Neurological Disorders

Laboratory reports for a client after an accident show a fracture in the temporal bone of the middle ear. Which type of fracture does the nurse suspect in this client? 1. Basilar skull fracture 2. Linear fracture 3. Depressed fracture 4. Temporal bone fracture

1. Basilar skull fracture

Which manifestation does interruption of the dorsal spinal cord column cause in a client with spinal cord injury? 1. Ipsilateral paralysis 2. Loss of proprioception 3. Positive Babinski sign 4. Loss of pain and temperature sensation

2. Loss of proprioception

The nurse educator is teaching a family about athetosis movements in clients with Huntington's disease. Which statement made by a family member indicates understanding? 1. "Athetosis refers to twisting and writhing movements." 2. "Athetosis refers to brief, irregular, dancing-like movements." 3. "When athetosis is severe, there are thrashing motions referred to as ballismus." 4. "Antipsychotic medications are symptomatically beneficial to treat athetosis."

1. "Athetosis refers to twisting and writhing movements."

The nurse is teaching about the diagnostic tests for spinal cord injury to a group of staff nurses. Which statement made by an attending nurse indicates the need for further teaching? 1. "Myelography demonstrates intrinsic spinal cord pathology." 2. "X-rays show injury or malalignment of bones." 3. "Subtle fractures and soft tissue injury are more evident with computerized topography (CT) scans." 4. "Magnetic resonance imaging (MRI) provides detailed pictures of the spinal cord, intervertebral discs, and cerebrospinal fluid (CSF) spaces."

1. "Myelography demonstrates intrinsic spinal cord pathology."

Which instruction does the nurse provide to a client who is prescribed an anticholinergic drug for symptomatic relief of Parkinson's disease? 1. "Watch out for side effects such as dry mouth and double vision after taking the medication." 2. "You will be able to perform daily activities at a normal pace after taking the medication." 3. "It is dangerous to participate in exercise therapy during the course of medication." 4. "Remember the medication may precipitate tremors during the initiation of therapy."

1. "Watch out for side effects such as dry mouth and double vision after taking the medication."

The nurse is providing care for multiple clients being treated for seizure disorder. Which client does the nurse expect to be diagnosed with status epilepticus? 1. A client experiencing a series of three tonic-clonic seizures 2. A client experiencing rapid alternate contraction and relaxation of muscles 3. A client experiencing seizure who appears to be staring into space for a few moments 4. A conscious client with rhythmic jerking movements of the arms and legs

1. A client experiencing a series of three tonic-clonic seizures

A client with cluster headaches is prescribed dihydroergotamine. Which client manifestations indicate the effectiveness of the therapy? Select all that apply. 1. Decreased nasal discharge 2. Reduced tearing from the eye 3. Relaxed cervicothoracic muscle 4. Reduced bradykinesia 5. Normalized deep tendon reflexes

1. Decreased nasal discharge 2. Reduced tearing from the eye

The nurse instructs a client to show their teeth, raise their eyebrows, and squeeze their eyes shut. Which section of the National Institutes of Health Stroke Scale is the nurse using to evaluate the client? 1. Facial palsy 2. Best language 3. Level of consciousness (LOC) 4. Sensory response

1. Facial palsy

The nurse is obtaining a history on a client who reports recent, severe headaches. Which factor(s) in the client's history most likely cause the nurse to identify migraine headaches? 1. Female gender, 58 years of age 2. History of closed head injury 3. Male, history of alcohol abuse 4. Recurrent upper respiratory infections

1. Female gender, 58 years of age

The nurse is examining a client involved in a motor vehicle accident. The client is unable to recall past events and places visited before the accident. Which lobe of the cerebrum does the nurse suspect has been injured? 1. Frontal lobe 2. Parietal lobes 3. Occipital lobes 4. Temporal lobes

1. Frontal lobe

The nurse is providing care for a client admitted with a diagnosis of cerebrovascular accident. The client exhibits left-side deficits, memory deficits, and emotional breakdowns coupled with aggressive behaviors. Which area does the nurse identify as being affected based on assessment findings? 1. Frontal lobe 2. Parietal lobe 3. Temporal lobe 4. Occipital lobe

1. Frontal lobe

The nurse is assessing an older adult client who has a history of a previous transient ischemic attack (TIA). The nurse finds elevated blood pressure and suspects injury to the trigeminal nerve. Which findings enable the nurse to suspect cranial nerve injury? Select all that apply. 1. Impaired chewing 2. Excessive salivation 3. No facial expressions 4. Loss of facial sensation 5. Decreased extraocular movements

1. Impaired chewing 4. Loss of facial sensation

The nurse administers IV recombinant tissue-type plasminogen activator (rt-PA) to a client diagnosed with an ischemic stroke. On further evaluation, the client still exhibits persistent vessel occlusion. Which treatment strategy does the nurse expect the health-care provider to prescribe? 1. Plan for a thrombectomy 2. Consult about an endarterectomy 3. Administer dabigatran (Pradaxa) 4. Start therapy with dipyridamole (Aggrenox)

1. Plan for a thrombectomy

Which supportive care is provided to a client diagnosed with Guillain-Barré syndrome? Select all that apply. 1. Provide mechanical ventilation. 2. Monitor hemodynamics continuously. 3. Provide physical and occupational therapy. 4. Administer antipsychotic medications as prescribed. 5. Provide speech therapy and swallowing interventions.

1. Provide mechanical ventilation. 2. Monitor hemodynamics continuously. 3. Provide physical and occupational therapy.

The nurse is preparing to discharge an adolescent from the hospital after an injury from playing a contact sport. The client states, "I am really angry I cannot play for the rest of the season. I don't understand the reasoning." On which factual information is the nurse likely to focus? 1. Reinjury increases the chance of long-term problems 2. Prescribed medications will interfere with ability to play 3. The health-care provider always decides on the side of caution 4. The brain masks symptoms of injury to avoid pain and dysfunction

1. Reinjury increases the chance of long-term problems

The nurse finds that a client has motor and sensory loss on the right side of the body. The diagnostic tests reveal ischemia and the confirmation of an ischemic stroke. Which additional finding indicates the client has ischemia in the left hemisphere? 1. Speech problem 2. Hearing problem 3. Learning problem 4. Smelling problem

1. Speech problem

The computerized tomography (CT) scan of a client shows traumatic subarachnoid hemorrhage. Which are the causes for this condition? Select all that apply. 1. Trauma to the carotid artery 2. Stretching of the vertebral artery 3. Rupture of the middle meningeal artery 4. Rotational-acceleration injury of the brain 5. Defects in the muscle layers of the artery wall

1. Trauma to the carotid artery 2. Stretching of the vertebral artery 4. Rotational-acceleration injury of the brain

Which cranial nerves are associated with extraocular movements? Select all that apply. 1. Trochlear 2. Abducens 3. Trigeminal 4. Hypoglossal 5. Oculomotor

1. Trochlear 2. Abducens 5. Oculomotor

Which statement made by the parent of a client with spinal cord injury causes the nurse to suspect an axial loading injury? 1. "My child was injured in a fireworks accident yesterday." 2. "My child was injured while diving in the swimming pool." 3. "My child was injured when he fell from the first floor of our house." 4. "My child was injured during an accident while driving at a fast speed."

2. "My child was injured while diving in the swimming pool."

The nurse is reviewing subdural hematomas with a group of staff nurses. Which statement made by an attending staff nurse indicates understanding? 1. "Subdural hematomas cause bleeding in the space below the skull bone and above the dura mater." 2. "Subdural hematomas cause bleeding in the space below the dura mater and above the arachnoid membrane." 3. "Subdural hematomas cause cerebral aneurysms in the terminal portion of the internal carotid artery." 4. "Subdural hematomas cause tearing of the cerebral and meningeal vessels within the subarachnoid space of the brain."

2. "Subdural hematomas cause bleeding in the space below the dura mater and above the arachnoid membrane."

The nurse is reviewing the most important intervention for clients with myasthenic crisis with staff nurses. Which statement by an attending nurse indicates understanding? 1. "The most important intervention is to constantly monitor the arterial blood gases." 2. "The forced vital capacity and negative inspiratory force are monitored every 2 to 4 hours." 3. "The client is closely monitored in an intensive care unit for decreased heart rate." 4. "Immunosuppressant agents are completely withdrawn during a myasthenic crisis."

2. "The forced vital capacity and negative inspiratory force are monitored every 2 to 4 hours."

The nurse is teaching a group of staff nurses about cerebrovascular disorders and associated pathophysiology. Which statement by an attending nurse requires correction? 1. "A small blood vessel infarction that is associated with hypertension is known as a lacunar infarct." 2. "The right atrium undergoes atrial fibrillation with stasis of blood and clot formation in an ischemic stroke." 3. "The ischemia of the brain is caused by a thromboembolism from carotid stenosis in a transient ischemic attack." 4. "The cerebral artery ruptures and causes a large amount of blood to compress the brain tissue in hemorrhagic shock."

2. "The right atrium undergoes atrial fibrillation with stasis of blood and clot formation in an ischemic stroke."

While assessing the motor strength in a client with a spinal cord injury, the nurse finds the movements of the client are active against gravity. Which score does the nurse record? 1. 2 2. 3 3. 4 4. 5

2. 3

After a theoretical session about edrophonium (Tensilon) testing, the nurse educator asks a staff nurse to select a client from a group with different neurological disorders on which to perform the test. Which client is the nurse expected to select? 1. A client with multiple sclerosis 2. A client with myasthenia gravis 3. A client with Huntington's disease 4. A client with Guillain-Barré syndrome

2. A client with myasthenia gravis

A health-care provider instructs the nurse to administer thrombolytic therapy to a client diagnosed with an ischemic stroke. Which detail does the nurse check in the client's health history before administering the medication? Select all that apply. 1. A history of diabetes 2. A history of bleeding ulcers 3. A history of a recent head injury 4. A history of aspirin use 5. A history of warfarin (Coumadin) use

2. A history of bleeding ulcers 3. A history of a recent head injury 5. A history of warfarin (Coumadin) use

While reviewing the clinical history of a client with brain injury, the nurse finds bruising of the mastoid process behind the ear of the affected side. Which fracture should the nurse suspect in the client? 1. Linear fracture 2. Basilar skull fracture 3. Depressed fracture 4. Frontal fossa fracture

2. Basilar skull fracture

In a client with Guillain-Barré syndrome, the health-care provider finds the possibility of performing plasmapheresis is low. Which other alternative treatment is recommended to produce the same effect as that of plasmapheresis? 1. Corticosteroids 2. Cerebrospinal fluid filtration 3. IV immunoglobulin 4. Immunomodulating agents

2. Cerebrospinal fluid filtration

Which pathophysiological condition particularly activates the trigeminovascular system? 1. Epilepsy 2. Cluster headache 3. Parkinson's disease 4. Tension headache

2. Cluster headache

Which neurotransmitter dysfunction has been implicated in Tourette's syndrome? 1. Serotonin 2. Dopamine 3. Acetylcholine 4. Gamma amino butyric acid (GABA)

2. Dopamine

The nurse is performing a Babinski reflex test on a client to assess the neurologic system. Which is the correct interpretation by the nurse? 1. A negative Babinski reflex indicates an upper motor neuron disorder. 2. Flaring of the toes in response to stimulation indicates an upper motor neuron disorder. 3. When the toes flex inward upon stimulation of the sole of the foot, the test is positive. 4. A negative reflex occurs with flaring of the toes in response to stimulation of the sole of the foot.

2. Flaring of the toes in response to stimulation indicates an upper motor neuron disorder.

The nurse is providing care for a client with multiple sclerosis (MS). Which treatment modality does the nurse expect to be prescribed for this client? 1. Long-term corticosteroid therapy 2. Immune-modulating therapy 3. Physical and occupational therapy 4. Pain management therapy

2. Immune-modulating therapy

The nurse is assessing a client with a spinal cord injury. Manifestations include miosis (constricted pupil), anhidrosis (lack of sweat), and ptosis (drooping eyelid) on the affected side. Which additional information causes the nurse to identify Horner's syndrome? 1. Fractures of L1 and L2 2. Injury at T1 and above 3. Damage to the ascending and descending neural tracts 4. Disruption of blood flow to the anterior two-thirds of the spinal cord

2. Injury at T1 and above

A client experienced traumatic brain injury (TBI) participating in a contact sport. The health-care provider is focused on preventing increased intracranial pressure (ICP). Which intervention does the nurse expect the health-care provider to prescribe initially? 1. Placing a catheter in the ventricles 2. Lowering blood pressure 3. Infusing hypertonic IV solution 4. Decompressing with a craniotomy

2. Lowering blood pressure

The nurse is providing care for a young male client with a spinal cord injury. The client expresses concern about the ability to perform sexually. Which nerve does the nurse recognize as being responsible for sexual function? 1. Cervical nerve 2. Lumbar nerve 3. Thoracic nerve 4. Sacral nerve

2. Lumbar nerve

Ion channel disorders, also called channelopathies, are responsible for a growing number of neurological diseases. Which type of ion channel disorders are identified? Select all that apply. 1. Treatment is with chemotherapy 2. Mutations in ion channel genes 3. Manifestations tend to be intermittent 4. Autoantibodies formed against ion channel proteins 5. Example of a resulting condition is myasthenia gravis

2. Mutations in ion channel genes 3. Manifestations tend to be intermittent 4. Autoantibodies formed against ion channel proteins

The medical reports of a client who experienced an accident show injuries at the sixth thoracic vertebra. Which condition does the nurse suspect in the client? 1. Concussion 2. Neurogenic shock 3. Diffuse axonal injury 4. Conus medullaris syndrome

2. Neurogenic shock

The nurse is assessing a client with a diagnosis of cerebrovascular accident. The client is not able to determine the relationship between designated body parts and other body parts, which the nurse records as proprioception. Which lobe of the cerebrum does the nurse determine is involved? 1. Frontal lobe 2. Parietal lobe 3. Occipital lobe 4. Temporal lobe

2. Parietal lobe

Which factor can cause herniation of the brainstem? 1. Cerebral vasospasm 2. Rupture of a cerebral artery 3. Compression of the optic nerve 4. Oculomotor nerve dysfunction

2. Rupture of a cerebral artery

A nurse is caring for four clients diagnosed with different cerebrovascular disorders. Which client is most likely to require an endarterectomy surgical procedure to prevent the recurrence of the condition? 1. The client with lacunar infarct 2. The client with ischemic stroke 3. The client with hemorrhagic stroke 4. The client with transient ischemic attack (TIA)

2. The client with ischemic stroke

The health-care provider is monitoring a client who is unconscious. Which assessments does the nurse expect the health-care provider to prescribe? Select all that apply. 1. Hearing 2. Vital signs 3. Orientation 4. Pupil response 5. Glasgow Coma Scale

2. Vital Signs 4. Pupil response 5. Glasgow Coma Scale

The nurse is reviewing neurogenic shock with staff nurses. Which statement made by an attending nurse indicates the need for additional review? Select all that apply. 1. "Neurogenic shock reduces the systemic blood pressure." 2. "Neurogenic shock results in peripheral vasodilation." 3. "Neurogenic shock causes flaccid muscles and paralysis." 4. "Loss of the anal reflex is the hallmark sign of neurogenic shock." 5. "Neurogenic shock is a lack of sympathetic outflow from the T1-L2 region."

3. "Neurogenic shock causes flaccid muscles and paralysis." 4. "Loss of the anal reflex is the hallmark sign of neurogenic shock."

The nurse is providing care for a client who is prescribed to undergo a polysomnogram. Which explanation of the test does the nurse provide? 1. "The test reveals the amount of spinal nerve injury present." 2. "Small temperature differences in an organ can be measured." 3. "The test measures brain and body activity during sleep." 4. "Your response to sensory stimulus can be monitored."

3. "The test measures brain and body activity during sleep."

The nurse is counseling a client newly diagnosed with multiple sclerosis (MS). Which explanation does the nurse provide if the client asks, "Why all of a sudden do I have this disease?" 1. "Your brain has scar tissue called gliotic plaques from infection." 2. "At some time you had an infection and did not seek medical care." 3. "Your body created antibodies that are attacking the covering of nerve cells." 4. "This is an inherited disease for which you have no responsibility."

3. "Your body created antibodies that are attacking the covering of nerve cells."

After performing a neurological examination on a client suspected of having a stroke, the nurse concludes that the client has a moderately severe impairment based on the National Institutes of Health Stroke Scale (NIHSS). Which score enabled the nurse to reach this conclusion? 1. 4 2. 10 3. 16 4. 28

3. 16

The nurse is providing care for multiple clients who are reporting headaches. The nurse's goal is to provide preventive care for the development of a migraine. Which client does the nurse prioritize as the first needing preventive therapy? 1. A client who experiences one or two migraine attacks per month 2. A young female client who stopped the use of oral contraceptives 3. A female client who is on therapy with vasodilators 4. A client who withdrew from consuming alcohol

3. A female client who is on therapy with vasodilators

The nurse is assessing the visual fields in a client who was diagnosed with a stroke. The nurse uses the National Institutes of Health Stroke Scale (NIHSS) to document a score of 3 in the client's assessment records. Which condition is associated with the score? 1. No visual loss 2. Partial hemianopia 3. Bilateral hemianopia 4. Complete hemianopia

3. Bilateral hemianopia

The nurse is caring for a client with a history of head injury in a motor vehicle accident. The client reports a lack of coordination and imbalance since the accident. Which part of the cerebrum does the nurse suspect to have been damaged? 1. Cerebrum 2. Brainstem 3. Cerebellum 4. Diencephalon

3. Cerebellum

A client is suspected to have a narrowing of the spinal cord. Which test does the health-care provider prescribe to confirm this diagnosis? 1. Angiography 2. Evoked potentials 3. Computerized tomography (CT) 4. Electronystagmography

3. Computerized tomography (CT)

Which neurotransmitter is depleted in clients with Parkinson's disease? 1. Acetylcholine 2. Serotonin 3. Dopamine 4. Glutamate

3. Dopamine

The research nurse, while participating in clinical trials, finds a client has receptive aphasia. Which pathophysiological change does the nurse expect to be the cause of this condition in the client? 1. Damage to the brainstem 2. Dysfunction in Broca's area 3. Dysfunction in Wernicke's area 4. Damage to one side of the cerebellum

3. Dysfunction in Wernicke's area

A computed tomography (CT) scan report for a client with a neurological disorder reveals the presence of bleeding in a specific area of the brain. On assessment, the nurse finds elevated blood pressure and cerebral edema. The health-care provider instructs the nurse to administer IV mannitol. Which condition does the nurse identify in the client? 1. Lacunar infarct 2. Ischemic stroke 3. Hemorrhagic stroke 4. Transient ischemic attack

3. Hemorrhagic stroke

A client who sustained a rear-end motor vehicle collision is admitted to the emergency department. Which injury does the nurse expect to be present in the client? 1. Penetrating injury 2. Rotational injury 3. Hyperextension injury 4. Hyperflexion injury

3. Hyperextension injury

The nurse is assessing a client who presents to the emergency room with a spinal cord injury. Which finding in the client's reports causes the nurse to suspect central cord syndrome? 1. Hemisection of the spinal cord 2. Acute intervertebral disc herniation 3. Hyperextension of the cervical spine 4. Fractures at L1 and L2

3. Hyperextension of the cervical spine

Which are symptoms of Horner's syndrome? Select all that apply. 1. Constipation 2. Incontinence 3. Lack of sweat 4. Drooping eyelid 5. Constricted pupil

3. Lack of sweat 4. Drooping eyelid 5. Constricted pupil

The caregiver of a client tells a nurse the client has paralysis of the upper and lower left limbs on the right side. On assessment, the nurse finds motor and sensory loss in the client's limbs. Which diagnostic procedure does the nurse expect the health-care provider to prescribe? 1. Blood studies 2. Electrocardiogram 3. Magnetic resonance angiography (MRA) 4. Computed tomography (CT) scan with contrast

3. Magnetic resonance angiography (MRA)

The nurse suspects cerebral edema in a client with a cerebral contusion. Which diagnostic test will confirm this? 1. Skull x-ray 2. Cerebral angiography 3. Magnetic resonance imaging (MRI) 4. Computerized tomography (CT) scan

3. Magnetic resonance imaging (MRI)

The nurse is providing care for a client admitted with a stroke. Which information and manifestation support the presence of an ischemic stroke? 1. Symptoms followed a contact injury 2. Medical history indicates chronic hypertension 3. Manifestations occurred over a period of hours 4. Diagnostic tests reveal increased cranial pressure

3. Manifestations occurred over a period of hours

The nurse in an extended care facility assesses a client diagnosed with a diffuse axonal brain injury. The client has been in a persistent coma for 6 months. The client's spouse states, "I just wish he would wake up so that we can resume our normal lives." Which factor does the nurse conclude is not understood by the spouse? 1. Clients with this injury do not awake from a coma. 2. Extensive brain surgery is needed to fully recover. 3. Most who regain consciousness are severely impaired. 4. Rehabilitation with physical therapy is essential.

3. Most who regain consciousness are severely impaired.

A client comes to the clinic and asks for a test to determine the possibility of developing Huntington's disease (HD). Which preparation does the nurse make to fulfill the request? 1. Acquires saliva to test for a genetic biomarker 2. Assesses the client for emotional symptoms 3. Obtains a small sample of blood from the client 4. Prepares testing to determine cognitive symptoms

3. Obtains a small sample of blood from the client

The nurse is counseling family members of a client diagnosed with a stroke. The family asks why the client cannot interpret or analyze visual information. Which part of the brain does the nurse identify as being damaged? 1. Frontal 2. Parietal 3. Occipital 4. Temporal

3. Occipital

A nurse is caring for four clients who have different cerebrovascular disorders. Which client would require a magnetic resonance angiography (MRA) to accurately confirm the client's condition? 1. The client with a brain tumor 2. The client with a cerebral abscess 3. The client with a carotid artery aneurysm 4. The client with a brain stroke

3. The client with a carotid artery aneurysm

The health-care provider prescribes myelography for a client who sustained a spinal cord injury. Which is the rationale for this diagnostic test? 1. To provide a detailed picture of the intervertebral discs 2. To provide information on the integrity of the carotid arteries 3. To look for obstructed cerebrospinal fluid (CSF) flow around the spinal cord 4. To show malalignment of the bones that may aggravate injury to the spinal cord

3. To look for obstructed cerebrospinal fluid (CSF) flow around the spinal cord

The nurse is preparing review material for staff nurses about cranial nerves and their functions. Which cranial nerves does the nurse plan to refer to as mixed cranial nerves? Select all that apply. 1. IV 2. VI 3. VII 4. IX 5. X

3. VII 4. IX 5. X

The registered nurse is teaching about Brown-Séquard syndrome to a group of student nurses. Which statement made by the student nurse indicates effective learning? 1. "Brown-Séquard syndrome causes incontinence." 2. "Brown-Séquard syndrome results in disrupted aortic blood flow." 3. "Brown-Séquard syndrome is characterized by swelling of the neuronal axons." 4. "Brown-Séquard syndrome is associated with penetrating injuries that lead to the hemisection of the spinal cord."

4. "Brown-Séquard syndrome is associated with penetrating injuries that lead to the hemisection of the spinal cord."

The nurse is discussing the interictal period with staff nurses. Which statement made by a nurse indicates understanding of the terminology? 1. "It is the actual time of the episode of the seizure." 2. "It is the time after the completion of the seizure." 3. "It is measured when the brain activity is abnormal." 4. "It is the phase between seizures if multiple seizures occur."

4. "It is the phase between seizures if multiple seizures occur."

The nurse is assessing the level of consciousness (LOC) of a client with a head injury. The client is totally unresponsive. What is the score using the National Institutes of Health Stroke Scale (NIHSS)? 1. 0 2. 1 3. 2 4. 3

4. 3

The nurse is reviewing the medical record of a client admitted with the diagnosis of an ischemic stroke involving the middle cerebral artery. For which reason does the nurse consider the client's condition to be serious? 1. Onset of deficits is sudden. 2. Treatment involves anticoagulants. 3. High risk of the condition recurring. 4. A large area of brain tissue is involved.

4. A large area of brain tissue is involved.

While reviewing the medication prescribed for a client, the nurse finds the client is on a therapy to decrease the release of the excitatory neurotransmitter glutamate. Which disorder does the nurse recognize in the client? 1. Myasthenia gravis 2. Huntington's disease 3. Guillain-Barré syndrome 4. Amyotrophic lateral sclerosis

4. Amyotrophic lateral sclerosis

The nurse is providing care for a client recently diagnosed with a cerebrovascular accident. For which reason does the nurse check the function of cranial nerve XII before advancing the client's prescribed diet from to full liquid to soft? 1. Verify the sense of smell 2. Determine the gag reflex 3. Ensure presence of facial sensation 4. Confirm ability for tongue movement

4. Confirm ability for tongue movement

Which manifestation does the nurse expect to find on assessment of a client with a skull fracture in the frontal fossa? 1. Whiplash 2. Battle's sign 3. Thunderclap headache 4. Periorbital ecchymosis

4. Periorbital ecchymosis

The nurse is teaching a family member about providing home care for a client with a T1 spinal cord injury. The nurse stresses bowel and bladder management to avoid autonomic dysreflexia. Which additional care does the nurse reinforce to prevent the complication? 1. Positioning that avoids poor body alignment 2. Providing massage to keep the leg muscles relaxed 3. Performing passive body exercise every day 4. Preventing the development of pressure ulcers

4. Preventing the development of pressure ulcers

The nurse is providing care for a client diagnosed with a hemorrhagic stroke. Which part of the brain is at greatest risk for interrupting cardiac and respiratory functions? 1. The pons 2. The midbrain 3. The cerebellum 4. The medulla oblongata

4. The medulla oblongata

While assessing the extent of spinal cord injury in a client using the American Spinal Injury Association (ASIA) impairment scale, the nurse concludes that the client belongs to category C. Which findings enable the nurse to reach this conclusion? 1. The sensory and motor functions are normal. 2. There is no sensory or motor function preserved in the sacral segments S4-S5. 3. The sensory function is preserved with no motor function below the neurological level. 4. There is motor function preserved, and most key muscles below the neurological level have a muscle grade less than 3.

4. There is motor function preserved, and most key muscles below the neurological level have a muscle grade less than 3.