NEURO NCLEX

A male client who had a stroke has left-sided hemiparesis. Which statement by the client indicates a need for further teaching in the area of self-care activities?

"I'm so proud that I did everything for the first time with my right arm."

The nurse is planning care for a client with Bell's palsy. Which measure should be included in the plan?

Instill artificial tears and place a patch over the affected eye at night.

The nurse is assessing the corneal reflex on an unconscious client. What should the nurse use as the safest stimulus to touch the client's cornea?

Wisp of cotton

The home care nurse is evaluating a client's understanding of the self-management of trigeminal neuralgia. Which client statement indicates that there is a need for further teaching?

"An analgesic will relieve my pain."

When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem?

"Avoid caffeine in your diet."

The nurse is assessing the neurological status of a client. The nurse should assess for new memory by asking the client which question?

"Can you repeat house, ring, and rope? I will have you repeat these words again in a few minutes."

The registered nurse assigns a new nurse a client who has Parkinson disease. The registered nurse determines that the new nurse accurately describes Parkinson's disease if which statement is made?

"Clients with Parkinson's disease may exhibit echolalia and repetition of sentences."

The nurse is performing an assessment of a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement?

"I can't swallow very well today."

Which statement made by a client with a spinal cord injury warrants follow-up by the nurse?

"I'm so angry that this happened to me."

The nurse teaches a client with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client would indicate the need for additional teaching?

"Symptoms I should watch for include fever and chest pain."

A client with Parkinson's disease is concerned because of tremors and asks the nurse what can be done to minimize them. Which statement should the nurse make to the client?

"Try grasping coins in your pocket or holding onto the arm of a chair."

The nurse admits a client who has right-sided weakness, aphasia, and urinary incontinence. The woman's daughter states, "If this is a stroke, it's the kiss of death." What initial response should the nurse make?

"You feel your mother is dying?"

The nurse is caring for a client with a thoracic spinal cord injury. As part of the nursing care plan, the nurse monitors for spinal shock. In the event that spinal shock occurs, which intravenous (IV) fluid should the nurse anticipate being prescribed?

0.9% Normal saline

The nurse picks up the chart of a post-craniotomy client and reads a prescription for dexamethasone (Decadron), 6 mg intravenously (IV) now. When preparing the medication, over what time frame should the nurse plan to administer the medication?

1 minute

The nurse is planning care for a client with a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)?

Assist the client to develop a daily bowel routine to prevent constipation.

A female client with myasthenia gravis expresses concern over her inability to smile, her drooping eyelids, and how the disease has made her weak and changed the way she looks. What is the appropriate client problem?

Body image disorder

A client with trigeminal neuralgia undergoes surgery for pain relief. In the postoperative period, which nursing intervention will prevent an episode of facial pain?

Bring the client room-temperature water for washing.

The nurse is assessing data on a client with the diagnosis of Brown-Séquard syndrome. Which findings should the nurse expect to note?

Ipsilateral paralysis and loss of touch and vibration

A client has a prescription for seizure precautions. The nurse should include which interventions when planning care for the client? Select all that apply.

Maintain the bed in the lowest position. Assist the client to ambulate in the hallway. Ensure that suctioning equipment is readily available. Monitor the client closely while the client is showering.

The registered nurse has taught a new nurse about the protective structures of the brain. How should the new nurse correctly identify the membranes that surround the brain and spinal cord?

Meninges

The nurse is performing an assessment on a client who has a suspected spinal cord injury. What is the priority nursing assessment?

Respiratory status

The nurse is caring for a client who had a craniotomy (supratentorial surgery). When assessing the client for the major postoperative complication following craniotomy, the nurse should monitor for which early sign?

Restlessness

A client is being prepared for lumbar puncture (LP). Which position should the nurse assist the client into for the procedure?

Side-lying, with the legs pulled up and the head bent down onto the chest

A family is trying to communicate with a stroke client with aphasia, and the nurse provides a list of interventions to the family to promote effective communication. Which interventions should the nurse place on the list? Select all that apply.

Speak to the client at a slow rate. Look directly at the client while listening. Allow sufficient time for the client to respond.

A client reports being recently diagnosed with Bell's palsy. The nurse observes the client to see if which signs/symptoms are visible?

Speech difficulties and one-sided facial droop

The nurse is assessing a client with Bell's palsy. The nurse should check the client for which signs/symptoms related to the disorder?

Speech or chewing difficulties accompanied by facial droop

The nurse is assessing the function of cranial nerve XII (hypoglossal nerve). The nurse should assess the function of this nerve by asking the client to perform which task?

Stick out the tongue and move it side to side.

A client has had a stroke with damage to the nondominant cerebral hemisphere and is experiencing unilateral neglect. Before discharge from the hospital, the nurse determines that the client has compensated for the neglect when what behavior is observed?

The client scans the environment before beginning to bathe the affected side.

The nurse is testing the function of a client's vestibulocochlear nerve (CN VIII). Which items should the nurse gather to perform the test?

Tuning fork and audiometer

A client with Guillain-Barré syndrome asks the nurse what caused the disorder. In formulating a response, the nurse incorporates what understanding about the theory of causation?

The cause is unknown.

Which technique should the nurse perform as the method for assessing a client's pupillary reaction to light?

Turn the penlight on, and move the light from the client's temporal area to the eye while the client looks straight ahead.

A client who has experienced a stroke has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is not sufficient to provide support. The nurse determines that the client could benefit from the somewhat greater support, stability, and safety provided by which devices? Select all that apply.

Walker Tripod cane Quadripod cane

The nurse provides instructions to the client with Bell's palsy regarding treatment measures for the disorder. Which statement by the client indicates a need for further instructions?

"I should place ice packs to the affected side of my face."

The clinic nurse is assessing a client for environmental risk factors related to neurological disorders. The nurse understands that which is least likely associated with neurological disorders?

Number of windows in the work area

The nurse notes that a client's eyes are continuously moving back and forth within the eye sockets. What disorder should the nurse document in the medical record that the client has?

Nystagmus

A hospitalized client has a halo-vest traction applied to treat a cervical dislocation. Which measure should the nurse include in the client's plan of care?

Perform ongoing cranial nerve assessment to monitor for nerve damage.

When the nurse taps at the level of the client's facial nerve, the response depicted in the figure is noted. How should the nurse document this finding on the client record? Refer to figure.

Positive Chvostek's sign

The nurse is caring for a client after a supratentorial craniotomy. The nurse places a sign above the client's bed stating that the client should be maintained in which position?

Semi-Fowler's

A client with trigeminal neuralgia asks the nurse what can be done to minimize the episodes of pain. Which symptoms should the nurse tell the client can trigger an attack?

Sensations of pressure or extreme temperature

A client is brought to the emergency department with a suspected spinal cord injury (SCI). The client has flaccid paralysis, the blood pressure (BP) is 70/50 mm Hg, and the pulse is 62 beats per minute. How should the nurse interpret these findings?

Spinal shock

The family of a client with spinal cord injury asks if spinal shock will go away quickly. The nurse's response is based on the understanding that spinal shock usually resolves in which time frame?

Spinal shock can last from 7 days to 3 months.

The nurse observes that a male client who had a stroke 2 weeks ago is using foul language when speaking with his wife. What conclusion should the nurse make based on the interpretation of the situation?

The client is frustrated.

A client with quadriplegia complains bitterly about the nurse's slow response to the call bell and the rigidity of the therapy schedule. Which analysis of this behavior should serve as a basis for planning nursing care?

The client is reacting to loss of control.

A client has an impaired corneal reflex on the right side after a head injury. How should the nurse instruct the client to best protect the eye?

Use sterile saline drops every few hours to keep the eye moist.

A client recovering from a stroke has become irritable and angry regarding limitations. Which is the best nursing approach to help the client regain motivation to succeed?

Use supportive statements to correct the client's behavior.

A client with paraplegia has the potential to injure to their legs because of the spasticity of the leg muscles. Which action should the nurse refrain from taking because it would be least appropriate in dealing with this problem?

Using limb restraints to immobilize the limbs

The nurse is caring for a client with a cerebellar lesion. Which of the devices should the nurse plan to obtain to assist the client in adapting to this problem?

Walker

The nurse develops a discharge plan for a client with diabetes mellitus who has peripheral neuropathy of the lower extremities. Which instructions should the nurse include in the plan? Select all that apply.

Wear support or elastic stockings. Apply lanolin or lubricating lotion to the legs and feet once or twice daily. Wash the feet and legs with mild soap and water and rinse and dry them well.

A client with diplopia has been given an eye patch to promote better vision and prevent injury. What should the nurse teach the client to do as part of the correct use of this item?

Wear the patch continuously, alternating eyes each day.

The nurse is assessing a client with a brainstem injury. What else should the nurse do in addition to performing the Glasgow Coma Scale?

Assess cranial nerve functioning and respiratory rate and rhythm.

A client arrives at the clinic complaining of a severe headache. The client states "It's a 10/10 headache. I took 600 mg of Ibuprofen (Motrin IB) over the past few hours and it has not decreased the pain." The nurse suspects that the client is experiencing a migraine but wants to validate the suspicion by asking which questions? Select all that apply.

Describe the pain. What other symptoms are you experiencing? What did you experience right before the headache began? Do you or a family member have a history of severe headaches?

The nurse is caring for a client who is newly diagnosed with a spinal cord injury. The nurse reviews the client's record, and anticipates that which medication is most likely to be prescribed?

Dexamethasone (Decadron)

The nurse is performing a neurological assessment on a client who had a stroke. The nurse performs which assessment technique to elicit the plantar reflex?

Firmly strokes the lateral sole of the foot and under the toes with a blunt instrument

The nurse caring for a spinal cord-injured client monitors for signs of spinal shock. For what findings should the nurse assess?

Flaccid paralysis of the legs, bowel and bladder retention, and areflexia

The nurse is caring for a recent spinal cord injury client. Which assessment findings should indicate to the nurse that the client is in spinal shock?

Flaccid paralysis of the legs, bowel and bladder retention, areflexia

The nurse is preparing to admit a client from the postanesthesia care unit who has had microvascular decompression of the trigeminal nerve. Which equipment should the nurse ask the unlicensed assistive personnel to make sure is at the bedside when the client arrives?

Flashlight and pulse oximeter

The nurse admits a client who has a diagnosis of Guillain-Barré syndrome to the nursing unit. During the assessment of the client, the nurse asks whether the client recently was diagnosed with which disease process?

Gastrointestinal (GI) infection

A client with Guillain-Barré syndrome has been asking many questions about the condition, and the nursing staff believes that the client is very discouraged about her condition. It is important for the nurse to include which information in discussions with the client?

Generally, a vast majority of people recover from this condition.

The nurse notes documentation that a client who experienced a stroke has receptive aphasia. Which characteristics of this type of aphasia should the nurse expect to note in the client? Select all that apply.

Has meaningless speech Makes up words when speaking Has difficulty understanding spoken words Has difficulty understanding written words

A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) protein is 750 mg/dL. How should the nurse interpret these results?

Higher than normal, supporting the diagnosis of Guillain-Barré

A client is brought to the ambulatory clinic by family after experiencing a seizure. Which information shared by the family is of the least value as part of history taking for this client?

How many hours the client slept the night before

In caring for a client with myasthenia gravis, the nurse should be alert for which manifestations of myasthenic crisis? Select all that apply.

Increased diaphoresis Bowel and bladder incontinence Absent cough and swallow reflex Sudden marked rise in blood pressure

A client has a prescription for seizure precautions. What should the nurse include when planning care for the client? Select all that apply.

Keep the bed in the lowest position. Have suction equipment readily available. Assist the client to ambulate in the hallway. Monitor the client while the client is showering.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. What should the nurse do to minimize the risk of recurrence?

Keep the linen wrinkle-free under the client.

What signs/symptoms validate the diagnosis of cluster headache? Select all that apply.

Miosis Rhinorrhea Increased activity by client

A client with a head injury and a feeding tube continuously tries to remove the tube. The nurse contacts the health care provider who prescribes the use of restraints. After checking the agency's policy and procedure regarding the use of restraints, the nurse uses which method in restraining the client?

Mitten restraints

A client with a head injury and a feeding tube continually tries to remove the tube. The nurse obtains a prescription to restrain the client and uses which device for the restraint?

Mitten splints

A client has had intracranial surgery and has a decreasing pulse rate with an increasing blood pressure. Which activities should the nurse implement? Select all that apply.

Monitoring fluid intake Keeping the client's neck midline Elevating the head of the bed to 30 degrees Administering the current prescription for mannitol (Osmitrol)

A client suddenly experiences a seizure, and the nurse notes that the client exhibits uncontrollable jerking movements. The nurse documents that the client experienced which type of seizure?

Myoclonic seizure

A client suddenly experiences a seizure, and the nurse notes that the client exhibits uncontrollable jerking movements. Which type of seizure should the nurse document that the client experienced?

Myoclonic seizure

A client recovering from a craniotomy complains of a "runny nose." Based on the analysis of the client's complaint, what is the best nursing action?

Notify the health care provider.

The nurse working on a rehabilitation unit is assigned to a client with cognitive-perceptual difficulties and fine motor coordination problems. With which rehabilitation team member should the nurse request a consultation?

Occupational therapist

A client who is paraplegic after a spinal cord injury (SCI) is learning muscle-strengthening exercises for the upper body. The nurse tells the client that which activity will give the client the least amount of muscle-strengthening benefit?

Performing active range of motion (ROM) to the hands

The nurse reviews the health care provider's (HCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the HCP should the nurse question?

Provide a clear liquid diet.

The nurse caring for a client with trigeminal neuralgia should implement which activity?

Providing warm mouthwash for mouth care

The nurse is caring for a client with an intracranial aneurysm. The nurse interprets that which observation is related to the dysfunction of cranial nerve III (oculomotor nerve)?

Ptosis of the left eyelid

A client with a leaking intracranial aneurysm has been placed on aneurysm precautions. A visiting family member wants to take the client to the unit lounge for "just a few minutes." Which concepts should the nurse use when explaining why the client must remain in the room?

Reduced environmental stimuli are needed to prevent aneurysm rupture.

The nurse is caring for a client with a herniated lumbar intervertebral disk who is experiencing low back pain. Which position should the nurse place the client in to minimize the pain?

Semi-Fowler's position with the knees slightly raised

The nurse is assessing the fluid balance of a client after craniotomy. Which abnormal data obtained on the first postoperative day should the nurse report?

Serum osmolality, 280 mOsm/kg H2O

When collecting data from a client with trigeminal neuralgia, the nurse should expect the client to report which finding?

Sharp knife-like pain after brushing her or his teeth

A client admitted to the hospital has Parkinson's disease as a concurrent problem. When the nurse ambulates this client for the first time, what type of gait will the nurse expect?

Shuffling and propulsive

The nurse is assigned to a client whose chart lists trigeminal neuralgia (tic douloureux) as a current clinical problem. The nurse should question the client about which manifestation associated with this disorder?

Spasms of pain in the face

During a neurological assessment, a client does not respond when the nurse walks into the room in front of the client. What action should the nurse take next to assess the client's level of consciousness (LOC)?

Speak in a loud voice to the client.

The nurse caring for a client with a neurological disorder is planning care to maintain nutritional status. The nurse is concerned about the client's swallowing ability. Which food item should the nurse eliminate from this client's diet?

Spinach

The nurse is teaching a client with myasthenia gravis about prevention of myasthenic and cholinergic crises. Which information stated by the client demonstrates that the client understood the teaching?

Take medications on time to maintain therapeutic blood levels.

A client recovering from a head injury becomes agitated at times. Which action should the nurse incorporate to calm this client?

Talk to the client about the familiar objects, such as family pictures, that are kept in the client's room.

The nurse is doing an initial assessment at the beginning of the work shift on a client who has a spinal cord injury. What method should the nurse use to assess the client's sensory ability?

Tell whether a cotton wisp or pin is touching the skin.

A client with thrombotic stroke experiences periods of emotional lability. The client alternately laughs and cries and intermittently becomes irritable and demanding. What should the nurse interpret this behavior as indicating?

That the client is experiencing the usual sequelae of a stroke

A client with a T-4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which assessment finding is indicative of this complication?

The client complains of a headache, and the blood pressure is elevated.

The nurse is performing a neurological assessment on an unconscious client. On application of a central noxious stimulus, the nurse observes the response shown in the figure. Which statement should the nurse use to correctly document this response on the client record? Refer to figure.

The client demonstrated decerebrate posturing.

A client with a spinal cord injury (SCI) expresses little interest in activities of any kind, but is very particular about the way the nurse gives the bath. How would the nurse interpret these requests?

The client has experienced significant loss and is seeking areas of control.

A client who is paraplegic after a recent spinal cord injury (SCI) intermittently refuses care by the nurse and becomes angry and belligerent at times. What interpretation should nurse make of the client's behavior?

The client is acting out feelings of anger about the accident and injury.

A client with myasthenia gravis has been prescribed edrophonium (Enlon) testing, formerly known as Tensilon test. After administration of the medication, the client shows no improvement in muscle tone. Based on this result, what does the nurse understand?

The client is experiencing cholinergic crisis.

The nurse is discharging a female client from the hospital who has a diagnosis of a thoracic 11 (T11) fracture with cord transection. The nurse has provided home care instructions to the client. Which action would indicate the need for further teaching before discharge?

The client jokes about no longer needing to worry about birth control.

Which intervention should the nurse include in a plan of care for a client with a T-4 spinal cord injury to prevent autonomic dysreflexia (hyperreflexia)?

The client performs self-catheterization every 6 hours.

The nurse caring for a client who is comatose notes in the chart that the client is exhibiting decerebrate posturing. How should the nurse understand that decerebrate posturing (abnormal extension) is characterized?

The extension of the extremities and pronation of the arms

A client begins to experience a tonic-clonic seizure. Which actions should the nurse take? Select all that apply.

Turn the client to the side. Maintain the client's airway. Loosen any restrictive clothing that the client is wearing. Protect the client from injury, and guide the client's movements.

A client with myasthenia gravis is having difficulty with the motor aspects of speech. The client has difficulty forming words, and the voice has a nasal tone. Which communication strategies should the nurse use when working with this client? Select all that apply.

Use a letter board or picture board. Ask questions requiring a yes or no response. Repeat what the client said to verify the message.

The nurse is caring for a client with hemiparesis of the left arm and leg. To be effective in helping the client's rehabilitation and self-care, the nurse teaches the family to place personal care articles in what area for the client?

Within the client's reach, on the right side

The nurse is caring for a client with a spinal cord injury. What should the nurse ask the client to do to assess the sensory ability of the client?

Discriminate between touch and pinprick stimuli.

The nurse is collecting data from a client being admitted to the hospital who has right-sided weakness, aphasia, and urinary incontinence. One of the client's family members states, "This is the end if this is a stroke." Which therapeutic response should the nurse make to the family member?

"You feel as if your family member is dying?"

The clinic nurse is providing follow-up care to a client with this type of device. The nurse documents that the client is in which device? Refer to figure.

A halo vest

The nurse is admitting a client to the hospital who has a diagnosis of Guillain-Barré syndrome. During the history taking, the nurse should ask the family if the client has recently experienced which physical problem?

A respiratory or gastrointestinal (GI) infection

In reviewing the record of a client, the nurse notes that the health care provider has documented the presence of Chvostek's sign. Based on this documentation, what should the nurse expect to note on assessment of the client?

A spasm of the facial muscles is elicited by tapping the facial nerve in the region of the parotid gland.

The nurse is evaluating the respiratory status of a client with Guillain-Barré syndrome. The nurse determines that the client requires continued respiratory care if which data are noted by the nurse?

Bilateral adventitious breath sounds

The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse assesses for the major symptom associated with Bell's palsy by checking the affected side for which finding?

Drooping of the mouth

The nurse is planning to assess a client who has a thoracic (T-10) spinal cord injury. Which findings should the nurse plan to focus on that are specific to this level of spinal cord involvement? Select all that apply.

Bowel and bladder function Reflexes in the lower extremities Voluntary movement of the lower extremities

The home care nurse provides instructions to the client with a halo vest. Which action should the nurse tell the client to take?

Carry the correct-size wrench to loosen the bolts during an emergency.

The home care nurse is visiting a male client with trigeminal neuralgia. As part of the nursing care plan, the nurse teaches the client to avoid factors that trigger pain. Which statement by the client indicates that there is a need for further teaching?

"Don't worry, I'm taking an early retirement, and I won't be going out much to start the pain again."

The nurse is caring for a client with a mild cerebral bleed as a result of a cerebral aneurysm rupture. The client tells you he is feeling very restless and anxious before visiting hours. Which comment by the client should assist the nurse in identifying the rationale for the feelings?

"I told my daughter I would be fully recovered in no time."

A client who is in halo traction says to the visiting nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which therapeutic response should the nurse make to the client?

"Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around."

The nurse makes a home care visit to a client with Bell's palsy. Which statement by the client indicates a need for further teaching?

"I am staying on a liquid diet."

The nurse provides home care instructions to a client who has had a recent application of a halo vest device. After teaching, which statement by the client should lead the nurse to determine that the client needs further instructions?

"I will drive only during bright daylight hours."

The nurse provides home care instructions to a client with Bell's palsy. Which statement by the client indicates a need for further teaching?

"If I vigorously massage my face, the paralysis will resolve quickly."

A young adult client with a spinal cord injury tells the nurse, "It's so depressing that I'll never get to have sex again." What is the realistic reply for the nurse to make to the client?

"It's still possible to have a sexual relationship, but it will be different."

The nurse has given discharge instructions to a post-craniotomy client. The nurse determines that the client needs further instructions if the client makes which statement?

"Sounds will have to be loud to be heard."

A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, "I'm no good to anyone. I might as well be dead." Which response should the nurse make to the client?

"You are feeling pretty bad about things right now."

While assisting a client with a spinal cord injury with activities of daily living, the client states, "I can't do this. I wish I were dead." Which therapeutic response should the nurse make to the client?

"You wish you were dead?"

A client is admitted to the hospital for repair of an unruptured cerebral aneurysm. Before surgery, the nurse performs frequent assessments on the client. Which assessment finding would be noted first if the aneurysm ruptures?

A decline in the level of consciousness

The nurse is caring for a client with a head injury and is monitoring the client for decerebrate posturing. Which is characteristic of this type of posturing?

Abnormal involuntary extension of the extremities

The nurse is preparing to assess a client who was admitted to the hospital with a diagnosis of trigeminal neuralgia (tic douloureux). On review of the client's record, which symptom should the nurse expect to note that the client is experiencing?

Abrupt onset of pain in the area of the fifth cranial nerve

A client has just been told by the health care provider that a cerebral angiogram will be done. Which piece of information should the nurse collect data from the client about?

Allergy to iodine or shellfish

A client is admitted to the hospital with a diagnosis of a leaking cerebral aneurysm and is scheduled for surgery. Which intervention should the nurse implement during the preoperative period?

Allow the client to ambulate to the bathroom.

When assisting a client who had a stroke to eat, how can the nurse promote independence?

Allow the client to participate in eating as much as possible.

The nurse who is caring for a client with a ruptured cerebral aneurysm keeps the room darkened, restricts visitors, and turns the television off. Which client problem should the nurse explore first, when the client exhibits a mild tachycardia, reports difficulty in sleeping, and seems withdrawn?

Anxiety

The nurse has formulated a client problem of hemineglect for a client with left-sided deficits. Which action should the nurse tell a family member who is assisting the client that it would be least helpful to the client to do?

Approach the client from the right side.

The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which sign is indicative of this complication of a spinal cord injury?

Areflexia below the level of injury

The home care nurse visits a client who had a stroke with resultant unilateral neglect who was recently discharged from the hospital. Which instruction should the nurse provide to the family regarding care?

Assist the client from the affected side.

A client with myasthenia gravis arrives at the emergency department, and crisis is suspected. The health care provider plans to administer edrophonium chloride to differentiate between myasthenic and cholinergic crisis. The nurse prepares to administer which medication if the client is in cholinergic crisis?

Atropine sulfate

The nurse is teaching measures to promote skin integrity to a client who is paralyzed due to a spinal cord injury (SCI) at the level of L4. The nurse determines that the client needs further instructions when the client wants to discuss which measure with the nurse?

Check skin for breakdown and redness with a mirror three times a week.

The nurse analyzes the results of a Romberg test performed on a client with Parkinson's disease. Which finding during testing best indicates that the client has a positive Romberg test?

Client begins to fall.

Documentation in the medical record of a hospitalized client shows that the client exhibits bradykinesia. Which assessment finding should the nurse expect to find?

Difficulty getting out of a chair and slowed motor movements

The nurse notes that the health care provider has documented that the client is experiencing bradykinesia. Which clinical manifestation should the nurse expect to observe on assessment of the client?

Difficulty getting out of a chair without arms and appears slowed down

A client with a subarachnoid hemorrhage secondary to ruptured cerebral aneurysm has been placed on aneurysm precautions. To provide a safe environment, the nurse should ensure that which item is provided to the client?

Daily stool softeners

A client with a recent complete T4 spinal cord transection tells the nurse that he will walk again as soon as the spinal shock resolves. Which statement provides the most accurate basis for planning a response to the client?

Denial can be protective while the client deals with the anxiety created by the new disability.

A client with refractory myasthenia gravis is told by the health care provider that plasmapheresis therapy is indicated. After the health care provider leaves the room, the client asks the nurse to repeat the health care provider's reason for prescribing this treatment. The nurse should tell the client that this therapy will most likely improve which problem?

Difficulty breathing

A client admitted to the hospital is suspected of having Guillain-Barré syndrome and the nurse performs an assessment. The nurse next reviews the client's medical record, expecting to note documentation of which manifestations of this disorder? Select all that apply.

Dysphagia Paresthesia Facial weakness Difficulty speaking

The nurse is telling a client with right-sided trigeminal neuralgia about strategies to minimize episodes of pain. Which activity should the nurse tell the client could precipitate an episode?

Eating foods that are very hot or very cold

The nurse is preparing to care for a postoperative client who has undergone left-sided craniotomy with a supratentorial incision. The nurse anticipates that the health care provider will prescribe that the head of the bed be placed in which position?

Elevated 30 to 45 degrees, with the client's head and neck midline

A client who has neuroleptic malignant syndrome has been admitted to the hospital. The nurse performs an assessment and expects to note which finding?

Elevation of temperature and parkinsonian symptoms

The nurse is monitoring the neurological status on a client with dementia and assessing the limbic system. Which item should the nurse assess to yield the best information about this area of functioning?

Emotions

The family of a client diagnosed with Parkinson's disease tells the nurse that the client is having difficulty adjusting to the disorder, and they do not know what to do to help. Which intervention should the nurse suggest to cope with effects of the disease?

Encourage and reinforce client efforts to exercise and perform activities of daily living.

A client with myasthenia gravis is ready to return home. The client confides that she is concerned that her husband will no longer find her physically attractive. What should the nurse include in the plan of care?

Encourage the client to share her feelings with her husband.

The nurse is teaching the family of a disoriented client with a neurological problem about providing an environment that will minimize confusion. What action in the home environment by the family indicates the need for further teaching?

Encourages multiple visitors at one time

The nurse is giving a client with Bell's palsy instructions about how to preserve muscle tone in the face and prevent denervation. What should the nurse tell the client to avoid?

Exposure of the face to cold and drafts

The nurse determines that motor function of which cranial nerve is intact if the client can perform the action shown in the figure? Refer to figure.

Facial

The nurse is providing medication information to a client receiving phenytoin (Dilantin). What is the most important teaching that the nurse should give to the client?

Good oral hygiene is needed, including brushing and flossing.

The nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. What is the best way for the nurse to explore subjects with the client regarding this behavior?

Have the client express the feelings in writing.

The nurse notes that a client with Guillain-Barré syndrome has a positive gag reflex but tends to drool excessively. The nurse implements which most important intervention to address this problem?

Have the client sit in high Fowler's with the head slightly flexed forward for eating.

The nurse monitors a client who experienced a head injury. Which signs/symptoms are manifestations of an increase in intracranial pressure (ICP)? Select all that apply.

Headache Pupillary changes Abnormal posturing Widened pulse pressure

The nurse is caring for a client who had a spinal cord injury (SCI) 48 hours ago. The nurse places the highest priority on reporting which assessment finding to the health care provider?

Hematest-positive nasogastric tube (NGT) drainage

A client with ruptured intracranial aneurysm has surgery delayed and is still maintained on bedrest, and subarachnoid precautions (aneurysm precautions) are still in place. Which prescription should the nurse question?

Heparin sodium (Heparin)

The nurse on the oncology unit is caring for a client with a brain tumor. The nurse understands that the client may experience which complications specifically associated with this diagnosis? Select all that apply.

Hydrocephalus Pituitary dysfunction Neurological deficits Increased intracranial pressure

Which clinical manifestation should lead the nurse to suspect neurogenic shock in a client with complete transection of the spinal cord at the T3 (thoracic 3)?

Hypotension and bradycardia

The nurse is told in a report that an assigned client suffered a right cerebral hemisphere stroke. The nurse expects to note which manifestations on assessment of the client? Select all that apply.

Impulsiveness Neglect of the left visual field Disorientation to time, place, and person

A client with Bell's palsy has dysfunction of cranial nerve (CN) VII. For which sign/symptom of this disorder should the nurse monitor the client?

Inability to close the eye and drooling

The nurse is collecting data from a client with a diagnosis of Bell's palsy. Which finding should the nurse expect to note in the client?

Inability to close the eye on the affected side

The nurse is planning a discharge teaching plan for a client with a spinal cord injury. To provide for a safe environment regarding home care, which option should be the priority in the discharge teaching plan?

Including the client's significant others in the teaching session

A client with multiple sclerosis is at risk for constipation. What should the home care nurse teach the client to do to manage this problem in the home setting?

Initiate a bowel movement (BM) every other day, 45 minutes after the largest meal of the day.

The nurse has a prescription to institute subarachnoid precautions (aneurysm precautions) for a client with a cerebral aneurysm. Which item should the nurse write on the care plan for this client?

Instruct the client not to strain with bowel movements.

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. Which finding should the nurse expect to note?

Ipsilateral paralysis and loss of touch and vibration

The nurse is giving the morning report to a nursing student coassigned to a postoperative craniotomy client. The student asks the nurse why the client is receiving codeine for pain, instead of a stronger opioid. Which piece of information about codeine should the nurse incorporate when giving a reply to the student?

It does not mask neurological signs.

The home care nurse is visiting a paraplegic client with a spinal cord injury. The nurse should determine that the client's wife needs further teaching if she said that she takes which action to try to prevent episodes of autonomic dysreflexia?

Keeps the air conditioner set on high

The nurse is preparing to discharge a hospitalized client with myasthenia gravis and has discussed methods to minimize the risk of aspiration during meals. The nurse determines that the client needs further teaching if the client states they will take which action while eating?

Lift the head while swallowing liquids.

The nurse is caring for a client who is newly diagnosed with a spinal cord injury. The nurse should anticipate that which should be the most likely medication to be prescribed?

Methylprednisolone sodium succinate (Solu-Medrol)

A client is admitted to the hospital in myasthenic crisis. The nurse should ask the client about which precipitating factor for this event?

Not taking prescribed medication

A client with a stroke has episodes of coughing while swallowing liquids. The client has developed a temperature of 101.6° F, oxygen saturation of 91% (down from 98% previously), slight confusion, noticeable dyspnea, and bilateral rhonchi. What action should the nurse take?

Notify the health care provider.

The nurse is assessing the neurological status of a client who had a craniotomy 3 days ago. Which sign/symptom indicated the need to notify the health care provider immediately?

Pain with forward flexion of the neck onto the chest

The nurse assesses a client for risk factors associated with a stroke. Which are risk factors? Select all that apply.

Smoking Hypertension Diabetes mellitus Oral contraceptive use

A client with a stroke has residual dysphagia. When a diet prescription is initiated, what should the nurse assist the client to do?

Place food on the unaffected side of the mouth.

The nurse is assigned to a stroke client who has left homonymous hemianopsia and is planning measures to help the client overcome the deficit. What should the nurse plan to do to assist the client with rehabilitation?

Place objects in the client's right field of vision.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which action should the nurse implement to prevent aspiration?

Position the client on the side if possible, with the head flexed forward.

The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving? Select all that apply.

Positive Babinski's reflex Development of hyperreflexia Return of the bulbocavernous reflex Return of reflex emptying of the bladder

The client reports pain in the lower back and pain and spasms in the hamstrings when the nurse attempts to extend the client's leg. How should the nurse record this finding on the client's medical record? Refer to figure.

Positive Kernig's sign

A client with a spinal cord injury is at risk of developing footdrop. What should the nurse use as the effective preventive measure?

Posterior splints

The nurse is developing a nursing care plan for a client with severe Alzheimer's disease. Which problem should the nurse identify as the priority?

Potential injury

The nurse is caring for a client with a C-6 spinal cord injury during the spinal shock phase. What should the nurse implement when preparing the client to sit in a chair?

Raise the head of the bed slowly to decrease orthostatic hypotensive episodes.

The nurse determines that a client with a spinal cord injury is experiencing an episode of autonomic dysreflexia. Which immediate action should the nurse take?

Raise the head of the bed, and remove the noxious stimulus.

The nurse is caring for a client with a spinal cord injury who is in spinal shock. The nurse performs an assessment on the client, knowing that which assessment will provide the best information about recovery from spinal shock?

Reflexes

A magnetic resonance imaging (MRI) test is prescribed for a client with Bell's palsy. Which nursing action is included in the client's plan of care to prepare for this test?

Remove all metal-containing objects from the client.

The nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, which action should the nurse teach the client to take?

Report frequent swallowing or postnasal drip.

The nurse is teaching a client with Parkinson's disease measures to maintain mobility. Which suggestions should the nurse include in discussions with the client?

Rock back and forth to initiate movement if bradykinesia occurs.

The nurse has developed a plan of care for a client diagnosed with a stroke. The nurse should be concerned with which aspect of care for this client when the client begins to ambulate?

Safety

The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention should the nurse include in the plan of care?

Teach the client about loss of motor function and decreased pain sensation.

After a cervical spine fracture, this device is placed on the client. The nurse develops a discharge plan for the client to ensure safety and includes which measures? Refer to figure. Select all that apply.

Teach the client how to ambulate with a walker. Demonstrate the procedure for scanning the environment for vision. Inform the client about the importance of wearing rubber-soled shoes.

The nurse is caring for a client who had a T2 spinal cord injury 2 weeks ago, developed spinal shock, and is experiencing difficulty urinating. Which finding indicates a successful outcome of the treatment plan for this client?

The client's urine is clear and yellow.

A family member of a client with a brain tumor states that he is feeling distraught and guilty for not encouraging the client to seek medical evaluation earlier. What should the nurse incorporate when formulating a response to the family member's statement?

The symptoms of a brain tumor may be easily attributed to another cause.

The nurse is in the room with a client when a seizure begins. The client's entire body becomes rigid, and the muscles in all four extremities alternate between relaxation and contraction. Following the seizure, which type of seizure should the nurse document that the client had experienced?

Tonic-clonic seizure

A client has been admitted to the hospital with a thrombotic stroke. The nurse questions the client about a history of which item that likely occurred in the few days that preceded the stroke?

Transient hemiparesis and loss of speech

The nurse is obtaining a history from a client who was admitted to the hospital with a thrombotic stroke. The nurse assesses the client, knowing that the client most likely experienced which sign/symptom before the stroke occurred?

Transient hemiplegia and loss of speech

A client has facial asymmetry, drooling, loss of tearing on 1 side, and inability to close the eye. The nurse interprets that the client has impaired function of which cranial nerve?

V (trigeminal)

A client with trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client?

Vanilla pudding and lukewarm milk

A client with refractory myasthenia gravis undergoes plasmapheresis therapy. What type of improvement by the client indicates to the nurse that the client obtained the intended effects of therapy?

Vital (respiratory) capacity

The nurse is accepting a postcraniectomy client in transfer from the postanesthesia care unit. How should the nurse plan to position the client who has a supratentorial incision?

With the head of the bed elevated 30 degrees

The nurse is caring for a client admitted to the hospital after sustaining a head injury. In which position should the nurse place the client to prevent increased intracranial pressure (ICP)?

With the head of the bed elevated at least 30 degrees

The nurse is reviewing the nursing care plan of a client with a right-sided stroke who has left-sided deficits. The nurse notes documentation that the client has unilateral neglect. The nurse plans care with the understanding that which action would be least helpful?

Approach the client from the right side.

The nurse preparing to care for a client with trigeminal neuralgia develops a plan of care for the client. What is a primary nursing intervention related to psychosocial dysfunction?

Asking the client to rate pain associated with sudden spasms of pain

A medication nurse is supervising a newly hired nurse who is administering pyridostigmine (Mestinon) orally to a client with myasthenia gravis. Which observation by the medication nurse indicates safe practice by the newly hired nurse before administering this medication?

Asking the client to take sips of water

A client with a stroke has episodes of coughing while swallowing liquids. The client has developed a temperature of 101° F; oxygen saturation is 92% (down from 97% previously); and the client has slight confusion, noticeable dyspnea, and bilateral rhonchi. The nurse interprets that these manifestations are compatible with which condition?

Aspiration

A client with a spinal cord injury (SCI) uses a special call light and summons the nurse for help. The nurse observes that the client is diaphoretic, has flushing of the face and neck, and is complaining of a severe headache. The pulse is 52 beats per minute, and the blood pressure is 210/102 mm Hg. The nurse quickly concludes that the client is experiencing which complication of SCI?

Autonomic dysreflexia

During the admission assessment, the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has an alteration in which area?

Balance and coordination

The nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. After the introduction of ice cold water into the auditory canal, the client's eyes remain midline. With which neurological assessment should the nurse conclude that this response is consistent?

Brain death

The nurse should use which standardized tool as a guide in assessing a client with a head injury and increased intracranial pressure (ICP)?

Glasgow Coma Scale

A client with trigeminal neuralgia asks the nurse what can be done to minimize the episodes of pain. The nurse's response is based on an understanding that what can trigger the pain?

Facial pressure or extreme temperature

The nurse is monitoring a client who recently underwent spinal fusion. Which assessment finding should the nurse report to the health care provider immediately?

An episode of incontinence

The nurse is evaluating the status of a client with myasthenia gravis. The nurse interprets that the client's medication regimen may not be optimal if the client continues to experience fatigue occurring at which time?

Following exertion and at the end of the day

A client is in a coma of unknown cause, and the health care provider has written several prescriptions for the client including the need for intubation. Which procedure should the nurse withhold until the client is properly intubated?

Gastric feeding

A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic studies to determine the cause of the assessment findings? Select all that apply.

Cerebral angiography Lumbar puncture (LP) Computed tomography (CT)

The nurse understands that this type of device is used to treat which condition? Refer to figure.

Cervical spine injury

A client with an occipital lobe infarct and homonymous hemianopsia will be discharged home and requires safe surroundings when ambulating, and the family is very concerned about providing a safe home environment for the client. The nurse provides the family with information about a safe home environment and tells the family that which action would be beneficial?

Color-contrasted doors and hallways in the home

The nurse is performing an assessment of a client with Parkinson's disease. Which finding indicates the most serious complication of this disorder?

Congested cough and coarse rhonchi heard on auscultation

A client with Parkinson's disease quickly develops akinesia while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem?

Consciously think about walking over imaginary lines on the floor.

A client with a stroke is prepared for discharge from the hospital. The health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention should the home care nurse's plan include when planning for the client's care?

Considers the use of active, passive, or active-assisted exercises in the home

The nurse is performing an assessment on a client who has experienced a stroke. The client's medical record indicates that the left side of the brain was affected. The nurse would expect to note which feature in the client on assessment?

Feeling of worthlessness

A client admitted to the nursing unit from the emergency department has a spinal cord injury at the level of the fourth cervical vertebrae (C-4). Which assessment should the nurse perform first when admitting the client to the nursing unit?

Listen to breath sounds.

A client comes into the health care clinic stating that she thinks she has restless legs syndrome. The nurse assesses the client and determines that which data are characteristics of this disorder? Select all that apply.

Burning sensations in the limbs Feeling the need to move the limbs repeatedly

The nurse is receiving a client from the emergency department who has a diagnosis of Guillain-Barré syndrome. The client's chief complaint is an ascending paralysis that has reached the level of the waist. Which items should the nurse plan to have available for emergency use?

Cardiac monitor and intubation tray

A client has been diagnosed with Bell's palsy. The nurse assesses the client to determine if which signs/symptoms are present?

Chewing difficulties and one-sided facial droop

The nurse is caring for a client with myasthenia gravis who is vomiting and complaining of abdominal cramps and diarrhea. The nurse notes that the client is hypotensive and experiencing facial muscle twitching. Which possible situation does this assessment data support?

Cholinergic crisis

A client with myasthenia gravis is experiencing prolonged periods of weakness, and the health care provider prescribes an edrophonium (Enlon) test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?

Cholinergic crisis is present.

While providing care to a client with a head injury, the nurse notes that a client exhibits this posture. What should the nurse document that the client is exhibiting? Refer to figure.

Decorticate posturing

The nurse has a prescription to institute aneurysm precautions for a client with a cerebral aneurysm. Which item should the nurse document on the plan of care for this client?

Instruct the client to not strain with bowel movements.

A client is experiencing diabetes insipidus as a result of cranial surgery. Which of these anticipated therapies should the nurse who is caring for the client plan to implement?

Intravenous (IV) replacement of fluid losses

A client diagnosed with Bell's palsy asks the nurse about the disorder. Which information should the nurse provide to the client? Select all that apply.

It is an acute paralysis of cranial nerve VII. It may occur as a result of an inflammatory process. The application of warm moist heat may alleviate discomfort. The client should eat and drink using the unaffected side of the face.

A client with Bell's palsy is distressed about the change in facial appearance. Which characteristic of Bell's palsy should the nurse tell the client about to help the client cope with the disorder?

It is not caused by stroke, and many clients recover in 3 to 5 weeks.

The nurse has implemented a plan of care for a client with a cervical 5 (C5) spinal cord injury to promote health maintenance. Which client outcome would indicate the effectiveness of the plan?

Maintenance of intact skin

A client who has experienced a stroke has episodes of coughing while swallowing liquids. The client has developed a temperature of 101° F, an oxygen saturation of 91% (down from 98% previously), is slightly confused, and has noticeable dyspnea. Which action should the nurse take?

Notify the health care provider.

A client who sustained a thoracic cord injury a year ago returns to the clinic for a follow-up visit, and the nurse notes a small reddened area on the coccyx. The client is not aware of the reddened area. After counseling the client to relieve pressure on the area by adhering to a turning schedule, which action by the nurse is most appropriate?

Teaching the client to use a mirror for skin assessment

The nurse is caring for a client who has undergone transsphenoidal resection of a pituitary adenoma. What should the nurse measure to detect occurrence of a common complication of this type of surgery?

Urine output

The nurse is caring for a client with left-sided Bell's palsy. Which statement by the client requires follow-up by the nurse?

"I don't know how I'll live with this stroke."

The nurse is caring for a client who is recovering from an episode of autonomic hyperreflexia. Which therapeutic statement should the nurse make to the client?

"I have some time if you would like to talk about what happened to you."

The nurse is caring for a client with an acute head injury. Which neurological sign should the nurse carefully assess as the primary indicator of neurological status?

Level of consciousness