NCLEX Neuro and Sensory Systems

A nurse is teaching a client with multiple sclerosis (MS) about how to manage urinary retention. Which instructions should the nurse include in the teaching session? Select all that apply. A. Using Credé maneuver B. Using an indwelling catheter C. Using anticholinergic medications D. Monitoring and restricting fluid intake to 800 mL daily E. Monitoring for and reporting signs of urinary tract infection

A. Using Credé maneuver E. Monitoring for and reporting signs of urinary tract infection

A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Why is this necessary? A. Reflexes have been lost. B. There is partial transection of the cord. C. There is damage above the sixth thoracic vertebra. D. Flaccid paralysis of the lower extremities has occurred.

C. There is damage above the sixth thoracic vertebra.

A client is admitted to the hospital with weakness in the right extremities and a slight difficulty with speech. Vital signs are within expected limits. What is the priority nursing action during the first 24 hours? A. Taking the client's temperature B. Evaluating the client's motor status C. Obtaining the client's urine for a urinalysis D. Monitoring the client's blood pressure for hypertension

B. Evaluating the client's motor status

During the immediate posttrauma period after injury to the frontal lobe of the brain, the nurse places a client in what position? A. Supine B. Side-lying C. Low-Fowler D. Trendelenburg

C. Low-Fowler

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm? A. Tonic-clonic seizures B. Decerebrate posturing C. Sudden severe headache D. Narrowed pulse pressure

C. Sudden severe headache

A client who has been immobilized for an extended period of time questions why the tilt table is being used. What is the nurse's best explanation of the tilt table's function? A. "It prevents hypertension." B. "It encourages increased activity." C. "It maintains circulation to the skin." D. "It prevents loss of calcium from long bones."

D. "It prevents loss of calcium from long bones."

Which is a clinical manifestation of a cluster headache? A. Vertigo B. Neck rigidity C. Phonophobia D. Ipsilateral tearing of the eye

D. Ipsilateral tearing of the eye

True or False: Parkinson's Disease most commonly affects patients in young adulthood, and there is currently no cure for the disease.

False: Parkinson's Disease most commonly affects patients in OLDER adulthood (60+), and there is currently no cure for the disease.

While interacting with a client who reported visual changes, the nurse finds that the client is frequently exposed to the sun. Which conditions might this client have? Select all that apply. A. Cataracts B. Entropion C. Pterygium D. Pinguecula E. Arcus senilis

A. Cataracts C. Pterygium D. Pinguecula

A patient with Parkinson Disease is experiencing weight loss due to difficulty chewing and swallowing. Which meal option below is the best for this patient? A. Scrambled eggs with a side of cottage cheese B. Grilled cheese with apple slices C. Baked chicken with bacon slices D. Tacos with refried beans

A. Scrambled eggs with a side of cottage cheese

A client is admitted to the ambulatory health clinic with a diagnosis of Bell palsy. What is most appropriate for the nurse to do? A. Teach facial exercises. B. Prepare the client for surgery. C. Tape the client's affected eyelid open. D. Record symmetrical progression of the paralysis.

A. Teach facial exercises.

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing? A. Moro B. Babinski C. Stepping D. Cremasteric

B. Babinski

Which test is used to diagnose diseases of the vestibular system? A. Rinne test B. Caloric test stimulus C. Pure-tone audiometry D. Auditory brain stem response

B. Caloric test stimulus

While assessing a patient with Parkinson's Disease, you note the patient's arms slightly jerk as you passively move them toward the patient's body. This is known as: A. Lead Pipe Rigidity B. Cogwheel Rigidity C. Pronate Rigidity D. Flexor Rigidity

B. Cogwheel Rigidity

A nurse is assessing a client with multiple sclerosis. Which common initial clinical effects should the nurse expect to find? Select all that apply. A. Headaches B. Nystagmus C. Skin infections D. Scanning speech E. Intention tremors

B. Nystagmus D. Scanning speech E. Intention tremors

A patient with Parkinson's Disease has slow movements that affects their swallowing, facial expressions, and ability to coordinate movements. As the nurse you will document the patient has: A. Akinesia B. "Freeze up" tremors C. Bradykinesia D. Pill-rolling

C. Bradykinesia

A patient is prescribed to take Carbidopa/Levodopa (Sinemet). As the nurse you know that which statement is incorrect about this medication: A. It can take up to 3 weeks for the patient to notice a decrease in signs and symptoms when beginning treatment with this medication. B. Body fluids can turn a dark color and stain clothes. C. This medication is most commonly prescribed with a vitamin B6 supplement. D. Carbidopa helps to prevent Levodopa from being broken down in the blood before it enters the brain. Hence, levodopa is able to enter the brain.

C. This medication is most commonly prescribed with a vitamin B6 supplement.

The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes associated with aging. Which statement made by the coworker indicates the nurse needs to intervene? A. "Clients with decreased sensory perception of touch should be carefully monitored for infection." B. "Clients with recent memory loss should be taught by repetition and by using memory aids that provide recurrent alerts." C. "Clients with slower processing time should be provided with sufficient time to respond to questions or directions." D. "Clients with decreased coordination should be instructed to hold handrails when ambulating."

A. "Clients with decreased sensory perception of touch should be carefully monitored for infection."

A client is admitted to the hospital with a diagnosis of myasthenia gravis. For which common early clinical finding should the nurse assess the client? A. Tearing B. Diplopia C. Nystagmus D. Exophthalmos

B. Diplopia

A client is admitted to the hospital with numbness of the hands and feet, which has progressed upward and now involves the arms, legs, and lower trunk. The client tells the nurse that approximately two weeks ago, the client experienced 48 hours of chills, fever, and upper respiratory congestion. A tentative diagnosis of Guillain-Barré syndrome is made. The nurse assesses for what major clinical manifestations of the syndrome? A. Ptosis and dysphagia B. Paresthesias and paralysis C. Atrophy and fasciculations D. Muscle weakness and drooling

B. Paresthesias and paralysis

A client with myasthenia gravis asks the nurse why the disease has occurred. Which pathology underlies the nurse's reply? A. A genetic defect in the production of acetylcholine (ACh) B. An inefficient use of the neurotransmitter acetylcholine C. A decreased number of functioning acetylcholine receptor (AChR) sites 4. An inhibition of the enzyme acetylcholinesterase (AChE), leaving the end plates folded

C. A decreased number of functioning acetylcholine receptor (AChR) sites

An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action? A. Interview the client without the presence of family members. B. Report the abuse to the appropriate state agency for investigation. C. Accept the adult child's explanation until more data can be collected. D. Refer the client's clinical record to the hospital ethics committee for review.

A. Interview the client without the presence of family members.

A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client? A. Maintain balance to improve stability B. Relieve pressure on weight-bearing joints C. Prevent further injury to weakened muscles D. Aid in controlling involuntary muscle movements

A. Maintain balance to improve stability

When a disaster occurs, the nurse may have to first treat mass hysteria that is indicated by what response? A. Panic B. Coma C. Euphoria D. Depression

A. Panic

A client who is legally blind is admitted to the hospital for surgery. Which nursing action is most appropriate when caring for this client? A. Enter the room while speaking softly. B. Touch the client gently before speaking. C. Hold the client by the elbow when ambulating. D. Keep the furniture in the same location in the room.

D. Keep the furniture in the same location in the room.

A nurse should plan to maintain a client who has experienced a subarachnoid hemorrhage in what position? A. Supine B. On the unaffected side C. In bed with the head of the bed elevated D. With sandbags on either side of the head

C. In bed with the head of the bed elevated

Which test is used to specifically detect intracranial aneurysms in clients? A. Diffusion imaging B. Magnetic resonance imaging C. Magnetic resonance angiography D. Magnetic resonance spectroscopy

C. Magnetic resonance angiography

As the home health nurse you are helping a patient with Parkinson's Disease get dressed. What item gathered by the patient to wear should NOT be worn? A. Velcro pants B. Pull over sweatshirt C. Non-slip socks D. Rubber sole shoes

D. Rubber sole shoes

Which cranial nerves assist with both sensory and motor functioning in a client? Select all that apply. A. Optic B. Facial C. Trochlear D. Accessory E. Trigeminal

B. Facial E. Trigeminal

A client is diagnosed with Parkinson disease and asks the nurse what causes the disease. On which underlying pathology does the nurse base a response? A. Disintegration of the myelin sheath B. Breakdown of upper and lower neurons C. Reduced acetylcholine receptors at synapses D. Degeneration of the neurons of the basal ganglia

D. Degeneration of the neurons of the basal ganglia

A 50-year-old male client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior? A. Ask the wife how she knows how the client feels. B. Instruct the wife to let the client answer for himself. C. When the wife leaves return to speak with the client. D. Acknowledge the wife but look at the client for a response.

D. Acknowledge the wife but look at the client for a response.

An older client with macular degeneration comes to the eye clinic. Which response reported by the client does the nurse identify as consistent with the diagnosis? A. Sees best in dim light B. Sees halos around lights C. Cannot see objects in the periphery D. Cannot see objects in the center of the visual field

D. Cannot see objects in the center of the visual field

A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed? A. Ability to chew and speak distinctly B. Capacity to smile and close the eyelids C. Effectiveness of respiratory exchange and ability to swallow D. Degree of anxiety and concern about the suspected diagnosis

C. Effectiveness of respiratory exchange and ability to swallow

You're patient with Parkinson's Disease has been taking Carbidopa/Levodopa for several years. The patient reports that his signs and symptoms actually become worse before the next dose of medication is due. As the nurse, you know what medication can be prescribed with this medication to help decrease this for happening? A. Anticholinergic (Benztropine) B. Dopamine agonists (Ropinirole) C. MOA Inhibitor Type B (Rasagiline) D. COMT Inhibitor (Entacapone)

D. COMT Inhibitor (Entacapone)

What should the nurse instruct the client to do to limit triggering the pain associated with trigeminal neuralgia? A. Drink iced liquids. B. Avoid oral hygiene. C. Apply warm compresses. D. Chew on the unaffected side.

D. Chew on the unaffected side.

While providing discharge teaching to a patient prescribed Ropinirole (Requip), you make it priority to teach the patient about what side effect? A. Drowsiness B. Dry mouth C. Coughing D. Dark sweat or saliva

A. Drowsiness

A spouse of a husband who has Parkinson's Disease explains to you that her husband experiences episodes while walking where he freezes and can't move. She asks what can be done to help with these types of episodes to prevent injury. Select all the options that are correct: A. Have the husband try to change direction of movement by moving in the opposite direction when the freeze ups occur. B. Use a cane with a laser point while walking. C. Have the husband try to push through the freeze ups. D. Encourage the husband to consciously lift the legs while walking (as with marching).

A. Have the husband try to change direction of movement by moving in the opposite direction when the freeze ups occur. B. Use a cane with a laser point while walking. D. Encourage the husband to consciously lift the legs while walking (as with marching).

You're providing diet education to a patient with Parkinson's Disease. Which statement below demonstrates the patient understood your teaching? Select all that apply: A. "I will limit foods high in fiber like fruits and vegetables in my diet." B. "I will be sure to drink 2 Liter of fluid per day." C. "It is very common for me to experience diarrhea with this disease." D. "I will avoid taking Carbidopa/Levodopa with a protein rich meal."

B. "I will be sure to drink 2 Liter of fluid per day." D. "I will avoid taking Carbidopa/Levodopa with a protein rich meal."

A nurse is teaching a client with multiple sclerosis about the disease. Which statement by the client indicates to the nurse that further teaching is needed? A. "I avoid use of a straw to drink liquids." B. "I will take a hot bath to help relax my muscles." C. "I plan to use an incontinence pad when I go out." D. "I may be having a rough time now, but I hope tomorrow will be better."

B. "I will take a hot bath to help relax my muscles."

A client with a supratentorial tumor is scheduled for external radiation therapy to the brain. What should the nurse plan to teach the client? A. A low-residue diet will be prescribed. B. Feelings of extreme tiredness will occur. C. The standard amount of radiation is given. D. Loss of memory will occur after therapy begins.

B. Feelings of extreme tiredness will occur.

You're providing free education to a local community group about the signs and symptoms of Parkinson's Disease. Select all the signs and symptoms a patient could experience with this disease: A. Increased Salivation B. Loss of smell C. Constipation D. Tremors with purposeful movement E. Shuffling of gait F. Freezing of extremities G. Euphoria H. Coordination issues

B. Loss of smell C. Constipation E. Shuffling of gait F. Freezing of extremities H. Coordination issues

A client who was a passenger in an automobile collision is admitted to the emergency department with rhinorrhea and bleeding from the ear. The healthcare provider determines that the client has a basilar head injury. What should the nurse anticipate is the initial focus of care for this client? A. Physical therapy B. Psychosocial support C. Nutritional management D. Antimicrobial administration

D. Antimicrobial administration

A physician orders a patient to take Benztropine (Cogentin). The patient has never taken this medication before and is due to take the first dose at 1000. What statement by the patient requires you to hold the dose and notify the physician? A. "I forgot to tell the doctor I take eye drops for my glaucoma." B. "I had a PET scan last week." C. "I take aspirin once day." D. "My hands are experiencing tremors at rest."

A. "I forgot to tell the doctor I take eye drops for my glaucoma."

The nurse is teaching a client about caring for a hearing aid. Which statements made by the client indicates the need for further learning? Select all that apply. A. "I should always keep my hearing aid on." B. "I can adjust the volume of my hearing aid." C. "I should check and replace the battery frequently." D. "I can use hair sprays and hair oil while wearing a hearing aid." E. "I can clean the ear mold with a soap and water with limited wetting."

A. "I should always keep my hearing aid on." D. "I can use hair sprays and hair oil while wearing a hearing aid."

The nurse is teaching a client about self-ear irrigation for cerumen removal at home. Which statements made by the client indicate the nurse needs to follow up? Select all that apply. A. "I should fill the syringe with hot water." B. "I should use a designed ear syringe for wax removal." C. "I should decrease the pressure if I feel any ear pain." D. "I should use cotton to remove any extra water in my ear." E. "I should irrigate until at least a cup of solution has been washed out of my ear canal."

A. "I should fill the syringe with hot water." D. "I should use cotton to remove any extra water in my ear."

Which type of cranial surgery involves opening the cranium with a drill? A. Burr hole B. Craniotomy C. Craniectomy D. Cranioplasty

A. Burr hole

You're caring for a patient with Parkinson's Disease that has tremors. Select the option that is INCORRECT about tremors experienced in this disease: A. The tremors are most likely to occur with purposeful movements. B. A common term used to describe the tremors in the hands and fingers is called "pill-rolling". C. Tremors are one of the most common signs and symptoms in Parkinson's Disease. D. Tremors in this disease can occur in the hands, fingers, arms, legs and even the lips and tongue.

A. The tremors are most likely to occur with purposeful movements.

Which factors can trigger a client's migraine attacks? Select all that apply. A. Fatigue B. Vertigo C. Aphasia D. Sleep problems E. Tingling sensations F. Hormonal fluctuations

A. Fatigue D. Sleep problems F. Hormonal fluctuations

A patient is taking Rasagiline "Azilect" for treatment of Parkinson's Disease. What foods do the patient want to limit in their diet? Select all that apply: A. Liver B. Aged Cheese C. Sweetbread D. Beer E. Fermented foods F. Shellfish

B. Aged Cheese D. Beer E. Fermented foods

The nurse on a community terrorism response team is reviewing triage protocols. In contrast to triage policies used during local emergency situations occurring in the hospital, triage practices during mass casualty events do not prescribe treatment for clients who have which type of injury? A. Multiple fractures B. Closed head injuries C. Internal abdominal trauma D. Radiation/chemical exposures

B. Closed head injuries

An adult client is brought to the emergency department by a friend who states, "We were all partying at a club, and all of a sudden my friend collapsed." Vital signs revealed a temperature of 99.2° F, pulse of 152, respiratory rate of 32, blood pressure of 163/92. After performing a physical assessment and collecting a health history from the client, what action should the nurse take next? A. Reassess the client and allow the friend to stay. B. Inform the healthcare provider of the client's status and prepare to start an intravenous (IV) line. C. Assign the client to a private room and put a cool cloth on the client's forehead. D. Place the client in a dimly lit room and perform a neurologic assessment every 15 minutes.

B. Inform the healthcare provider of the client's status and prepare to start an intravenous (IV) line.

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours? A. Maintain comfort B. Prevent pressure ulcers C. Prevent flexion contractures of the extremities D. Improve venous circulation in the lower extremities

B. Prevent pressure ulcers

A registered nurse teaches a nursing student about cluster headaches. Which statement made by the nursing student indicates a need for further teaching? A. "Each episode of a cluster headache may last up to 3 hours." B. "Pupillary constriction occurs during the period of cluster headaches." C. "Pulsating pain is the characteristic type of pain that occurs in cluster headaches." D. "Cluster headaches occur for weeks to months followed by a period of remission."

C. "Pulsating pain is the characteristic type of pain that occurs in cluster headaches." (Sharp stabbing pain is the characteristic type of pain that occurs in cluster headaches.)

A client with myasthenia gravis asks the nurse, "What is going to happen to me and to my family?" Which information about what the client can anticipate should be incorporated into the nurse's response? A. High cure rate with proper treatment B. Slowly progressive course without remissions C. Chronic illness with exacerbations and remissions D. Poor prognosis, with death occurring in a few months

C. Chronic illness with exacerbations and remissions

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. A. Spasticity B. Incontinence C. Flaccid paralysis D. Respiratory failure E. Lack of reflexes below the injury

C. Flaccid paralysis E. Lack of reflexes below the injury

A client with C8 tetraplegia is admitted to the emergency room. The client develops a blood pressure of 80/40 mm Hg, pulse 48 beats/min, and respiratory rate (RR) of 18 breaths/min. The nurse suspects which condition? A. Autonomic dysreflexia B. Hemorrhagic shock C. Neurogenic shock D. Pulmonary embolism

C. Neurogenic shock

A client sustains a vertebral fracture at the T1 level and is admitted to the emergency department. During a detailed neurologic assessment, the nurse expects to identify which clinical manifestation? A. Difficulty breathing B. Inability to move the lower arms C. Normal biceps reflexes in the arms D. Loss of pain sensation in the hands

C. Normal biceps reflexes in the arms

A client has experienced an episode of myasthenic crisis. Upon review of the client history by the nurse, which finding will most likely be a precipitating factor of the myasthenic crisis? A. Getting too little exercise B. Taking excess medication C. Omitting doses of medication D. Increasing intake of fatty foods

C. Omitting doses of medication

As the nurse you know that Parkinson's Disease tends to affect the _____________ of the midbrain, which leads to the depletion of the neurotransmitter ________________. A. red nucleus, acetylcholine B. leminisci, norepinephrine C. substantia nigra, dopamine D. tectum nigra, dopamine

C. substantia nigra, dopamine

A client is admitted to the hospital with the diagnosis of a right-sided brain attack (stroke). The client is right-handed. Which task will be most difficult for this client? A. Eating meals B. Writing letters C. Combing the hair D. Dressing every morning

D. Dressing every morning

A nurse is caring for a client with a tumor of the cerebellum. What clinical manifestation does the nurse expect the client to exhibit? A. Absence of the knee-jerk reflex B. Change in level of consciousness C. Inability to execute voluntary movements D. Inability to execute coordinated movements

D. Inability to execute coordinated movements

The nurse is caring for a client two days after the client had a brain attack (cerebrovascular accident, CVA). To prevent the development of plantar flexion, which action should the nurse take? A. Place a pillow under the thighs. B. Elevate the knee gatch of the bed. C. Encourage active range of motion. D. Maintain the feet at right angles to the legs.

D. Maintain the feet at right angles to the legs.

A client is having a tonic-clonic seizure. Which is a priority nursing action? A. Elevating the head of the bed B. Restraining the client's arms and legs C. Placing a tongue blade in the client's mouth D. Taking measures to prevent injury

D. Taking measures to prevent injury