NCLEX Neuro

The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

Limiting bladder catheterization to once every 12 hours

The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take?

Raise the head of the bed and remove the noxious stimulus

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?

"I will drive only during the daytime."

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply

1. Pad the bed's side rails. 2. Place an airway at the bedside. 3.Place oxygen equipment at the bedside. 4. Place suction equipment at the bedside.

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply.

3. Semi-Fowler's position 5. With the foot of the bed flat

The nurse is caring for a client following a craniotomy in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to the Figure.

A

The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client?

Comparing the amount of prescribed weights with the amount in use

The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity?

Exhaling during repositioning

The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively?

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

The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse?

Head turned to the side

The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom?

Minor headache

The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria?

Separates into concentric rings and tests positive for glucose

The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted?

Severe, throbbing headache

The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time?

The primary health care provider (PHCP) reviews the x-ray results.