2900 Exam#2 Neuro NCLEX Questions

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

A nurse documents that a client with SCI has full strength in the left arm on initial assessment. Which assessment actions has the nurse taken? Select all that apply. A) The nurse has asked the client to move the arm on the bed. B) The nurse has asked the client to dangle the arm off the bed and move it. C) The nurse has asked the client to move the arm against the nurse's resistance. D) The nurse asks the client to move the arm with the other hand. E) The nurse asks the client to bend at the waist and touch the floor.

A) The nurse has asked the client to move the arm on the bed. B) The nurse has asked the client to dangle the arm off the bed and move it. C) The nurse has asked the client to move the arm against the nurse's resistance.

In neurogenic shock, a patient will experience a decrease in tissue perfusion. This deprives the cells of oxygen that make up the tissues and organs. Select all the mechanisms, in regards to pathophysiology, of why this is occurring: A. Loss of vasomotor tone B. Increase systemic vascular resistance C. Decrease in cardiac preload D. Increase in cardiac afterload E. Decrease in venous blood return to the heart F. Venous blood pooling in the extremities

A. Loss of vasomotor tone C. Decrease in cardiac preload E. Decrease in venous blood return to the heart F. Venous blood pooling in the extremities

You are the nurse caring for a patient with increased intracranial pressure. What should you include in your care for the patient? SATA A. complete neuro checks every 1-2 hours B. know the neuro baseline of the patient C. immediately report any change in level of consciousness to the provider D. place the patient in high Fowler's position

A. complete neuro checks every 1-2 hours B. know the neuro baseline of the patient C. immediately report any change in level of consciousness to the provider

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

A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size

C. Restlessness

The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient's cerebral perfusion pressure, and how do you interpret this as the nurse? a) 90 mmHg, normal b) 62 mmHg, abnormal c) 36 mmHg, abnormal d) 56 mmHg, normal

a) 90 mmHg, normal

You are the nurse working in the NICU. Which patient needs the most immediate response in relation to a neurologic concerned? 1. 3 week old infant with a sudden screaking, cat-like cry 2. newly admitted neonate with significant head molding following a long labor and delivery 3. 2 day old infant with a positive Babinski reflex 4. 1 month old admitted with an infection presenting cross-eyed

????????? 1. 3 week old infant with a sudden screaking, cat-like cry

The nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

?????????? B. Hyponatremia

The nurse is assessing a client with a traumatic head injury and suspects increased intracranial pressure​ (IICP). Which assessment finding supports this​ suspicion? (Select all that​ apply.) A. Hemiparesis B. Blurred vision C. Double vision D. Increased heart rate E. Drowsiness

A (Hemiparesis), B (Blurred vision), C (Double vision), E (Drowsiness)? Anna, this is your question, what'd ya get? Haha

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? 1. Coughing 2. Sneezing 3. Talking 4. Valsalva maneuver 5. Vomiting

1. Coughing 2. Sneezing 4. Valsalva maneuver 5. Vomiting

Patient is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Which past medical history finding makes the client most at risk for this disease? (Select all that apply) 1) Respiratory infection during the previous month 2) GI infection during the previous two weeks 3) Spinal injury within the last 2 years 4) Meningitis within the past 5 years 5) Seizure activity within the last 6 months

1) Respiratory infection during the previous month 2) GI infection during the previous two weeks

The nurse plans morning care for a client hospitalized after a cerebrovascular accident (CVA). resulting in left-sided paralysis and homonymous hemianopia. During morning care the nurse should 1) provide care from the client's right side 2) speak loudly and distinctly when talking to the client 3) reduce the level of lighting in the client's room to prevent glare 4) provide all of the client's care to reduce his energy expenditure

1) provide care from the client's right side (because his vision on the left is limited.)

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week

1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 4. Turning and repositioning the client at least every 2 hours

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. 1. Loosening restrictive clothing. 2. Restraining the client's limbs. 3. Removing the pillow and raising padded side rails. 4. Positioning the client to the side, if possible, with the head flexed forward. 5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist.

1. Loosening restrictive clothing. 3. Removing the pillow and raising padded side rails. 4. Positioning the client to the side, if possible, with the head flexed forward.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance.

1. The client is aphasic. 2. The client has weakness on the right side of the body. 4. The client has weakness on the right side of the face and tongue.

The nurse is caring for the client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure 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.

2- Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

The nurse is planning care for a client who experienced a cerebrovascular accident with residual dysphagia. Which action will the nurse plan to avoid during meals? 1. Feed the client slowly 2. Give the client thin liquids 3.Give foods with consistency of oatmeal. 4. Place food on the unaffected side of the mouth.

2. Give the client thin liquids

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

3. Immobilize the client's head and neck

The nurse is caring for a client who has been admitted to the hospital with a diagnosis of Guillain-Barre syndrome, which past medical history finding makes the client most at risk for this disease? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month

4. Respiratory or gastrointestinal infection during the previous month

The nurse is assessing the client after sustaining a closed head injury. When applying nail bed pressure, the client's body suddenly stiffens, the eyes roll upward, and there is increased salvation and loss of swallowing reflexes. Which observation should the nurse document? A. Decerebrate posturing observed B. Decorticate posturing observed C. Positive Kernig's sign observed D. Tonic seizure activity observed

???? D. Tonic seizure activity observed

A patient with a spinal cord injury at T1 is complaining of a headache and appears very anxious. What should be the nurse's first action? A. Notify the HCP B. Elevate the HOB C. Assess bladder fullness D. Educate the patient that this is an expected feeling with their injury

????? C. Assess bladder fullness

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

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings, your priority intervention would be: A. Administering a PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning

Answer: C. Remove extra blankets and give the patient a cool bath Rationale: A fever will increase the metabolic needs of the patient, as well as their ICP and cerebral blood volume. A cool - not cold - bath can be given, extra blankets can be removed, antipyretics could be given if ordered. Shivering can also increase ICP, so the RN must take caution to avoid cooling the patient too quickly.

1. You're working on a neuro unit. Which of your patients below are at risk for developing neurogenic shock? Select all that apply:* A. A 36-year-old with a spinal cord injury at L4. B. A 42-year-old who has spinal anesthesia. C. A 25-year-old with a spinal cord injury above T6. D. A 55-year-old patient who is reporting seeing green halos while taking Digoxin.

B. A 42-year-old who has spinal anesthesia. C. A 25-year-old with a spinal cord injury above T6.

Which of the following patients are at most risk for a subdural hematoma? A. A 30-year-old female with polycystic kidney disease B. A 6-year-old boy that hit his head after jumping off the swings at the playground C. The 80-year-old male who is an alcoholic D. The 46-year-old who has hypertension and is a smoker

B. A 6-year-old boy that hit his head after jumping off the swings at the playground

A patient's MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding? A. Vision problems B. Balance impairment C. Language difficulty D. Impaired short-term memory

B. Balance impairment

Cerebral edema is occurring in a patient. The patient is losing consciousness and vital signs, such as heart rate and blood pressure, are abnormal. What portion of the brain is compromised? A. Frontal lobe B. Brainstem C. Cerebellum D. Temporal lobe

B. Brainstem

A nurse is evaluating a 25 y/o male who was brought in with traumatic injury including TBI. The nurse is evaluating breathing patterns for signs of late stage ICP. Which breathing pattern is the nurse looking for? A. Kussmaul breathing B. Cheyne Stokes respirations C. Agonal respirations D. Atacix respirations

B. Cheyne Stokes respirations

You're providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select the most common causes you would discuss during the in-service. (SATA) A. Hypoglycemia B. Distended bladder C. Sacral pressure injury D. Fecal impaction E. Urinary tract infection

B. Distended bladder C. Sacral pressure injury D. Fecal impaction E. Urinary tract infection

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? 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 consult.

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

Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12

C. BP 200/60, HR 50, RR 8

Your patient has a history of epilepsy. While helping the patient to the restroom, the patient reports having this feeling of déjà vu and seeing spots in their visual field. Your next nursing action is to? A. Continue assisting the patient to the restroom and let them sit down. B. Initiate the emergency response system. C. Lay the patient down on their side with a pillow underneath the head. D. Assess the patient's medication history.

C. Lay the patient down on their side with a pillow underneath the head.

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? A. Bladder distention B. Neurological deficit C. Pulse ox readings D. Client's feelings about the injury

C. Pulse ox readings

During nursing report you learn that the patient you will be caring for has Guillain-Barre syndrome. As the nurse you know that this disease tends to present with: A. Signs and symptoms that are symmetrical and ascending that start in the upper extremities B. Signs and symptoms that are asymmetrical and ascending that start in the upper extremities C. Signs and symptoms that are symmetrical and ascending that start in the lower extremities D. Signs and symptoms that are unilateral and descending that start in the lower extremities

C. Signs and symptoms that are symmetrical and ascending that start in the lower extremities

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.) Current medications B.) Complete head to toe assessment C.) Time of onset of stroke D.) Upcoming surgical procedure

C.) Time of onset of stroke

Your patient who had a stroke has issues with understanding speech. What type of aphasia is this patient experiencing and what area of the brain is affected? A. Expressive; Wernicke's area B. Receptive, Broca's area C. Expressive; hippocampus D. Receptive; Wernicke's area

D. Receptive, Wernicke's Area

A patient who suffered a stroke one month ago is experiencing hearing problems along with issues learning and showing emotion. On the MRI what lobe in the brain do you expect to be affected? A. Frontal Lobe B. Occipital Lobe C. Parietal Lobe D. Temporal Lobe

D. Temporal Lobe

The RN is about to assess for bowel impaction in a patient who has developed autonomic dysreflexia. What is the nurse's priority assessment (What is the nurse's priority before performing the assessment?)? A.) To avoid using lubricants B.) To stimulate the bowel with rectal manipulation C.) To slowly administer a saline solution prior to assessment D.) To instill an anesthetic jelly prior to assessment

D.) To instill an anesthetic jelly prior to assessment

You're teaching a group of nursing students about Guillain-Barré Syndrome and how it can affect the autonomic nervous system. Which signs and symptoms verbalized by the students demonstrate they understood the autonomic involvement of this syndrome? Select all that apply: a) Altered body temperature regulation b) Inability to move facial muscles c) Cardiac dysrhythmias d) Orthostatic hypotension e) Bladder distention

a) Altered body temperature regulation c) Cardiac dysrhythmias d) Orthostatic hypotension e) Bladder distention

The patient was admitted to trauma due to TBI as the result of a motorcycle injury. The previous nurse gives hand off and verbalizes the patient was A&O x 4, affect was calm. When doing the initial assessment during shift change, the patient verbalizes the following, what data is concerning to the nurse? Select all that apply a) Patient appears restless and agitated b) Patient verbalizes a headache, pain 8/10 c) Patient has no appetite d) Patient verbalizes feeling fatigued e) Patient reports feelings of sadness

a) Patient appears restless and agitated b) Patient verbalizes a headache, pain 8/10 d) Patient verbalizes feeling fatigued

A Public Health Nurse is visiting a patient who is post stroke. While she is making a focused assessment which questions are appropriate to ask the patient? SATA a. Do you have a history of fainting or seizures? b. Have you noticed changes in your vision, hearing, or smelling? c. Have you noticed a change in your balance or coordination? d. Have you noticed any change in your memory? e. Are you currently in therapy and if so, what kind?

a. Do you have a history of fainting or seizures? b. Have you noticed changes in your vision, hearing, or smelling? c. Have you noticed a change in your balance or coordination? d. Have you noticed any change in your memory?

A patient had surgery for resection of a brain tumor and arrives in the post anesthesia care unit (PACU) with a temperature of 100.0 F, BP of 130/76, HR of 64, a urinary catheter in place, and oxygen at 2 L/min via NC. After 1 hour, the nurse notes all of the following information. Which assessment finding should the nurse immediately report? a) Presence of a gag reflex b) BP 148/58 and HR 48 c) Urine output of 50 mL during the past hour d) Temp of 99.8 F

b) BP 148/58 and HR 48

You receive a patient who is suspected of experiencing a stroke. You conduct a stroke assessment with the NIH Stroke Scale and the patient scores a 40. According to the scale, the result is: a) No stroke symptoms b) Severe stroke symptoms c) Mild stroke symptoms d) Moderate stroke symptoms

b) Severe stroke symptoms

The nurse is caring for the client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising? a. Increased temp, increased pulse, increased respirations, decreased BP b. Increased temp, decreased pulse, decreased respirations, increased BP c. Decreased temp, decreased pulse, increased respirations, decreased BP d. Decreased temp, increased pulse, decreased respirations, increased BP

b. Increased temp, decreased pulse, decreased respirations, increased BP

The nurse is teaching a client about the cause of a transient ischemic attack​ (TIA). Which should the nurse​ include? a) Sudden intracranial bleed b) Vascular blockage c) Brief period of a neurologic deficit d) Formation of a clot in a blood vessel

c) Brief period of a neurologic deficit

A nurse is caring for a patient with increased intracranial pressure (ICP) following a diagnosis of traumatic brain injury. The patient is on a ventilator and requires suctioning. Which of the following is a priority when suctioning a patient with increased intracranial pressure? a) Suction as needed since the patient requires airway clearance. b) Limit suction to every 30 minutes instead of every hour. c) Limit the suction passes to reduce elevations in ICP. d) Limit suctioning because decreased blood pressure may occur.

c) Limit the suction passes to reduce elevations in ICP.

You're providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority? a) keeping the head of the bed greater than 45 degrees at all times b) repositioning the patient every thirty minutes c) keeping the patient's spine immobilized d) avoid log-rolling the patient during transport

c) keeping the patient's spine immobilized

A nurse educator is teaching students about the risk for stroke. Which of the following would place the patient most at risk for hemorrhagic stroke? a. Presence of atrial fibrillation b. Use of oral contraceptives c. Blood pressure 160/100 mmHg d. Resting heart rate of 78 bpm.

c. Blood pressure 160/100 mmHg