question. Recalling that this medication increases dopaminergic action and thinking about the pathophysiology associated with Parkinson's disease will direct you to the correct option. Remember that this medication is used to treat Parkinson's disease.

At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with acute brain attack (stroke) earlier in the day. The nurse determines that the client's airway is patent if which data are identified? 1.Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear 2.Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear 3.Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally 4.Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath sounds in lung bases

2. The client's airway is most protected if all of the respiratory parameters measured fall within normal limits. Therefore the respiratory rate should ideally be 16 to 20 breaths/min, the oxygen saturation should be greater than 95%, and the breath sounds should be clear. The correct option is the only one that meets all three criteria. * Use the ABCs-airway, breathing, and circulation-to answer the question. Note that the correct option identifies the highest oxygen saturation level.

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? 1.Body stiffening 2.Spasms of the entire body 3.Sudden loss of consciousness 4.Brief flexion of the extremities

2. The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Options 1, 3, and 4 identify the tonic phase of a seizure. * Note the strategic words most likely. Focus on the subject of the question, clonic phase of a seizure. Use knowledge regarding the characteristics of this phase of the seizure, recalling that spasm of the body occurs in this phase. This will direct you to the correct option.

The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record? 1.Muscle wasting 2.Mild clumsiness 3.Altered mentation 4.Diminished gag reflex

2. The initial symptom of ALS is a mild clumsiness, usually noted in the distal portion of one extremity. The client may complain of tripping and drag one leg when the lower extremities are involved. Mentation and intellectual function usually are normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations. * Use knowledge regarding the early manifestations of ALS to assist in answering the question. Focusing on the strategic word initial in the question and noting the word mild in the correct option will direct you to this one.

The home care nurse is making a visit to a client who is wheelchair bound after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1.Updating the home safety sheet 2.Leaving the client in an unchilled area of the room 3.Noting a bowel movement on the client progress note 4.Recording the amount of urine obtained with catheterization

2. The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm. * Note the subject, autonomic dysreflexia. Note the word prevent. This implies an action orientation on the part of the nurse. Each of the incorrect options contains an item related to documentation rather than an action to be taken by the nurse just before leaving.

Acetazolamide (Diamox) is prescribed for a client hospitalized with a diagnosis of a supratentorial lesion. The nurse understands that which is the primary action of the medication? 1.Prevention of hypertension 2.Prevention of hyperthermia 3.Decrease in cerebrospinal fluid production 4.Maintenance of blood pressure adequate for cerebral perfusion

3. Acetazolamide (Diamox) is a carbonic anhydrase inhibitor. It is used in the client with or at risk for increased intracranial pressure to decrease cerebrospinal fluid production. Options 1, 2, and 4 are not actions of this medication. * Focus on the diagnosis presented in the question and the strategic word primary in the question. Note the relationship between supratentorial in the question and cerebrospinal in the correct option.

The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit the most specific information regarding this client's disorder? 1."Do your eyes feel dry?" 2."Do you have any spasms in your throat?" 3."Are you having any difficulty chewing food?" 4."Do you have any tingling sensations around your mouth?"

3. Bell's palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulties. * Note the strategic word most. Focus on the subject, manifestations of Bell's palsy. Recalling that palsy is a type of paralysis will direct you to the correct option.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? 1.Sudden loss of consciousness occurred. 2.Signs and symptoms occurred suddenly. 3.The client experienced paresthesias a few days before admission to the hospital. 4.The client complained of a severe headache, which was followed by sudden onset of paralysis.

3. Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on one side of the body. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with brain attack (stroke) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. * Focus on the client's diagnosis, thrombotic brain attack (stroke). Note that options 1, 2, and 4 are comparable or alike and indicate a sudden occurrence. Recalling that a cerebral thrombosis does not occur suddenly will direct you to the correct option.

The nurse is preparing for the admission to the unit of a client with a diagnosis of seizures and is preparing to institute full seizure precautions. Which item is contraindicated for use if a seizure occurs? 1.Oxygen source 2.Suction machine 3.Padded tongue blade 4.Padding for the side rails

3. Full seizure precautions include bed rest with padded side rails in a raised position, a suction machine at the bedside, having diazepam (Valium) or lorazepam (Ativan) available, and providing an oxygen source. Objects such as tongue blades are contraindicated and should never be placed in the client's mouth during a seizure. * Note the word full and the closed-ended word contraindicated in the question. Recall that objects should not be placed in the client's mouth during a seizure. This principle will direct you to the correct option.

The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the health care provider (HCP)? 1.Backache 2.Headache 3.Neck stiffness 4.Feelings of fatigue

3. Headache is relatively common after the procedure, but neck stiffness, especially on flexion, and pain should be reported because they signal meningeal irritation. The client also is monitored for evidence of allergic reactions to the dye such as confusion, dizziness, tremors, and hallucinations. Feelings of fatigue may be normal, and back discomfort may be owing to the positions required for the procedure. *Focus on the subject, the finding indicating the need to notify the HCP. Recalling that meningeal irritation is a complication and that neck stiffness is a characteristic sign will direct you to the correct option.

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's-eyes maneuver) if which condition is present in the client? 1.Dilated pupils 2.Lumbar trauma 3.A cervical cord injury 4.Altered level of consciousness

3. In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure. * Focus on the subject, contraindication to performing the oculocephalic response. Visualize this maneuver and recall that with a cervical injury, the head is not turned but maintained in a midline position.

The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin (Ditropan XL). The nurse evaluates the effectiveness of the medication by asking the client which assessment question? 1."Are you consistently fatigued?" 2."Are you having muscle spasms?" 3."Are you getting up at night to urinate?" 4."Are you having normal bowel movements?"

3. Oxybutynin is an antispasmodic used to relieve symptoms of urinary urgency, frequency, nocturia, and incontinence in clients with uninhibited or reflex neurogenic bladder. Expected effects include improved urinary control and decreased urinary frequency, incontinence, and nocturia. Options 1, 2, and 4 are unrelated to the use of this medication. * Focus on the subject, the effectiveness of oxybutynin, and think about its classification. Recalling that this medication is used to treat bladder dysfunction will direct you to the correct option.

A client who has had a brain attack (stroke) is being managed on the medical nursing unit. At 0800, the client was awake and alert with vital signs of temperature 98° F orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99° F orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? 1.Reorient the client. 2.Retake the vital signs. 3.Call the health care provider (HCP). 4.Administer an antihypertensive PRN.

3. The important nursing action is to call the HCP. The deterioration in neurological status, decreasing pulse, and increasing blood pressure with a widening pulse pressure all indicate that the client is experiencing increased intracranial pressure, which requires immediate treatment to prevent further complications and possible death. The nurse should retake the vital signs and reorient the client to surroundings. If the client's blood pressure falls within parameters for PRN antihypertensive medication, the medication also should be administered. However, options 1, 2, and 4 are secondary nursing actions. * Note the subject, care of the client who experiences brain attack (stroke). Noting the changes in neurological signs and vital signs and that these changes indicate a deterioration in the client's condition will direct you to the correct option.

The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse reviews the health care provider's documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome? 1.Multifocal seizures 2.Altered level of consciousness 3.Abrupt onset of a fever and headache 4.Development of progressive muscle weakness

4. A hallmark clinical manifestation of Guillain-Barré syndrome is progressive muscle weakness that develops rapidly. Seizures are not normally associated with this disorder. The client does not have symptoms such as a fever or headache. Cerebral function, level of consciousness, and pupillary responses are normal. * Focus on the subject, Guillain-Barré syndrome. Think about the pathophysiology that occurs with this disorder. Recalling that progressive muscle weakness occurs will direct you to the correct option.

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? 1.Return of spinal shock 2.Malignant hypertension 3.Impending brain attack (stroke) 4.Autonomic dysreflexia (hyperreflexia)

4. Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death. * Note the strategic word immediately. Focus on the client's diagnosis, spinal cord injury, and recall the complications that can occur after this type of injury. Noting the client's signs and symptoms and recalling these complications will direct you to the correct option.

A client had a transsphenoidal resection of the pituitary gland. The nurse notes drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse should look for drainage that is of which characteristic? 1.Serosanguineous only 2.Bloody with very small clots 3.Sanguineous only with no clot formation 4.Serosanguineous, surrounded by clear to straw-colored fluid

4. CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous (from the surgery) and surrounded by an area of clear or straw-colored drainage. The typical appearance of CSF drainage is that of a "halo." The nurse also would further verify actual CSF drainage by testing the drainage for glucose, which would be positive. * Eliminate options 1 and 3 first because of the closed-ended word only. Regarding the remaining options, recall that CSF is clear to straw-colored.

The nurse is performing an assessment on a client with a diagnosis of thrombotic brain attack (stroke). Which assessment question would elicit data specific to this type of stroke? 1."Have you had any headaches in the past few days?" 2."Have you recently been having difficulty with seeing at nighttime?" 3."Have you had any sudden episodes of passing out in the past few days?" 4."Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

4. Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on one side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness. * Focus on the subject, the signs and symptoms of a thrombotic stroke. It is necessary to know that cerebral thrombosis does not occur suddenly, and in the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on one side of the body.

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. The nurse should expect to note documentation of which early symptom of this disease? 1.Aphasia 2.Agnosia 3.Difficulty with swallowing 4.Balance and coordination problems

4. Early symptoms of Huntington's disease include restlessness, forgetfulness, clumsiness, falls, balance and coordination problems, altered speech, and altered handwriting. Difficulty with swallowing occurs in the later stages. Aphasia and agnosia do not occur. * Note the strategic word early. Recalling the pathophysiology of Huntington's disease and that alterations in balance and coordination occur will direct you to the correct option.

The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client? 1.Keep the window blinds open. 2.Turn on a small spotlight above the client's head. 3.Make sure the door to the room is open at all times. 4.Prohibit or limit the use of a radio or television and reading.

4. Environmental stimuli are kept to a minimum with subarachnoid precautions to prevent or minimize increases in intracranial pressure. For this reason, lighting is reduced by closing window blinds and keeping the door to the client's room shut. Overhead lighting also is avoided for the same reason. The nurse prohibits television, radio, and reading unless this is so stressful for the client that it would be counterproductive. In that instance, minimal amounts of stimuli by these means are allowed with approval of the health care provider. * Focus on the subject, aneurysm precautions, noting the words controlling the environment. Then analyze each of the options in terms of how the intervention could affect the intracranial pressure.

The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because the client's speech will be characteristic of which finding? 1.Intact 2.Rambling 3.Characterized by literal paraphasia 4.Associated with poor comprehension

4. Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words spoken by another, and speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke's aphasia may exhibit a rambling type of speech. * Focus on the subject, global aphasia. Knowledge of the characteristics associated with global aphasia is required to answer this question. Remember that global aphasia is associated with poor comprehension.

The nurse is developing a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client? 1.Place an eye patch on the left eye. 2.Place personal articles on the client's right side. 3.Approach the client from the right field of vision. 4.Instruct the client to turn the head to scan the right visual field.

4. Homonymous hemianopsia is a loss of half of the visual field. The nurse instructs the client to scan the environment and stands within the client's intact field of vision. The nurse should not patch the eye because the client does not have double vision. The client should have objects placed in the intact fields of vision, and the nurse should approach the client from the intact side. * Focus on the subject, a visual problem, and recall the definition of homonymous hemianopsia. Recalling that the client loses half of the visual field will assist in directing you to the correct option.

The nurse is developing a plan of care for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome? 1.Encourage communication. 2.Provide a consistent daily routine. 3.Promote adequate bowel elimination. 4.Increase the client's awareness of the affected side.

4. In anosognosia, the client exhibits neglect of the affected side of the body. The nurse will plan care activities that remind the client to perform actions that require looking at the affected arm or leg, as well as activities that will increase the client's awareness of the affected side. Options 1, 2, and 3 are not associated with this deficit. * Focus on the subject, care of the client following brain attack (stroke). Recall that in anosognosia the client demonstrates neglect of the affected side of the body. This will direct you to the correct option.

The nurse is preparing a plan of care for a client with a diagnosis of brain attack (stroke). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? 1.The client will be easily fatigued. 2.The client will have difficulty speaking. 3.The client will have difficulty swallowing. 4.The client will exhibit neglect of the affected side.

4. In anosognosia, the client neglects the affected side of the body. The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else. Options 1, 2, and 3 are not associated with anosognosia. * Focus on the subject, care of the client with a brain attack (stroke). Knowledge of the definition of anosognosia and the associated manifestations is required to answer this question. Remember that in anosognosia the client neglects the affected side of the body.

The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction? 1.Temperature 2.Blood pressure 3.Ability to speak 4.Level of consciousness

4. Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the client's level of consciousness is the most critical index of CNS dysfunction. * Note the strategic word most in the question. Focusing on the subject of the question, a neurological problem, will assist in directing you to the correct option. Also, the correct option is the umbrella option.

The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs more information if he or she states an intention to take which action? 1.Refrain from smoking alone. 2.Take all prescribed medications on time. 3.Have the spouse nearby when showering. 4.Drink alcohol in small amounts and only on weekends.

4. The client should avoid the intake of alcohol. Alcohol could interact with the client's seizure medications, or the alcohol could precipitate seizure activity. The client should take all medications on time to avoid decreases in therapeutic drug levels, which could precipitate seizures. The client should not bathe in the shower or tub without someone nearby and should not smoke alone, to minimize the risk of injury if a seizure occurs. * Note the strategic words needs more information. This phrase indicates a negative event query and the need to select the incorrect client statement. The word safety guides you to think about appropriate safety measures that should be used in the home. Use general medication guidelines to assist in answering correctly, and remember that alcohol is restricted, not limited.

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? 1.Had a very mild stroke 2.Most likely suffered a transient ischemic attack 3.May have difficulty with language abilities only 4.Is likely to have perceptual and spatial disabilities

4. The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities. * Think about the anatomical location of the stroke. Eliminate option 3 first because of the closed-ended word only. Regarding the remaining options, it is necessary to recall that perceptual and spatial disabilities occur in the client with a right hemispheric stroke.

The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do? 1.Prevent stressful situations. 2.Avoid activities that may cause fatigue. 3.Avoid contact with people with an infection. 4.Avoid activities that may cause pressure near the face.

4. The pain that accompanies trigeminal neuralgia is triggered by stimulation of the trigeminal nerve. Symptoms can be triggered by pressure such as from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by stimulation by a draft or cold air. Options 1, 2, and 3 are not associated with triggering episodes of pain. * Focus on the subject, measures to prevent pain. Focus on the pathophysiology associated with this disorder, and think about the precipitating factors to answer this question. Recalling the anatomical location of the trigeminal nerve and that the pain is triggered by stimulation of the trigeminal nerve will direct you to the correct option.

The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse should plan to ask the client which question to elicit the most specific information regarding this disorder? 1."Do you have any visual problems?" 2."Are you having any problems hearing?" 3."Do you have any tingling in the face region?" 4."Is the pain experienced a stabbing type of pain?"

4. Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last for seconds to minutes. The pain often is characterized as stabbing or as similar to an electric shock. It is accompanied by spasms of facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. Options 1, 2, and 3 do not elicit data specifically related to this disorder. * Note the strategic word most. Focus on the subject, assessment of trigeminal neuralgia. Note the word neuralgia in the question and the relationship of this word to pain noted in the correct option.

The nurse is performing an assessment on a client suspected of having trigeminal neuralgia (tic douloureux). Which assessment question would elicit data specific to this disorder? 1."Have you had any facial paralysis?" 2."Have you noticed that your eyelid has been drooping?" 3."Have you had any numbness and tingling in your face?" 4."Have you had any sharp pain or any twitching in any part of your face?"

4. Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last from seconds to minutes. The pain often is described as either stabbing or similar to an electric shock. It is accompanied by spasms of the facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. * Focus on the subject, the manifestations of trigeminal neuralgia. Note the word tic in the name of the disorder. Recalling that a tic is a nervous twitch will assist in directing you to the correct option.