116- RLE 3rd

A client is brought to the trauma bay after a motor vehicle collision with rollover. The client is unconscious but breathing. On the neurological assessment, the client does not respond to his/her name. The nurse performs a sternal rub and the client's eyes open, arms flex in no particular direction, and the client mumbles incoherently. The nurse anticipates the next action to be which of the following? a. Prepare for rapid sequence intubation b. Move on to your secondary survey c. Facilitate family presence d. Administer normal saline through 2 large bore IV's

a. Prepare for rapid sequence intubation

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? a.It is possible the client can hear the family. b.The family needs immediate crisis intervention. c.The client might have wanted a visit from the hospital chaplain. d.The family could benefit from a conference with the health care provider.

a.It is possible the client can hear the family.

condition of absence of equal pupil size (unequal size of pupils)

anisocoria

A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply. a. Decerebrate posturing b. Dilated non reactive pupils c. Deep tendon reflexes d. Absent corneal reflex

b. Dilated non reactive pupils c. Deep tendon reflexes d. Absent corneal reflex

Which statement concerning the areas of the brain is true? a.The cerebellum is the center for speech and emotions. b.The hypothalamus controls body temperature and regulates sleep .c.The basal ganglia are responsible for controlling voluntary movements. d.Motor pathways of the spinal cord and brainstem synapse in the thalamus.

b.The hypothalamus controls body temperature and regulates sleep

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: a. Tolerate the pain b. Decrease the perception of pain c. Escape the source of pain d. Divert attention from the source of pain.

c. Escape the source of pain

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? a.Flaccid paralysis of all extremities b.Adduction of the arms at the shoulders c.Rigid extension and pronation of the arms and legs d.Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

c. Rigid extension and pronation of the arms and legs

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decerebrate

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Highest GCS score

15

Lowest GCS score

3

What is sequence of assessing a client glasgow coma scale

Check, Observe, Stimulate, Rate

A client who had a stroke is seen bumping into things on the side and is having difficulty picking up the beginning of the next line of what he is reading. The client is experiencing which of the following conditions? A. Visual neglect B. Astigmatism C. Blepharitis D. Homonymous Hemianopsia

D. Homonymous Hemianopsia

When rating a patient using the Glasgow Coma Scale, what would be appropriate for the LPN/LVN to ask the patient to do in order to test the patient's motor response? A. Roll his eyes in a circle. B. Take a deep breath and exhale. C. Describe the view from his window. D. Touch his nose with his left index finger.

D. Touch his nose with his left index finger.

what are the three components of gcs score

E4, V5, M6

A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration?

Establishing a toileting schedule

What are the three components of the Glasgow Coma Scale?

Eye Response, Verbal Response, Motor Response

A nurse would use which standardized tool as a guide in assessing a client with a head injury and increased intracranial pressure (ICP)? A. Snellen chart B. Pulse oximetry graph C. Visual Analogue Scale D. Glasgow Coma Scale

Glasgow Coma Scale

If when you approach the patient they are awake and looking at you, how would you record this on the Glasgow Coma Scale?

Spontaneous eye opening is present if the patient is considered able to look at something without stimulation.

What possible sequence of responses is assessed in the eye component?

Spontaneous, To Sound, To Pressure, None

The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact?

The patient: moves the head and shoulders against resistance with equal strength.

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? 1. Diencephalon 2. Medulla 3. Midbrain 4. Cortex

3. Midbrain

You apply nail bed pressure to an unresponsive adult. His eyes open while he he pulls his hand away. He then says, "Mom, where's my pickle weasel?" What's his GCS?

GCS 9

A client who has sustained a head injury is being evaluated in the emergency room. The nurse performs a neurological assessment and notes that the client is somnolent. Which of the following describes an somnolent client response? Select all that apply. a. Falls asleep between stimulation b. Needs stimulation to follow commands c. Alert and following commandsDoes not respond at all d. Difficult to arouse

a. Falls asleep between stimulation b. Needs stimulation to follow commands d. Difficult to arouse

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? a.6 b.12 c.15 d.24

a.6

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? a.Providing sensory cues b.Giving simple, clear directions c.Providing a stable environment d.Encouraging multiple visitors at one time

d. Encouraging multiple visitors at one time

The nurse is assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client's peripheral response to pain? a.Sternal rub b.Pressure on the orbital rim c.Squeezing of the sternocleidomastoid muscle d.Nail bed pressure

d. Nail bed pressure

A GCS of 15 indicates

fully awake, alert, and oriented client.

The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? A. Cerebellar function B. Intellectual function C. Cerebral function D. Sensory function

C. Cerebral function

When increased ICP is suspected, the nurse performs a complete neurologic assessment. What does the pupillary response indicate? A. High pressure can cause blurred vision. B. Hemorrhage can cause visual impairment. C. Pupil dilation is the first sign of increased ICP. D. Pupil changes can be caused by pressure on the ocular nerve.

C. Pupil dilation is the first sign of increased ICP.

The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? A. Sit with the client for a few minutes .B. Administer an analgesic. C. Inform the nurse manager. D. Call the physician immediately.

D. Call the physician immediately.

The nurse is performing a "neuro check" on a patient who has demonstrated a decreased LOC. What is the best way to assess the patient's neuromuscular status? A. Measure the patient's vital signs B. Test the reaction of the patient's pupils to light C. Check the patient's response to the stimulus of pinching. D. Determine whether the patient is able to move his legs and arms

D. Determine whether the patient is able to move his legs and arms

When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n):

Positive Romberg sign.

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a.Reflexes will be normal. b.Reflexes cannot be elicited. c.All reflexes will be diminished but present d.Some reflexes will be present, depending on the area of injury.

a.Reflexes will be normal.

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention is dangerous to perform? a) Elevating the head of his bed b) Performing a lumbar puncture c) Placing him on mechanical ventilation d) Giving him a barbiturate

b) Performing a lumbar puncture

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a.Extinction b.Astereognosis c.Graphesthesia d.Tactile discrimination

b. Astereognosis

Which of the following describes decerebrate posturing? a. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers b. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet c. Supination of arms, dorsiflexion of feet d. Back arched; rigid extension of all four extremities

b. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet

A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? a. The client leaves the siderails down. b. The client uses a mirror to inspect his skin. c. The client repositions onlyafter being reminded to doso. d. The client hangs his left arm over the side of the wheelchair.

b. The client uses a mirror toinspect his skin.

A client who has suffered a head injury is brought in to the emergency department. The nurse assesses the client's level of consciousness by first checking for alertness and orientation. What is the most appropriate question for the nurse to ask in order to assess if the client is alert and oriented? a. Do you know where you are right now? b. What month is it? c. Did anyone come in with you? d. Are you having any pain?

b. What month is it?

The post-head injury client opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? a. GCS = 3 b. GCS = 6 c. GCS = 9 d. GCS = 11

c. GCS = 9

A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? a. Assess full ROM to determine extent of injuries b. Call for an immediate chest x-ray c. Immobilize the client's head and neck d. Open the airway with the head-tilt chin-lift maneuver

c. Immobilize the client's head and neck

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

c. Impaired verbal communication

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?a.Positive Babinski sign b.Plantar reflex abnormal c.Plantar reflex present d.Plantar reflex 2+ on a scale from "0 to 4+"

c.Plantar reflex present

During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves?

cranial nerve VII, the facial nerve.

A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? a. Widening pulse pressure b. Decrease in the pulse rate c. Dilated, fixed pupil d. Decrease in LOC

d. Decrease in LOC

A nurse is caring for a client who has experienced a head injury. The nurse is performing a focused neurological exam and documents that the client's mental status is obtunded. Which best describes a client's affect as obtunded?a. The client is easily awakened with voice from normal sleep b. The client does not respond to any stimulation c. The client only arouses to painful stimuli d. The client has very slow responses and decrease interest in the environment

d. The client has very slow responses and decrease interest in the environment