Neuro exam questions NSG 2525

Scrambled eggs, applesauce, and thickened milk

A patient with Parkinson's Disease is undergoing a swallow study because she is experiencing difficulty swallowing. What food choices are most appropriate for this patient to reduce the risk of aspiration?

Flaccid paralysis, bradycardia, and hypotension.

A patient with a cervical neck fracture at the C5 level is admitted to the ICU following initial treatment in the ER. During initial assessment of the patient, the nurse recognizes the presence of spinal shock upon finding?

Shifts of fluid into brain cells

A patient with a serum sodium level of 115 has a decreasing level of consciousness and complains of headache. The nurse knows the patient is at risk for cerebral edema caused by?

Aphasia??

A patient with a stroke caused by thrombosis of the middle cerebral artery experiences right sided paralysis of the upper and lower extremities, facial drooping on the right side. Based on the location of the patient's stroke, an additional assessment finding the nurse would expect to present is?

Maintaining the backrest elevation at greater than 30 degrees

Which nursing intervention will assist in preventing respiratory complications in the client with Parkinson's disease?

"Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches."

A nurse is preparing a teaching plan for a client with migraine headaches who is receiving a beta blocker to help manage this disorder. Which instruction would be appropriate to relay to the client?

Cloudy appearance in CSF, increased WBC count, decreased glucose.

A nurse is reviewing the lab results from a lumbar puncture performed in a client with a diagnosis of meningitits. Which lab findings would be noted with bacterial meningitis?

Repositioning the client so that the reddened area does not bear weight

A nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which is the nurse's best action?

Schedule a STAT CT scan of the head

A 78 year old client is admitted to the ED with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?

Elevate the back rest to 30 degrees and notify the health care provider.

A client admitted to the ICU with a brain attack (stroke) complains of a headache and becomes lethargic and unable to articulate words when speaking. Which is the nurse's priority action?

Respiratory pattern and airway

A client has arrived by ambulance at the emergency department after a cervical spinal cord injury. Which assessment is a priority for the nurse to perform at this time?

Poor judgement and impulsive behavior, expressive aphasia, right sided hemiparesis, slow cautious movements

A client has been admitted with a diagnosis of left hemisphere CVA. Which of the following neurological defects would the nurse assess for? SATA

Notify the healthcare team immediately.

A client is admitted with a brain attack (stroke). On neurologic assessment, a nurse notes that the clients arms, wrists, and fingers have become flexed, and there is internal rotation and plantar flexion of the legs. What would be the nurse's best action?

Respiratory statues

A client is brought to the emergency room after a motor vehicle accident that has resulted in a head injury. Which assessment will the nurse perform immediately?

Fluid restriction

A client is experiencing SIADH as a result of cranial surgery. The nurse who is caring for the client plans to implement which of these anticipated therapies?

The anuerysm is re-bleeding.

A client who experienced a minor hemorrhagic stroke from an aneurysm 1 week ago reports a severe headache accompanied by an episode of nausea and vomiting. Which conclusion can the nurse make based on this info?

Decreased muscle spasms in the lower extremities.

A patient diagnosed with MS has been admitted to your unit for an exacerbation. Included in the admission order is baclofen (Lioresal). What would you include as an expected outcome of this medication?

Palpating the area over the bladder for distention

A client who suffered a spinal cord injury at level T5 last month develops a flushed face and blurred vision. On taking vital signs, the nurse notes the BP to be 220/105. Which is the nurse's best action?

Notify the physician??

A client with a brain attack (stroke) has had episodes of coughing while swallowing liquids. The client now has developed a temp of 101.7, an O2 88%, confusion, and noticeable dyspnea. The nurse would take which appropriate action?

Rehabilitation will teach you how to maintain the functional ability you have

A client with paraplegia is scheduled to participate in a rehabilitation program. The client does not understand the need for rehabilitation and states, "The paralysis will not go away and it will not get better." Which is the nurse's best response?

Risk for injury related to denial of deficits and impulsiveness.

A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the affects of right brain damage, the nurse monitors for?

BP 148/78, HR 54, RR 18-24

A patient is admitted to the hospital with a head injury resulting from an automobile accident. On admission the patient's vital signs are Temp 98.6, BP 128/68, P 110, RR 26. One hour after admission, the nurse notes the presence of the Cushing's Triad when the vital signs are?

Mannitol (Osmitrol)

A patient is being admitted to the neuro ICU following an acute head injury. The patient has cerebral edema. The nurse would expect to administer what priority medications to reduce the cerebral edema.

Turn him on his side.

A male patient with a metastatic brain tumor is having a seizure and vomiting. The family calls for the nurse. What should the nurse do first?

The timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke.

A nurse has instructed the client with myasthenia gravis to take drugs on time and to eat meals 45 to 60 minutes after taking the anticholinesterase drugs. The client asks why the timing of meals is so important. Which is the nurse's best response?

Motor movement by command, spontaneous eye opening, orientation to person place and time.

A nurse is assessing the LOC of a client who suffered a head injury. She uses the glascow coma scale and determines that client's score is 15. Which response did the nurse assess in the client? SATA

The return of reflex activity

A nurse is caring for a client experiencing a spinal shock after spinal cord injury. Which clinical manifestation indicates the resolution of spinal shock?

Wear your brace when you are out of bed

A nurse is caring for a client who has undergone a spinal fusion. Which specific postoperative instructions will the nurse give the client?

Stroking the inner aspect of the thigh

A nurse is caring for a client with an upper motor neuron lesion who wishes to achieve bladder control. Which intervention is most likely to be effective in stimulating initiation of voiding for the client?

Preparing the client for intubation

A nurse is caring for a patient with Guillian Barre Syndrome who has been admitted to the ICU. During the last two hours, the nurse noticed that the clients respiratory vital capacity has declined, and the client is having difficulty clearing secretions. Which is the nurse's priority action?

Offer the client the commode or urinal every 2 hours

A nurse is preparing a client for discharge home who is incontinent after a stroke. Which instructions regarding bladder training will the nurse include in the teaching plan for the clients family?

Places the wheelchair parallel to the bed on the patient's unaffected side.

After 3 days, a patient with ischemic stroke has stable symptoms and she is taught to balance herself sitting on the edge of the bed. To teach the patient to transfer from the bed to the wheelchair, the nurse?

The urine output is 40ml/hr

After having a craniotomy, the client is receiving desmopressin acetate (DDAVP) intranasally for surgically induced diabetes insipidus (DI). Which manifestation or behavior indicates to the nurse that the medication is adequate?

Whisper from varying distances and locations behind the worker and ask them what was said.

An occupational nurse is preparing to assess a workers 8th cranial nerve. What is the most appropriate way to complete this test?

elevate HOB to 30 degrees

An unconscious patient has decreased tissue perfusion of the brain due to cerebral tissue swelling. An appropriate nursing intervention for this problem is to?

Symptom onset greater than 3 hours prior to admission, current anticoagulation therapy, recent abdominal surgery. ????

As a member of the stroke team at your institute you know that the contraindications for thrombolytic therapy includes what? SATA

"As I start this drug I will need to have my blood taken frequently to check the level of the drug."

Following recovery from a stroke, a 68 year old patient developed seizures with motor symptoms beginning in the right arm with progression to unconsciousness. The physician prescribes phenytoin (Dilantin) for controlled seizures. A statement by the patient that indicates understanding of the self care related to this drug includes:

Rapid hand movements with no purpose.

For which motor changes in the client with Huntington's Disease will the nurse monitor?

Abnormal movement

For which side effect in the client with Parkinson's Disease who has been taking a combination of carbidopa-levodopa drug (Sinemet) for 3 years will the nurse monitor?

The head positioned midline and elevated atleast 30 degrees.

How does the nurse position the client who is 4 hours post-op after a supratentorial craniotomy?

Sudden onset of shortness of breath

Immediately after undergoing a ____, the nurse watches for what complication in the client with myasthenia gravis?

What would you like to be done if you have difficulty breathing?

In discussing advanced directives, a client with ALS states that he does not want to be placed on a mechanical vent. Which is the nurses best response?

Risk identification and counseling should proceed genetic testing

In planning an in-service program on Huntington's disease, which statement does the nurse include?

Clear drainage from the incision site

In providing discharge teaching to a client after a lumbar laminectomy. The nurse instructs the client to return to the hospital for which potential complication?

Increase cerebral spinal fluid, protein level without increased cell count

In reviewing laboratory data on a client, the nurse correlates which finding with Guillane Barre Syndrome (GBS)?

"Do you live in a crowded residence?"

In taking the history of a client suspected of having bacterial meningitis, which question is most important for the nurse to ask?

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

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?

Battle's sign.

The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered level of consciousness. Following a skull x-ray the patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture.

"Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider"

The client diagnosed with Huntington gene but has no symptoms ask for opinions related to family planning. Which is the nurse's best response?

The antiplatet medication, aspirin

The client diagnosed with a TIA is being discharged from the hospital. Which medication would the nurse expect the physician to prescribe?

Document the finding as the only action

The client has the right ____ 1 day ago during ____ surgery. When the client ____wrinkles. Which is the nurse's best action?

"Do not take warfarin while on this medication."

The client is prescribed phenytoin (Dilantin) for treatment of seizure disorder. Which precautions or instructions will be taught to this client?

2.0 to 3.0

The client is receiving warfarin (Coumadin) therapy after a thrombotic stroke. Which INR indicates that anticoagulation is adequate?

Eccymosis

The client recovering from a TIA has been prescribed clopidogrel (Plavix). Which symptoms or clinical manifestations should alert the nurse of an adverse effect of the medication?

Suctioning the client

The client with myasthenia gravis is _____. Which nursing intervention is a priority for this client?

Pain on flexion of the neck

The nurse assesses for which clinical manifestation in the client with suspected meningitis?

Occupational therapy

The nurse collaborates most closely with which health care discipline in providing adaptive equipment to assist with activities of daily living in the client with a spinal cord injury?

Cocaine abuse

The nurse correlates which data from the client's history as a risk for brain attack?

Assess the client for loss of motor function and decreased pain sensation.

The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention should the nurse include in the plan of care?

Elevate HOB 15-30 degrees, contact HCP if ICP is greater than 20 mm Hg, Monitor neurological status using the Glasgow Coma Scale.

The nurse has established a goal to maintain intracranial pressure within the normal range for a client who had a craniotomy for an epidural hematoma 12 hours ago. What should the nurse do?

A respiratory or GI infection

The nurse is admitting a client to the hospital who has a diagnosis of Guillian Barre Syndrome. During the history taking, the nurse asks the family member if the client has recently experienced?

Dilated and fixed pupils

The nurse is assessing a client with ICP. The nurse should notify the health care provider about which initial change in the client's condition?

Elevate the HOB, loosen restrictive clothing, assess for bladder distention and bowel impaction, administer antihypertensive meds.

The nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notices flushed skin, diaphoresis above T5, and a BP of 162/96. The client reports a severe, pounding headache. Which nursing interventions are appropriate for this client? SATA

Intravenous diazepam (Valium)

The nurse is caring for a patient on the neuro unit who is in status epilepticus. What medication does the nurse know may be given to halt the seizures immediately?

Rest in an air-conditioned environment

The nurse is caring for a patient with MS. The patient tells the nurse the hardest thing to deal with is fatigue. When teaching patient how to reduce fatigue, what should the nurse tell the patient to do?

Assist the client to develope a daily bowel routine to prevent constipation.

The nurse is planning care for a client with a T3 spinal cord injury. The nurse includes which intervention in the plan to prevent autonomic dysreflexia?

80 ml/hr

The nurse is preparing to administer a dose of IV dexamethasone (decadron) to a client after craniotomy. The medicine is available in a 20-ml IV bag and the nurse wants to administer the medication over 15 minutes.At what rate (mL/hr) will the nurse set the pump

80ml/hr

The nurse is preparing to administer a dose of intravenous dexamethasone (decadron) to a client after craniotomy. The medicine is available in a 20-ml IV bag and the nurse wants to administer the medication over 15 minutes. At what rate (ml/hr) will the nurse set the pump?

Inability to comprehend spoken or written words.

The nurse monitors for which clinical manifestation in the client who has experienced a subdural hematoma resulting in damage in the Wernicke's area?

Contractures

The nurse monitors for which complication in the client with incomplete upper motor neuron lesions?

Performing nasopharyngeal suctioning

The nurse notes clear drainage from the nose of a patient with a frontal skull fracture and recognizes an intervention that is absolutely contraindicated for this patient is?

Brain tumors increase cerebral mass, resulting in increased intracranial pressure.

The patient seeks care for an increasing headache and nausea and vomiting. When diagnostic testing for brain tumor is performed, the client asks the nurse what will happen to him if he has a brain tumor. The nurse's response to the patient is based on knowledge that

"I may need a ventilator until the paralysis goes away."

What statement from the client with Guillian Barre Syndrome indicates that teaching about disease progression is effective?

Placing oxygen and suction equipment at the bedside.

When caring for a patient with epilepsy who was hospitalized and successfully treated for status epilepticus, a precaution that the nurse institutes includes?

The drugs used to treat my headaches increase blood flow to the brain

When teaching a patient about management of her migraine headaches, the nurse determines that additional instruction is needed when the patient says

Performing necessary physically demanding activities in the morning

When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to?

She had viral infection about 2 weeks ago

Which condition or factors in a ___aged woman, diagnosed with Guillane Barre syndrome are most likely to have ___?

Participate in regular exercise programs

Which instructions will the nurse include as part of client ___?

Immobilizing the affected portion of the spinal column

Which intervention is most likely to achieve the expected outcome of preventing deterioration and neurological status in a client with vertebral fracture?

Explain that it is important that the trunk remain in alignment. Avoid sitting up, arching the back, or twisting to either side.

Which is the priority teaching focus for the client with an unstable thoracic vertebral fracture that is being treated with immobilization prior to surgery?

Lorazepam (Ativan)

Which medication will the nurse prepare to administer to the client who is experiencing status epilepticus?

Hyperventilating with 100% oxygen for 60 seconds before suctioning

Which nursing action assists the intubated client to maintain adequate oxygenation after a head injury?

Position the client in the upright position with the head slightly forward and flexed during meals

Which nursing intervention for nutrition will the nurse implement to prevent complications from cranial nerve IX impairment in a client who has experienced a stroke?

Assisting the client with activities of daily living (ADLS)

Which nursing intervention is aimed at reducing symptoms of myasthenia gravis?

Ptosis OR Difficulty or inability to perform the six cardinal positions of gaze

Which physical assessment finding does the nurse expect to observe in a client with myasthenia gravis (MG)?

Have suction equipment at beside, ensure that client has IV access, place oxygen equipment at the bedside, keep bedrails up at all times

Which precautions will the nurse institute to ensure the safety of a client with epilepsy who has been hospitalized? Select all that apply

"I can offer smaller meals with bite-size portions and a nutritional supplement."

Which statement indicates that the family has a good understanding of the changes in motor movement associated with Parkinson's Disease?

Fall prevention

Which teaching interventions is the most appropriate for the client with Parkinson's disease?

Gently flex the clients head and neck onto the chest and observe for flexion of the hips and knees.

Which technique will the nurse use to elect the brudzinski reflex in a client being assessed for meningititis?

Clear, increased protein level, normal glucose level

With which laboratory values and observations of the client's cerebral spinal fluid does the nurse correlate as most indicative of viral meningitis?

The spinal cord injury is anterior caused by hyperflexion injury.

Within 4 hours after a cervical spinal cord injury, the client cannot perform motor movements, however maintains the sensation of deep touch. What is the nurse's interpretation of this finding?

Anterior spinal cord injury

Within 4 hours of a cervical spinal injury the client can discriminate light touch and position of the arms but cannot perform any motor function. What is the nurse's interpretation of the finding?