NCLEX Neurologic and Sensory Systems

During a routine clinic visit, an older adult complains about being unable to sleep well at night and then feeling sleepy throughout the next day. The nurse should advise the client to use what sleep promotion technique? A. Exercise daily B. Read in bed before sleeping C. Avoid naps during the daytime D. Have a hot cup of tea at bedtime

A. Exercise daily

External ventricular drains monitor ICP and are inserted where? A. Subarachnoid space B. Lateral Ventricle C. Epidural space D. Right Ventricle

B. Lateral Ventricle

A nurse is caring for a client who had a brain attack (cerebrovascular accident) two weeks ago. What should the nurse do to help the client develop independence? A. Establish long-range goals for the client. B. Reinforce success in tasks accomplished. C. Point out errors in performance on which to focus. D. Explain ways the client can regain independence in activities.

B. Reinforce success in tasks accomplished.

A client with a cerebrovascular accident ("brain attack") has dysarthria. What should the nurse include in the plan of care to address this problem? A. Routine hygiene B. Liquid formula diet C. Prevention of aspiration D. Effective communication

D. Effective communication

A male client who sustained a head injury is admitted to the hospital. The client is able to open his eyes to pain stimulus and to localize the pain, but the verbal response is found to be confused. What would be the score of the client based on the Glasgow coma scale. Record your answer as a whole number. ________

11

A client recently diagnosed with multiple sclerosis says, "I had planned to get married before the end of the year. After this diagnosis, I might not be ready. Maybe I should call off the wedding." Which is the best response by the nurse? A. "You don't feel able to make a decision at this time?" B. "Have you spoken to your fiancé about your feelings?" C. "Your fiancé loves you and I'm sure still wants to marry you." D. "These are your feelings now, but don't decide until you feel better and can cope."

A. "You don't feel able to make a decision at this time?"

The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient's cerebral perfusion pressure, and how do you interpret this as the nurse? A. 90 mmHg, normal B. 62 mmHg, abnormal C. 36 mmHg, abnormal D. 56 mmHg, normal

A. 90 mmHg, normal

You're educating a group of nursing students about left side brain damage. Select all the signs and symptoms noted with this type of stroke: A. Aphasia B. Denial about limitations C. Impaired math skills D. Issues with seeing on the right side E. Disoriented F. Depression and anger G. Impulsive H. Agraphia

A. Aphasia C. Impaired math skills D. Issues with seeing on the right side F. Depression and anger H. Agraphia

A client has a diagnosis of myasthenia gravis. What does the nurse recall are associated clinical manifestations? A. Blurred vision along with episodes of vertigo B. Tremors of the hands when attempting to lift objects C. Partial improvement of muscle strength with mild exercise D. Involvement of the distal muscles rather than the proximal muscles

A. Blurred vision along with episodes of vertigo

Select the main structures below that play a role with altering intracranial pressure: A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater

A. Brain C. Cerebrospinal Fluid D. Blood

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees

A. Coughing B. Sneezing D. Valsalva maneuver E. Vomiting

A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? Select all that apply. A. Coughing or sneezing B. Sitting on cold surfaces C. Standing for extended periods D. Lying supine while flexing the knees E. Straining when having a bowel movement

A. Coughing or sneezing E. Straining when having a bowel movement

Select all the signs and symptoms that occur with increased ICP: A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing

A. Decorticate posturing D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing

Before performing a visual system assessment, the nurse observes that the client is dressed in an unusual color combination of clothes. The client's eye examination reveals changes in the retina. Which condition might this client have? A. Decrease in cones B. Retinal vascular changes C. Overall loss of photoreceptor cells D. Macular degeneration of the retina

A. Decrease in cones

The nurse is supporting cognitive ability in clients with Alzheimer disease. Which actions will the nurse take? Select all that apply. A. Encouraging caregivers to support safe independence B. Using calendars, clocks, and pictures to support memory C. Providing a limited number of choices to support decision-making D. Quizzing the client regularly to assess orientation to person, place, and time E. Administering prescribed rivastigmine to the client with severe Alzheimer dementia

A. Encouraging caregivers to support safe independence B. Using calendars, clocks, and pictures to support memory C. Providing a limited number of choices to support decision-making

A client who has been taking spironolactone is admitted to the hospital with hypokalemia. The nurse will assess the client for which clinical findings? Select all that apply. A. Lethargy B. Thready, weak pulse C. Muscle weakness D. Hyperactive deep tendon reflexes E. Numbness and tingling of the hands and feet

A. Lethargy B. Thready, weak pulse C. Muscle weakness

Which of the following is contraindicated in a patient with increased ICP? A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications

A. Lumbar puncture

A client has carotid atherosclerotic plaques, and a right carotid endarterectomy is performed. Two hours after surgery the client demonstrates progressive hypotension. Which action should the nurse take? A. Notify the healthcare provider B. Increase the intravenous (IV) flow rate C. Raise the head of the bed D. Place the client in the Trendelenburg position

A. Notify the healthcare provider

You're collecting vital signs on a patient with ICP. The patient has a Glasgow Coma Scale rating of 4. How will you assess the patient's temperature? A. Rectal B. Oral C. Axillary

A. Rectal

A client has a history of progressive carotid and cerebral atherosclerosis and experiences transient ischemic attacks (TIAs). How does the nurse explain TIAs to the client? A. Temporary episodes of neurologic dysfunction B. Intermittent attacks caused by multiple small clots C. Ischemic attacks that result in progressive neurologic deterioration D. Exacerbations of neurologic dysfunction alternating with remissions

A. Temporary episodes of neurologic dysfunction

When assessing the progress of a client being treated for myasthenia gravis, the nurse expects what change in muscle strength? A. Partial improvement of muscle strength with mild exercise B. Fluctuating weakness of muscles innervated by the cranial nerves C. Little change regardless of the therapy initiated D. Dramatic worsening with anticholinesterase drugs

B. Fluctuating weakness of muscles innervated by the cranial nerves

A patient is admitted with uncontrolled atrial fibrillation. The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for? A. Ischemic thrombosis B. Ischemic embolism C. Hemorrhagic D. Ischemic stenosis

B. Ischemic embolism

A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication? A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.

B. Mannitol will cause water and electrolyte reabsorption in the renal tubules.

You're educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition: A. TIAs are caused by a temporary decrease in blood flow to the brain. B. TIAs produce signs and symptoms that can last for several weeks to months. C. A TIAs is a warning sign that an impending stroke may occur. D. TIAs don't require medical treatment.

B. TIAs produce signs and symptoms that can last for several weeks to months. D. TIAs don't require medical treatment.

The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier

B. Vasodilation of cerebral vessels D. Leaking proteins into the brain barrier

Which patient below is at most risk for a hemorrhagic stroke? A. A 65 year old male patient with carotid stenosis. B. A 89 year old female with atherosclerosis. C. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago. D. A 55 year old female with atrial flutter.

C. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago.

Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12

C. BP 200/60, HR 50, RR 8

A nurse is evaluating sensory changes in a client whose spinal cord was severed at the level of T6 and T7. What does this evaluation process require? A. Client squeezing the nurse's hand B. Nurse monitoring the client's vital signs C. Client stating where the pinching sensation is felt D. Nurse observing the skin for color changes below the lesion

C. Client stating where the pinching sensation is felt

While assessing a client recovering from a head injury, the nurse notices a loss of movement in the client's tongue while attempting to talk. Which could be the possible reason for the client's condition? A. Damage to the facial nerve B. Damage to the trigeminal nerve C. Damage to the hypoglossal nerve D. Damage to the glossopharyngeal nerve

C. Damage to the hypoglossal nerve

A married couple in their 80s is living independently. They have three adult children. The husband, who is alert but forgetful, has an enlarged prostate and at times is incontinent of urine. The wife has diabetes and rheumatoid arthritis and walks with difficulty. Both need assistance with bathing, dressing, and meal preparation. What does the nurse suggest as the most suitable plan for this couple? A. Admit them together to a nursing home. B. Place them together in an assisted-living facility. C. Keep them in their home with a home health aide. D. Encourage them to move in with one of their children.

C. Keep them in their home with a home health aide.

A client is diagnosed with stage 3 of Parkinson disease. Which clinical manifestations are found in the client? Select all that apply. A. Akinesia B. Masklike face C. Postural instability D. Unilateral limb involvement E. Increased gait disturbances

C. Postural instability E. Increased gait disturbances

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would? A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning

C. Remove extra blankets and give the patient a cool bath

A client with a history of hypertension is admitted to the hospital immediately after a brain attack (cerebrovascular accident, CVA). The client is unconscious, and the vital signs are temperature 98° F (36.7° C), pulse 78 beats per minute, respiration 16 breaths per minute, and blood pressure 120/80 mm Hg. Which nursing concern is a priority for this client? A. Injury B. Constipation C. Respiratory distress D. Decreased fluid volume

C. Respiratory distress

A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size

C. Restlessness

A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will? A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP

C. cause vasodilation and increase the ICP

A client who has a history of seizures is scheduled for an arteriogram at 10:00 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9:00 AM. What should the nurse do? A. Omit the 9:00 AM dose of the drug. B. Give the same dosage of the drug rectally. C. Administer the drug with 30 mL of water at 9:00 AM. D. Ask the healthcare provider to prescribe an alternate route of administration.

D. Ask the healthcare provider to prescribe an alternate route of administration.

A nurse is caring for a client who is scheduled for surgery for a detached retina. Which goal of surgery identified by the client indicates that the preoperative teaching is effective? A. Promote growth of new retinal cells. B. Adhere the sclera to the choroid layer. C. Graft a healthy piece of retina in place. D. Create a scar that aids in healing retinal holes.

D. Create a scar that aids in healing retinal holes.

A client expresses concern about insomnia and asks, "What can I do to get better sleep?" What activities should the nurse recommend? Select all that apply. A. Drink a glass of wine. B. Engage in vigorous exercise before bedtime. C. Eat foods containing lysine. D. Follow the same bedtime ritual each night. E. Perform deep-breathing exercises.

D. Follow the same bedtime ritual each night. E. Perform deep-breathing exercises.

After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which clinical indicators should the nurse monitor the client? Select all that apply. A. Polyuria B. Insomnia C. Bradycardia D. Increased weight E. Decreased serum sodium F. Decreased level of consciousness

D. Increased weight E. Decreased serum sodium F. Decreased level of consciousness

A patient is demonstrating signs and symptoms of stroke. The patient reports loss of vision. What area of the brain do you suspect is affected based on this finding? A. Brain stem B. Hippocampus C. Parietal lobe D. Occipital lobe

D. Occipital lobe

The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? A. Dehydration B. Skin breakdown C. Electrolyte imbalances D. Urinary tract infections

D. Urinary tract infections

A client is diagnosed as having a right-sided brain attack (cerebrovascular accident) and is admitted to the hospital. When preparing to care for this client, which intervention should the nurse perform? A. Apply elastic stockings to prevent flaccid leg muscles. B. Use a bed cradle to prevent dorsiflexion of the feet. C. Implement passive range-of-motion (ROM) exercises to prevent muscle atrophy. D. Use a hand roll while supporting the left upper extremity on a pillow to prevent contractures.

D. Use a hand roll while supporting the left upper extremity on a pillow to prevent contractures.

A patient who suffered a stroke one month ago is experiencing hearing problems along with issues learning and showing emotion. On the MRI what lobe in the brain do you expect to be affected? A. Frontal lobe B. Occipital lobe C. Parietal lobe D. Temporal lobe

D. Temporal lobe

Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery.

B. A patient who is admitted with a traumatic brain injury.

On which principle should a nurse base client teaching when planning to assist a client to reestablish a regular pattern of defecation? A. Sedentary activities produce muscle atony. B. Increased fluid promotes ease of evacuation. C. Peristalsis is initiated by the gastrocolic reflex. D. Increased potassium is needed for normal neuromuscular irritability.

C. Peristalsis is initiated by the gastrocolic reflex.

What assessment finding requires immediate intervention if found while a patient is receiving Mannitol? A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst

B. Crackles throughout lung fields

During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing

B. Decerebrate posturing

The registered nurse (RN) is teaching a student nurse about taking a current history from a client who is suspected to have a neurologic disorder. Which statement made by the student nurse indicates the RN needs to follow up? Select all that apply. A. "I should ask the client about insomnia." B. "I should ask the client about diabetes mellitus." C. "I should ask the client about weakness and clumsiness." D. "I should ask the client about any difficulty in swallowing." E. "I should ask the client about numbness and tingling sensations."

A. "I should ask the client about insomnia." B. "I should ask the client about diabetes mellitus."

The nurse is caring for a 60-year-old client who is at an increased risk of corneal damage. Which instructions should the nurse share with the client? Select all that apply. A. "Use saline drops." B. "Improve lighting at home." C. "Increase humidity at home." D. "Wear prescribed lens for best vision." E. "Have corrective lenses solely for reading."

A. "Use saline drops." C. "Increase humidity at home." D. "Wear prescribed lens for best vision."

You're maintaining an external ventricular drain. The ICP readings should be? A. 5 to 15 mmHg B. 20 to 35 mmHg C. 60 to 100 mmHg D. 5 to 25 mmHg

A. 5 to 15 mmHg

A patient has right side brain damage from a stroke. Select all the signs and symptoms that occur with this type of stroke: A. Right side hemiplegia B. Confusion on date, time, and place C. Aphasia D. Unilateral neglect E. Aware of limitations F. Impulsive G. Short attention span H. Agraphia

B. Confusion on date, time, and place D. Unilateral neglect F. Impulsive G. Short attention span

You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is: A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg

B. 60-100 mmHg

A patient's MRI shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding? A. Vision problems B. Balance impairment C. Language difficulty D. Impaired short-term memory

B. Balance impairment

A patient has a ventriculostomy. Which finding would you immediately report to the doctor? A. Temperature 98.4 'F B. CPP 70 mmHg C. ICP 24 mmHg D. PaCO2 35

C. ICP 24 mmHg

While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips

D. Flexion of the hips