Neuro ATI Practice #1

A nurse is caring for a client who is 6 days postoperative following a craniotomy for removal of an intracerebral aneurysm. The client has been transferred from the ICU to the PACU. The nurse should assess the client for early signs of increased intracranial pressure (ICP) when the client states A. "Could you get me a bowl? I feel nauseated." B. "I'm so bored in here. I want to go home." C. "Can you assist me to the bathroom? I need to urinate." D. "I think I'm constipated. I haven't had a stool

A. "Could you get me a bowl? I feel nauseated." Rationale: Nausea and vomiting may occur with increased ICP. The classic three symptoms of increased ICP in a conscious client are nausea, headache, and diplopia (double vision). A client report of nausea should be investigated immediately.

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following is an appropriate response by the nurse? A. "Incorporate nonverbal cues in the conversation" B. "Ask multiple choice questions as part of the conversation" C. "Use a higher-pitched tone of voice when speaking" D. " Use simple child-like statements when speaking"

A. "Incorporate nonverbal cues in the conversation"

An older adult client in a long-term care facility had a cerebrovascular accident (CVA) 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility? A. A reddened area over the sacrum B. Stiffness in the lower extremities C. Difficulty moving the upper extremities D. Difficulty hearing some types of sounds

A. A reddened area over the sacrum Rationale: A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.

A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the priority action by the nurse? A. Administer antibiotics when available. B. Reduce environment stimuli. C. Document intake and output. D. Maintain seizure precautions.

A. Administer antibiotics when available.

A client has a increased intracranial pressure following a closed-head injury. The nurse should recognize which of the following interventions as contraindicated for this client? A. Cough and deep breath B. Elevate the head of the bed. C. Avoid neck and hip flexion. D. Log roll when repositioning.

A. Cough and deep breath

A nurse is caring for a client at a rehabilitation center 3 weeks after a cerebrovascular accident (CVA). Because the client's CVA affected the left side of the brain, which of the following goals should the nurse anticipate including in the client's rehabilitation program? A. Establish the ability to communicate effectively. B. Have a regular, formed stool at least every other day. C. Learn to control impulsive behavior. D. Improve left-side motor function

A. Establish the ability to communicate effectively.

37. A nurse is caring for a client following surgical treatment for a brain tumor near the hypothalamus. For which of the following is the client at risk? A. Inability to regulate body temperature B. Bradycardia C. Visual disturbances D. Inability to perceive sound

A. Inability to regulate body temperature Rationale: The nurse should be aware that the hypothalamus controls body temperature, fluid balance, particular emotions (such as pleasure and fear), sleep, and appetite.

A nurse creates a plan of care for a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is within normal limits? A. Pushes the painful stimulus away. B. Extends the body part toward the stimuli. C. Shows no reaction to the painful stimuli. D. Flexes the upper and extends the lower extremities.

A. Pushes the painful stimulus away. Rationale: The client who pushes the painful stimulus away is a normal response that is purposeful and appropriate.

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following statements indicated the nurse understands the rationale for using this solution? A. Reduce edema of the brain. B. Provide fluid hydration C. Increase cell size in the brain. D. Expand extracellular fluid volume.

A. Reduce edema of the brain. Rationale: An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream.

A client is recovering from a cerebrovascular accident (CVA). Which of the following information should the nurse include when teaching family members about repositioning? (Select all that Apply) A. Remove pillows prior to repositioning. B. Elevate the bed to waist height. C. Position the client towards the edge of the bed with a foam wedge. D. Stand with feet wide apart. E. Face the direction of movement when positioning the client.

A. Remove pillows prior to repositioning. B. Elevate the bed to waist height. D. Stand with feet wide apart. E. Face the direction of movement when positioning the client.

A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate finding by the nurse? A. Severe headache B. Bradycardia C. Increased muscle tone D. Oriented to time, person, place

A. Severe headache Rationale: The nurse should find as a sign of meningococcal meningitis severe headache due to meningeal inflammation. Tachycardia, decreased muscle tone, and NOT oriented to Time, person, place.

A nurse is caring for a client who has an acute respiratory illness. The nursse should monitor the client for which of the following manifestations of impeding airway obstruction. (Select all that apply). A. Tachycardia B. Nausea C. Retractions D. Muscle tremors E. Restlessness

A. Tachycardia C. Retractions E. Restlessness

A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If the client manifests increased intracranial pressure, which of the following findings should the nurse expect? (Select all that apply) A. Violent headache B. Neck pain and stiffness C. Slurred speech D. Projectile vomiting E. Rapid Loss of Consciousness

A. Violent headache C. Slurred speech D. Projectile vomiting E. Rapid Loss of Consciousness

A nurse is caring for a conscious client who has an airway obstruction. Which of the following is an appropiate intervention> A. Tilt the head and lift the chin B. Begin the Heimlich maneuver. C. Turn the client to the side. D. Perform a blind finger sweep.

B. Begin the Heimlich maneuver.

A nurse is collaborating on care for a client following a cerebrovascular accident (CVA). Which of the following should be addressed by an occupational therapist? A. Using assistive devices B. Completing self-care C. Thickening clear liquids D. Transferring from chair to bed.

B. Completing self-care

A nurse is planning care for a client who has a decreased level of consciousness from bacterial meningitis. The client is receiving continuous nourishment via gastrostomy tube (G-tube) feedings due to an inability to swallow. Which of the following is the priority action by the nurse? A. Turn and position the client every 2hr. B. Elevate the head of the client's bed 30 to 45 degrees C. Change the client's G-tibe dressing D. Place sequential compression devices (SCDs) on the client while in bed

B. Elevate the head of the client's bed 30 to 45 degrees Rationale: elevating the head of the client's bed will decrease the risk of aspiration

A nurse is caring for a school-age child who sustained a closed head injury. Which of the following findings is an early indicator of increased intracranial pressure? A. Pupils 4 mm and reactive. B. Irritability C. Bradycardia and hypertension D> Glasgow Coma Scale of 14.

B. Irritability

A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provide. Which of the following nutritional therapies will likely be prescribed? A. NPO until dysphagia subsides B. Supplements via nasogastric tube C. Initiation of total parenteral nutrition D. Soft residue diet.

B. Supplements via nasogastric tube

A nurse is caring for a lient who has hemianopsia following a cerebrovascular accident (CVA). The nurse should document an improvement in this condition when the nurse observes that the client A. walks independently with a cane B. eats items from both side of her lunch tray. C. has infrequent episodes of crying D. Maintain communication with others.

B. eats items from both side of her lunch tray.

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm/Hg. Which assessment should the nurse recognize as a late sign of ICP? (SATA) A. Tachypnea B. Hyperthermia C. Bradycardia D. Nonreactive dilated pupils E. Widened pulse pressure

C. Bradycardia D. Nonreactive dilated pupils E. Widened pulse pressure

A nurse is assessins a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? A. Kernig's sign B. Nuchal rigidity C. Brudzinski sign D. Bradykinesia

C. Brudzinski sign

A nurse is caring for a client who has increased intracranial pressure. Which of the nursing interventions by the nurse is appropriate? A. Teach controlled coughing and deep breathing B. Provide a brightly lit environment C. Elevate the head of the bed 30 degrees D. Encourage a minimum intake of 2000 mL/day of clear fluids.

C. Elevate the head of the bed 30 degrees

A nurse on a pediatric unit is caring for a client who has a brain tumor. To help ensure the client's safety, which of the following actions should the nurse take? A. Do not allow the child to ambulate in his room allow. B. Limit contact with other pediatric clients. C. Initiate seizure precautions for the child. D. Have the child use a wheelchair for all out-of-bed activities.

C. Initiate seizure precautions for the child.

A nurse is planning care for a 6-year-old client who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care? A. Place the client in semi-Fowler's position B. Admit the client to a private room. C. Measure head circumference every shift. D. Implement seizure precautions.

C. Measure head circumference every shift.

An acute care nurse receives shift report for a client with increased intracranial pressure and is told the client demonstrates decorticate posturing? which of the following should the nurse expect to observe upon assessment of this client? A. Extension of the extremities B. Pronation of the hands C. Plantar flexion of the legs. D. External rotation of the lower extremities.

C. Plantar flexion of the legs.

A nurse is caring for an adolescent client in the emergency department who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hour. Which of the following is an appropiate action by the nurse? A. Slow the rate to 20 mL/hr B. Continue the rate at 125 mL/hr C. Slow the rate to 50 mL/hr D. Increase the rate to 250 mL/hr

C. Slow the rate to 50 mL/hr

A client has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement to prevent foot-drop? A. Place sandbags to maintain right plantar flexion B. Position soft pillows against the bottom of the feet. C. Support the right foot in dorsiflexion with a footboard. D. Splint the right lower extremity to maintain proper alignment.

C. Support the right foot in dorsiflexion with a footboard.

A nurse is monitoring a client who is at risk for increase intracranial pressure. While assessing the client's cranial nerves, the nurse should check the function of cranial nerve 3 by A. Testing visual acuity. B. Observing for facial asymmetry C. eliciting the gag reflex. D. Checking the pupillary response to light.

D. Checking the pupillary response to light.

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). The nurse should know that which of the following client findings supports this suspicion? A. Cyanotic fingertips B. Nuchal Rigidity C. Fever D. Diplopia.

D. Diplopia.

A nurse is admitting a client who has bacterial meningitis. The nurse notes during the physical examination that the client cannot extend his leg when his hip is flexed so that his thigh rests on his abdomen. The nurse should document this as which of the following? A. Brudzinski's sign B. Chvostek's sign C. Goodell's sign D. Kernig's sign

D. Kernig's sign Rationale: Kernig's sign is an inability to extend the leg completely when sitting or lying with the thigh flexed on the abdomen. Only some clients with meningitis display this sign, however.

A nurse admits a client who has a concussion for overnight observation. Alert and oriented on admission, the client reports a headache along with neck pain and generalized muscle aches. The nurse knows that a manifestation considered an early indication of increased intracranial pressure (ICP) is A. bradycardia. B. ipsilateral pupil dilation. C. Widening Pulse pressure D. Lethargy

D. Lethargy

An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. When performing a neurological examinations, which of the following is the most reliable indicator of cerebral status? A. Pupil Response B. Deep tendon reflexeds C. Muscle strength D. Level of consciousness

D. Level of consciousness

A nurse is caring for a client who is diagnosed with a cerebrovascular accident (CVA, stroke). Which of the following actions should be implemented to prevent deep-vein thrombosis (DVT)? A. Massage lower extremities daily B. Check for positive Homans' sign C. Monitor the client's level of consciousness D. Place sequential compression devices bilaterally.

D. Place sequential compression devices bilaterally.

A nurse is caring for a child with suspected diagnosis of bacterial meningitis. Which of the following is a priority for action for the nurse to take? A. Prepare the child for a lumbar puncture. B. Administer an intravenous antibiotic C. Obtain stool cultures D. Place the child in isolation

D. Place the child in isolation

A nurse is developing an educational poster regarding risk factors for cerebrovascular accidents (CVA) for a group of clients. In a listing of non modifiable risk factors, the nurse should include A. Smoking B. Obesity C. Hypertension D. Race

D. Race

A nurse is caring for a client who has just had an evacuation of a subdural hematoma following a head injury. Which of the following is the nurse's highest priority assessment? A. Intracranial pressure B. Serum electrolytes C. Temperature D. Respiratory status.

D. Respiratory status.

A nurse is caring for a client who has meningitis, a temperature of 39.7C (103.5F) and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? A. Dehydration B. Seizures C. Burns D. Shivering

D. Shivering

A nurse is receving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the followinf is an appropriate conclusion based on this data? A. The client can follow simple motor commands. B. The client is unable to make vocal sounds. C. The client is unconscious. D. The client opens his eyes when spoken to.

D. The client opens his eyes when spoken to.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). TO determine if the client is experiencing pain, the nurse should use A. pulse and blood pressure findings. B. behavioral indicators and affect C. facial expressions and grimaces D. a self-report pain rating scale.

D. a self-report pain rating scale.

A nurse is caring for a 5-month-old undergoing a lumbar puncture to rule out meningitis. The nurse who is planning to assist with the procedure should A. utilize a papoose board to restrain limbs. B. position the infant seated on the side of table. C. have several other nurses help hold the infant. D. hold the infant's chin to his chest and knees to his abdomen.

D. hold the infant's chin to his chest and knees to his abdomen. Rationale: the client is position on the side in a fetal position (knees curled to abdomen and chin tucked to chest).