NCLEX CNS

Which Glasgow Coma Scale score is indicative of a severe head injury? a. 7 b. 9 c. 11 d. 13

a. 7 A score between 3 and 8 is generally accepted as indicating a severe head injury.

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? a. Alteration in level of consciousness (LOC) b. Bradycardia c. Slurred speech d. Decreased heart rate

a. Alteration in level of consciousness (LOC) The first sign of possible subdural hematoma is a change in LOC. Speech may be affected later as the client experiences continued reduction in oxygenation. Bradycardia and a decreased heart rate occur later if the condition isn't treated.

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? a. Burr holes b. Insertion of Crutchfield tongs c. Hypophysectomy d. Application of Halo traction

a. Burr holes An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.

Which of the following is the earliest sign of increasing intracranial pressure (ICP)? a. Change in level of consciousness (LOC) b. Restlessness c. Pupil changes d. Seizures

a. Change in level of consciousness (LOC) The earliest sign of increasing ICP is a change in LOC. Other manifestations of increasing ICP are vomiting, headache, and posturing.

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate? a. Edema to the head with bruising of the mastoid process b. Edema to the head and a blackened eye c. Edema to the head with a large scalp laceration d. Edema to the head with fixed pupils

a. Edema to the head with bruising of the mastoid process Battle's sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.

Which is the primary vector of arthropod-borne viral encephalitis in North America? a. Mosquitoes b. Birds c. Spiders d. Ticks

a. Mosquitoes The primary vector in North America related to anthropoid-borne virus encephalitis is a mosquito. Birds are associated with the West Nile virus. Spiders and ticks are not vectors for arthropod-borne virus encephalitis.

A patient is diagnosed with an aggressive, primary malignant brain tumor. The nurse is aware that the glioma: a. Originated within the brain tissue. b. Metastasized from a cancer in another part of the body. c. Originated from the coverings of the brain. d. Developed on the cranial nerves.

a. Originated within the brain tissue. The most aggressive type of malignant brain tumor is a glioma, which originates within the brain tissue.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? a. Risk for injury b. Dressing or grooming self-care deficit c. Disturbed sensory perception (visual) d. Impaired verbal communication

a. Risk for injury Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.

Which client should the nurse assess for degenerative neurologic symptoms? a. The client with Huntington disease. b. The client with glioma. c. The client with Paget disease. d. The client with osteomyelitis.

a. The client with Huntington disease.

Myasthenia gravis occurs when antibodies attack which receptor sites? a. Serotonin b. Acetylcholine c. GABA d. Dopamine

b. Acetylcholine In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and GABA are not receptor sites that are attacked in myasthenia gravis.

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? a. Spinal shock b. Autonomic dysreflexia c. Thrombophlebitis d. Orthostatic hypotension

b. Autonomic dysreflexia Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.

A patient diagnosed with a tumor in the cerebellar region would expect to have changes in which of the following? a. Vision b. Balance and coordination c. Hearing d. Cognition

b. Balance and coordination If a tumor is present in the cerebellar area, the nurse might expect to see changes in balance and coordination. Vision, hearing, and cognition are not affected by a tumor in the cerebellar area.

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? a. It refers to the difficulties suffered by the client and family related to the changes in the client. b. It results from initial damage to the brain from the traumatic event. c. It refers to the permanent deficits seen after the rehabilitation process. d. It results from inadequate delivery of nutrients and oxygen to the cells.

b. It results from initial damage to the brain from the traumatic event. The primary injury results from the initial damage from the traumatic event. The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.

Nursing assessment findings reveal joint swelling and tenderness and a butterfly rash on the face. The nurse suspects which of the following? a. Scleroderma b. Systemic lupus erythematous c. Fibromyalgia d. Ankylosing spondylitis

b. Systemic lupus The butterfly rash is a unique skin manifestation of systemic lupus erythematous. Other clinical manifestaftions include joint swelling and tenderness, pain on movement, and morning stiffness. The disease can affect all body systems.

A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative care plan, the nurse should include which action? a. Keeping a pillow under the client's knees at all times b. Turning the client from side to side, using the logroll technique c. Maintaining bed rest for 72 hours after the laminectomy d. Placing the client in semi-Fowler's position

b. Turning the client from side to side, using the logroll technique To avoid twisting the spine or hips when turning a client onto the side, the nurse should use the logroll technique. (Twisting after a laminectomy could injure the spine.) After surgery, the nurse shouldn't put anything under the client's knees or place the client in semi-Fowler's position because these actions increase the risk of deep vein thrombosis. Typically, the client is allowed out of bed by the first or second day after a laminectomy.

The primary arthropod vector in North America that transmits encephalitis is the a. flea. b. mosquito. c. tick. d. horse.

b. mosquito. Arthropod-borne viruses, or arboviruses, are maintained in nature through biologic transmission between susceptible vertebrate hosts by blood feeding arthropods (mosquitoes, psychodids, ceratopogonids, and ticks). Arthropod vectors transmit several types of viruses that cause encephalitis. The primary vector in North America is the mosquito.

The earliest sign of serious impairment of brain circulation related to increased ICP is: a. A bounding pulse. b. Hypertension. c. A change in consciousness. d. Bradycardia.

c. A change in consciousness. The earliest sign of increasing ICP is a change in the LOC. Any changes in LOC should be reported immediately.

Which are risk factors for spinal cord injury (SCI)? Select all that apply. a. Caucasian ethnicity b. Female gender c. Alcohol use d. Young age e. Drug abuse

c. Alcohol use d. Young age e. Drug abuse The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI emphasizes the importance of primary prevention.

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture? a. Depressed b. Simple c. Basilar d. Comminuted

c. Basilar Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? a. Flaccid b. Normal c. Decerebrate d. Decorticate

c. Decerebrate Decerebrate posturing, the result of lesions at the midbrain, is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available? a. Nasogastric tubing b. IV tensilon c. Equipment to maintain infection control precautions d. Extra lighting

c. Equipment to maintain infection control precautions An important component of nursing care for the client with meningits is instituting infection control precautions until 24 hours after initiation of antibiotic therapy. Oral and nasal discharge is considered infectious. This client may well experience photophobia, so the lighting should be kept dim. IV Tensilon is used to diagnose myasthenia gravis.

Which is the most common cause of spinal cord injury (SCI)? a. Falls b. Sports-related injuries c. Motor vehicle crashes d. Acts of violence

c. Motor vehicle crashes The most common cause of SCI is motor vehicles crashes, which account for 35% of the injuries. Falls, sports-related injuries, and acts of violence are also potential causes of SCI, but are not most common.

The nurse educator is teaching nursing students about various types of brain tumors. The instructor recognizes that teaching has been effective when students correctly identify a client whose lab work indicates excessively high levels of thyroid stimulating hormone would most likely be diagnosed with which type of tumor? a. Angioma b. Glioblastoma c. Pituitary adenoma d. Neuroma

c. Pituitary adenoma Adrenocorticotropic hormone (ACTH)-producing pituitary adenomas result in Cushing's disease, which is characterized by signs and symptoms that include a "buffalo hump," a rounded face, and striae.

The nurse is assessing a client with a confirmed spinal cord tumor. The client states, "I've been too embarrassed to tell anyone but, I have been awakened at night because I've wet the bed." It would be a priority for the nurse to further assess the client for which complication? a. Urinary tract infection b. Knowledge deficit c. Spinal cord compression d. Impaired skin integrity

c. Spinal cord compression With spinal tumors, there is the risk of compression from the tumor on structures and organs surrounding the spinal cord. Urinary incontinence indicates decreased spinal cord function due to spinal cord injury related to compression from the tumor. Although the nurse may include further assessment for urinary tract infection, knowledge deficit and impaired skin integrity, these would not be the priority assessment. Spinal chord compression is considered a medical emergency and requires immediate treatment to prevent permanent neurologic damage.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? a. T10 b. S2 c. T6 d. L4

c. T6 Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond? a. "This form of muscular dystrophy is a relatively benign disease that progresses slowly." b. "You should ask your physician about that." c. "The strength of your arms and pelvic muscles will decrease gradually, but this should cause only slight disability." d. "You may experience progressive deterioration in all voluntary muscles."

d. "You may experience progressive deterioration in all voluntary muscles." The nurse should tell the client that muscular dystrophy causes progressive, symmetrical wasting of skeletal muscles, without neural or sensory defects. The mixed form of the disease typically strikes between ages 30 and 50 and progresses rapidly, causing deterioration of all voluntary muscles. Because the client asked the nurse this question directly, the nurse should answer and not simply refer the client to the physician. Limb-girdle muscular dystrophy causes a gradual decrease in arm and pelvic muscle strength, resulting in slight disability. Facioscapulohumeral muscular dystrophy is a slowly progressive, relatively benign form of muscular dystrophy; it usually arises before age 10.

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? a. Paraplegia b. Areflexia c. Tetraplegia d. Autonomic dysreflexia

d. Autonomic dysreflexia Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury.

Bell's palsy is a paralysis of which of the following cranial nerves? a. Otic b. Trigeminal c. Optic d. Facial

d. Facial Acute paralysis of cranial nerve 7 but may also affect cranial nerves 5 (trigeminal) and 8 (vestibulocochlear [auditory]). aka cranial polyneuritis. - results in a unilateral paralysis in the facial muscle of expression - most common type of peripheral facial paralysis - pain behind ear or on face may precipitate the paralysis by a few hours or a few days - acute maximum paralysis: 48 hrs - 5 days - most go into remission within 3 months but some have residual weakness and a few will have permanent neuro damage

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? a. Assess for pupillary response frequently. b. Assess vital signs frequently. c. Reposition the client frequently. d. Take daily weights.

d. Take daily weights. A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process.

The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? a. The client has serous drainage from the nose. b. The client has ecchymosis in the periorbital region. c. The client has an elevated temperature. d. The client has cerebral spinal fluid (CSF) leaking from the ear.

d. The client has cerebral spinal fluid (CSF) leaking from the ear. Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? a. The client will verbalize an understanding of feelings that preempt seizure activity. b. The client will take the seizure medication at the same time daily. c. The client will post emergency numbers on the refrigerator for ease of obtaining. d. The client will remain free of injury if a seizure does occur.

d. The client will remain free of injury if a seizure does occur. All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.

Which statement(s) reflect nursing interventions for a client with post-polio syndrome? a. The nurse must avoid the use of heat applications in the treatment of muscle and joint pain b. The nurse administers antiretroviral agents per order. c. The nurse plans patient activities for evening hours rather then morning hours d. The nurse provides care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the client

d. The nurse provides care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the client No specific medical or surgical treatment is available for this syndrome and therefore nursing plays a pivotal role in the team approach to assisting clients and families in dealing with the symptoms of progressive loss of muscle strength and significant fatigue. Nursing interventions are aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the client. Clientss need to plan and coordinate activities to conserve energy and reduce fatigue. Important activities should be planned for the morning as fatigue often increases in the afternoon and evening. Pain in muscles and joints may be a problem. Nonpharmacologic techniques such as the application of heat and cold are most appropriate because these clients tend to have strong reactions to medications.

Bone density testing in clients with post-polio syndrome has demonstrated a. osteoarthritis. b. no significant findings. c. calcification of long bones. d. low bone mass and osteoporosis.

d. low bone mass and osteoporosis. Bone density testing in clients with post-polio syndrome has demonstrated low bone mass and osteoporosis. Thus, the importance of identifying risks, preventing falls, and treating osteoporosis must be discussed with clients and their families.