Chapter 36 & 40

The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate? a. Local trauma from the insertion of the needle b. An overwhelming infection c. A normal finding; the fluid will be sent for testing to determine other factors d. A subarachnoid hemorrhage

c. A normal finding; the fluid will be sent for testing to determine other factors

The nurse is completing a neurological assessment and uses the whisper test to assess which cranial nerve? a. Olfactory (I) b. Facial (VII) c. Acoustic (VIII) d. Vagus (X)

c. Acoustic (VIII)

Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking? a. Rigidity b. Ataxia c. Agnosia d. Spasticity

b. Ataxia

Clients who have suffered neurologic deficits from various causes, including cerebrovascular accident, closed head injury, etc., have all experienced which phase of neurologic deficit? a. recovery b. acute c. chronic d. management

b. acute

The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated? a. antibiotic b. antihistamine c. bronchodilator d. cardio tonic

b. antihistamine

A client with a neurologic impairment reports having problems with constipation. Which foods might the nurse recommend? a. meat b. vegetables c. ice cream d. white rice

b. vegetables

The nurse is talking with the mother of a client who is diagnosed with a traumatic brain injury. The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction, made by the nurse, is most correct? a. "The client may be experiencing a change in affect due to the brain injury." b. "All traumatic brain injury clients act in this similar way." c. "The client has underlying aggression problems, which manifest in behavior." d. "The client has demonstrated this behavior before and is now anticipated."

a. "The client may be experiencing a change in affect due to the brain injury."

Which of the following Glasgow Coma Scale scores indicates coma? a. 7 b. 13 c. 11 d. 9

a. 7

The nurse is providing education about meningitis to a community group of adolescents preparing for their first year at college and who plan to live in a dormitory. Which of the following would be important to include? a. Obtain the meningococcal conjugated vaccine. b. Avoid contact with others and large gatherings. c. Eat all meals in isolation. d. Delay the college experience until age 25 years.

a. Obtain the meningococcal conjugated vaccine.

.A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? a. "When did you last take any medication?" b. "Are you allergic to seafood or iodine?" c. "How much do you weigh?" d. "When did you last have something to eat or drink?"

b. "Are you allergic to seafood or iodine?"

Which of the following areas of the brain are responsible for temperature regulation? a. Pons b. Thalamus c. Hypothalamus d. Medulla

c. Hypothalamus

The nurse is providing postoperative care for a client who just underwent surgery to remove a metastatic intramedullary tumor. On postoperative day 3, the client states, "I am really looking forward to going running again, it had become too difficult because of the loss of feeling in my feet." Which should the nurse address in the client's care plan? a. Impaired cognition b. Anxiety c. Knowledge deficit d. Body image disturbance

c. Knowledge deficit

A client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response? a. Permanent improvement after 60 to 90 treatments b. Gradual improvement over several months c. Symptom improvement that lasts a few weeks after TPE ceases d. Permanent improvement after 4 to 6 months of treatment

c. Symptom improvement that lasts a few weeks after TPE ceases

Which cranial nerve is tested by listening to a ticking watch? a.Facial b.Trigeminal c.Acoustic d.Vagus

c.Acoustic

The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication? a. 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days b. It can be administered every 6 hours for 10 days. 2 hours prior to the administration of antibiotics for 7 days d. 1 hour after the antibiotic has infused and daily for 7 days

a. 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. a. Absence of pupillary response b. Pupil reacts to light c. Pupil reaction quick d. Pinpoint pupils e. Unequal pupils

a. Absence of pupillary response d. Pinpoint pupils e. Unequal pupils

A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's reported headache? a. Dimming the lights and reducing stimulation b. Initiating a patient-controlled analgesia (PCA) of morphine sulfate c. Distracting the client with activity d. Administering hydromorphone IV as needed

a. Dimming the lights and reducing stimulation

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? a. Decreased intracranial adaptive capacity b. Risk for aspiration c. Risk for impaired skin integrity d. Risk for falls

b. Risk for aspiration

An client is 10 years status post-CVA and has been a resident for 7 years in a long-term care facility. Twice a week, the client attends group counseling and physical therapy sessions despite having contractures and inability to walk since the original stroke. Why does the client receive physical and psychological therapy? a. spouse insists on client receiving therapies b. therapies prevent complications c. facility policy requires therapies d. insurance pays for therapies

b. therapies prevent complications

A client with MS has been admitted to the hospital following an acute exacerbation. When planning the client's care, the nurse addresses the need to enhance the client's bladder control. What aspect of nursing care is most likely to meet this goal? a. Establish a timed voiding schedule. b. Avoid foods that change the pH of urine. c. Perform intermittent catheterization q6h. d. Administer anticholinergic drugs as prescribed.

a. Establish a timed voiding schedule.