NCLEX Neurology/Sensory Systems

A client with dementia and chronic confusion is suspected to have Alzheimer disease. Which imaging technique is specific for Alzheimer disease? A. Diffusion imaging (DI) B. Magnetic resonance imaging (MRI) C. Magnetic resonance angiography (MRA) D. Magnetic resonance spectroscopy (MRS)

D. Magnetic resonance spectroscopy (MRS)

The nurse assesses for damage to the glossopharyngeal (ninth cranial) and vagus (tenth cranial) nerves. Which action will the nurse ask the client to perform? A. Shrug B. Smell C. Smile D. Swallow

D. Swallow

A client has a diagnosis of trigeminal neuralgia. When assessing the client's trigeminal nerve function, which should the nurse evaluate? A. Corneal sensation B. Facial expressions C. Ocular muscle movement D. Shrugging of the shoulders

A. Corneal sensation

A client is admitted to the hospital for cranial surgery. What does the nurse include in the preoperative plan of care? A. Helping the client put on a wig before the client's visitors arrive B. Obtaining the client's consent for shaving the client's head C. Braiding the client's hair to keep it restrained during surgery D. Telling the client that the head is shaved after administering anesthesia

B. Obtaining the client's consent for shaving the client's head

Postoperatively, a client complains about a variety of minor environmental factors, frequently changes positions, and avoids eye contact. The nurse responds to these observations by stating, "Let me get you some cold water and your pain pill, and you'll be much better." What does the nurse's response demonstrate? A. An empathic recognition of anxiety B. Addressing of the client's needs C. An inappropriate interpretation of the assessment findings D. Advanced problem solving and critical thinking skills

C. An inappropriate interpretation of the assessment findings

Haloperidol 100 mg intramuscularly (IM) stat has been prescribed for a client who is battered and agitated after a street brawl. What does the nurse conclude after reviewing the prescription? A. The medication is appropriate and should be given as prescribed. B. The medication is inappropriate because it takes one week for antidepressants to be effective. C. The dose is more than recommended. D. The route of administration is incorrect.

C. The dose is more than recommended.

A client has surgery for the creation of burr holes after sustaining head trauma. Which early clinical manifestation of meningeal irritation does the nurse assess in the client? A. Sunset eyes B. Kernig sign C. Plantar reflex D. Homans sign

B. Kernig sign

A client's relative asks the nurse what a cataract is. Which explanation should the nurse provide? A. An opacity of the lens B. A thin film over the cornea C. A crystallization of the pupil D. An increase in the density of the conjunctiva

A. An opacity of the lens

A nurse is assessing a client in the outpatient clinic who complains of excessive daytime sleepiness, sudden muscle weakness during intense emotions, and an inability to walk just after waking or before going to sleep. Which sleep disorder is the client experiencing? A. Nocturia B. Narcolepsy C. Sleep apnea D. Sleep deprivation

B. Narcolepsy

While hospitalized, a client has a hypertensive crisis and a brain attack (cerebrovascular accident, CVA). Initially, the nurse should place the client in which position? A. Supine B. Side-lying C. Orthopneic D. Trendelenburg

B. Side-lying

The nurse evaluates that the teaching about myasthenic and cholinergic crises is understood when a client who is diagnosed with myasthenia gravis states that which characteristic is common to both crises? A. Diarrhea B. Salivation C. Difficulty breathing D. Abdominal cramping

C. Difficulty breathing

A client has had a carotid endarterectomy. To monitor for the complication of cranial nerve dysfunction, the nurse assesses the client for which finding? A. Labored breathing B. Edema of the neck C. Difficulty in swallowing D. Alteration in blood pressure

C. Difficulty in swallowing

A client who had a cerebrovascular accident (CVA, "brain attack") is starting to eat lunch. Which client behavior indicates to the nurse that the client may be experiencing left hemianopsia? A. Asks to have food moved to the left side of the tray B. Drops the coffee cup when trying to use the right hand C. Ignores the food on the left side of the tray when eating D. Reports not being able to use the right arm to help eat meals

C. Ignores the food on the left side of the tray when eating

A man walks into the emergency room (ER) with sunglasses on and tells the nurse that he fell off a ladder and hit his head and was unconscious for a few minutes. What is the most appropriate next question the nurse should ask the client? A. "Did you pass out?" B. "Can you take off your sunglasses?" C. "Are you injured anywhere else?" D. "How many feet (meters) did you fall?"

B. "Can you take off your sunglasses?"

On the first postoperative evening after a lumbar laminectomy, a client states, "My feet are as numb as they were before the operation." Which is the nurse's best response? A. "Let me elevate your feet so the numbness will decrease more quickly." B. "That's important to know. I will inform your healthcare provider about the numbness." C. "Continue to let me know how you feel. It often takes time before this feeling subsides." D. "There is no cause for concern because the numbness will disappear as soon as the anesthesia wears off."

C. "Continue to let me know how you feel. It often takes time before this feeling subsides."

A client is admitted to the hospital with an altered level of consciousness. When assessing this client the nurse understands that level of consciousness extends along a continuum. Place the following words that describe level of consciousness in order from the most alert to the least alert. 1. Lethargic 2. Alert 3. Obtunded 4. Confused

2. Alert 4. Confused 1. Lethargic 3. Obtunded

While assessing a client for hearing acuity, which questions asked by the nurse helps in assessing the personal history of the client? Select all that apply. A. "Are you diabetic?" B. "Do you work in a noisy environment?" C. "Do you have a history of ear infections?" D. "Do you have a history of diseases due to vitamin C deficiency?" E. "Do you have a habit of listening to loud music?"

A. "Are you diabetic?" B. "Do you work in a noisy environment?" C. "Do you have a history of ear infections?" E. "Do you have a habit of listening to loud music?"

A client who had a brain attack (cerebrovascular accident, CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. How will the nurse document this finding in the client's medical record? A. Anomia B. Apraxia C. Dysarthria D. Dysphagia

A. Anomia

After assessing a client, the nurse anticipates that the client has a chalazion. Which statement made by the client helps the nurse reach this conclusion? A. "I have severe pain in my eyes." B. "I am unable to tolerate bright light." C. "I always feel something in my eyes." D. "I get an itching sensation in my eyes."

B. "I am unable to tolerate bright light."

The nurse is assessing a client for recall memory. Which statements made by the client indicate that the client's recall memory is intact? Select all that apply. A. "I was born in New York city." B. "I came to the hospital in a car." C. "You asked me to repeat the words apple, street, and chair." D. "I was admitted on the 24th of September at 5 in the evening." E. "I had an appointment with a neurophysician last month."

B. "I came to the hospital in a car." C. "You asked me to repeat the words apple, street, and chair." D. "I was admitted on the 24th of September at 5 in the evening." E. "I had an appointment with a neurophysician last month."

When preparing a client for discharge after a laminectomy, the nurse evaluates that further health teaching is necessary when the client makes which statement? A. "I should sleep on a firm mattress to support my back." B. "I should spend most of the day sitting in a straight-back chair." C. "I should put a pillow under my legs when sleeping on my back." D. "I should avoid lifting heavy objects until the healthcare provider tells me I can."

B. "I should spend most of the day sitting in a straight-back chair."

An 80-year-old client with dementia of the Alzheimer type is admitted to a nursing home. A family member visits and remarks how thin and wrinkled the client has become. Which response by the nurse will help the family member most to understand the aging process? A. "Most people at that age should be careful about weight gain." B. "This is typical of older adults; they really don't eat well." C. "It looks as though the frequent tanning has taken its toll." D. "As we age, we lose the tissue that helps puff out the skin."

D. "As we age, we lose the tissue that helps puff out the skin."

A nurse provides education to a client with myasthenia gravis about how to prevent myasthenic crisis. The nurse evaluates that the teaching is effective when the client makes which statement? A. "I'll take an antihistamine at the first sign of a cold." B. "I should skip a dose of pyridostigmine bromide (Mestinon) if it upsets my stomach." C. "We've told our daughter to wait to visit until her cold is better." D. "The healthcare provider may need to adjust the dosage of my medication if I'm more active."

D. "The healthcare provider may need to adjust the dosage of my medication if I'm more active."

A client who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO2 of 33 mm Hg. What action is most important for the nurse to take? A. Encourage the client to slow the breathing rate. B. Auscultate the client's lungs and suction if indicated. C. Advise the healthcare provider that the client needs supplemental oxygen. D. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure.

D. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure.

The nurse assesses a 65-year-old client's electronic medical records and notices a history of increased lens density. Which nursing actions will be most appropriate for this client? Select all that apply. A. Performing keratoplasty B. Performing phacoemulsification C. Monitoring for pain and eye redness D. Monitoring the client's blood glucose levels E. Assessing if the client is under antiplatelet medication

D. Monitoring the client's blood glucose levels E. Assessing if the client is under antiplatelet medication

The nurse assists the healthcare provider in performing a lumbar puncture. When pressure is placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is expected to increase. Which sign should the nurse expect the healthcare provider to document? A. Homans B. Romberg C. Chvostek D. Queckenstedt

D. Queckenstedt

A client with a 5-year history of myasthenia gravis is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. Which assessment finding should the nurse expect the client to report? A. Weakness decreases after hot baths B. Weakness improves with muscle use C. Strength improves immediately after meals D. Strength decreases with repeated muscle use

D. Strength decreases with repeated muscle use

In caring for the client with burr holes for a subdural hematoma postoperatively on day 2, the nurse notes the client has an increased temperature to 101.3 F° (38.5° C). What does the nurse understand about this reaction? A. This is a normal assessment for the client with a subdural hematoma. B. This is a normal reaction day 2 postoperatively, and the nurse will administer acetaminophen as prescribed by the healthcare provider. C. Because the client has burr holes, this is not an accurate measurement. D. The client is exhibiting signs of an infection, and the healthcare provider needs to be notified

D. The client is exhibiting signs of an infection, and the healthcare provider needs to be notified

A client reports a severe unilateral throbbing headache, nausea, intolerance to light and sound, and double vision. Which phase of this headache involves double vision? A. Aura phase B. Headache phase C. Prodromal phase D. Termination phase

A. Aura phase

A nurse is caring for a client with expressive aphasia. Which action should the nurse include when planning for the long-term care of this client? A. Begin helping the client to write. B. Encourage the client to acknowledge that this disability is permanent. C. Wait for communication to be initiated by the client even if it takes a long time. D. Assist family members to accept the fact that they cannot communicate verbally with the client.

A. Begin helping the client to write.

Bed rest is prescribed after a client's cerebrovascular accident (CVA, "brain attack") results in right hemiplegia. Which exercises should the nurse incorporate into the client's plan of care 24 hours after the brain attack? A. Passive range-of-motion exercises B. Active exercises of the extremities C. Light weight-lifting exercises of the right side D. Isotonic exercises that will capitalize on returning muscle function

A. Passive range-of-motion exercises

A client is hospitalized with head trauma. Which imaging test should the nurse anticipate being prescribed by the primary healthcare provider to rule out a cervical spine fracture? A. Plain x-ray B. Cerebral angiography C. Computed tomography (CT) D. Positron emission tomography (PET)

A. Plain x-ray

A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity? A. Push-ups to strengthen arm muscles B. Leg lifts to prevent hip contractures C. Balancing exercises to promote equilibrium D. Quadriceps-setting exercises to maintain muscle tone

A. Push-ups to strengthen arm muscles

The registered nurse (RN) is teaching an older adult with a hearing problem due to cerumen impaction. Which instructions should the nurse share with the client? A. "Nausea and vomiting are to be expected when you irrigate." B. "Wash the external ears daily with soap and water." C. "Use cool water to irrigate your ear." D. "Use 70 mL of irrigating fluid each time."

B. "Wash the external ears daily with soap and water."

A client falls from a two-story building and is taken to the hospital unconscious. Which finding identified during the initial nursing assessment should be of most concern to the nurse? A. Glasgow Coma Scale (GCS) score of 8 B. Bleeding from the ears C. Pupils reactive to light D. Depressed fontanel

B. Bleeding from the ears

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? A. Insert a urinary retention catheter. B. Institute measures to prevent constipation. C. Encourage an increase in the intake of caffeine. D. Suggest that a carbonated beverage be ingested daily.

B. Institute measures to prevent constipation.

The nurse is teaching a client with multiple sclerosis methods to reduce fatigue. Which statement indicates an understanding of the education? A. Take a hot bath. B. Rest in an air-conditioned room. C. Increase the dose of muscle relaxants. D. Avoid naps during the day.

B. Rest in an air-conditioned room.

A nurse performs a Rinne test during physical assessment of a client. The client indicates that the sound is louder when the vibrating tuning fork is placed against the mastoid bone than when held closely to the ear. What conclusion should the nurse make about these results? A. This represents an expected finding. B. The client may have a sensorineural deficit. C. This is evidence of a conductive hearing loss. D. The client has an inflammation of the mastoid.

C. This is evidence of a conductive hearing loss.

While performing a visual system assessment, the nurse observes that the client has a misalignment of the right eye. The client reports to the nurse, "I am having double vision." What may be the cause of this condition? A. Myasthenia gravis B. Periorbital tumors C. Conjunctival blood vessels rupture D. Abnormalities of extraocular muscle actions

D. Abnormalities of extraocular muscle actions

A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding would the nurse expect and need to monitor frequently in this client? A. Localized seizures B. Skin desquamation C. Hyperactive reflexes D. Ascending weakness

D. Ascending weakness

A client who sustained a severe head injury remains unconscious. During the client's assessment, the nurse observes bleeding from the left ear and rhinorrhea. What injury does the nurse conclude that drainage from the ear and nose indicates? A. Contusion B. Concussion C. Nose fracture D. Basilar fracture

D. Basilar fracture

A nurse is caring for a client who just has had surgery on the ear. The nurse should assess for which early indicator of potential damage to the motor branch of the facial nerve? A. Pain behind the ear B. Bitter, metallic taste C. Dryness of the mouth D. Inability to wrinkle the forehead

D. Inability to wrinkle the forehead

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma? A. Constant blurring B. Abrupt attacks of acute pain C. Sudden, complete loss of vision D. Impairment of peripheral vision

D. Impairment of peripheral vision

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. Which diagnostic test result will the nurse check for confirmation of this diagnosis? A. Myelography B. Lumbar puncture C. Electromyography D. Computed tomography

D. Computed tomography

While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which condition should the nurse record in the assessment findings? A. Decortication B. Pronator drift C. Babinski's sign D. Decerebration

D. Decerebration

Which antiinfective agent may lead to blindness if not used correctly by the client in prescribed amounts? A. Bromfenac B. Natamycin C. Trifluridine D. Gentamicin

D. Gentamicin

Which drug will most likely cause the client's eyelids to itch and eyes to burn as side effects? A. Ketorolac B. Ofloxacin C. Diclofenac D. Vidarabine

D. Vidarabine

A healthcare provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply. A. Double vision B. Problems with cognition C. Difficulty swallowing saliva D. Intention tremors of the hands E. Drooping of the upper eyelids F. Nonintention tremors of the extremities

A. Double vision C. Difficulty swallowing saliva E. Drooping of the upper eyelids

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma? A. Monitor the client for signs of brain injury. B. Check for hemorrhaging from the oral and nasal cavities. C. Elevate the foot of the bed if the client develops symptoms of shock. D. Observe for clinical indicators of decreased intracranial pressure and temperature.

A. Monitor the client for signs of brain injury.

A nurse is performing the history and physical examination of a client with Parkinson disease. Which assessments identified by the nurse support this diagnosis? Select all that apply. A. Nonintention tremors B. Frequent bouts of diarrhea C. Masklike facial expression D. Hyperextension of the neck E. Rigidity to passive movement

A. Nonintention tremors C. Masklike facial expression E. Rigidity to passive movement

A client who is receiving medication for an eye disorder reports bleeding in the eye. Which drug will the nurse most likely observe written in the medication administration record? A. Ketorolac B. Trifluridine C. Natamycin D. Ciprofloxacin

A. Ketorolac

A client is diagnosed with the genetic disorder osteogenesis imperfecta. Which condition can be anticipated in the client at an age of 30? A. Loss of auditory acuity B. Loss of visual acuity C. Loss of smell perception D. Loss of touch perception

A. Loss of auditory acuity

While caring for a client who had an accident, the nurse suspects injury to the frontal lobe. Which statements by the client may support the nurse's conclusion? Select all that apply. A. "I am unable to play the piano." B. "I am unable to hear properly." C. "I am unable to move my eyes." D. "I am unable to concentrate on anything." E. "I am unable to taste any flavors in the foods I eat."

A. "I am unable to play the piano." C. "I am unable to move my eyes." D. "I am unable to concentrate on anything."

A client diagnosed with Bell palsy has many questions about the course of the disorder. Which information should the nurse share with the client? A. Cool compresses decrease facial involvement. B. Pain occurs with transient ischemic attacks (TIAs). C. Most clients recover from the effects in several weeks. D. Body changes should be expected with residual effects.

C. Most clients recover from the effects in several weeks.