Neurological NCLEX Prep

The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client? 400 to 500 mL with each meal and 500 to 600 mL in the evening before bedtime 400 to 500 mL with each meal and additional fluids in the morning but not after midday 400 to 500 mL with each meal, with all extra fluid concentrated in the afternoon and evening 400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon

400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon.

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? A walker Eyeglasses A hearing aid A bath thermometer

A hearing aid

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A negative Kernig's sign Absence of nuchal rigidity A positive Brudzinski's sign A Glasgow Coma Scale score of 15

A positive Brudzinski's sign

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? Head of bed flat, head and neck midline Head of bed flat, head turned to the nonoperative side Head of bed elevated 30 to 45 degrees, head and neck midline Head of bed elevated 30 to 45 degrees, head turned to the operative side

Head of bed elevated 30 to 45 degrees, head and neck midline

The nurse is positioning a client who has increased intracranial pressure. Which position should the nurse avoid? Head midline Head turned to the side Neck in neutral position Head of bed elevated 30 to 45 degrees

Head turned to the side

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching? "I will rest each afternoon after my walk." "I should cough and deep breathe many times during the day." "I can change the time of my medication on the mornings when I feel strong." "If I get abdominal cramps and diarrhea, I should call my health care provider."

I can change the time of my medication on the mornings when I feel strong

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? "I will wash my face with cotton pads." "I'll have to start chewing on my unaffected side." "I should rinse my mouth if toothbrushing is painful." "I'll try to eat my food either very warm or very cold."

I'll try to eat my food either very warm or very cold

The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit specific information regarding this client's disorder? "Do your eyes feel dry?" "Do you have any spasms in your throat?" "Are you having any difficulty chewing food?" "Do you have any tingling sensations around your mouth?"

Are you having any difficulty chewing food?

At 8:00 a.m., a client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98º F (37.2º C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99º F (36.7º C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? Reorient the client. Retake the vital signs. Call the primary health care provider (PHCP). Administer an antihypertensive PRN (as needed).

Call the PHCP

The nurse is caring for a client with a neurological deficit involving the hippocampus. On assessment of the client, which signs and symptoms would most likely be noted? Disoriented to client, place, and time Affect flat, with periods of emotional lability Cannot recall what was eaten for breakfast today Unable to add and subtract; does not know who is president

Cannot recall what was eaten for breakfast today

A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be most concerned about? Glaucoma Emphysema Hypertension Diabetes mellitus

Emphysema

The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply. Eye opening Reflex response Best verbal response Best motor response Pupil size and reaction

Eye opening Best verbal response Best motor response

The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse should expect to observe which finding in the client? Facial drooping Periorbital edema Ptosis of the eyelid Twitching on the affected side of the face

Facial drooping

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? Fluid is clear and tests negative for glucose. Fluid is grossly bloody in appearance and has a pH of 6. Fluid clumps together on the dressing and has a pH of 7. Fluid separates into concentric rings and tests positive for glucose.

Fluid separates into concentric rings and tests positive for glucose

The nurse has taught a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that further teaching is needed if the client states the need to take which action? Bend at the knees to pick up objects. Increase fiber and fluid intake in the diet. Strengthen the back muscles by swimming or walking. Get out of bed by sitting straight up and swinging the legs over the side of the bed.

Get out of bed by sitting straight up and swinging the legs over the side of the bed

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. Giving tepid sponge baths Applying a hypothermia blanket Covering the client with blankets Administering acetaminophen per protocol Placing ice packs over the client's abdomen and in the axilla and groin

Giving tepid sponge baths Applying a hypothermia blanket Administering acetaminophen per protocol

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement? "Here's the MedicAlert bracelet I obtained." "I should take my medications an hour before mealtime." "Going to the beach will be a nice, relaxing form of activity." "I've made arrangements to get a portable resuscitation bag and home suction equipment."

Going to the beach will be a nice, relaxing form of activity.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific primary health care provider prescriptions, the nurse should plan to place the client in which positions? Select all that apply. Head midline Neck in neutral position Flat, with head turned to the side Head of bed elevated 30 to 45 degrees Head of bed elevated with the neck extended

Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees

The nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath sounds. Which judgment should the nurse formulate for the client? Impaired nutritional intake Increased risk for aspiration Increased likelihood for injury Susceptibility to fluid volume deficit

Increased risk for aspiration

A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation? Annual influenza vaccination Ingestion of increased fruits and vegetables An established routine of walking 2 miles each evening A recent period of extreme outside ambient temperatures

Ingestion of increased fruits and vegetables

A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care? Inability to care for self Interruption in skin integrity Interruption in physical mobility Inability to perform daily activities

Interruption in physical mobility

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. Keep suction equipment at the bedside. Elevate the head of the bed 30 degrees. Keep the client lying in a supine position. Keep the head and neck in good alignment. Administer prescribed respiratory treatments as needed.

Keep suction equipment at the bedside Elevate the head of the bed 30 degrees Keep the head and neck in good alignment Administer prescribed respiratory treatments as needed

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Limiting bladder catheterization to once every 12 hours Turning and repositioning the client at least every 2 hours Ensuring that the client has a bowel movement at least once a week

Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Turning and repositioning the client at least every 2 hours

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? Updating the home safety sheet Leaving the client in an unchilled area of the room Noting a bowel movement on the client progress note Recording the amount of urine obtained with catheterization

Leaving the client in an unchilled area of the room

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. Loosening restrictive clothing Restraining the client's limbs Removing the pillow and raising padded side rails Positioning the client to the side, if possible, with the head flexed forward Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

Loosening restrictive clothing Removing the pillow and raising padded side rails Positioning the client to the side, if possible, with the head flexed forward

The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern? Difficulty articulating words Lung vital capacity of 10 mL/kg Paralysis progressing from the toes to the waist A blood pressure (BP) decrease from 110/78 mm Hg to 102/70 mm Hg

Lung vital capacity of 10 mL/kg

The nurse is reviewing the record for a client seen in the health care clinic and notes that the primary health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record? Muscle wasting Mild clumsiness Altered mentation Diminished gag reflex

Mild clumsiness

The nurse is caring for a client with bacterial meningitis. The nurse should anticipate that an antibiotic with which characteristics will be prescribed for the client? One that has a long half-life One that acts within minutes to hours One that can be easily excreted in the urine One that is able to cross the blood-brain barrier

One that is able to cross the blood-brain barrier

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 30 to 35 mm Hg (30 to 35 mm Hg) PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)

PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)

The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions should be included in the plan? Select all that apply. Leave the lights on in the client's room at night. Place a blood pressure cuff at the client's bedside. Close the shades in the client's room during the day. Allow the client to drink 1 cup of caffeinated coffee a day. Allow the client to ambulate 4 times a day with assistance.

Place a blood pressure cuff at the client's bedside Close the shades in the client's room during the day

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? Notify the neurologist. Loosen tight clothing on the client. Place the client in a sitting position. Check the urinary catheter tubing for kinks or obstruction.

Place the client in a sitting position

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? Keeping the client on a stretcher Logrolling the client onto a soft mattress Logrolling the client onto a firm mattress Placing the client on a bed that provides spinal immobilization

Placing the client on a bed that provides spinal immobilization

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. Use products that contain alcohol. Position the client on his or her side. Brush the teeth with a small, soft toothbrush. Cleanse the mucous membranes with soft sponges. Use lemon glycerin swabs when performing mouth care.

Position the client on his or her side. Brush the teeth with a small, soft toothbrush. Cleanse the mucous membranes with soft sponges.

A client with neck and upper extremity pain has been diagnosed with cervical radiculitis. What does the nurse anticipate as being the cause of these clinical manifestations? Pressure on a spinous process Pressure on a spinal nerve root Pressure on a central spinal cord Pressure on a posterior facet joints

Pressure on a spinal nerve root

The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply. Provide physical aspects of care. Prevent pushing or straining activities. Limit caffeinated coffee to 1 cup per day. Keeping the lights on in the client's room. Maintain the head of the bed at 15 degrees.

Provide physical aspects of care. Prevent pushing or straining activities. Maintain the head of the bed at 15 degrees

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? Giving client full control over care decisions and restricting visitors Providing positive feedback and encouraging active range of motion Providing information, giving positive feedback, and encouraging relaxation Providing intravenously administered sedatives, reducing distractions, and limiting visitors

Providing information, giving positive feedback, and encouraging relaxation

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply. Providing sensory cues Giving simple, clear directions Providing a stable environment Keeping family pictures at the bedside Encouraging family members to visit at the same time

Providing sensory cues Giving simple, clear directions Providing a stable environment Keeping family pictures at the bedside

At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention? Tightened screws Red skin areas under the jacket Clean and dry lamb's wool jacket lining Finger-width space between the jacket and the skin

Red skin areas under the jacket

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? Reduce environmental noise. Allow visitors as desired by the client and family. Awaken the client every 2 to 3 hours to monitor mental status. Cluster nursing activities to reduce the number of interruptions.

Reduce environmental noise

At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's airway is patent if which data are identified? Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath sounds in lung bases

Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear

The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan? Maintain the client in a flat position. Restrict fluid intake for a period of 2 hours. Assess the client's ability to void and move the extremities. Inspect the puncture site for swelling, redness, and drainage.

Restrict fluid intake for a period of 2 hours

The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? Walking on the toes Unsteady and staggering Shuffling and propulsive Broad-based and waddling

Shuffling and propulsive

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? Taking medications as scheduled Eating large, well-balanced meals Doing muscle-strengthening exercises Doing all chores early in the day while less fatigued

Taking medications as scheduled

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. The client is aphasic. The client has weakness on the right side of the body. The client has complete bilateral paralysis of the arms and legs. The client has weakness on the right side of the face and tongue. The client has lost the ability to move the right arm but is able to walk independently. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance.

The client is aphasic The client has weakness on the right side of the body The client has lost the ability to move the right arm but is able to walk independently

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? The client will be easily fatigued. The client will have difficulty speaking. The client will have difficulty swallowing. The client will exhibit neglect of the affected side.

The client will exhibit neglect of the affected side

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? The intracranial pressure reading is normal. The intracranial pressure reading is elevated. The intracranial pressure reading is borderline. An intracranial pressure reading of 8 mm Hg is low.

The intracranial pressure reading is normal

The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. Thicken liquids. Assist the client with eating. Assess for the presence of a swallow reflex. Place the food on the affected side of the mouth. Provide ample time for the client to chew and swallow.

Thicken liquids. Assist the client with eating. Assess for the presence of a swallow reflex. Provide ample time for the client to chew and swallow

A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should take which actions? Select all that apply. Giving the client thin liquids Thickening liquids to the consistency of oatmeal Placing food on the unaffected side of the mouth Allowing plenty of time for chewing and swallowing Leave the client alone so that the client will gain independence by feeding self

Thickening liquids to the consistency of oatmeal Placing food on the unaffected side of the mouth Allowing plenty of time for chewing and swallowing

A client has a cerebellar lesion. The nurse would plan to obtain which item for use by this client? Walker Slider board Raised toilet seat Adaptive eating utensils

Walker

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa in which position? 15 degrees of Trendelenburg's Side-lying with the head of the bed flat With the head of the bed elevated at least 30 degrees With the head of the bed elevated no more than 10 degrees

With the head of the bed elevated at least 30 degrees