Neurologic NCLEX Questions
The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which? 1.Place objects in the client's impaired field of vision. 2.Approach the client from the impaired field of vision. 3.Discourage the client from wearing his or her own eyeglasses. 4.Remind the client to turn the head to scan the lost visual field.
1. Remind the client to turn the head to scan the lost visual field. Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and performs client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses if they are available.
A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client makes which statement? 1."I can resume a full activity level immediately." 2."I need to stay in a cool environment when possible." 3."I should increase my fluid intake for the next 24 hours." 4."I need to monitor my voiding for adequacy of urine output."
1."I can resume a full activity level immediately." Discharge instructions for the client hospitalized for hyperthermia include prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.
The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How should the nurse interpret the client's situation? 1.It is possible the client can hear the family. 2.The family needs immediate crisis intervention. 3.The client may have wanted a visit from the hospital chaplain. 4.The family could benefit from a conference with the primary health care provider.
1.It is possible the client can hear the family. Some clients who have awakened from an unconscious state report that they remember hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is still intact and act accordingly. Research has also demonstrated that positive outcomes are associated with coma stimulation, that is, speaking to and touching the client.
The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client? 1.Within the client's reach, on the left side 2.Within the client's reach, on the right side 3.Just out of the client's reach, on the left side 4.Just out of the client's reach, on the right side
1.Within the client's reach, on the left side Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. Other helpful activities with hemiparesis include range-of-motion exercises to the affected side and muscle-strengthening exercises to the unaffected side.
The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client? 1.Discouraging the family from touching the client 2.Explaining equipment and procedures on an ongoing basis 3.Ensuring adherence to visiting hours to ensure the client's rest 4.Encouraging the family not to "give in" to their feelings of grief
2.Explaining equipment and procedures on an ongoing basis Families often need assistance to cope with the sudden, severe illness of a loved one. The nurse can help the family of an unconscious client by assisting them to work through their feelings of grief. The nurse should explain all equipment, treatments, and procedures, and supplement or reinforce information given by the primary health care provider. The family should be encouraged to touch and speak to the client and to become involved in the client's care to the extent that they are comfortable. The nurse should allow the family to stay with the client as much as possible and should encourage them to eat and sleep adequately to maintain their strength.
A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which findings noted in the client history indicates that the client may be ineligible for this diagnostic procedure? Select all that apply. 1. Hypertension 2.Hip replacement 3.Permanent pacemaker 4.Prosthetic valve replacement 5.Chronic obstructive pulmonary disorder
2.Hip replacement 3.Permanent pacemaker 4.Prosthetic valve replacement The client having an MRI must have all metallic objects removed because of the magnetic field generated by the device. A careful history is done to determine if any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if there is significant risk.
The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which complications of hypothermia blanket use? Select all that apply. 1.Frostbite 2.Skin breakdown 3.Arterial insufficiency 4.Venous insufficiency 5.Diminished peripheral perfusion
2.Skin breakdown 5.Diminished peripheral perfusion When a hypothermia blanket is used, the skin is inspected frequently for pressure points that over time could lead to skin breakdown, and peripheral perfusion is observed to ascertain for signs of it being diminished. Options 1, 3, and 4 are not complications of hypothermia blanket use.
The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure? 1.Keeping a supply of suction catheters at the bedside 2.Suctioning for longer than 30 seconds 3.Auscultating breath sounds to determine the need for suctioning 4.Hyper-oxygenating the client before, during, and after suctioning
2.Suctioning for longer than 30 seconds Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is present. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently if there is a need. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. The client should not be suctioned for longer than 10 seconds at one time to prevent cerebral hypoxia and an increase in intracranial pressure.
A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse should provide reassurance to the client about the procedure? 1."You will be able to eat before the procedure unless you get nauseated easily. If so, you should eat lightly." 2."The MRI machine is a long, hollow narrow tube, and may make you feel somewhat claustrophobic." 3."Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure." 4."It is necessary to remove any metal or metal-containing objects before having the MRI done to avoid the metal being drawn into the magnetic field."
3."Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure." The MRI scanner is a hollow tube, which gives some clients a feeling of claustrophobia. Metal objects must be removed before the procedure so that they are not drawn into the magnetic field. The client may eat and take all prescribed medications before the procedure. If a contrast medium is used, the client may wish to eat lightly if there is a tendency to get nauseated easily. The client lies supine on a padded table, which moves into the imager. The client must lie still during the procedure. The imager makes tapping noises while scanning. The client is alone in the imager, but the nurse can reassure the client that the technician is in voice communication with the client at all times during the procedure.
The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? Select all that apply. 1.Epistaxis 2.Periorbital edema 3.Bruising behind ears ("Battle's sign") 4.Bruising around eyes ("raccoon eyes") 5.Purulent drainage from the auditory canal 6.Bloody or clear drainage from the auditory canal
3.Bruising behind ears ("Battle's sign") 4.Bruising around eyes ("raccoon eyes") 6.Bloody or clear drainage from the auditory canal Bloody or clear watery drainage from the auditory canal, "Battle's sign" and "raccoon eyes" indicate a cerebrospinal fluid leak following trauma and suggest a basal skull fracture. This warrants immediate attention. Option 5 is indicative of an infectious process. Options 1 and 2 are not specifically associated with a basal skull fracture.
A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse should plan which approach as therapeutic in assisting the client to cope with the disease? 1.Plan only a few activities for the client during the day. 2.Cluster activities at the end of the day when the client is most bored. 3.Encourage and praise perseverance in exercising and performing ADL. 4.Assist the client with activities of daily living (ADL) as much as possible.
3.Encourage and praise perseverance in exercising and performing ADL. The client with Parkinson's disease tends to become withdrawn and depressed and therefore should become an active participant in his or her own care to prevent this. Activities should be planned throughout the day to prevent daytime sleeping and boredom. The nurse gives the client encouragement and praises the client for perseverance. Activities such as exercise help prevent progression of the disease, and self-care improves self-esteem.
A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that there is a need for further teaching if the nurse observes which action by the family? 1.Applying a pre-molded splint 2.Performing active ROM to the affected leg 3.Encouraging the client to stand unassisted on the leg 4.Providing passive range of motion (ROM) to the affected leg
3.Encouraging the client to stand unassisted on the leg The question is worded to elicit an unsafe action on the part of the family. Depending on the client's functional ability, either passive or active ROM is indicated to keep the joint moving freely. Application of a pre-molded splint would also keep the limb aligned and in good position. The client should not attempt to stand unsupported on a weak or paralyzed limb. The inability to bear weight will cause the client to fall.
A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration? 1.Using adult diapers 2.Inserting an indwelling urinary catheter 3.Establishing a toileting schedule 4.Padding the bed with an absorbent cotton pad
3.Establishing a toileting schedule A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. An indwelling urinary catheter should be used only when necessary because of risk of infection. Use of diapers or pads is the least acceptable alternative because the risk of skin breakdown exists.
A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor? 1.Too little exercise 2.Omitted doses of medication 3.Increased doses of medication 4.Decreased intake of fatty foods
3.Increased doses of medication Myasthenic crisis is often caused by undermedication and responds to administration of cholinergic medications such as neostigmine and pyridostigmine. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are incorrect options. Overexertion and overeating could trigger myasthenic crisis.
A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety? 1.Speak loudly to the client. 2.Place the client on aspiration precautions. 3.Provide a clear path for ambulation without obstacles. 4.Prohibit intensely smelling foods such as onions and tuna.
3.Provide a clear path for ambulation without obstacles. Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Testing the shower water temperature would be useful if there were impairment of peripheral nerves. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerves VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior one third of the tongue, respectively.
A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? 1.Walker 2.Slider board 3.Raised toilet seat 4.Adaptive eating utensils
3.Raised toilet seat The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. Adaptive eating utensils may be beneficial when the client has partial paralysis of the hand. A raised toilet seat is useful when the client does not have the mobility or ability to flex the hips. A slider board is used in transferring a client from a bed to stretcher or wheelchair.
The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement? 1."I will wash my face with cotton pads." 2."I'll have to start chewing on the unaffected side." 3."I should rinse my mouth if tooth brushing is painful." 4."I will try to eat my food either very warm or very cold."
4."I will try to eat my food either very warm or very cold." Facial pain can be minimized by using cotton pads and room temperature water to wash the face. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If tooth brushing triggers pain, sometimes an oral rinse after meals is more helpful.
The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which should the nurse check before the procedure? 1. Claustrophobia 2.Excessive weight 3.Allergy to salmon 4.Allergy to iodine or shellfish
4.Allergy to iodine or shellfish The client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which can be determined by questioning the client about allergies to iodine or shellfish. Allergy to salmon is not associated with this procedure. Claustrophobia and excessive weight are areas of concern with magnetic resonance imaging.
The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? 1.Providing sensory cues 2.Giving simple, clear directions 3.Providing a stable environment 4.Encouraging multiple visitors at one time
4.Encouraging multiple visitors at one time Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in the amounts and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion and agitation can be minimized by reducing environmental stimuli (such as television, multiple visitors) and keeping familiar personal articles (such as family pictures) at the bedside.
The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center which is located in which part of the brain? 1.Cerebrum 2.Cerebellum 3.Hippocampus 4.Hypothalamus
4.Hypothalamus Hypothalamic damage causes hyperthermia, which may also be called "central fever." It is characterized by a persistent high fever with no diurnal variation. There is also an absence of sweating. Options 1, 2, and 3 are not associated with temperature regulation.