NEURO Prep U - Study Guide

A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The healthcare provider calls and asks for a report on the client's condition. Based on the documentation below, how would the nurse respond?

"The client's ICP remains elevated."

A client has just undergone a lumbar puncture (LP). Which finding should the nurse immediately report to the health care provider (HCP)?

A moderate amount of serous fluid was noted on the lumbar dressing.

Which action is contraindicated for a client with seizure precautions?

assessing the client's oral temperature with a glass thermometer

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate an understanding of the instructions? Select all that apply.

"If brushing my teeth is too painful, I'll try to rinse my mouth instead." "I'll try to chew my food on the unaffected side." "Drinking fluids at room temperature should reduce pain."

A nurse is caring for a client declared brain dead following a motor vehicle accident. When the nurse enters the client's room, his spouse and family are talking with friends about the possibility of organ donation. Which statement by the nurse reflects an ethical practice dilemma?

"If you're thinking about organ donation, my sister is waiting for a kidney transplant. She'd be an excellent recipient. I can give you her phone number."

It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client:

"You will need to hold your head very still during the examination."

A client is scheduled to undergo cerebral angiography to allow for examination of the cerebral arteries. Place the following interventions in the order in which the nurse would perform them. All options must be used.

1.Encourage the client to verbalize questions about the procedure with nurse and health care provider. 2.Make sure the client has signed an informed consent form. 3.Confirm no allergies to iodine, seafood, or radiopaque dyes. 4.Administer antianxiety medication if ordered. 5.Maintain the affected extremity in straight alignment for 6 hours as ordered.

Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?

Activity is resumed gradually; the client can resume usual activities in 5 to 6 weeks.

A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?

Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

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. Turn the client to the side. Place a pillow under the client's head.

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with chin resting on flexed knees

A client has been injured in a snowmobile accident and is airlifted to the trauma center with a neck injury. The nurse needs to implement which of the following interventions if the injury is at the C4 level? Select all that apply.

Mechanical ventilation to prevent hypoxemia and hypercapnia Assessment of level and extent of paralysis

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate?

Meningeal irritation

When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for:

aspiration

A client returns from a myelogram, for which an iodized oil was used. The nurse should include which instruction in the plan of care?

assessment of lower extremity movement and sensation

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition?

decrease in level of consciousness (LOC)

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness.

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the client's first response to pain will be to:

escape the source of pain.

The nurse should instruct the client with low back pain to avoid:

exceeding the prescribed exercise program.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. The nurse should:

explain how to overcome a freezing gait by telling the client to march in place.

The client with a lumbar laminectomy asks to be turned onto the side. The nurse should:

get another nurse to help logroll the client into position.

A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage?

head of the bed elevated to 30 degrees with the client's head in a neutral position

After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which postoperative complication?

intraocular hemorrhage

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

occipital

Which action is not appropriate when providing oral hygiene for a client who has had a stroke?

placing the client on the back with a small pillow under the head

The nurse is assessing an infant diagnosed with bacterial meningitis. The nurse should ask the parent if the infant has which symptoms? Select all that apply.

poor feeding vomiting fever

Which respiratory pattern indicates increasing intracranial pressure in the brain stem?

slow, irregular respirations

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for:

sudden, severe hypertension

A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a corticosteroid ointment, one-half inch in the lower conjunctival sac four times a day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent:

increased intraocular pressure (IOP).

The best method to remove cerumen from a client's ear involves:

irrigating the ear gently.

A nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy.

The primary goal in the plan of care for the client after cataract removal surgery is to:

promote safety at home.

The nurse is to check a client's gag reflex. The most effective technique for testing the gag reflex is to:

touch the back of the client's throat with a tongue blade.

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?

An isolation room three doors from the nurses' station

The nurse is caring for a client with a subdural hematoma. Which of the following is the priority outcome?

Ensure airway patency and optimal oxygen levels and protect from injury.

A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client?

"You are in the hosipital. You were in an accident and unconscious."

As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability?

"I can participate in sexual activity but might not experience orgasm."

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?

"The movements occur from muscle reflexes that cannot be initiated or controlled by the brain."

A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client reports a headache. The mother questions pain medication for home. Which response by the nurse is most appropriate?

"Your child has a mild concussion; acetaminophen can be given."

The parent of a child who is taking an antibiotic for bilateral otitis media tells the nurse that they have stopped the medicine since the child is better and are saving the rest of the medication to use the next time the child gets sick. What should the nurse tell the parent?

"Your child needs all of the medicine so that the infection clears."

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.

1.Ease the client to the floor. 2.Maintain a patent airway. 3.Obtain vital signs. 4.Record the seizure activity observed.

A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?

15

A child with meningitis is to receive 1,000 mL of dextrose 5% in normal saline over 12 hours. At what rate in milliliters per hour should the nurse set the pump? Round your answer to the nearest whole number.

83

The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure and monitors the blood pressure for signs of widening pulse pressure. The client's current blood pressure is 170/80 mm Hg. What is the client's pulse pressure? Record your answer using a whole number.

90

Which of the following clients requires increased sensory stimulation to prevent sensory deprivation?

A 65-year-old client who has employment-induced presbycusis and advanced glaucoma

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 bpm; and respiratory rate of 30 shallow breaths/min. What should the nurse do first?

Activate the Rapid Response Team (RRT).

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

Alternatively patch one eye every 2 hours.

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?

Attaching braces or splints to each foot and leg

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?

Declining level of consciousness (LOC)

A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests?

EEG, blood cultures, and neuroimaging studies

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

When completing a nursing assessment on a client admitted with a neck injury, which of the following findings would indicate an incomplete spinal cord injury (SCI)?

Evidence of voluntary motor and sensory function below the level of injury

A nurse is caring for a client who's had surgery to repair a hip fracture. The client says his left hand and arm are numb and he can't move the extremity. The nurse contacts the physician, who suspects brachioplexus nerve damage. What additional priority assessment does the nurse need?

Function of the client's left hand before the operation

Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which body system?

GI

A client with glaucoma is to receive 3 gtt of acetazolamide in the left eye. What should the nurse do?

Have the client look up while the nurse administers the eyedrops.

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Helicopod

The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring?

I&O

When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis?

Improved muscle strength after I.V. administration of edrophonium chloride.

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?

Increase the frequency of client observation.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

Keeping the client in one position to decrease bleeding

A parent of a child with a moderate head injury asks the nurse, "How will you know if my child is getting worse?" The nurse should tell the parents that best indicator of the child's brain function is:

LOC

Which is the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury?

Leg girth

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume

The nurse has administered mannitol IV. Which is a priority assessment for the nurse to make after administering this drug?

Monitor urine output.

Which of the following nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?

Test the nasal drainage for glucose.

After 5 days of hospitalization, a client who is receiving morphine sulfate for pain control asks for pain medication with increasing frequency and exhibits increased anxiety and restlessness. The vital signs are within normal ranges. What is a possible cause of this behavior?

The client has developed tolerance to the dose of morphine.

The nurse is caring for a client with a diagnosis of cerebrovascular accident (CVA) with left-sided hemiparesis. What would be important nursing measures in the acute phase of care? Select all that apply.

Turn and position every 2 hours. Perform passive range of motion on the affected side. Support the affected side with pillows.

The client with a head injury receives mannitol during surgery to help decrease intracranial pressure. Which finding indicates that the drug is having the desired effect?

Urine output increases.

A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention?

Urine retention or incontinence

Which is the most effective way for a nurse to assess for posterior nasal bleeding in a client who has had nasal surgery?

Use a penlight to inspect the back of the pharynx for bleeding.

An adult client has bacterial conjunctivitis. What should the nurse teach the client to do? Select all that apply.

Wash the hands after touching the eyes. Use warm saline soaks four times per day to remove crusting. Avoid touching the eyes. Apply topical antibiotic without touching the tip of the tube to the eye.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. Which nursing intervention protects the client without increasing the intracranial pressure (ICP)?

Wrap the hands in soft "mitten" restraints.

A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client? The client will:

actively participate in the rehabilitation process as appropriate.

A history of which factors will complicate the recovery from a concussion? Select all that apply.

attention deficit/hyperactivity disorder (ADHD) depression migraines previous concussion

A client with alcohol dependency has peripheral neuropathy. The nurse should develop a teaching plan that emphasizes:

avoiding use of an electric blanket.

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:

cranial nerves IX and X.

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

dysfunction in the brain stem.

A nurse on a rehabilitation unit is caring for a client who sustained a head injury in a motor vehicle accident. She notes that the client has become restless and agitated during therapy; previous documentation described the client as cooperative during therapy sessions. The nurse's priority action should be to:

gather assessment data and notify the physician of the change in the client's status.

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?

inner ear

A short time after cataract surgery, the client has nausea. The nurse should first:

medicate the client with an antiemetic, as prescribed.

A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which of the following?

meningitis

A nurse is monitoring a client for adverse reactions to dantrolene. Which adverse reaction is most common?

muscle weakness

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?

new onset of footdrop

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. The nurse should:

notify the health care provider (HCP).

Following nasal surgery, the client has packing in the nose. The nurse should:

perform frequent mouth care.

A client is experiencing autonomic dysreflexia. The nurse should first:

place the client in Fowler's position.

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction?

pulling up the client under the left shoulder when getting the client out of bed to a chair

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon's eyes and Battle's sign.

The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. The nurse should:

readminister the residual to the client and continue with the feeding.

A client uses timolol maleate eyedrops. The expected outcome of this drug is to control glaucoma by:

reducing aqueous humor formation.

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

respiratory acidosis

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

risk for injury

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?

semi-Folwer's

After the client returns from surgery for a deviated nasal septum, the nurse should place the client in what position?

semi-Fowler's

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:

she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

Which action would not be appropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a ruptured disc?

starting an IV line at keep-open rate

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent?

succinylcholine

The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document:

the client's hand-grasp strength is equal.

In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because:

the rehabilitation plan will be guided by it.

Sodium polystyrene sulfonate is prescribed for a client following crush injury. The drug is effective if:

the serum potassium is 4.0 mEq/L (4.0 mmol/L).

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?

unequal pupil size

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences.