NCLEX Neuro

A male client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program. B. Keeping the linen wrinkle-free under the client. C. Preventing unnecessary pressure on the lower limbs. D. Limiting bladder catheterization to once every 12 hours.

D. Limiting bladder catheterization to once every 12 hours.

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Pressure on the orbital rim C. Squeezing the sternocleidomastoid muscle D. Nail bed pressure

D. Nail bed pressure

A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? A. Headache B. Lumbar spinal cord injury C. Neurogenic shock D. Noxious stimuli

D. Noxious stimuli

A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure the client to ensure client safety? A. Speak loudly to the client. B. Test the temperature of the shower water. C. Check the temperature of the food on the delivery tray. D. Provide a clear path for ambulation without obstacles.

D. Provide a clear path for ambulation without obstacles.

During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? A. Elevate the client's legs. B. Put the client flat in bed. C. Put the client in Trendelenburg's position. D. Put the client in the high-Fowler's position.

D. Put the client in the high-Fowler's position.

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: A. Is clear and tests negative for glucose. B. Is grossly bloody in appearance and has a pH of 6. C. Clumps together on the dressing and has a pH of 7. D. Separates into concentric rings and tests positive for glucose.

D. Separates into concentric rings and tests positive for glucose.

Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except? A. acetaminophen (Tylenol) B. dexamethasone (Decadron) C. mannitol (Osmitrol) D. phenytoin (Dilantin) E. nitroglycerin (Nitrostat)

E. nitroglycerin (Nitrostat)

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

B. Pupil size and pupillary response

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? A. Evaluate urine specific gravity. B. Anticipate treatment for renal failure. C. Provide emollients to the skin to prevent breakdown. D. Slow down the IV fluids and notify the physician.

A. Evaluate urine specific gravity. Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce the antidiuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration.

Which of the following values is considered normal for ICP? A. 0 to 15 mm Hg B. 25 mm Hg C. 35 to 45 mm Hg D. 120/80 mm Hg

A. 0 to 15 mm Hg

If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: A. Body temperature control B. Balance and equilibrium C. Visual acuity D. Thinking and reasoning

A. Body temperature control

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. A. Elevate the HOB to 90 degrees. B. Loosen constrictive clothing. C. Use a fan to reduce diaphoresis. D. Assess for bladder distention and bowel impaction. E. Administer antihypertensive medication.

A. Elevate the HOB to 90 degrees. B. Loosen constrictive clothing. D. Assess for bladder distention and bowel impaction. E. Administer antihypertensive medication.

A client who is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? A. Laceration of the middle meningeal artery. B. Rupture of the carotid artery. C. Thromboembolism from a carotid artery. D. Venous bleeding from the arachnoid space.

A. Laceration of the middle meningeal artery.

Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? A. Placing the client on the back with a small pillow under the head. B. Keeping portable suctioning equipment at the bedside. C. Opening the client's mouth with a padded tongue blade. D. Cleaning the client's mouth and teeth with a toothbrush.

A. Placing the client on the back with a small pillow under the head.

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? A. Reposition the client to avoid neck flexion. B. Administer 1 g Mannitol IV as ordered. C. Increase the ventilator's respiratory rate to 20 breaths/minute. D. Administer 100 mg of pentobarbital IV as ordered.

A. Reposition the client to avoid neck flexion.

Which of the following respiratory patterns indicate increasing ICP in the brain stem? A. Slow, irregular respirations B. Rapid, shallow respirations C. Asymmetric chest expansion D. Nasal flaring

A. Slow, irregular respirations

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A. Time of onset of current stroke B. Complete physical and history C. Current medications D. Upcoming surgical procedures

A. Time of onset of current stroke

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases. B. Pupils are 8 mm and nonreactive. C. Systolic blood pressure remains at 150 mm Hg. D. BUN and creatinine levels return to normal.

A. Urine output increases.

A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? A. Position the client flat in bed. B. Check the fluid for dextrose with a dipstick. C. Suction the nose to maintain airway patency. D. Insert nasal and ear packing with sterile gauze.

B. Check the fluid for dextrose with a dipstick.

The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? A. Head midline B. Head turned to the side C. Neck in neutral position D. Head of bed elevated 30 to 45 degrees

B. Head turned to the side

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Self-care deficit: Dressing/grooming

B. Ineffective breathing pattern

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? A. Vomiting continues. B. Intracranial pressure (ICP) is increased. C. The client needs mechanical ventilation. D. Blood is anticipated in the cerebrospinal fluid (CSF).

B. Intracranial pressure (ICP) is increased.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program. B. Limiting bladder catheterization to once every 12 hours. C. Keeping the linen wrinkle-free under the client. D. Preventing unnecessary pressure on the lower limbs.

B. Limiting bladder catheterization to once every 12 hours.

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A. Abnormal flexion of the upper extremities and extension of the lower extremities. B. Rigid extension and pronation of the arms and legs. C. Rigid pronation of all extremities. D. Flaccid paralysis of all extremities.

B. Rigid extension and pronation of the arms and legs.

The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that 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 can walk independently. D. The client has lost the ability to move the right arm but can walk independently.

B. The client has weakness on the right side of the body, including the face and tongue.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 mg/dl. B. A right-sided carotid bruit. C. A blood pressure of 220/120 mmHg. D. The presence of bronchogenic carcinoma.

C. A blood pressure of 220/120 mmHg.

Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? A. A client with a brain injury. B. A client with a herniated nucleus pulposus. C. A client with a high cervical spine injury. D. A client with a stroke.

C. A client with a high cervical spine injury.

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: A. A cerebral lesion B. A temporal lesion C. An intact brainstem D. Brain death

C. An intact brainstem

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature

C. Blood pressure

The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? A. Cerebellar function B. Intellectual function C. Cerebral function D. Sensory function

C. Cerebral function

What is the expected outcome of thrombolytic drug therapy? A. Increased vascular permeability B. Vasoconstriction C. Dissolved emboli D. Prevention of hemorrhage

C. Dissolved emboli

A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? A. Subdural hematoma B. Subarachnoid hemorrhage C. Epidural hematoma D. Contusion

C. Epidural hematoma

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: A. Tolerate the pain. B. Decrease the perception of pain. C. Escape the source of pain. D. Divert attention from the source of pain.

C. Escape the source of pain.

A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? A. Assess full ROM to determine extent of injuries. B. Call for an immediate chest x-ray. C. Immobilize the client's head and neck. D. Open the airway with the head-tilt-chin-lift maneuver.

C. Immobilize the client's head and neck.

A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A. Autonomic dysreflexia B. Hypervolemia C. Neurogenic shock D. Sepsis

C. Neurogenic shock

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? A. Autonomic dysreflexia B. Hemorrhagic shock C. Neurogenic shock D. Pulmonary embolism

C. Neurogenic shock

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? A. Frontal B. Occipital C. Parietal D. Temporal

C. Parietal

A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? A. Loosen tight clothing or accessories B. Assess for any bladder distention C. Raise the head of the bed D. Administer antihypertensive

C. Raise the head of the bed

Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Large amounts of very dilute urine C. Restlessness and confusion D. Widened pulse pressure

C. Restlessness and confusion

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for A STAT computer tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consultation.

C. Schedule for A STAT computer tomography (CT) scan of the head.

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A. The assistant places a gait belt around the client's waist prior to ambulating. B. The assistant places the client on the back with the client's head to the side. C. The assistant places her hand under the client's right axilla to help him/her move up in bed. D. The assistant praises the client for attempting to perform ADL's independently.

C. The assistant places her hand under the client's right axilla to help him/her move up in bed.

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A. To reduce intraocular pressure. B. To prevent acute tubular necrosis. C. To promote osmotic diuresis to decrease ICP. D. To draw water into the vascular system to increase blood pressure.

C. To promote osmotic diuresis to decrease ICP.

A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: A. Introducing ice water into the external auditory canal. B. Touching the cornea with a wisp of cotton. C. Turning the client's head suddenly while holding the eyelids open. D. Shining a bright light into the pupil.

C. Turning the client's head suddenly while holding the eyelids open.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. A thrombolytic medication B. A beta-blocker medication C. An anti-hyperuricemic medication D. An oral anticoagulant medication

D. An oral anticoagulant medication

The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the physician immediately.

D. Call the physician immediately.

The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: A. Skull fracture B. Concussion C. Subdural hematoma D. Epidural hematoma

D. Epidural hematoma

A client who had a stroke is seen bumping into things on the side and is having difficulty picking up the beginning of the next line of what he is reading. The client is experiencing which of the following conditions? A. Visual neglect B. Astigmatism C. Blepharitis D. Homonymous Hemianopsia

D. Homonymous Hemianopsia

Problems with memory and learning would relate to which of the following lobes? A. Frontal B. Occipital C. Parietal D. Temporal

D. Temporal