NCLEX style neuro Exam 3

20. The client with a brain attack (stroke) has residual dysphagia. When a 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

Answer A. Before the client with dysphagia 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.

1. 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.

Answer A. The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum.

6. 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.

Answer B. 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

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

Answer B. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

1. A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? A. Caucasian race B. Female sex C. Obesity D. Bronchial asthma

Answer C. Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age. The client's race, sex, and bronchial asthma aren't risk factors for CVA.

10. 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

Answer C. 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.

8. 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

Answer D. 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.

21. The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (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

Answer D. Clients 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. Options A, B, and C are not adaptive behaviors.

3. 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.

Answer D. 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.

30. During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment evaluates: A. cranial nerves I and II. B. cranial nerves III and V. C. cranial nerves VI and VIII. D. cranial nerves IX and X.

Answer D. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

29. 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.

Answer D. The headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary.

41. A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? 1. Unequal pupil size 2. Decreasing systolic blood pressure 3. Tachycardia 4. Decreasing body temperature

Answer: 1. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

33. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: 1. Desmopressin (DDAVP, stimate) 2. Dexamethasone (Decadron) 3. Ethacrynic acid (Edecrin) 4. Mannitol (Osmitrol)

Answer: 1. A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Dexamethasone, a glucocorticoid, is administered to treat cerebral edema. This medication may be ordered for the head injured patient. Ethacrynic acid and mannitol are diuretics, which would be contraindicated.

1. 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? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.

Answer: 1. A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction, so having suction equipment at the bedside is necessary. Padded tongue blades are safe to use. A toothbrush is appropriate to use.

4. When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? 1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). 2. Emergent; the client is poorly oxygenated. 3. Normal 4. Significant; the client has alveolar hypoventilation.

Answer: 1. A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.

3. 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? 1. Urine output increases 2. Pupils are 8 mm and nonreactive 3. Systolic blood pressure remains at 150 mm Hg 4. BUN and creatinine levels return to normal

Answer: 1. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

42. Which of the following respiratory patterns indicate increasing ICP in the brain stem? 1. Slow, irregular respirations 2. Rapid, shallow respirations 3. Asymmetric chest expansion 4. Nasal flaring

Answer: 1. Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

13. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: 1. A positive Brudzinski's sign 2. A negative Kernig's sign 3. Absence of nuchal rigidity 4. A Glascow Coma Scale score of 15

Answer: 1. Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

1. 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? 1. Reposition the client to avoid neck flexion 2. Administer 1 g Mannitol IV as ordered 3. Increase the ventilator's respiratory rate to 20 breaths/minute 4. Administer 100 mg of pentobarbital IV as ordered.

Answer: 1. The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.

7. 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? 1. An oral anticoagulant medication. 2. A beta-blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

Answer: 1. Thrombi form secondary to atrial fibrillation, therefore, an anticoagulant would be anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge verses intravenous. Beta blockers slow the heart rate and lower the blood pressure. Anti-hyperuricemic medication is given to clients with gout. Thrombolytic medication might have been given at initial presentation but would not be a drug prescribed at discharge.

3. 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? 1. Evaluate urine specific gravity 2. Anticipate treatment for renal failure 3. Provide emollients to the skin to prevent breakdown 4. Slow down the IV fluids and notify the physician

Answer: 1. Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

49. A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply. 1. Decerebrate posturing 2. Dilated nonreactive pupils 3. Deep tendon reflexes 4. Absent corneal reflex

Answer: 2, 3, 4. A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not be seen.

12. 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? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

Answer: 2. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

16. 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? 1. Position the client flat in bed 2. Check the fluid for dextrose with a dipstick 3. Suction the nose to maintain airway patency 4. Insert nasal and ear packing with sterile gauze

Answer: 2. Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. Placing the client flat in bed may increase ICP and promote pulmonary aspiration. The nose wouldn't be suctioned because of the risk for suctioning brain tissue through the sinuses. Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.

2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Rapid Dilantin administration can cause cardiac arrhythmias. 3. Dilantin should be mixed in dextrose and water before administration. 4. Dilantin should be administered through an IV catheter in the client's hand.

Answer: 2. Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. Therapeutic drug levels range from 10 to 20 mg/ml. Dilantin shouldn't be mixed in solution for administration. However, because it's compatible with normal saline solution, it can be injected through an IV line containing normal saline. When given through an IV catheter hand, Dilantin may cause purple glove syndrome.

5. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? 1. Bloody drainage from the ears 2. Frequent swallowing 3. Guaiac-positive stools 4. Hematuria

Answer: 2. Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Blood or fluid draining from the ear may indicate a basilar skull fracture.

5. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Cholesterol level 2. Pupil size and pupillary response 3. Bowel sounds 4. Echocardiogram

Answer: 2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Cholesterol level is an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours. An echocardiogram is not needed for the client with a thrombotic stroke.

2. 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 priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for A STAT computer tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

Answer: 3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment, because only an ischemic stroke can use rt-PA. This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated. Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching. Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol.

7. 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? 1. Assess full ROM to determine extent of injuries 2. Call for an immediate chest x-ray 3. Immobilize the client's head and neck 4. Open the airway with the head-tilt chin-lift maneuver

Answer: 3. All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. ROM would be contraindicated at this time. There is no indication that the client needs a chest x-ray. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. In addition, the head-tilt chin-lift maneuver wouldn't be used until the cervical spine injury is ruled out.

26. An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? 1. "Watch him for keyhole pupil the next 24 hours." 2. "Expect profuse vomiting for 24 hours after the injury." 3. "Wake him every hour and assess his orientation to person, time, and place." 4. "Notify the physician immediately if he has a headache."

Answer: 3. Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are assessed frequently for 24 hours. A keyhole pupil is found after iridectomy. Profuse or projectile vomiting is a symptom of increased ICP and should be reported immediately. A slight headache may last for several days after concussion; severe or worsening headaches should be reported.

4. During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: 1. Pulse 2. Respirations 3. Blood pressure 4. Temperature

Answer: 3. Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the priority is blood pressure

2. 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? 1. To reduce intraocular pressure 2. To prevent acute tubular necrosis 3. To promote osmotic diuresis to decrease ICP 4. To draw water into the vascular system to increase blood pressure

Answer: 3. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

43. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? 1. Give the client a warming blanket 2. Administer low-dose barbiturate 3. Encourage the client to hyperventilate 4. Restrict fluids

Answer: 3. Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.

6. Which of the following signs and symptoms of increased ICP after head trauma would appear first? 1. Bradycardia 2. Large amounts of very dilute urine 3. Restlessness and confusion 4. Widened pulse pressure

Answer: 3. The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

3. 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? 1. Current medications. 2. Complete physical and history. 3. Time of onset of current stroke. 4. Upcoming surgical procedures.

Answer: 3. The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. A complete history is not possible in emergency care. Upcoming surgical procedures will need to be delay if t-PA is administered. Current medications are relevant, but onset of current stroke takes priority.

6. What is the expected outcome of thrombolytic drug therapy? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage

Answer: 3. Thrombolytic therapy is use to dissolve emboli and reestablish cerebral perfusion.

46. Which of the following describes decerebrate posturing? 1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers 2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet 3. Supination of arms, dorsiflexion of feet 4. Back arched; rigid extension of all four extremities.

Answer: 4. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

44. A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? 1. Widening pulse pressure 2. Decrease in the pulse rate 3. Dilated, fixed pupil 4. Decrease in LOC

Answer: 4. A decrease in the client's LOC is an early indicator of deterioration of the client's neurological status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

6. After a hypophysectomy, vasopressin is given IM for which of the following reasons? 1. To treat growth failure 2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH) 3. To reduce cerebral edema and lower intracranial pressure 4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.

Answer: 4. After hypophysectomy, or removal of the pituitary gland, the body can't synthesize ADH. Somatropin or growth hormone, not vasopressin is used to treat growth failure. SIADH results from excessive ADH secretion. Mannitol or corticosteroids are used to decrease cerebral edema.