Neuro

A

What is the priority nursing diagnosis for a client experiencing a migraine headache? A. Acute pain related to biologic and chemical factors B. Anxiety related to change in or threat to health status C. Hopelessness related to deteriorating physiologic condition D. Risk for injury related to side effects of medical therapy

B

Which client should you, as a charge nurse assign to a new RN graduate who is on orientation to the neurologic unit? A. 28-year-old newly-admitted client with SCI (spinal cord injury) B. 67-year-old who had a stroke 3 days ago and has left-sided weakness C. 85-year-old with dementia who is to be transferred to a long-term care today D. 54-year-old with Parkinson disease who needs assitance with bathing

C

Which interventions should the nurse's plan of care include to help prevent autonomic dysreflexia in a patient with SCI? Select all that apply. 1. Check for fecal impactions 2. Monitor BP for hypotension 3. Check urinary drainage system for obstructions 4. Monitor bowel movements 5. Instruct patient to wear a medic alert bracelet A. 2, 3, 5 B. 1, 4, 5 C. 4, 5 D. 1, 3

D

Which of the following are late signs of rising ICP? A. Pailledema B. Change in LOC C. Vomiting D. Hypertension

A

You are mentoring a student nurse in the ICU while caring for a client with meningococcal meningitis. Which action by the student requires that you intervene most rapidly? A. Entering the room without putting on a mask and gown B. Instructing the family that visits are restricted to 10 minutes C. Giving the client a warm blanket when he says he feels cold. D. Checking the client's pupil response to light every 30 minutes

B

You have just admitted a client with bacterial meningitis who reports severe headache with photophobia and has a temperature of 102.6 degrees orally. Which prescribed intervention should be implemented first? A. Administer codeine 15mg orally for client's headache B. Infuse ceftriaxone (Rochephin) 2000mg IV to treat the infection. C. Given acetaminophen (Tylenol) 650mg orally to reduce the fever. D. Give furosemide (Lasix) 40 mg IV to decrease ICP.

C

A 22-year-old is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale, yellow in color. The nurse should follow up this finding proptly because it is suggestive of: A. ICP B. epidural hematoma C. leakage of cerebrospinal fluid D. meningitis

C

A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure. The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? A. Furosemide B. phenytoin C. lidocaine D. mannitol

D

A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? A. disturbed sensory perception (visual) B. Self-care deficient: dressing/grooming C. Impaired verbal communication D. Risk for injury

B

A female client with a suspected brain tumor is scheduled for computed tomograhy (CT). What should the nurse do when preparing the client for this test? A. Immobilize the neck before the client is moved onto stretcher. B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. C. Place cap over client's head D. Administer a sedative as ordered.

D

A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety? A. speak loudly to the client B. test the temperature of the shower water C. Check temperature of the food on delivery tray D. Provide a clear path for ambulation without obstacles

D

A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? A. side-lying with a pillow under the hip B. Prone, with a pillow under the abdomen C. prone, slight-Trendelenburg's position D. Side-lying, with the legs pulled up and head bent down onto chest.

B

A nurse is caring for a patient who is 8 hours post surgery for a spinal cord tumor. Neurologic checks should include which of the following? Select all that apply 1. Movement of upper and lower extremities 2. Monitoring sensation 3. Bowel and bladder function 4. Strength assessment A. 1, 3, 4 B. 1, 2, 4 C. 2, 3, 4 D. 1, 2, 3

C

A patient admitted to the emergency room has a history of a spinal tumor. Which of the following signs and symptoms should alert the nurse to the possiblity of SCC? A. Seizures B. Headache C. Back pain D. Diplopia

B

A patient has just been admitted to the hospital with a diagnosis of brain tumor. She makes a comment that drinking alcohol has caused her brain tumor. The nurse understands that which of the following is a cause of brain tumor? A. Smoking B. Ionizing radiation C. Diet high in fat D. Exposure to sun

D

A patient is scheduled for EEG tomorrow. Which of the following information should the nurse provide to the patient prior to the procedure? A. Antiseizure meds need to be taken prior the procedure B. Sedation will be given during the procedure C. There is a slight chance of electric shock D. Maintain sleep-deprived state the night before procedure

A

A patient is undergoing a cerebral angiograpy to rule out an aneurysm. When preparing the patient for the procedure, the nurse would include which of the following in her instructions? A. Expect a metallic taste when the contrast agent is injected. B. You will need a full bladder prior to procedure C. Maintain an NPO status D. General sedation will be given prior to procedure

C

A patient sustained a C6 SCI 4 hours ago. Which of the following nursing diagnoses is a priority? A. Urinary retention B. Risk for impaired skin integrity C. Ineffective breathing pattern D. Powerlessness

B

A patient with Parkinson's disease is seen in the neurology clinic for treatment. The nurse identifies this disorder as being caused by a lack of which of the following neurotransmitters? A. Acetylcholine B. Dopamine C. Serotonin D. Gamma-aminobutyric acid (GABA)

D

A patient with a decreased LOC and an absent gag refex was just admitted to the neurologic unit. IN what position whould the nurse place the patient? A. Prone B. HOB should be elevated to 45-90 degrees C. flat D. side lying with HOB elevated 10-30 degrees

B

After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the ER. He's unconscious and his pupils are nonreactive. Which intervention would be most dangerous for the client? A. place him on mechanical ventilation B. Perform lumbar puncture C. Give him a barbiturate D. Elevate HOB

D

An 18-year-old man is admitted witha closed head injury that he sustained in a motorcycle accident. He has been showing an upward trend in his ICP measurements. Which of the following interventions should be the first action that the nurse takes? A. Administer 100mg of IV pentobarbital as ordered B. Increase ventilator settings to a respiratory rate of 20 breaths/min C. Administer 20 g of IV mannitol as ordered D. Reposition the patient to avoid neck flexion

D

During a routine physical exam to assess a male client's deep tendon reflexes, the nurse should make sure to: A. use the pointed end of the reflex hammer when striking the achilles tendon B. Tap the tendon slowly and softly C. Hold the reflex hammer tightly D. Support the joint where the tendon is being tested.

C

For a male client with suspected ICP, a most appropriate respiratory goal is to: A. prevent respiratory alkalosis B. Lower arterial pH C. promote carbon dioxide elimination D. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

C

Paramedics have brought an intubated patient to the ED following a head injury due to acceleration-deceleration motor vehicle accident. ICP is suspected. An appropriate nursing intervention would include what? A. Keep HOB flat at all times B. Teach the patient to perform Valsalva maneuver C. Administer antipyretics on a PRN basis D. Perform endotracheal suctioning every hour.

C

The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered LOC. Following a skull fracture x-ray, the patient is diagnosed with basilar skull fracture. Which sign should alert the nurse to this type of fracture? A. Babinski sign B. Kernig's sign C. Battle's sign D. Brudzinski's sign

A

The nurse assesses the LOC of a patient who suffered a head injury and determines that the patient's GCS score is 15. Which of the following responses did the nurse assess to determine the GCS score? Select all that apply. 1. Spontaneous eye opening 2. tachycardia, hypotension, bradycardia 3. ability to follow commands 4. unequal pupil size 5. orientation to person place and time A. 1, 3, 5 B, 1, 3, 4 C. 2, 4, 5 D. 2, 3, 5

A

The nurse is assisting with a lumbar puncture. The nurse understands that which of the following common complications can occur following the procedure? A. Post-lumbar puncture headache B. Herniation of intracranial contents C. Spinal epidural abcess D. meningitis

A

The nurse is caring for a patient with ICP caused by a traumatic brain injury. Which of the following clinical manifestations would indicate that the patient is experiencing increased brain compression causing brainstem damage? A. Hyperthermia B. Tachycardia C. Hypertension D. Bradypnea

B

The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? A. Head midline B. head turned to the side C. Neck in neutral position D. Head of bed elevated 30-45 degrees

B

The nurse is testing the cranial nerves of a patient diagnosed with myasthenia gravis. The nurse asks the patient to clench his jaw while she palpates the temporal and masseter muscles. The nurse is correctly testing which cranial nerve? A. Abducens B. Trigeminal C. Acoustic D. hypoglossal

B

The nurse notices clear fluid draining from the nose of a patient who sustained a head injury 2 hours ago. This may indicate the presence of which of the following conditions? A. Cerebral concussion B. Basal skull fracture C. Brain tumor D. sinus infection