NCLEX Neuro/Sensory Systems

You need to obtain informed consent from a patient for a procedure. The patient experienced a stroke three months ago. The patient is unable to sign the consent form because he can't write. This is known as what: A. Agraphia B. Alexia C. Hemianopia D. Apraxia

A. Agraphia

The nurse is caring for a client who reports excessive tearing. Which disorders does the nurse suspect could be responsible for the client's condition? Select all that apply. A. Chalazion B. Entropion C. Hordeolum D. Conjunctivitis E. Keratoconjunctivitis sicca

A. Chalazion B. Entropion D. Conjunctivitis

While conversing with a patient who had a stroke six months ago, you note their speech is hard to understand and slurred. This is known as: A. Dysarthria B. Apraxia C. Alexia D. Dysphagia

A. Dysarthria

A nurse is assessing a client whose mouth is drooping over to the left. Which cranial nerve should the nurse assess further? A. Left facial nerve B. Right facial nerve C. Left abducens nerve D. Right abducens nerve

A. Left facial nerve

A patient has experienced right side brain damage. You note the patient is experiencing neglect syndrome. What nursing intervention will you include in the patient's plan of care? A. Remind the patient to use and touch both sides of the body daily. B. Offer the patient a soft mechanical diet with honey thick liquids. C. Ask direct questions that require one word responses. D. Offer the bedpan and bedside commode every 2 hours.

A. Remind the patient to use and touch both sides of the body daily.

A client is admitted to the emergency department with head and chest injuries sustained in a motor vehicle accident. What clinical findings indicate that the client is responding to medical intervention and is ready to be transferred from the emergency department to a critical care unit? A. Stable vital signs and pain B. Pale and alert but restless C. Increasing temperature and apprehension D. Fluctuating vital signs and drowsy but easily roused

A. Stable vital signs and pain

Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke? A. A patient with a CT scan that is negative. B. A patient whose blood pressure is 200/110. C. A patient who is showing signs and symptoms of ischemic stroke. D. A patient who received Heparin 24 hours ago.

B. A patient whose blood pressure is 200/110. D. A patient who received Heparin 24 hours ago.

A client has a craniotomy for a meningioma. For which response should the nurse assess the client in the postanesthesia care unit? A. Dehydration B. Blurred vision C. Wound infection D. Narrowing pulse pressure

B. Blurred vision

Soon after admission to the hospital with a head injury, a client's temperature increases to 102.2° F (39° C). The nurse considers that the client has sustained injury to which structure? A. Thalamus B. Hypothalamus C. Temporal lobe D. Globus pallidus

B. Hypothalamus

You're a home health nurse providing care to a patient with myasthenia gravis. Today you plan on helping the patient with bathing and exercising. When would be the best time to visit the patient to help these tasks? A. Mid-afternoon B. Morning C. Evening D. Before bedtime

B. Morning

Myasthenia gravis occurs when antibodies attack the __________ receptors at the neuromuscular junction leading to ____________. A. metabotropic; muscle weakness B. nicotinic acetylcholine; muscle weakness C. dopaminergic adrenergic; muscle contraction D. nicotinic adrenergic; muscle contraction

B. nicotinic acetylcholine; muscle weakness

A client experiences expressive aphasia as a result of a brain attack (cerebrovascular accident, CVA). The client's spouse asks whether the client's speech will ever return. What is the best response by the nurse? A. "It should return in several months." B. "You will have to ask the primary healthcare provider." C. "It is hard to say how much improvement will occur." D. "Unfortunately, your spouse will no longer be able to speak."

C. "It is hard to say how much improvement will occur."

A patient with myasthenia gravis will be eating lunch at 1200. It is now 1000 and the patient is scheduled to take Pyridostigmine. At what time should you administer this medication so the patient will have the maximum benefit of this medication? A. As soon as possible B. 1 hour after the patient has eaten (at 1300) C. 1 hour before the patient eats (at 1100) D. at 1200 right before the patient eats

C. 1 hour before the patient eats (at 1100)

A client who sustains a stroke has a loss of proprioception and fine touch. Which artery does the nurse suspect is damaged? A. Lateral cerebral B. Middle cerebral C. Anterior cerebral D. Posterior cerebral

C. Anterior cerebral

You're patient has expressive aphasia. Select all the ways to effectively communicate with this patient? A. Fill in the words for the patient they can't say. B. Don't repeat questions. C. Ask questions that require a simple response. D. Use a communication board. E. Discourage the patient from using words.

C. Ask questions that require a simple response. D. Use a communication board.

A client has returned from spinal surgery. Which action is essential for the nurse to take? A. Encourage the client to drink fluids. B. Log-roll the client to the prone position. C. Assess the client's feet for circulation and sensation. D. Observe the client's bowel movements and voiding patterns.

C. Assess the client's feet for circulation and sensation.

Which meal option would be the most appropriate for a patient with myasthenia gravis? A. Roasted potatoes and cubed steak B. Hamburger with baked fries C. Clam chowder with mashed potatoes D. Fresh veggie tray with sliced cheese cubes

C. Clam chowder with mashed potatoes

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis? A. Narrowed airways B. Impaired immunity C. Ineffective coughing D. Viscosity of secretions

C. Ineffective coughing

A patient who has hemianopia is at risk for injury. What can you educate the patient to perform regularly to prevent injury? A. Wearing anti-embolism stockings daily B. Consume soft foods and tuck in chin while swallowing C. Scanning the room from side to side frequently D. Muscle training

C. Scanning the room from side to side frequently

You're reading the physician's history and physical assessment report. You note the physician wrote that the patient has apraxia. What assessment finding in your morning assessment correlates with this condition? A. The patient is unable to read. B. The patient has limited vision in half of the visual field. C. The patient is unable to wink or move his arm to scratch his skin. D. The patient doesn't recognize a pencil or television.

C. The patient is unable to wink or move his arm to scratch his skin.

A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority? A. Notifying the receiving unit of the transfer B. Having the client's records ready for the transfer C. Verifying that the family has been notified of the transfer D. Checking that a bag-valve mask is available during the transfer

D. Checking that a bag-valve mask is available during the transfer

You're 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 client with myasthenia gravis has increased difficulty swallowing. Which action will the nurse take to prevent the aspiration of food? A. Offer three large meals a day. B. Assess the client's respiratory status before and after meals. C. Seek a change in the diet prescription from soft foods to clear liquids. D. Schedule meals with the peak effect of an anticholinesterase muscle stimulant.

D. Schedule meals with the peak effect of an anticholinesterase muscle stimulant.

A client goes to the primary healthcare provider because of fatigue, double vision, and muscle weakness. A diagnosis of myasthenia gravis is suspected. When collecting a health history, the nurse expects the client to report which information? A. Muscle weakness improving after a period of rest B. Symptoms worse in the morning upon awakening C. Periods of hyperactivity D. Slow, insidious onset of muscle weakness

A. Muscle weakness improving after a period of rest

Select all the signs and symptoms below that can present in myasthenia gravis: A. Respiratory failure B. Increased salivation C. Diplopia D. Ptosis E. Slurred speech F. Restlessness G. Mask-like appearance of looking sleepy H. Difficulty swallowing

A. Respiratory failure C. Diplopia D. Ptosis E. Slurred speech F. Restlessness G. Mask-like appearance of looking sleepy H. Difficulty swallowing

During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke. Which risk factors below for stroke are modifiable? A. Smoking B. Family history C. Advanced age D. Obesity E. Sedentary lifestyle

A. Smoking D. Obesity E. Sedentary lifestyle

A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question? A. Continue anticonvulsants B. Teach isometric exercises C. Continue osmotic diuretics D. Keep head of bed at 30 degrees

B. Teach isometric exercises

A nurse is performing a neurologic assessment of a client. Which equipment is required when preparing to assess the vagus nerve (cranial nerve X) of the client? A. Tuning fork B. Ophthalmoscope C. Tongue depressor D. Cotton and a straight pin

C. Tongue depressor

You're educating a patient about the pathophysiology of myasthenia gravis. While explaining the involvement of the thymus gland, the patient asks you where the thymus gland is located. You state it is located? A. behind the thyroid gland B. within the adrenal glands C. behind the sternum in between the lungs D. anterior to the hypothalamus

C. behind the sternum in between the lungs

After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. To ensure adequate cerebral blood flow, which action should the nurse take? A. Clear the ear of draining fluid. B. Discontinue anticonvulsant therapy. C. Elevate the head of the bed 30 degrees. D. Monitor serum carbon dioxide levels routinely.

D. Monitor serum carbon dioxide levels routinely.

The neurologist is conducting a Tensilon test (Edrophonium) at the bedside of a patient who is experiencing unexplained muscle weakness, double vision, difficulty breathing, and ptosis. Which findings after the administration of Edrophonium would represent the patient has myasthenia gravis? A. The patient experiences worsening of the muscle weakness. B. The patient experiences wheezing along with facial flushing. C. The patient reports a tingling sensation in the eyelids and sudden ringing in the ears. D. The patient experiences improved muscle strength.

D. The patient experiences improved muscle strength.

You're preparing to help the neurologist with conducting a Tensilon test. Which antidote will you have on hand in case of an emergency? A. Atropine B. Protamine sulfate C. Narcan D. Leucovorin

A. Atropine

You're assessing your patient's pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as: A. Hemianopia B. Opticopsia C. Alexia D. Dysoptic

A. Hemianopia

A client is going for a magnetic resonance imaging (MRI). What should the nurse ascertain before taking the client to the procedure? A. Scheduled medications have been given. B. All metal, such as jewelry and hair ornaments, has been removed. C. Adequate prehydration has been given. D. The client has emptied the bladder.

B. All metal, such as jewelry and hair ornaments, has been removed.

You're assisting a patient who has right side hemiparesis and dysphagia with eating. It is very important to: A. Keep the head of bed less than 30'. B. Check for pouching of food in the right cheek. C. Prevent aspiration by thinning the liquids. D. Have the patient extend the neck upward away from the chest while eating.

B. Check for pouching of food in the right cheek.

You're providing teaching to a group of patients with myasthenia gravis. Which of the following is not a treatment option for this condition? A. Plasmapheresis B. Cholinesterase medications C. Thymectomy D. Corticosteroids

B. Cholinesterase medications

You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. 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

In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered? A. 6 hours after the onset of stroke symptoms B. 3 hours before the onset of stroke symptoms C. 3 hours after the onset of stroke symptoms D. 12 hours before the onset of stroke symptoms

C. 3 hours after the onset of stroke symptoms

What should the nurse emphasize when providing discharge instructions for a client with the diagnosis of Addison disease? A. Limit physical activity. B. Restrict sodium in the diet. C. Continue steroid replacement therapy. D. Schedule frequent health care appointments.

C. Continue steroid replacement therapy.

A client is admitted to the hospital after sustaining a head injury. Which is the most reliable sign of increased intracranial pressure the nurse can monitor for? A. Rise in respiratory rate B. Narrowing of pulse pressure C. Decrease in the level of consciousness D. Increase in the diastolic blood pressure

C. Decrease in the level of consciousness

The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response? A. Hemodynamic changes related to tilt table positioning B. Deteriorating myelin sheath C. Distended large intestine D. Crushed spinal cord

C. Distended large intestine

A client is admitted to the hospital with weakness in the right extremities, and speech that is slightly slurred. A diagnosis of brain attack (cerebrovascular accident, CVA) is suspected. During the first 24 hours after symptom onset, which action is priority? A. Assess the temperature B. Monitor bowel sounds C. Evaluate motor status D. Obtain a urinalysis

C. Evaluate motor status

Which patient below is MOST at risk for developing a cholinergic crisis? A. A patient with myasthenia gravis is who is not receiving sufficient amounts of their anticholinesterase medication. B. A patient with myasthenia gravis who reports not taking the medication Pyridostigmine for 2 weeks. C. A patient with myasthenia gravis who is experiencing a respiratory infection and recently had left hip surgery. D. A patient with myasthenia gravis who reports taking too much of their anticholinesterase medication.

D. A patient with myasthenia gravis who reports taking too much of their anticholinesterase medication.

Which part of the brain contains the client's "central switchboard" of the central nervous system? A. Cerebrum B. Brain stem C. Cerebellum D. Diencephalon

D. Diencephalon