Test 5: Neuro

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a. Left-sided cerebrovascular accident (CVA) b. Right-sided cerebrovascular accident (CVA) c. Transient ischemic attack (TIA) d. Completed Stroke

A

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? a. Monitoring is needed as rapid neurologic deterioration may occur. b. Symptoms will evolve over a period of 1 week. c. The crash cart with defibrillator is kept nearby. d. Bleeding continues into the intracerebral area.

A

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? a. Seizure was 1 minute in duration including tonic-clonic activity. b. Sleeping quietly after the seizure c. The client cried out before the seizure began. d. Seizure began at 1300 hours.

A

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? a. Neurologic examination b. Computed tomography (CT) scan c. Radiography d. Myelography

A

When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms? a. Perform stretching exercises and frequent position change. b. Apply cool or warm cloth to head or eyes. c. Eliminate use of bright lights when working. d. Avoid certain foods.

A

The nurse is working on a neurosurgical unit. Which of the following nursing interventions are included in the plan of care following spinal surgery? Select all that apply. a. Monitor vital signs b. Intake and output c. Neurovascular assessment of the lower extremity d. Dressing assessment e. PEARLA f. Social History g. Coughing and deep breathing

A, B, C, D, G

A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. a. Neglect of objects and people on the left side b. Left-sided hemiplegia c. Hyperaware of deficits d. Tendency to distractibility e. Impairment of long-term memory

A, B, D

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? a. No bowel movement since yesterday b. Nausea c. Frequent voiding d. Complaint of headache off and on for past month

B

A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA? a. Severe headache b. Impaired muscle coordination c. Nausea and vomiting d. Respiratory distress

B

A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? a. It constricts the blood vessels in my head. b. I use this to prevent migraines. c. It alleviates my sensitivity to light and sound. d. I take this when I get a headache.

B

A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client? a. Take drugs only after meals at night. b. Use caution while driving or performing hazardous activities. c. Avoid caffeine and alcohol. d. Avoid crowds.

B

A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken? a. Know this is a normal finding for CVA. b. Perform a vision field assessment. c. Assist the client with feeding. d. Reposition the tray and plate.

B

A client with increased intracranial pressure is receiving mannitol via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment? a. Hyperpyrexia is resolving. b. Urine output is increased. c. Level of consciousness is improving. d. Blood pressure is rising.

B

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? a. Hypostatic pneumonia b. Brain tumor c. Epilepsy d. Trigeminal neuralgia

B

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? a. Physician maintains aseptic procedure. b. Cerebrospinal fluid is cloudy in nature. c. Client states a pressure relief in the head. d. Client states a piercing feeling.

B

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? a. Respiratory pattern b. Pulse and blood pressure c. Numbness and tingling d. Pain level

B

The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved? a. Blood vessels dilate circulating blood. b. Herniation occurs through the foramen magnum. c. Venous congestion occurs, causing peripheral edema. d. Additional inflammation occurs in the brain.

B

The nurse is caring for a client with GuillainBarré syndrome. Which assessment finding would indicate the need for oral suctioning? a. Decreased pulse rate, abdominal breathing b. Increased pulse rate, adventitious breath sounds c. Decreased pulse rate, respirations of 20 breaths/minute d.Increased pulse rate, respirations of 16 breaths/minute

B

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? a. Include fish, liver, and chicken in diet. b. Take small meals of nutrient and calorie-dense food. c. Include additional servings of fruits and raw vegetables. d. Increase the intake of calcium and proteins.

B

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? a. Intracranial hematoma b. Epidural hematoma c. Cerebral Hematoma d. Extradural hematoma e. Subdural hematoma

B

A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse? a. The client has a history of concussions from playing hockey. b. The client is HIV positive. c. The client's medications include warfarin. d. The client is a heart transplant recipient.

C

A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? a. Relieves migraines b. Increases appetite c. Relaxes muscles d. Reduces hypotension

C

A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client? a. Alert and oriented times three b. Blood pressure 180/98 mm Hg c. Grade V on the HuntHess Scale d. Complaint of severe splitting headache

C

A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? a. Tension headaches are easier to treat. b. Cluster headaches can cause severe debilitating pain. c. Migraines often coincide with menstrual cycle. d. Headaches are the most common type of reported pain.

C

A client who has experienced an initial transient ischemic attack (TIA) states: I'm glad it wasn't anything serious. Which is the best nursing response to this statement? a. TIA symptoms are short lived and resolve within 24 hours. b. I sense that you are happy it was not a stroke. c. TIA is a warning sign. Let's talk about lowering your risks. d.People who experience a TIA will develop a stroke.

C

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? a. Administer morning dose of anticonvulsant. b. Administer Percocet as ordered. c. Elevate the head of the bed. d. Complete a head-to-toe assessment.

C

A mother brings her 6-year-old child to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be? a. A concussion is a blow to the head that is minor and has no real consequences. b. A concussion is a blow to the head that bruises the brain. c. A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain. d. A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull.

C

The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first? a. The client with an open head injury b. The client with a concussion c. The client with a basilar fracture d. The client with a coup injury

C

The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/leaking of cerebral spinal fluid (CSF)? a. Swelling b. Change in the level of consciousness (LOC) c. Halo Sign d. Signs of increased intracranial pressure (IICP) e. High pulse rate

C

The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care? a. The client whose father has Parkinson's disease b. The client who was in a bike accident last summer c. The client who played soccer in college d. The client with history of seizures

C

The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care? a. Hospice care uses a team approach and provides complete care. b. All hospice clients die at home. c. Clients and families are the focus of hospice care. d. The physician coordinates all the care delivered.

C

A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client? a. Disturbed Sleep Pattern b. Impaired Home Maintenance c. Altered Nutrition d. Hopelessness

D

A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy? a. Resume antilipemic drugs. b. Observe for facial swelling. c. Encourage deep breathing and coughing. d. Anticipate need for endotracheal intubation.

D

A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? a. Take an antacid frequently. b. Avoid fiber in the diet. c. Take an herbal form of feverfew. d. Avoid heavy lifting.

D

The brain stem holds the medulla oblongata. What is the function of the medulla oblongata? a. Controls striated muscle activity in blood vessel walls b. Transmits sensory impulses from the brain to the spinal cord c. Controls parasympathetic nerve impulses in the pons d. Transmits motor impulses from the brain to the spinal cord

D

The client with a cerebral aneurysm asks the nurse, What's the big fuss over a headache?Which is the best response from the nurse regarding to a cerebral aneurysm? a. A headache means your aneurysm is leaking blood into the brain. b. Don't worry. The aneurysm has probably been there since birth. c. The headache can be an indication that the aneurysm is growing. d. Your physician wants to evaluate the location and condition of the aneurysm.

D

The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline with carbidopa-levodopa to the medication regime should result in which purpose? a. Replaces dopamine b. Relieves symptoms of dyskinesia c. Prevents side effects from carbidopa-levodopa d. Slows the progression of the disease

D

The nurse is caring for a client who has had intracranial surgery and is being discharged home. What instructions would the nurse give the client besides instructions on the medication? a. You can cover the incision with your hair. b. You can expect swelling above the incision. c. Understand that headaches are uncommon. d. Expect sensory changes, such as hearing a clicking sound, around the bone flap.

D

The nurse is caring for a client who was discovering unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? a. Tylenol may be administered for aches. b. Follow up with regular physician is encouraged. c. A light meal may be eaten if desired. d. Observe for any signs of behavioral changes.

D

The nurse is caring for a client with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used? a. Traction equipment b. A firm mattress c. Bandages and tape d. A cervical collar

D

The nurse is caring for a stuporous client in the intensive care unit. Which assessment finding is documented to reflect an improvement in the client's level of consciousness? a. Stuporous b. Semicomatose c. Conscious d. Somnolent

D

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? a. Electroencephalogram b. Myelogram c. Echoencephalography d. Cerebral angiography

D

When caring for a client who has had intracranial surgery, what is the most important parameter to monitor? a. Intake and output b. Extreme thirst c. Nutritional status d. Body temperature

D

The nurse is assessing a client's ability to detect sensation in the upper extremity. Which nursing actions would be appropriate? Select all that apply. a. Touch the client with the pads of the finger. b. A gentle pinch using the fingers. c. A light prick using a needle. d. Place a warm cotton ball on the arm. e. Drag the alcohol pad over the skin.

A, B, D, E

The nurse is caring for a client with a spinal cord injury leaving paralysis. When planning care related to the musculoskeletal system, which considerations are important? Select all that apply. a. Limited range of motion b. Weight bearing c. Bone demineralization d. Spasticity e. Contractures

A, C, D, E

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

A, C, E

The nurse suspects that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? Select all that apply. a. Poikilothermia b. Loss of hunger sensation c. Circulatory failure d. No perspiration below the level of the injury e. Bladder distention

A, D, E

The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered? Select all that apply. a. Analgesics b. Corticosteroids c. Antidepressants d. Loop diuretics e. Anticonvulsants f. Antibiotics

A, E, F

Which nursing assessment finding is most indicative of a hemorrhagic stroke? a. Client history of atrial fibrillation b. Sudden onset of breathing alterations c. Client history of hyperlipidemia d. Symptoms evolving over 24 to 48 hours

B

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? a. Cerebral b. Subdural c. Epidural d. Intracerebral Skeletal

B

While the nurse is making initial rounds after coming on shift, a client thrashes about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having? a. Migraine b. Cluster c. Sinus d. Tension

B

A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of tissue plasminogen activator (TPA) in a client with CVA requires which of the following? Select all that apply. a. Used concurrently with heparin therapy b. Administer within 3 hours of onset of symptoms. c. Presence of an ischemic stroke d. The symptoms are no longer evolving. e. Administer intramuscular for faster response. f. Administer for hemorrhagic strokes.

B, C

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. a. Pain and stiffness of the extremities b. Cloudy cerebral spinal fluid c. Low antidiuretic hormone (ADH) levels d. Low white blood cell (WBC) count e. Low red blood cell (RBC) count f. Purpura of hands and feet

B, F

A nurse is working in a neurologist's office. The physician orders a Romberg test. Which nursing action is correct? a. Have the client close his eyes and discriminate between dull and sharp. b. Have the client touch his nose with one finger. c. Have the client close his eyes and stand erect. d. Have the client close his eyes and jump on one foot.

C

The nurse and physician are viewing a brain scan, which indicates bleeding at the point of impact to the skull and edema on the opposite side. The client is sleeping but can be aroused. The client has no memory of accident. The nurse provides all details to the next shift and is most accurate to report which type of injury? a. Coup injury b. Head injury c. Contrecoup injury d. Contusion

C

Which neurons transmit impulses from the CNS? a. Sensory b. Dendrites c. Motor d. Neurilemma

C

A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply. a. Administration of tissue plasminogen activator b. Removal of the carotid artery c. Carotid endarterectomy d. Percutaneous transluminal coronary artery angioplasty e. Balloon angioplasty of the carotid artery followed by stent placement

C, E

The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply. a. Exposure to flashing light b. Prolonged positioning c. Red wine d. Nausea e. Menstruation f. Change in environmental temperature

C, E

Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply. a. Brisk pupil response b. Glasgow Coma Scale of 15 c. Elevated systolic blood pressure d. Generalized pain e. Stiff neck f. Wide pulse pressure

C, E, F