NUR 211 Neuro Practice Questions

20. A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? A) Magnetic resonance imaging (MRI) B) Electroencephalography (EEG) C) Electromyelography (EMG) D) Computed tomography (CT)

B) Electroencephalography (EEG)

33. When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A) Head turned slightly to the right side B) Elevation of the head of the bed C) Position changes every 15 minutes while awake D) Extension of the neck

B) Elevation of the head of the bed

6. A client is brought to the emergency department by the paramedics. The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify what components of HHS? Select all that apply. A) Leukocytosis B) Glycosuria C) Dehydration D) Hypernatremia E) Hyperglycemia

B) Glycosuria C) Dehydration D) Hypernatremia E) Hyperglycemia

1. The nurse is assess the client who has Type II Diabetes. Which findings indicate to the nurse that the client is experiencing HHNS? Select all that apply a. Serum osmolality 364 mOsm/kg b. Blood glucose level 160 mg/dL c. Very dry mucous membranes d. Blood pressure of 90/42 mm Hg e. Urine output 500 mL past 8 hours

Answer: a, c & d a. Serum osmolality of 364 is elevated. The extremely high blood glucose levels in HHNS increase serum osmolality. b. Blood glucose levels for HHNS are usually over 600 mg/dL c. Persistent hyperglycemia in HHNS causes osmotic diuresis, a loss of water and electrolytes and extreme dehydration. Very dry mucous membranes are a sign of dehydration. d. Hypotension from the loss of water and electrolytes in HHNS e. Urine output of 500 mL in 8 hours is normal. Clients with HHNS experience polyuria.

16. A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply. A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT D) Salt-wasting syndrome E) Increased ICP

A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT

14. The nurse is preparing to discharge a client with a halo device. The nurse determines that the client needs further instruction if the client states that he or she will: a. Use a straw to drink b. Drive only during the daytime c. Use caution because the device alters balance d. Wash the skin daily under the lamb's wool liner of the vest

Answer: b Client with a halo device can't turn their head and are unsafe to drive. All the other statements are true.

1. A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client? A) Do not eliminate insulin when nauseated and vomiting. B) Report elevated glucose levels greater than 150 mg/dL (8.3 mmol/L). C) Eat three substantial meals a day, if possible. D) Reduce food intake and insulin doses in times of illness.

A. Do not eliminate insulin when nauseated and vomiting.

1. The nurse is assessing the client with a tentative diagnosis of meningitis. Which findings should the nurse associate with meningitis? Select all that apply a. Nuchal rigidity b. Severe headache c. Pill-rolling tremor d. Photophobia

Answer: a, b, d All answers are correct except pill-rolling tremors which are associated with Parkinson's disease

If cholinergic crisis-

pt muscle weakness may increase after the administration of Tensilon

13. The nurse caring for a client in ICU diagnosed with Guillain--Barré syndrome should prioritize monitoring for what potential complication? A) Impaired skin integrity B) Cognitive deficits C) Hemorrhage D) Autonomic dysfunction

D) Autonomic dysfunction

3. A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the client will require further teaching when the client states what? A) "I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours." B) "If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six to eight times a day." C) "I will call the doctor if I am not able to keep liquids in my body due to vomiting or diarrhea." D) "I will call the doctor if my blood sugar is over 300 mg/dL (16.6 mmol/L) or if I have ketones in my urine."

A) "I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours."

15. The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? A) "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." B) "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." C) "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." D) "The sudden, severe headache increases muscle tone and can cause further nerve damage."

A) "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."

12. The nurse is caring for a client whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be prescribed to control this? A) Baclofen B) Dexamethasone C) Mannitol D) Phenobarbital

A) Baclofen

25. A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? A) Cardiac and respiratory status B) Seizure activity C) Pain D) Fluid and electrolyte balance

A) Cardiac and respiratory status

13. The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? A) Change the client's position frequently B) Provide a high-protein diet C) Provide light massage at least daily D) Teach the client deep breathing and coughing exercises

A) Change the client's position frequently

11. The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A) Ensure that the player is not moved B) Obtain the player's vital signs, if possible C) Perform a rapid assessment of the player's range of motion D) Assess the player's reflexes

A) Ensure that the player is not moved

32. A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? A) Evidence of hemorrhagic stroke B) Blood pressure of ³180/110 mm Hg C) Evidence of stroke evolution D) Previous thrombolytic therapy within the past 12 months

A) Evidence of hemorrhagic stroke

28. The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? A) Facial droop B) Dysrhythmias C) Periorbital edema D) Projectile vomiting

A) Facial droop

18. What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I? A) Have the client identify familiar odors with the eyes closed B) Assess papillary reflex C) Utilize the Snellen chart D) Test for air and bone conduction (Rinne test)

A) Have the client identify familiar odors with the eyes closed

9. An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the client is at increased risk for what complication of his injury? A) Hematoma B) Skull fracture C) Embolus D) Stroke

A) Hematoma

27. The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A) Provide a board of commonly used needs and phrases B) Have the client speak to loved ones on the phone daily C) Help the client complete their sentences as needed D) Speak in a loud and deliberate voice to the client

A) Provide a board of commonly used needs and phrases

34. A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A) The client should mobilize as soon as she is physically able. B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C) The client should remain on bed rest until she expresses a desire to mobilize. D) Lack of mobility will greatly increase the client's risk of stroke recurrence.

A) The client should mobilize as soon as she is physically able.

10. The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A) Young age B) Frequent travel C) African-American race D) Male gender E) Alcohol or drug use

A) Young age D) Male gender E) Alcohol or drug use

11. The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The client has begun treatment with pyridostigmine bromide. What change in status would most clearly suggest a therapeutic benefit of this medication? A) Increased muscle strength B) Decreased pain C) Improved GI function D) Improved cognition

A) Increased muscle strength

7. The nurse is developing a plan of care for a client with Guillain--Barré syndrome. Which of the following interventions should the nurse prioritize for this client? A) Using the incentive spirometer as prescribed B) Maintaining the client on bed rest C) Providing aids to compensate for loss of vision D) Assessing frequently for loss of cognitive function

A) Using the incentive spirometer as prescribed

1. The client with Guillain-Barre' syndrome is scheduled to receive plasmapheresis treatments. The client's spouse asks the nurse about the purpose of plasmapheresis treatments. Which explanation is correct? a. "Plasmapheresis removes excess fluid from the bloodstream." b. "plasmapheresis will increase the protein levels in the blood." c. "Plasmapheresis removes circulating antibodies from the blood." d. "Plasmapheresis infuses lipoproteins to restore the myelin sheath."

Answer C Plasmapheresis is a procedure in which harmful antibodies are removed from the blood. During the procedure, blood is removed from the client, the plasma is separated, and blood cells without the plasma are returned to the client.

1. The nurse is assessing the client following a closed head injury. When applying nailbed pressure, the client's body suddenly stiffens, the eyes roll upward and there is an increase in salivation and loss of swallowing reflex. Which observation should the nurse document? a. Decerebrate posturing observed b. Decorticate posturing observed c. Positive Kernig's sign observed d. Seizure activity observed

Answer D Body stiffening, eyes rolled upward, increase in salivation, and a loss of swallowing reflex are signs consistent with the tonic phase of a tonic-clonic seizure. This phase is followed by the clonic phase with violent muscle contractions.

14. The nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of the surgery if the client exhibits: a. A negative Kernig sign b. Absence of nuchal rigidity c. A positive Brudzinski sign d. A Glasgow coma scale score of 15

Answer: C Signs of meningitis include a positive Kernig sign, presence of nuchal rigidity and a positive Brudzinski sign. A GSC of 15 is a perfect score.

What am I? 1. S/S polyuria, polydipsia 2. Urine will be diluted 3. Blood chemistry will be concentrated 4. Can treat with free water and D5W 5. There is no cure, name can fool you

Answer: Diabetes Insipidus

What am I? 1. Can be caused by infection or stomach virus 2. Rapid onset 3. S/S rapid deep breathing, dehydration, abdominal pain 4. PH, CO2, HCO3 are all low 5. Treat with rehydration, restore electrolytes, and reverse acidosis

Answer: Diabetic Ketoacidosis

What am I? 1. Usually caused by an illness or stressor 2. s/s increased BS, dehydration, AMS 3. Gradual onset and hard to manage 4. Treat with IVF and replacing electrolytes 5. Anion gap <12

Answer: Hyperglycemic Hyperosmolar Syndrome (HHS)

What am I? 1. Very rare 2. Need to find cause and treat it 3. May need intubation or hemodynamic monitoring 4. S/S depression, stupor, high CO2 levels, hypothermia 5. Treat with IV levothyroxine

Answer: Myxedema Coma

What am I? 1. Will require MRI 2. Can prevent with folic acid 3. Could cause paralysis 4. Increase in latex allergy 5. Sac-like protrusion

Answer: Spina Bifida Cystica

What am I? 1. Patient will need MRI 2. Not visible externally 3. May not require treatment 4. May have dark hairy patch, port wine stain, dimple 5. Defect in vertebra not spinal cord

Answer: Spina Bifida Occulta

What am I? 1. S/S decreased urine output and hyponatremia 2. Urine concentrated 3. Blood chemistry diluted 4. Fluid restriction-no free water! 5. Treat with 3% NS; furosemide

Answer: Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH)

What am I? 1. Rapid onset 2. S/S tachycardia, fever, AMS 3. Do not give this patient ASA 4. Fatal if not treated in 48 hours 5. Treat with IV dextrose, PTU, or iodine

Answer: Thyroid Storm

1. The nurse is administering IV mannitol to decrease the client's ICP following a craniotomy. Which laboratory test result should the nurse monitor during the client's treatment with mannitol? a. Serum osmolarity b. WBCs c. Serum cholesterol d. Erythrocyte sedimentation rate (ESR)

Answer: a Mannitol is an osmotic diuretic, serum osmolarity with be increased as fluid is pulled from the tissues, thus decreasing cerebral edema postoperatively. Serum osmolarity levels should be assessed as a parameter to determine proper dosage and insure the client is not becoming dehydrated.

1. The nurse is implementing interventions for the client who has increased ICP. The nurse knows that which result will occur if the increased ICP is left untreated? a. Displacement of brain tissue b. Increase in cerebral perfusion c. Increase in the serum pH level d. Leakage of cerebrospinal fluid

Answer: a a. Correct - if untreated, increased ICP causes a shift in brain tissue and can result in irreversible brain damage and possibly death. b. ICP compresses structures within the cranium and leads to a decrease in cerebral perfusion, not increased cerebral perfusion. (As ICP increases; CPP decreases) c. ICP compresses structures within the cranium and leads to acidosis; the pH level is decreased in acidosis. d. Leakage of CSF could occur if there were an opening in the subarachnoid space that could occur with trauma, but there is no indication that the increased ICP is due to trauma.

1. The nurse is caring for the client with a spinal cord injury at the C6 vertebrae. Which findings support the nurse's conclusion that the client may be experiencing autonomic dysreflexia? Select all that apply a. Blurred vision b. BP 198/102 c. Heart rate 150 bpm d. Extreme headache e. Sweaty face and arms

Answer: a, b, d, & e a. Blurred vision results from the HTN occurring with autonomic dysreflexia b. HTN is a symptom of autonomic dysreflexia from overstimulation of the SNS c. Bradycardia (not tachycardia) is a symptom of autonomic dysreflexia d. HA results from the HTN e. Sweating results from the sympathetic stimulation above the level of injury

1. The nurse is evaluates the client who is being treated for DKA. Which finding indicates that the client is responding to the treatment plan? a. Eyes sunken and skin flushed b. Skin moist with rapid elastic recoil c. Serum potassium level is 3.3 mEq/L d. ABG results are pH 7.25, Paco2 30, HCO3 17

Answer: b - these are signs that the patient is well hydrated A - incorrect - s/sx of dehydration C - incorrect - hypokalemia D - incorrect - you might see these ABG results in the DKA patient when they first present to the hospital

14. The client is in status epilepticus. Which interventions, if prescribed should be included in this client's immediate treatment? Select all that apply a. Administer dexamethasone intravenously. b. Give oxygen and prepare for endotracheal intubation c. Obtain a defibrillator and prepare to use it immediately d. Remove nearby objects to the client from injury e. Administer lorazepam intravenously STAT x

Answer: b, d, & e a. Incorrect: steroids are not administered for seizures b. Correct: Status epilepticus is a medical emergency. The client is at risk for hypoxia and permanent brain damage. The client needs additional oxygen, and intubation will secure the airway. c. Incorrect: this is not a lethal heart rhythm d. Correct: Care is taken to protect the client from injury during the seizure e. Correct: Either lorazepam (Ativan) or diazepam (Valium) is administered initially to terminate the seizure because they can be administered more rapidly than phenytoin (Dilantin).

1. The client develops SIADH secondary to a pituitary tumor. The client's assessment findings include thirst, weight gain, fatigue, and a serum sodium of 127 mEq/L. Which intervention, if prescribed should the nurse implement to treat SIADH? a. Elevate the head of the bed 55 degrees b. Administer vasopressin IV c. Restrict fluids to 800-1000 mL per day d. Give 0.3% sodium chloride per IV infusion

Answer: c a. Incorrect - position client to promote venous return to the heart b. Incorrect - Vasopressin is an ADH and will aggravate the client's problem c. If symptoms are mild and hyponatremia is not severe, treatment includes fluid restriction to 800-1000 ml/day. d. Incorrect - Hypertonic saline should be reserved for treatment of severe hyponatremia

14. The nurse is caring for a client who takes phenytoin (Dilantin) for seizures. During the assessment, the nurse notes the client also takes birth control pills. Which teaching should the nurse include? a. It is not important to take this medication as prescribed b. If you are having stomach upset you may stop taking your medicine c. There is a potential for decreased effectiveness of birth control pills with phenytoin d. There is an increased risk of thrombophlebitis while taking phenytoin

Answer: c Dilantin should be taken as prescribed on a scheduled dose. The client should not stop taking the medication without the approval of the HCP. There is a risk of increased bleeding with Dilantin due to blood dyscrasias.

14. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dl. A continuous IV infusion of regular insulin is initiated, along with rehydration with IV NS. The blood sugar is now 240 mg/dl. The nurse would next prepare to administer which of the following? a. Ampule of 50% dextrose b. NPH insulin subcutaneously c. IV fluids containing 5% dextrose d. Phenytoin (Dilantin) for the prevention of seizures

Answer: c During the management of DKA, when the blood glucose level falls to around 250, the infusion rate is reduced and a 5% dextrose solution is added. NPH is not used to treat DKA. 50% dextrose is used to treat hypoglycemia. Phenytoin is used for seizures and is a CNS depressant. It is generally not used for DKA.

7. The nurse learns in report that the client admitted with a vertebral fracture has a halo external fixation device in place. Which intervention should the nurse plan? a. Ensure the traction weight hangs freely b. Remove the vest from the device at bedtime c. Cleanse sites where the pins enter the skull d. Screw the pins in the skull daily to tighten

Answer: c There are no weights involved in a halo device The vest is never removed until the fracture has completely stabilized. The surgeon will tighten the pins as needed.

1. The nurse is caring for the client experience Guillain-Barr' syndrome. It is most important for the nurse to monitor the client for which complication? a. Autonomic dysreflexia b. Septic emboli c. Cardiac dysrhythmias d. Respiratory failure

Answer: d

1. The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis? a. No change in condition b. Complaints of muscle spasms c. An improvement of the weakness d. A temporary worsening of the condition

Answer: d An injection of edrophonium injection makes the client in cholinergic crisis temporarily feel worse. An improvement in the weakness indicates myasthenia crisis.

14. The nurse is teaching the client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: a. Eating large, well balanced meals b. Doing muscle-strengthening exercises c. Doing all their chores in the early morning while less fatigued d. Taking medications on time to maintain therapeutic blood levels

Answer: d Clients with MG are taught to space out activities and meals throughout the day and should eat small meals to avoid overeating. Muscle strengthening exercises are not helpful. Taking medications correctly is the most important thing to avoid crises.

14. The client is admitted to the hospital with a diagnosis of Guillain-Barre' syndrome. The nurse inquires during the nursing admission interview if the client has a history of: a. Seizures or trauma to the brain b. Meningitis during the last 5 years c. Back injury or trauma to the spinal cord d. Respiratory or gastrointestinal infection during the past month

Answer: d Guillain-Barre' is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a recent history of GI or respiratory infection. Occasionally, the syndrome may be triggered by vaccinations or in rare cases surgery

14. The nurse has instructed the family of a client with brain attack (stroke) who has homonymous hemianopsia about measure to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state they will: a. Place objects in the client's impaired field of visioin. b. Discourage the client from wearing eyeglasses c. Approach the client from the impaired field d. Remind the client to turn the head to scan the lost visual field.

Answer: d Homonymous hemianopsia is loss of half of the visual field. The client should wear eyeglasses if they have them. The client should be approached from the unimpaired side.

14. The client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower extremities d. Limiting bladder catheterization to once every 12 hours

Answer: d The most common causes of autonomic dysreflexia are bowel and bladder distention. Catheterization should be performed every 4-6 hours. All the other interventions are appropriate.

1. Michael is a 24 year old man who presents with a 6 hour history of sudden onset of inability to raise his eyebrow or smile on the right side. He also reports decreased lacrimation in the right eye and difficulty closing the right eyelid. The rest of his health history and physical exam is otherwise unremarkable. This likely represents paralysis of cranial nerve (CN): a. III. b. VIII. c. IV. d. VII.

Answer: d (KNOW HOW TO ASSESS ALL CRANIAL NERVES)

10. A client has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this client's immediate care? Select all that apply. A) Administering diuretics to prevent fluid overload B) Administering beta-blockers to reduce heart rate C) Administering insulin to reduce blood glucose levels D) Applying interventions to reduce the client's temperature E) Administering corticosteroids

B) Administering beta-blockers to reduce heart rate D) Applying interventions to reduce the client's temperature

24. The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A) Generalized pain B) Alteration in level of consciousness (LOC) C) Tonic-clonic seizures D) Shortness of breath

B) Alteration in level of consciousness (LOC)

3. A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? A) Placing the client on a fluid restriction as prescribed B) Applying thigh-high elastic stockings C) Administering an antifibrinolytic agent D) Assisting the client with passive range-of-motion (PROM) exercises

B) Applying thigh-high elastic stockings

22. The nurse is performing a neurologic assessment of a client whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)? A) Assess the client's vital signs and correlate these with the client's baselines B) Assess the client's eye opening and response to stimuli C) Document that the client currently lacks a level of consciousness D) Facilitate diagnostic testing in an effort to obtain objective data

B) Assess the client's eye opening and response to stimuli

2. A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? A) Respiratory distress and projectile vomiting B) Bradycardia and hypertension C) Tachycardia and agitation D) Third-spacing and hyperthermia

B) Bradycardia and hypertension

29. A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A) Prevent complications of immobility B) Maintain and improve cerebral tissue perfusion C) Relieve anxiety and pain D) Relieve sensory deprivation

B) Maintain and improve cerebral tissue perfusion

5. A client with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the client's initial phase of treatment? A) Monitoring the client for dysrhythmias B) Maintaining and monitoring the client's fluid balance C) Assessing the client's level of consciousness D) Assessing the client for signs and symptoms of venous thromboembolism

B) Maintaining and monitoring the client's fluid balance

1. A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities

B) Neck flexion produces flexion of knees and hips

7. Following a spinal cord injury a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A) Complete the pin site care to decrease risk of infection B) Notify the neurosurgeon of the occurrence C) Stabilize the head in a lateral position D) Reattach the pin to prevent further head trauma

B) Notify the neurosurgeon of the occurrence

1. The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? Select all that apply A) Epistaxis B) Periorbital edema C) Bruising over the mastoid D) Unilateral facial numbness

B) Periorbital edema C) Bruising over the mastoid

3. A male client presents to the clinic reporting a headache. The nurse notes that the client is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? A) Negative Brudzinski sign B) Positive Kernig sign C) Hyperpatellar reflex D) Sluggish pupil reaction

B) Positive Kernig sign

37. As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply. A) INR above 1.0 B) Recent intracranial pathology C) Sudden symptom onset D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission

B) Recent intracranial pathology D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission

17. A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? A) Withholding stimulants 24 to 48 hours prior to exam B) Removing all metal-containing objects C) Instructing the client to void prior to the MRI D) Initiating an IV line for administration of contrast

B) Removing all metal-containing objects

14. A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? A) The client will be unable to use a wheelchair. B) The client will be unable to swallow food. C) The client will be continent of urine, but incontinent of bowel. D) The client will require full assistance for all aspects of elimination.

B) The client will be unable to swallow food. D) The client will require full assistance for all aspects of elimination.

4. A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? A) Preparation for emergency craniotomy B) Watchful waiting and close monitoring C) Administration of inotropic drugs D) Fluid resuscitation

B) Watchful waiting and close monitoring

5. A client with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process? A) Cyclosporine B) Acyclovir C) Cyclobenzaprine D) Ampicillin

B) Acyclovir

8. A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. A) Obtain a blood type and cross-match B) Administer antipyretics as prescribed C) Perform frequent neurologic assessments D) Monitor pain levels and administer analgesics E) Place the client in positive pressure isolation

B) Administer antipyretics as prescribed C) Perform frequent neurologic assessments D) Monitor pain levels and administer analgesics

14. 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 4 to 6 months of treatment B) Symptom improvement that lasts a few weeks after TPE ceases C) Permanent improvement after 60 to 90 treatments D) Gradual improvement over several months

B) Symptom improvement that lasts a few weeks after TPE ceases

21. A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test? A) "No metal objects can enter the procedure room." B) "You need to fast for 8 hours prior to the test." C) "You will need to lie still throughout the procedure." D) "There will be a lot of noise during the test."

C) "You will need to lie still throughout the procedure."

35. The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? A) Naproxen 250 PO b.i.d. B) Calcium carbonate 1000 mg PO b.i.d. C) Aspirin 81 mg PO o.d. D) Lorazepam 1 mg SL b.i.d. PRN

C) Aspirin 81 mg PO o.d.

38. A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A) Acute pain B) Septicemia C) Bleeding D) Seizures

C) Bleeding

9. A nurse caring for a client with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? A) Glucose in the urine B) Albumin in the urine C) Highly dilute urine D) Leukocytes in the urine

C) Highly dilute urine

19. When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII? A) Palpate trapezius muscle while client shrugs shoulders against resistance B) Administer the whisper or watch-tick test C) Observe for facial movement symmetry, such as a smile D) Note any hoarseness in the client's voice

C) Observe for facial movement symmetry, such as a smile

2. A client with Guillain--Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? A) Administer bronchodilators as prescribed B) Remind the client of the importance of deep breathing and coughing exercises C) Prepare to assist with intubation D) Administer supplementary oxygen by nasal cannula

C) Prepare to assist with intubation

7. The nurse is teaching a client that the body needs iodine for the thyroid to function. What food would be the best source of iodine for the body? A) Eggs B) Shellfish C) Table salt D) Red meat

C) Table salt

30. The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A) Mild, intermittent seizures can be expected B) Take ibuprofen for complaints of a serious headache C) Take antihypertensive medication as prescribed D) Drowsiness is normal for the first week after discharge

C) Take antihypertensive medication as prescribed

8. A client is prescribed corticosteroid therapy. What would be priority information for the nurse to give the client who is prescribed long-term corticosteroid therapy? A) The client's diet should be low protein with ample fat. B) The client may experience short-term changes in cognition. C) The client is at an increased risk for developing infection. D) The client is at a decreased risk for development of thrombophlebitis and thromboembolism.

C) The client is at an increased risk for developing infection.

23. A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? A) To decrease cerebral edema B) To prevent seizure activity that is common following a TIA C) To remove atherosclerotic plaques blocking cerebral flow D) To determine the cause of the TIA

C) To remove atherosclerotic plaques blocking cerebral flow

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

C) Dimming the lights and reducing stimulation

6. A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client? A) All at one time, to provide a longer rest period B) Before meals, to stimulate her appetite C) In the morning, with frequent rest periods D) Before bedtime, to promote rest

C) In the morning, with frequent rest periods

9. The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? A) Maintaining the client's functional independence B) Providing health education C) Monitoring neurologic status closely D) Promoting mobility

C) Monitoring neurologic status closely

12. The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client? A) Suctioning secretions B) Facilitating ABG analysis C) Providing ventilatory assistance D) Administering tube feedings

C) Providing ventilatory assistance

26. A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? A) Passive range-of-motion exercises to prevent contractures B) Supine positioning C) Early initiation of physical therapy D) Absolute bed rest in a quiet, nonstimulating environment

D) Absolute bed rest in a quiet, nonstimulating environment

31. A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A) Sit with the client for a few minutes B) Administer an analgesic C) Inform the nurse manager D) Call the health care provider immediately

D) Call the health care provider immediately

2. An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A) Administration of antihypertensive medications B) Administering sodium bicarbonate intravenously C) Reversing acidosis by administering insulin D) Fluid and electrolyte replacement

D) Fluid and electrolyte replacement

4. A medical nurse is aware of the need to screen specific clients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what client population does hyperosmolar nonketotic syndrome most often occur? A) Clients who are obese and who have no known history of diabetes B) Clients with type 1 diabetes and poor dietary control C) Adolescents with type 2 diabetes and sporadic use of antihyperglycemics D) Middle-aged or older people with either type 2 diabetes or no known history of diabetes

D) Middle-aged or older people with either type 2 diabetes or no known history of diabetes

36. A nurse in the ICU is providing care for a client who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the client is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? A) Report this finding to the health care provider as an indication of decreased metabolism B) Provide more stimulation to the client and monitor the client closely C) Recognize this as the expected clinical course of a hemorrhagic stroke D) Report this to the health care provider as a possible sign of clinical deterioration

D) Report this to the health care provider as a possible sign of clinical deterioration

8. A 13 year old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. What assessment finding would rule out discharging the client? A) The client reports a headache. B) The client reports pain at the site where the ball hits his head. C) The client is visibly fatigued. D) The client's speech is slightly slurred.

D) The client's speech is slightly slurred.

5. A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? A) The client received a blood transfusion. B) The client's analgesia regimen was recently changed. C) The client was not repositioned during the night shift. D) The client's urinary catheter became occluded.

D) The client's urinary catheter became occluded.

4. The nurse caring for a client diagnosed with Guillain--Barré syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurse's communication with the client should reflect the possibility of what sign or symptom of the disease? A) Intermittent hearing loss B) Tinnitus C) Tongue enlargement D) Vocal paralysis

D) Vocal paralysis

14. The client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: a. Is clear and tests negative for glucose b. Is grossly bloody in appearance and has a pH of 6 c. Clumps together on the dressing and has a pH of 7 d. Separates into concentric rings (halos) and tests positive for glucose

halos) Answer: d

. If myasthenic crisis-

pt muscle weakness will decrease after the administraion of Tensilon.