CH 36

A client presents to the emergency department status post seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? A) Lumbar puncture B) Echoencephalography C) Nerve conduction studies D) EMG

A

A female client undergoes a scheduled electroencephalogram (EEG). Which of the following postprocedure activities should the nurse carry out for the client?A) Allow the client to rest and shampoo the client's hair. B) Provide the client with adequate caffeine-rich drinks. C) Measure the level of consciousness (LOC) of the client. D) Measure the heart and the pulse rate.

A

The critical care nurse is giving report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? A) Comatose B) Somnolence C) Stupor D) Normal

A

When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data?A) When, if any, was your last narcotic use? B) Do you have any history of forgetfulness? C) Have you been diagnosed with any mental health issues? D) Have you experienced any unusual sensations?

A

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. A) Unequal pupils B) Pupil reaction quick C) Pinpoint pupils D) Absence of pupillary response E) Pupil reacts to light

A, C, D

The nurse is assessing a client's ability to detect sensation in the upper extremity. Which nursing actions would be appropriate? Select all that apply. A) Place a warm cotton ball on the arm. B) A light prick using a needle. C) A gentle pinch using the fingers. D) Drag the alcohol pad over the skin. E) Touch the client with the pads of the finger.

A, C, D, E

The client is waiting in a triage area to learn the medical status of his family following a motor vehicle accident. The client is pacing, taking deep breaths, and wringing the hands. Considering the effects in the body systems, what effects does the nurse anticipate in the liver? A) The liver will cease function and shunt blood to the heart and lungs. B) The liver will convert glycogen to glucose for immediate use. C) The liver will produce a toxic by product in relation to stress. D) The liver will maintain a basal rate of functioning.

B

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? A) Physician maintains aseptic procedure. B) Cerebrospinal fluid is cloudy in nature. C) Client states a piercing feeling. D) Client states a pressure relief in the head.

B

The nurse is caring for a client in the emergency department with diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. For which action, made by the nurse aide, would the nurse provide further instruction? A) The nurse aide used mild soapy water to clean the face. B) The nurse aide moved the client's head to clean behind the ears. C) The nurse aide cleaned the eye area from the inner to outer eye area. D) The nurse aide cleaned the neck and upper chest area.

B

The nurse is caring for a client in the neurologic intensive care unit. The nurse is noting from the assessment findings that the client is lacking a connection because motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit? A) Midbrain B) Medulla oblongata C) Pons D) Subarachnoid space

B

The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord? A) Coccyx B) Second lumbar vertebrae C) Eleventh thoracic vertebrae D) Fifth lumbar vertebrae

B

The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated? A) Bronchodilator B) Antihistamine C) Cardiotonic D) Antibiotic

B

The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? A) Observing the reaction of pupils to light B) Observing the client's response to painful stimulus C) Using the Romberg test D) Assessing the client's sensitivity to temperature, touch, and pain

B

The nurse is caring for a stuporous client in the intensive care unit. Which assessment finding is documented to reflect an improvement in the client's level of consciousness? A) Conscious B) Somnolent C) Stuporous D) Semicomatose

B

The family nurse practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?A) Moving the head toward both sides B) Lightly tapping the lower portion of the neck to detect sensation C) Moving the head and chin toward the chest D) Gently pressing the bones on the neck

C

The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, "What do you want?" Which level of conscious should the nurse document? A) Conscious B) Semicomatose C) Somnolent D) Stuporous

C

The nurse is caring for a client newly diagnosed with multiple sclerosis. The client indicates that there is so much to understand at one time. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. Which nursing action is correct? A) Tell the client not to worry about the fine details. B) Tell the client that there is so much to learn; you can meet to discuss it again. C) Tell the client that the covering is called myelin and that you can discuss at the next meeting. D) Tell the client that the disease process requires more research.

C

The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer? A) Headache and pain in the neck B) Claustrophobia C) Allergic reaction to the imaging material D) Allergic reaction to radioactive rays

C

The nurse is employed in a neurologist's office, performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve? A) Cranial nerve II B) Cranial nerve VI C) Cranial nerve VIII D) Cranial nerve XI

C

The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate to the nurse that the client is in a semi comatose state? A) A score of 20 B) A score of 15 C) A score of 9 D) A score of 4

C

The nurse is working in an outpatient studies unit administering neurologic tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. The nurse is most correct to state which? A) The paste is removed with acetone. B) The paste is removed with a special soap. C) The paste is removed with standard shampoo. D) The paste is removed by flushing with warm water.

C

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture? A) Administer antihistamines to the client. B) Provide adequate caffeine-rich drinks to the client. C) Assess the level of consciousness (LOC) and the pupil response of the client. D) Position the client flat for at least 3 hours.

D

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, which deficits are anticipated? A) A delayed reaction in identification of information due to slowed passages of information to brain B) A delayed reaction in cognitive ability to understand the relayed information C) A delayed reaction in processing the information transferred from the environment D) A delayed reaction in response due to the interrupted impulses from the central nervous system

D

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? A) Frontal B) Parietal C) Temporal D) Occipital

D

The brain stem holds the medulla oblongata. What is the function of the medulla oblongata? A) Transmits sensory impulses from the brain to the spinal cord B) Controls striated muscle activity in blood vessel walls C) Controls parasympathetic nerve impulses in the pons D) Transmits motor impulses from the brain to the spinal cord

D

The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? A) Cranial nerve I B) Cranial nerve V C) Cranial nerve XI D) Cranial nerve XII

D

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? A) Myelogram B) Electroencephalogram C) Echoencephalography D) Cerebral angiography

D

Which neurons transmit impulses from the CNS? A) Sensory B) Neurilemma C) Dendrites D) Motor

D

Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of a muscular body area? A) Computed tomography (CT) B) Magnetic resonance imaging (MRI) C) Positron emission tomography (PET) D) Single-photon emission computed tomography (SPECT)

A

A critical care nurse is documenting her assessment of a client she is caring for. The client is status post resection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean? A) The client has an abnormal posture response to stimuli. B) The client is not responding to stimuli. C) The client is hyperresponsive on the left. D) The client is hyporesponsive on the left.

B

A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? A) Abnormal posture B) Flaccidity C) Weak muscular tone D) Decorticate posturing

B

A nurse is working in a neurologist's office. The physician orders a Romberg test. Which nursing action is correct? A) Have the client touch his nose with one finger. B) Have the client close his eyes and stand erect. C) Have the client close his eyes and discriminate between dull and sharp. D) Have the client close his eyes and jump on one foot.

B

The nurse is caring for a post-lumbar puncture client experiencing an intense headache. The physician is notified and arriving to assess the client. If the physician chooses aggressive treatment, which nursing action is anticipated? A) Hanging an intravenous solution B) Drawing venous blood to perform a blood patch C) Applying ice to the back of the neck D) Offering caffeinated drinks

B

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse is correct to instruct on the action of which system? A) Musculoskeletal system B) Sympathetic nervous system C) Parasympathetic nervous system D) Endocrine system

B