N321: Exam 2 - NCLEX Style-Questions (Neuro)

The client with a stroke has residual dysphagia. When the diet order is initiated, the nurse avoids doing which of the following? A. Giving the client thin liquids B. Thickening liquids to the consistency of oatmeal C. Placing food on the unaffected side of the mouth D. Allowing plenty of time for chewing and swallowing

A. Giving the client thin liquids R: Before the client with dyshagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.

A patient with a suspected closed head injury has bloody nasal drainage. The nurse suspects that this patient has a cerebrospinal fluid (CSF) leak when observing which of the following? A) A halo sign on the nasal drip pad B) Decreased blood pressure and urinary output C) A positive reading for glucose on a Test-tape strip D) Clear nasal drainage along with the bloody discharge

A) A halo sign on the nasal drip pad R: When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose.

Which of the following nursing actions should be implemented in the care of a patient who is experiencing increased intracranial pressure (ICP)? A) Monitor fluid and electrolyte status astutely. B) Position the patient in a high Fowler's position. C) Administer vasoconstrictors to maintain cerebral perfusion. D) Maintain physical restraints to prevent episodes of agitation.

A) Monitor fluid and electrolyte status astutely. R: Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which of the following complications (select all that apply)? A) Vision loss B) Cerebral edema C) Pituitary dysfunction D) Parathyroid dysfunction E) Focal neurologic deficits

A) Vision loss B) Cerebral edema C) Pituitary dysfunction E) Focal neurologic deficits R: Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure (ICP) and cerebral edema can appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.

The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which of the following changes in vital signs would the nurse interpret as a manifestation of increased intracranial pressure? A) Tachypnea B) Bradycardia C) Hypotension D) Narrowing pulse pressure

B) Bradycardia R: Changes in vital signs indicative of increased intracranial pressure are known as Cushing's triad, which consists of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

A nursing student is caring for a client with a stroke who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which of the following strategies to help the client adapt to this deficit? A. Tells the client to scan the environment B. Approaches the client from the unaffected side C. Places the bedside articles on the affected side D. Moves the commode and chair to the affected side

B. Approaches the client from the unaffected side (APPROACH FROM AFFECTED SIDE!!!) R: The nurse teaches the client to scan the environment to become aware of that half of the body and approaches the client form the affected side to increase awareness further.

The nurse is caring for the client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? A. Loosening restrictive clothing B. Restraining the client's limbs C. Removing the pillow and raising padded side rails D. Positioning the client to the side, if possible, with the head flexed forward

B. Restraining the client's limbs R: Nursing Actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising the side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.

The nurse is assigned to care for a client with complete right-sided hemiparesis, the nurse plans care knowing that in this condition: A. The client has complete bilateral paralysis of the arms and legs B. The client has weakness on the right side of the body, including the face and tongue C. The client has lost the ability to move the right arm but is able to walk independently D. The client has lost the ability to feed and bathe self without assistance.

B. The client has weakness on the right side of the body, including the face and tongue R: Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is weakness of the face and tongue, arm and leg on one side. Complete bilateral paralysis does not occur in the condition. The client with right- sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing and ambulating.

he nurse is assessing the adaptation of the client to changes in the functional status after a stroke. The nurse assesses that the client is adapting most successfully if the client: A. Gets angry with family if they interrupt a task B. Experiences bouts of depression and irritability C. Has difficulty with using modified feeding utensils D. Consistently uses adaptive equipment in dressing self

D. Consistently uses adaptive equipment in dressing self R: Client's are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.

The nurse has instructed the family of a client with a stroke who has homonymous hemianopsia (vision) about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will: A. Place objects in the client's impaired field of vision B. Discourage the client from wearing eyeglasses. C. Approach the client from the impaired field of vision D. Remind the client to turn the head to scan the lost visual field.

D. Remind the client to turn the head to scan the lost visual field. R: Homonymous hemianopsia is loss of half of the visual field. The client with Homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision: The nurse encourages the use of personal eye glasses, if they are available.

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? a. Immobilize the neck before the client is moved onto a stretcher. b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. c. Place a cap over the client's head. d. Administer a sedative as ordered.

b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. R: Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan.

During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: a. use the pointed end of the reflex hammer when striking the Achilles tendon. b. support the joint where the tendon is being tested. c. tap the tendon slowly and softly d. hold the reflex hammer tightly.

b. support the joint where the tendon is being tested.

Nurse Maureen witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to opens the airway in this victim by using which method? a. Flexed position b. Head tilt-chin lift c. Jaw thrust maneuver d. Modified head tilt-chin lift

c. Jaw thrust maneuver R: If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt-chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an inappropriate position for opening the airway.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a. prevent respiratory alkalosis. b. lower arterial pH. c. promote carbon dioxide elimination. d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

c. promote carbon dioxide elimination. R: The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.

A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? a. Disturbed sensory perception (visual) b. Self-care deficient: Dressing/grooming c. Impaired verbal communication d. Risk for injury

d. Risk for injury R: Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Although the other options may be appropriate, they're secondary because they don't immediately affect the client's health or safety.

A male client is having a tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the client's arms and legs. c. Place a tongue blade in the client's mouth. d. Take measures to prevent injury.

d. Take measures to prevent injury. R: Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth