NCLEX Style Questions- NEURO

Which action is NOT appropriate when providing oral care for a client who has had a stroke? A. Placing the client on the back with a small pillow under the head B. Keeping portable suctioning equipment at the bedside C. Opening the client's mouth with a padded tongue blade D. Cleaning the client's mouth and teeth with a toothbrush

A. Placing the client on the back with a small pillow under the head Rationale: A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.

A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. The client's Glasgow Coma Score is ___________________?

15 Rationale: The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of the eye opening, best motor response, and best verbal response on a scale of 3 to 15. The client who scores the best on all three assessments scores 15 points.

Which respiratory pattern indicates increasing ICP in the brain stem? A. Slow, irregular respirations B. Rapid, shallow respirations C. Asymmetric chest excursion D. Nasal flaring

A. Slow, irregular respirations Rationale: Neural control of respiration takes place in the brain stem. Deterioration and pressure produce slow and irregular respirations. Rapid and shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Select all that apply: A. Maintaining upright position while eating B. Restricting the diet to liquids until swallowing improves C. Introducing foods on the unaffected side of the mouth D. Keeping distractions at a minimum E.Cutting the food into large pieces of finger food

A, C, D Rationale: A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided. Large pieces of food could cause choking; the food should be cut into bite-sized pieces.

A client is at risk for Increased intracranial pressure (ICP). Which finding is priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia D. Decreasing body temperature

A. Unequal pupil size Rationale: Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in systolic BP, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

Which would the nurse include in a teaching plan for a patient with seizures going home on gabapentin? A. Take all the medication until it is gone B. Notify the healthcare provider if vision changes occur C. Store gabapentin in the refrigerator D. Take gabapentin with an antacid to protect against ulcers

B. Notify the healthcare provider if vision changes occur Rationale: Gabapentin may impair vision. Changes in vision, concentration, or coordination should be reported to the HCP. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to be stored at room temperature and out of direct light. It should not be taken with antacids.

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used. A. Maintain a patent airway B. Record the seizure activity observed C. Ease the client to the floor D. Obtain vital signs

C, A, D, B Rationale: To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phrase, body parts affected and sequence of involvement, and autonomic signs should be recorded.

What is a priority nursing intervention in the postictal phase of a seizure? A. Reorient the client to time, person, and place B. Determine the client's level of sleepiness C. Assess the client's breathing pattern D. Position the client comfortably

C. Assess the client's breathing pattern Rationale: A priority for this client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes reset but is of less importance than ascertaining the that the airway is patent.

The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale, the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do? A. Attempt to arouse the client B. Reposition the client with the extremities in normal alignment C. Chart the client's level of consciousness as coma. D. Notify the healthcare provider

C. Chart the client's level of consciousness as coma. Rationale: The client has a score of 6 (eye opening to pain=2; verbal response, incomprehensible sounds=2, best motor response, abnormal extension=2); a score >7 is indicative of coma. While the nurse should continue to speak to the client, at this time the client will not be able to be aroused. The nurse should continue to provide skin care and appropriate alignment, but the client will continue to have a motor response of limb extension. It is not necessary to notify the HCP as this assessment does not represent a significant change in neurological status.

Which activity should the nurse encourage the client to avoid when there is a risk for increased ICP? A. Deep breathing B. Turning C. Coughing D. Passive range of motion exercises

C. Coughing Rationale: Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.

A client has an increased ICP of 20mmHg. The nurse should: A. Give the client a warming blanket B. Administer low-dose barbiturates C. Encourage the client to take deep breaths to hyperventilate D. Restrict fluids

C. Encourage the client to take deep breaths to hyperventilate Rationale: Normal ICP is 15mmHg or less for 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20mmHg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure >80mmHg.

A client arrives in the emergency department with an ischemic stroke. Because the healthcare team is considering administering tissue plasminogen activator (t-PA) administration, the nurse should first: A. Ask what medications the client is taking B. Compete a history and health assessment C. Identify the time of onset of the stroke D. Determine if the client is scheduled for any surgical procedures

C. Identify the time of onset of the stroke Rationale: Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when the client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.

Following a stroke, a client has dysphagia and left-sided facial paralysis. Which feeding technique will be most helpful at this time? A. Encourage sipping diluted liquid meal supplements from a straw B. Position the client with the bed at a 30 degree angle C. Offer solid foods from the unaffected side of the mouth D. Feed the client a soft diet from a spoon into the left side of the mouth

C. Offer solid foods from the unaffected side of the mouth Rationale: Following a stroke, it is easiest for clients with dysphagia (difficulty swallowing) to swallow solid foods; the nurse introduces foods on the unaffected side. Liquid foods are difficult to swallow, and the client with facial paralysis will have difficulty sipping using a straw. The head of the bed is elevated to 90 degrees, or the client is instructed to sit up, if possible, while eating to prevent choking and aspiration.

The nurse is assessing a client for decerebrate posturing. The nurse should assess the client for: A. Internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers B. Back hunched over and rigid flexion of all four extremities with supination of the arms and plantar flexion of the feet C. Supination of the arms and dorsiflexion of the feet D. Back arched and rigid extension of all four extremities

D. Back arched and rigid extension of all four extremities Rationale: Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

The nurse is assessing a client with increasing ICP. The nurse should notify the healthcare provider about which early change in the client's condition? A. Widening pulse pressure B. Decrease in the pulse rate C. Dilated, fixed pupils D. Decrease in the level of consciousness (LOC)

D. Decrease in the level of consciousness (LOC) Rationale: A decrease in the client's LOC is an early indicator of deterioration of the client's neurological status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? A. Jerking in one extremity that spreads gradually to adjacent areas B. Vacant staring and abruptly ceasing all activity C. Facial grimacing, patting motion, and lip smacking D. Loss of consciousness, body stiffening, and violent muscle contractions

D. Loss of consciousness, body stiffening, and violent muscle contractions Rationale: A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (e.g. jerking in the extremity spreading to other areas of the body.). An absence seizure usually occurs in the children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking.

It is the night before a client is to have a CT scan of the head without contrast. The nurse should tell the client: A. You must shampoo your hair tonight to remove all of the oil and dirt B. You may drink fluids until midnight, but after that, drink nothing until the scan is completed C. You will have some hair shaved to attach a small electrode to your scalp D. You will need to hold your head very still during the examination

D. You will need to hold your head very still during the examination Rationale: The client will be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes. In some instances, food and fluids may be withheld for 4 to 6 hours before the procedure if a contrast medium is used because the radiopaque substance sometimes causes nausea. There is no special preparation for the CT scan, so a shampoo the night before is not required. The client may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT scan, nor is the head shaved.