Saunders Neuro Nclex RN
A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply.
1.Giving tepid sponge baths 2.Applying a hypothermia blanket 3.Covering the client with blankets 4.Administering acetaminophen per protocol 5.Placing ice packs over the client's abdomen and in the axilla and groin Answer: 1,2,4
A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2?
It will cause arteriovenous shunting. 2.It will cause vasodilation of blood vessels in the brain. 3.It will cause blood vessels in the circle of Willis to collapse. 4.It will cause hyperresponsiveness of blood vessels in the brain. Anwser: 2
The nurse reviews the primary health care provider's (PHCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the PHCP should the nurse question?
1.Clear liquid diet 2.Bilateral calf measure 3.Monitor vital signs frequently 4.Passive range-of-motion (ROM) exercises Answer:1
Which assessment finding should the nurse expect to note in the client hospitalized with a diagnosis of stroke who has difficulty chewing food?
1.Dysfunction of vagus nerve (cranial nerve X) 2.Dysfunction of trigeminal nerve (cranial nerve V) 3.Dysfunction of hypoglossal nerve (cranial nerve XII) 4.Dysfunction of spinal accessory nerve (cranial nerve XI) Answer:2
The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation?
1.Brain death 2.A cerebral lesion 3.A temporal lesion 4.An intact brainstem Anwser:4
The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs further teaching if the client makes which statements?
1."I will perform facial exercises." 2."I will expose my face to cold to decrease the pain." 3."I will massage my face with a gentle upward motion." 4."I will wrinkle my forehead, blow out my cheeks, and whistle frequently." Answer:2
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?
1."We need to discourage him from wearing eyeglasses." 2."We need to place objects in his impaired field of vision." 3."We need to approach him from the impaired field of vision." 4."We need to remind him to turn his head to scan the lost visual field." Anwser:4
A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information?
1.Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 2.The client has compulsive habits that should be ignored as long as they are not harmful. 3.The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. 4.Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable. Answer: 4
The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding?
1.Bilateral loss of pain and temperature sensation 2.Ipsilateral paralysis and loss of touch and vibration 3.Contralateral paralysis and loss of touch, pressure, and vibration 4.Complete paraplegia or quadriplegia, depending on the level of injury Answer: 2
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?
1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning Anwser: 4
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?
1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning Answer:4
The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study?
1.Electrolyte panel 2.Liver function studies 3.Renal function studies 4.Blood glucose level determination Anwser:2
A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family had hoped. The nurse plans to implement which approach as most helpful to the client and family at this time?
1.Emphasize progress in a realistic manner. 2.Set high goals to give the client something to "aim for." 3.Tell the family to be extremely optimistic with the client. 4.Inform the client and family of standardized goals of care. Anwser:1
The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome?
1.Encourage communication. 2.Provide a consistent daily routine. 3.Promote adequate bowel elimination. 4.Increase the client's awareness of the affected side. Anwser:4
The nurse is caring for a client who is on bed rest as part of aneurysm precautions. The nurse should avoid doing which action when giving respiratory care to this client?
1.Encouraging hourly coughing 2.Assisting with incentive spirometer 3.Encouraging hourly deep breathing 4.Repositioning gently side to side every 2 hours Answer:1
The nurse is evaluating a function of the limbic system as a part of the neurological status of a client. What should the nurse assess?
1.Experience of pain 2.Affect or emotions 3.Response to verbal stimuli 4.Insight, judgment, and planning Answer: 2
The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply
1.Eye opening 2.Reflex response 3.Best verbal response 4.Best motor response 5.Pupil size and reaction Anwser: 1,3,4
A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply.
1.Fever 2.Seizures 3.Hypoxia 4.Ischemia 5.Hypotension 6.Increased intracranial pressure (ICP) Anwser: 3,4,5,6
The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?
1.Gets angry with family if they interrupt a task 2.Experiences bouts of depression and irritability 3.Has difficulty with using modified feeding utensils 4.Consistently uses adaptive equipment in dressing self Answer: 4
A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should take which actions? Select all that apply.
1.Giving the client thin liquids 2.Thickening liquids to the consistency of oatmeal 3.Placing food on the unaffected side of the mouth 4.Allowing plenty of time for chewing and swallowing 5.Leave the client alone so that the client will gain independence by feeding self Answer: 2,3,4
The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific primary health care provider prescriptions, the nurse should plan to place the client in which positions? Select all that apply.
1.Head midline 2.Neck in neutral position 3.Flat, with head turned to the side 4.Head of bed elevated 30 to 45 degrees 5.Head of bed elevated with the neck extended Answer:1,2,4
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?
1.Hyperreflexia 2.Positive reflexes 3.Flaccid paralysis 4.Reflex emptying of the bladder Answer:3
A client who suffered a stroke is prepared for discharge from the hospital. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action should the nurse include in the client's plan of care?
1.Implement ROM exercises to the point of pain for the client. 2.Consider the use of active, passive, or active-assisted exercises in the home. 3.Encourage the client to be dependent on the home care nurse to complete the exercise program. 4.Develop a schedule of ROM exercises every 2 hours while awake even if the client is fatigued. Anwser:2
A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?
1.Is disoriented to person, place, and time 2.Affect is flat, with periods of emotional lability 3.Cannot recall what was eaten for breakfast today 4.Demonstrates inability to add and subtract; does not know who is the president of the United States Anwser:2
The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions should be included in the plan? Select all that apply.
1.Leave the lights on in the client's room at night. 2.Place a blood pressure cuff at the client's bedside. 3.Close the shades in the client's room during the day. 4.Allow the client to drink 1 cup of caffeinated coffee a day. 5.Allow the client to ambulate 4 times a day with assistance. Anwser: 2,3
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply.
1.Loosening restrictive clothing 2.Restraining the client's limbs 3.Removing the pillow and raising padded side rails 4.Positioning the client to the side, if possible, with the head flexed forward 5.Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist Answer: 1,3,4
The nurse is providing discharge education to a client diagnosed with trigeminal neuralgia. Which medication will likely be prescribed upon discharge for this condition?
1.Lorazepam 2.Gabapentin 3.Carisoprodol 4.Chlordiazepoxide Answer:2
A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action?
1.Observe the client demonstrating the transfer technique. 2.Start a restorative nursing program before an injury occurs. 3.Seize the opportunity to discuss potential nursing home placement. 4.Determine the number of falls that the client has had in recent weeks. Anwser:1
A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges?
1.PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 2.PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 30 to 35 mm Hg (30 to 35 mm Hg) 3.PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 4.PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg) Answer:4
A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect?
1.Return of spinal shock 2.Malignant hypertension 3.Impending brain attack (stroke) 4.Autonomic dysreflexia (hyperreflexia) Answer:4
The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse plan to do to ensure client safety?
1.Speak loudly to the client. 2.Test the temperature of the shower water. 3.Check the temperature of the food on the dietary tray. 4.Provide a clear path for ambulation without obstacles. Anwser:4
The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply.
1.Speaking to the client at a slower rate 2.Allowing plenty of time for the client to respond 3.Completing the sentences that the client cannot finish 4.Looking directly at the client during attempts at speech 5.Shouting words if it seems as though the client has difficulty understanding Anwser: 1,2,4
A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment?
1.Taste 2.Smell 3.Vision 4.Hearing Answer:3
Which intervention should the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace?
1.Tell the client to inspect the environment for safety hazards. 2.Inform the client about the importance of sitting as much as possible. 3.Inform the client that lotions and body powders can be used for skin breakdown. 4.Instruct the client to tighten the brace during meals and to loosen it for the first 30 minutes after each meal. Anwser:1
The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document?
1.The intracranial pressure reading is normal. 2.The intracranial pressure reading is elevated. 3.The intracranial pressure reading is borderline. 4.An intracranial pressure reading of 8 mm Hg is low. Answer:1
A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area?
1.The left side of the body 2.The right side of the body 3.Both sides of the body equally 4.Cranial nerves only, such as speech and pupillary response Answer:1
The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse include when planning care for this client? Select all that apply.
1.Using a RotoRest bed 2.Ensuring that weights hang freely 3.Removing the weights to reposition the client 4.Assessing the integrity of the weights and pulleys 5.Comparing the amount of prescribed traction with the amount in use Anwser: 1,2,4,5
A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration?
1.Using adult diapers 2.Inserting a Foley catheter 3.Establishing a toileting schedule 4.Padding the bed with an absorbent cotton pad Answer: 3
A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/minute range. The client is also complaining of nausea. Which cranial nerve damage should the nurse expect that the client is experiencing?
1.Vagus (CN X) 2.Hypoglossal (CN XII) 3.Spinal accessory (CN XI) 4.Glossopharyngeal (CN IX) Anwser1
A client has a cerebellar lesion. The nurse would plan to obtain which item for use by this client?
1.Walker 2.Slider board 3.Raised toilet seat 4.Adaptive eating utensils Answer:1
The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action?
1.Wears a turban to cover the incision 2.Indicates that facial puffiness will be a permanent problem 3.Verbalizes that periorbital bruising will disappear over time 4.States an intention to purchase a hairpiece until hair has grown back Answer:2
