Neuro Passpoint Questions
A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply. Assist the client to the floor. Place a pillow under the client's head. Give the prescribed dose of oral phenytoin. Insert an oral suction device to remove secretions in the mouth. Turn the client to the side.
Correct response: Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head. Explanation: During a seizure, the nurse should assist the client to the floor to reduce the risk of falling and turn the client on the side to help clear the mouth of oral secretions. If available, it is appropriate to place a pillow under the client's head to protect against injury. It is inappropriate to introduce anything into the mouth during a seizure because of the risk of choking or compromising the airway; therefore, oral medications and suction devices should not be used.
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? Shock Encephalitis Increased intracranial pressure (ICP) Status epilepticus
Correct response: Increased intracranial pressure (ICP) Explanation: When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.
A client with quadriplegia is experiencing severe muscle spasms. To relieve them, a physician orders baclofen, 5 mg P.O. three times daily. What is the principal indication for baclofen? Acute, painful musculoskeletal conditions Skeletal muscle hyperactivity secondary to cerebral palsy Spasticity related to stroke Muscle spasms with paraplegia or quadriplegia from spinal cord lesions
Correct response: Muscle spasms with paraplegia or quadriplegia from spinal cord lesions Explanation: Baclofen's principal clinical indication is for the paraplegic or quadriplegic client with spinal cord lesions, most commonly caused by multiple sclerosis or trauma. For these clients, baclofen significantly reduces the number and severity of painful flexor spasms. Baclofen isn't indicated for acute, painful musculoskeletal conditions; skeletal muscle hyperactivity secondary to cerebral palsy; or spasticity related to stroke.
A nurse is working on a surgical floor. The nurse must logroll a client following a: thoracotomy. hemorrhoidectomy. cystectomy. laminectomy.
laminectomy. Explanation: The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.
After administering meperidine hydrochloride, the nurse determines its effectiveness as an analgesic was related to its ability to: reduce the perception of pain. decrease the sensitivity of pain receptors. interfere with pain impulses traveling along sensory nerve fibers. block the conduction of pain impulses along the central nervous system.
reduce the perception of pain. Opioid analgesics relieve pain by reducing or altering the perception of pain. Meperidine hydrochloride does not decrease the sensitivity of pain receptors, interfere with pain impulses traveling along sensory nerve fibers, or block the conduction of pain impulses in the central nervous system.
A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client? "I will get your family." "Can you tell me your name and where you live?" "I will bet you are a little confused right now." "You are in the hosipital. You were in an accident and unconscious."
"You are in the hosipital. You were in an accident and unconscious." Explanation: It is important to first explain where a client is to orient him or her to time, person, and place. Offering to get the family and asking questions to determine orientation are important, but the first comments should let the client know where he or she is and what has happened. It is useful to be empathetic to the client, but making a comment such as "I will bet you are a little confused" is not helpful and may cause anxiety.
Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin? Take all the medication until it is gone. Notify the health care provider (HCP) if vision changes occur. Store gabapentin in the refrigerator. Take gabapentin with an antacid to protect against ulcers.
Notify the health care provider (HCP) if vision changes occur. Explanation: 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.
After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in the legs, and calls the nurse in excitement to report the leg movement. Which response by the nurse would be the most accurate? "These movements indicate that the damaged nerves are healing." "This is a good sign. Keep trying to move all the affected muscles." "The return of movement means that eventually you should be able to walk again." "The movements occur from muscle reflexes that cannot be initiated or controlled by the brain."
Correct response: "The movements occur from muscle reflexes that cannot be initiated or controlled by the brain." Explanation: The movements occur from muscle reflexes and cannot be initiated or controlled by the brain. After the period of spinal shock, the muscles gradually become spastic owing to an increased sensitivity of the lower motor neurons. It is an expected occurrence and does not indicate that healing is taking place or that the client will walk again. The movement is not voluntary and cannot be brought under voluntary control.
A client has had a cerebrovascular accident (CVA) which has affected the left side of the client's brain. The nurse should assess the client for: expressive aphasia. dyslexia. apraxia. agnosia.
Correct response: expressive aphasia. Explanation: Broca's area, which controls expressive speech, is located on the left side of the brain. Therefore, a client with a cerebrovascular accident in this area is likely to exhibit expressive or motor aphasia. Dyslexia, the inability of a person with normal vision to interpret written language, is thought to be due to a central nervous system defect in the ability to organize graphic symbols. Apraxia is the inability to perform purposeful movements in the absence or loss of motor power, sensation, or coordination. Agnosia is the loss of comprehension of auditory, visual, or other sensations despite an intact sensory sphere.
A client is receiving cyclobenzaprine for management of a herniated lumbar disk. Which finding indicates the drug is providing the intended relief? The client's muscles are not in spasm. The client is sedated. The client is not anxious. The client can take deep breaths.
The client's muscles are not in spasm.
A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the health care provider (HCP) immediately? diffuse, aching sensation in the L4 to L5 area new onset of footdrop pain in the lower back when the leg is lifted pain in the lower back that radiates to the hip
Correct response: new onset of footdrop Explanation: Neurologic symptoms, such as footdrop, or bowel or bladder changes, should be reported to the HCP immediately. When musculoskeletal strain causes back pain, these symptoms may take 4 to 6 weeks to resolve. As an accompanying symptom of acute low back pain, the client may have a diffuse, aching sensation in the L4 to L5 area, pain in the lower back when the leg is lifted, or pain that radiates to the hip.
Which of the following nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma? Disorientation, increasing blood pressure, bradycardia, and bradypnea Verbal and motor responses, reactive constricting pupils, and hypoventilation Presence of the corneal blink response, drooling, tachycardia, and tachypnea Eye opening response when spoken to, verbal response, and spontaneous purposeful movements
Disorientation, increasing blood pressure, bradycardia, and bradypnea Explanation: Alterations in consciousness and disorientation over the last 2 hours are indicative of increased intracranial pressure. Vital sign changes also indicate the vasomotor control centers in the brain are affected, resulting in increased pulse pressure and bradycardia. Bradypnea indicates that the respiratory center is also affected. Each of the other choices represents normal findings on a Glasgow coma scale, except for hypoventilation.
The nurse is assessing a client for decerebrate posturing. The nurse should assess the client for: internal rotation and adduction of arms with flexion of elbows, wrists, and fingers. back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet. supination of arms, dorsiflexion of the feet. back arched, rigid extension of all four extremities.
Correct response: back arched, rigid extension of all four extremities. Explanation: 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.
