NCLEX Neuro

The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which assessment question?

"Are you getting up at night to urinate?"

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply.

2Hyperoxygenating before suctioning 4Maintaining the head and neck in midline position 5Maintaining the head of the bed (HOB) at 30 degrees elevation

A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse would take which actions? Select all that apply.

2Thickening liquids to the consistency of oatmeal 3Placing food on the unaffected side of the mouth 4Allowing plenty of time for chewing and swallowing

The nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are part of the circle of Willis? Select all that apply.

3Anterior cerebral artery 4Internal carotid arteries 5Posterior cerebral artery

An older client in an acute state of disorientation is brought to the hospital emergency department by the client's daughter. The daughter states that the client was "clear as a bell this morning." The nurse determines from this piece of information that which is an unlikely cause of the disorientation?

Alzheimer's disease

The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse would incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech?

Associated with poor comprehension

The nurse is caring for a client who had a stroke and is experiencing a neurological deficit involving the hippocampus. On assessment of the client, which signs and symptoms would most likely be noted?

Cannot recall what was eaten for breakfast today

The nurse reviews the primary health care provider's (PHCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the PHCP would the nurse question?

Clear liquid diet

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP?

Confusion

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?

Consistently uses adaptive equipment in dressing self

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse would bring which most essential items into the client's room?

Electrocardiographic monitoring electrodes and intubation tray

A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client would the nurse be most concerned about?

Emphysema

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration?

Establishing a toileting schedule

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves?

Eye movements

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

Fluid separates into concentric rings and tests positive for glucose.

The nurse is providing discharge education to a client diagnosed with trigeminal neuralgia. Which medication will likely be prescribed upon discharge for this condition?

Gabapentin

The nurse is positioning a client who has increased intracranial pressure as a result of a head injury. Which position would the nurse plan to avoid?

Head turned to the side

The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What would the nurse assess for when monitoring for gastrointestinal complications?

Hematest-positive nasogastric tube drainage

A client brought to the emergency department had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what would the nurse include in the client's assessment?

History of prior trauma

A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, would the nurse identify as being unrelated to the exacerbation?

Ingestion of increased fruits and vegetables

The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action?

Initiating a bowel movement every other day, 45 minutes after the largest meal of the day

The nurse is creating a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which would the nurse include in the plan of care for the client?

Instruct the client to turn the head to scan the right visual field.

A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse would include which client problem in the plan of care?

Interruption in physical mobility

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client?

Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse would instruct the client about the importance of returning to the clinic for monitoring of which laboratory study?

Liver function studies

The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern?

Lung vital capacity of 10 mL/kg

The nurse is caring for a client with bacterial meningitis. The nurse would anticipate that an antibiotic with which characteristics will be prescribed for the client?

One that is able to cross the blood-brain barrier

A client had a transsphenoidal resection of the pituitary gland to remove a pituitary tumor. The nurse notes drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse would look for drainage that is of which characteristic?

Serosanguineous, surrounded by clear to straw-colored fluid

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction?

Sounds will not be heard clearly unless they are loud.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record?

The client experienced paresthesias a few days before admission to the hospital.

The nurse is caring for a client who appears agitated. What first approach would the nurse take to assess this client for agitation?

Use the Richmond Agitation-Sedation Scale (RASS) tool.

The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit specific information regarding this client's disorder?

"Are you having any difficulty chewing food?"

The nurse suspects a client is showing signs of delirium. Which question would the nurse ask the client first to assess for delirium?

"Do you know where you are?"

A client is somewhat nervous about undergoing magnetic resonance imaging (MRI). Which statement by the nurse would provide the most reassurance to the client about the procedure?

"Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure."

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement?

"Going to the beach will be a nice, relaxing form of activity."

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke?

"Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client experiencing chronic pain following a musculoskeletal injury, and the nurse instructs the client about the purpose of the TENS unit. Which statement by the client indicates the need for further teaching?

"Hospitalization is required because the unit is not portable."

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching?

"I can change the time of my medication on the mornings when I feel strong."

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?

"I don't need to use my walker to get to the bathroom."

The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs further teaching if the client makes which statements?

"I will expose my face to cold to decrease the pain."

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?

"I'll try to eat my food either very warm or very cold."

The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse would plan to ask the client which question to elicit the most specific information regarding this disorder?

"Is the pain experienced a stabbing type of pain?"

The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" The nurse would plan to make which appropriate response to the client?

"Pain is due to stimulation of the affected nerve by pressure and temperature."

A new registered nurse (RN) is assisting the RN in admitting a client who has a diagnosis of hypothermia. The RN provides education to the new RN on anticipated vital signs in the client with hypothermia. Which statement by the new RN indicates that the teaching has been effective?

"The client will likely exhibit decreased heart rate and decreased blood pressure."

A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client?

"This is not a stroke, and many clients recover in 3 to 5 weeks."

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home?

"Was the client awake and talking right after the injury?"

The nurse has instructed the family of a client with a stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?

"We need to encourage head turning to scan the lost visual field."

The home health nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals related to decreased muscle strength. Which suggestions would the nurse give to the client? Select all that apply.

1Chew food thoroughly. 2Cut food into very small pieces. 4Sit straight up in the chair while eating. 5Swallow when the chin is tipped slightly downward to the chest.

The nurse is planning to perform an assessment of the client's level of consciousness following a head injury using the Glasgow Coma Scale. Which assessments would the nurse include in order to calculate the score? Select all that apply.

1Eye opening 3Best verbal response 4Best motor response

The nurse is caring for a client who has become increasingly agitated. The nurse knows that which finding(s) most likely would contribute to the client's agitation? Select all that apply.

1Full bladder 2Postoperative pain 3Separation from family 4Uncomfortable position

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply.

1Giving tepid sponge baths 2Applying a hypothermia blanket 4Administering acetaminophen per protocol

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific primary health care provider prescriptions, the nurse would place the client in which positions? Select all that apply.

1Head midline 2Neck in neutral position 4Head of bed elevated 30 to 45 degrees

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply.

1Keep suction equipment at the bedside. 2Elevate the head of the bed 30 degrees. 4Keep the head and neck in good alignment. 5Administer prescribed respiratory treatments as needed.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.

1Keeping the linens wrinkle-free under the client 2Preventing unnecessary pressure on the lower limbs 4Turning and repositioning the client at least every 2 hours

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions would the nurse take? Select all that apply.

1Loosening restrictive clothing 3Removing the pillow and raising padded side rails 4Positioning the client to the side, if possible, with the head flexed forward

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions would the nurse take? Select all that apply.

1Loosening restrictive clothing. 3Removing the pillow and raising padded side rails. 4Positioning the client to the side, if possible, with the head flexed forward.

A client is experiencing delirium with associated clinical findings of disorientation, abnormal thought processes, and inappropriate behavior. Which interventions can the nurse implement to best manage the client's delirium? Select all that apply.

1Maintain the client's safety 4Delirium monitoring with a standardized tool 5Cluster nursing care to allow for uninterrupted sleep periods

The nurse is caring for a client with an intracranial aneurysm who has been alert. Which signs and symptoms are an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply.

1Mild drowsiness 4Slight slurring of speech 5Less frequent spontaneous speech

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures would the nurse include in planning for the client's safety? Select all that apply.

1Padding the side rails of the bed 2Placing an airway at the bedside 5Placing oxygen and suction equipment at the bedside 6Flushing the intravenous catheter to ensure that the site is patent

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures would the nurse include in planning for the client's safety? Select all that apply.

1Padding the side rails of the bed. 2Placing an airway at the bedside. 5Placing oxygen and suction equipment at the bedside. 6Flushing the intravenous catheter to ensure that the site is patent.

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply.

1Postictal status 2Duration of the seizure 3Changes in pupil size or eye deviation 4Seizure progression and type of movements

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention would be included in the care plan for this client? Select all that apply.

1Provide oral hygiene after each meal. 2Assess swallowing ability frequently. 3Allow the client sufficient time to eat. 4Maintain a suction machine at the bedside.

The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply.

1Provide physical aspects of care. 2Prevent pushing or straining activities. 5Maintain the head of the bed at 15 degrees.

The nurse is planning care for a client who displays confusion secondary to a brain attack (stroke). Which approaches by the nurse would be helpful in assisting this client? Select all that apply.

1Providing sensory cues 2Giving simple, clear directions 3Providing a stable environment 4Keeping family pictures at the bedside

The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply.

1Speaking to the client at a slower rate 2Allowing plenty of time for the client to respond 4Looking directly at the client during attempts at speech

The nurse is evaluating the respiratory outcomes for a client with Guillain-Barré syndrome. The nurse determines that which are acceptable outcomes for the client? Select all that apply.

1Spontaneous breathing 2Oxygen saturation of 98% 4Normal arterial blood gas levels 5Vital capacity within normal range

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.

1The client is aphasic. 2The client has weakness on the right side of the body. 4The client has weakness on the right side of the face and tongue.

The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which would the nurse include in the plan? Select all that apply.

1Thicken liquids. 2Assist the client with eating. 3Assess for the presence of a swallow reflex. 5Provide ample time for the client to chew and swallow.

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

1Time the seizure. 3Stay with the child. 5Move furniture away from the child.

The client with a cervical spine injury has cervical tongs applied in the emergency department. What would the nurse include when planning care for this client? Select all that apply.

1Using a RotoRest bed 2Ensuring that weights hang freely 4Assessing the integrity of the weights and pulleys 5Comparing the amount of prescribed traction with the amount in use

The nurse is caring for a client with a head injury who has an intracranial pressure (ICP) monitoring device. The nurse would become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding?

22 mm Hg

A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse would include which interventions in the plan of care to maintain client safety after this procedure? Select all that apply.

2Keep the head of the bed flat. 3Place pillows under the length of the legs. 4Use a logrolling technique for repositioning. 5Assist the client with eating meals and drinking fluids.

The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions would be included in the plan? Select all that apply.

2Place a blood pressure cuff at the client's bedside. 3Close the shades in the client's room during the day.

The nurse is administering mouth care to an unconscious client. The nurse would perform which actions in the care of this person? Select all that apply.

2Position the client on his or her side. 3Brush the teeth with a small, soft toothbrush. 4Cleanse the mucous membranes with soft sponges.

A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply.

3Hypoxia 4Ischemia 5Hypotension 6Increased intracranial pressure (ICP)

The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client?

400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client?

A cervical spinal cord injury

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process?

A chronic disability characterized by impaired muscle movement and posture

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even-tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem?

A long-term sequela of the injury

The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional?

A neuropsychologist

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery?

A positive Brudzinski's sign

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation?

A significant sway when the client stands erect with feet together, arms at the sides, and the eyes closed

A client with a herniated disk who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to which member of the health care team?

A social worker

A client has slight weakness in the right leg. On the basis of this assessment finding, the nurse determines that the client would benefit most from the use of which item?

A straight leg cane

A client with myasthenia gravis has become increasingly weaker. The primary health care provider 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 is administered. Which finding would indicate that the client is in cholinergic crisis?

A temporary worsening of the condition

The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client who sustained a head injury. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How would the nurse document these findings?

Abnormal

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse would perform which action?

Acknowledge the client's anger and continue to encourage participation in care.

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?

Affect is flat, with periods of emotional lability

The nurse is evaluating a function of the limbic system as a part of the neurological status of a client. What would the nurse assess?

Affect or emotions

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem?

Altered breathing pattern

The nurse is caring for a client diagnosed with bacterial meningitis. Which clinical manifestation would the nurse monitor for, indicating increased intracranial pressure?

Altered mental status

A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse would keep which most important items available at the client's bedside?

Ambu bag and suction equipment

The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client who sustained a head injury. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation?

An intact brainstem

The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the appropriate nursing intervention?

Assist the client to eat with the left hand to build strength.

The nurse is assessing the client's gait and notes that it is unsteady and staggering. Which description would the nurse use when documenting the assessment finding?

Ataxic

A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The primary health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis?

Atropine sulfate

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What would the nurse immediately suspect?

Autonomic dysreflexia (hyperreflexia)

The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which would the nurse instruct the client to do?

Avoid activities that may cause pressure near the face.

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. The nurse would expect to note documentation of which early symptom of this disease?

Balance and coordination problems

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse would ask the client if the pain is worsened or aggravated by which factor?

Bending or lifting

The nurse in the neurological unit is monitoring a client with a head injury for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item?

Blood pressure

A 5-year-old child arrives at the emergency department, and the child's parents state that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

Bradycardia

At 8:00 a.m., a client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98° F (37.2° C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99° F (36.7° C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse would take which action first?

Call the primary health care provider (PHCP).

The nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication would the nurse anticipate to be prescribed?

Chlorpromazine

The nurse is assessing a client's muscle strength and notes that when asked, the client cannot maintain the hands in a supinated position with the arms extended and eyes closed. How would the nurse correctly document this finding on the medical record?

Client is exhibiting pronator drift.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?

Cloudy CSF, elevated protein, and decreased glucose levels

A client who suffered a brain attack (stroke) is prepared for discharge from the hospital. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action would the nurse include in the client's plan of care?

Consider the use of active, passive, or active-assisted exercises in the home.

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate?

Contact the primary health care provider (PHCP).

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition would the nurse document?

Damage to the auditory association areas

The nurse is performing an assessment on a client with a head injury and notes that the client is assuming this posture. The nurse contacts the primary health care provider and reports that the client is exhibiting which posture? Refer to figure.

Decorticate rigidity

A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client?

Decreased heart rate and decreased blood pressure

The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse reviews the primary health care provider's documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome?

Development of progressive muscle weakness

A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom?

Difficulty closing the eyelid on the affected side

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention would the nurse plan to implement?

Draw blood for arterial blood gas analysis.

The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs further teaching if the client states an intention to take which action?

Drink alcohol in small amounts and only on weekends.

Which assessment finding would the nurse expect to note in the client hospitalized with a diagnosis of brain attack (stroke) who has difficulty chewing food?

Dysfunction of trigeminal nerve (cranial nerve V)

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse would bring which most essential items into the client's room?

Electrocardiographic monitoring electrodes and intubation tray

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action would the nurse take?

Elevate the head of the bed.

A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family had hoped. The nurse plans to implement which approach as most helpful to the client and family at this time?

Emphasize progress in a realistic manner.

The nurse is caring for a client who is on bed rest as part of aneurysm precautions. The nurse would plan to avoid taking which action when giving respiratory care to this client?

Encouraging hourly coughing

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

Exhaling during repositioning

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention would the nurse plan to incorporate into the care routine for the client and family?

Explaining equipment and procedures on an ongoing basis

The nurse is assessing the function of cranial nerve XII in a client who sustained a brain attack (stroke). To assess function of this nerve, which action would the nurse ask the client to perform?

Extend the tongue.

The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse would expect to observe which finding in the client?

Facial drooping

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?

Flaccid paralysis

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How would the nurse document the Glasgow Coma Scale (GCS) score?

GCS = 9

The nurse has taught a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that further teaching is needed if the client states the need to take which action?

Get out of bed by sitting straight up and swinging the legs over the side of the bed.

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse would place the client in which position postoperatively?

Head of bed elevated 30 to 45 degrees, head and neck midline

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse would place the client in which position?

Head of the bed elevated 30 degrees with the head in midline position

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. On the basis of these findings the nurse suspects dysfunction in which area of the brain?

Hypothalamus

The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly?

Hypothalamus

The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest in Williams' position to minimize the pain. The nurse would put the bed in what position?

In semi-Fowler's position, with the knees slightly flexed

The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and would tell the spouse to report which side effect if it occurs?

Inability to urinate

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse would include activities that will achieve which outcome?

Increase the client's awareness of the affected side.

The nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath sounds. Which judgment would the nurse formulate for the client?

Increased risk for aspiration

The nurse is caring for a client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action?

Indicates that facial puffiness will be a permanent problem

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding?

Ipsilateral paralysis and loss of touch and vibration

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse would make which interpretation?

Is likely to have perceptual and spatial disabilities

The nurse is planning discharge teaching for a client started on acetazolamide for a supratentorial lesion from a head injury. Which information about the primary action of the medication would be included in the client's education?

It decreases cerebrospinal fluid production.

Members of the family of an unconscious client with increased intracranial pressure from a head injury are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation?

It is possible the client can hear the family.

A client with chronic obstructive pulmonary disease who sustained a head injury has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2?

It will cause vasodilation of blood vessels in the brain.

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)?

Leaving the client in an unchilled area of the room

The nurse in the neurological unit is caring for a client with a supratentorial lesion from a brain injury. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction?

Level of consciousness

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action?

Listen to breath sounds.

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention would be included in the plan of care?

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How would the nurse interpret this information?

Meal choices represent an area of client control and need to be encouraged as much as is nutritionally reasonable.

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?

Meningitis

The nurse is reviewing the record for a client seen in the health care clinic and notes that the primary health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder would the nurse expect to see documented in the record?

Mild clumsiness

A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that family members need further teaching if they verbalize to call the primary health care provider (PHCP) for which client sign or symptom?

Minor headache

A thymectomy accomplished via a median sternotomy approach is performed in a client with a diagnosis of myasthenia gravis. The nurse creates a postoperative plan of care for the client that would include which intervention?

Monitor the chest tube drainage.

The nurse is evaluating the use of a cane for a client who sustained a stroke who has residual left-sided weakness. The nurse would intervene and correct the client if the nurse observed that the client performs which action?

Moves the cane when the right leg is moved

The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition?

Muscle spasm in the area of the herniated disk

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the pediatrician's prescriptions and would contact the pediatrician to question which prescription?

Nasotracheal suction as needed.

The nurse is monitoring a client with a suspected intervertebral disc problem who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the primary health care provider (PHCP)?

Neck stiffness

The nurse is caring for a client diagnosed with Alzheimer's disease. The nurse would anticipate that the client has changes in which component of the nervous system?

Neuronal dendrites

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate?

Notify the primary health care provider (PHCP).

A client with multiple sclerosis tells a home health care nurse about having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action?

Observe the client demonstrating the transfer technique.

The home care nurse is visiting a client who is recovering at home after suffering a stroke 2 weeks ago. The client's spouse states that the client has difficulty feeding themself and difficulty with swallowing food and fluids. Which would be the initial nursing action?

Observe the client feeding themself.

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor?

Omitting doses of medication

The nurse is preparing for the admission to the unit of a client with a diagnosis of seizures and asks the nursing student to institute full seizure precautions. Which item if noted in the client's room would need to be removed and warrants the need to review seizure precautions with the student?

Padded tongue blade

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges?

Pao2 80 to 100 mm Hg, Paco2 35 to 38 mm Hg

A client with a traumatic brain injury is able, with eyes closed, to identify a set of keys placed in their hands. On the basis of this assessment finding, the nurse determines that there is appropriate function of which lobe of the brain?

Parietal

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention?

Place the client in a sitting position.

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action?

Placing the client on a bed that provides spinal immobilization

A client with neck and upper extremity pain has been diagnosed with cervical radiculitis. What does the nurse anticipate as being the cause of these clinical manifestations?

Pressure on a spinal nerve root

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse would use which technique to test the client's peripheral response to pain?

Pressure on nail beds

A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted?

Problem with understanding language

The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client?

Prohibit or limit the use of a radio or television and reading.

The nurse is preparing to care for a client with suspected meningitis after a lumbar puncture. The nurse would plan to place the client in which best position following the procedure?

Prone with a small pillow under the abdomen

The client has an impairment of cranial nerve II. Specific to this impairment, what would the nurse plan to do to ensure client safety?

Provide a clear path for ambulation without obstacles.

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and would include which intervention in the plan?

Providing a quiet atmosphere with dimmed lighting

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness?

Providing information, giving positive feedback, and encouraging relaxation

A client who has experienced a stroke has partial hemiplegia of the left leg. The nurse interprets that the client could benefit from the support and stability provided by which item?

Quad cane

The nurse cares for a client immediately following a lumbar laminectomy procedure. The client reports numbness and tingling down the left lateral thigh and knee. What is the next action for the nurse to take?

Question the client about preoperative symptoms.

At the beginning of the work shift, the nurse assesses the status of a client wearing a halo device. The nurse determines that which assessment finding requires intervention?

Red skin areas under the jacket

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP?

Reduce room noise.

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Reposition the infant frequently.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease?

Respiratory or gastrointestinal infection during the previous month

At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's airway is patent if which data are identified?

Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear

The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan?

Restrict fluid intake for a period of 2 hours.

The nurse is assessing the client's level of consciousness and documents that the client has delirium. On the basis of this documentation, the nurse would determine that there is damage to which area of the nervous system?

Reticular activating system and cerebral hemispheres

The nurse is reviewing the record of a child with increased intracranial pressure from a head injury and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

Rigid extension and pronation of the arms and legs

The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse would plan to place the client in which position?

Semi-Fowler's

The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client would most likely be maintained in which position?

Semi-Fowler's position

The nurse is assessing fluid balance in a client with a head injury who has undergone a craniotomy. The nurse would assess for which finding as a sign of overhydration, which would aggravate cerebral edema?

Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)

The nurse is teaching a client with paraplegia from a spinal cord injury measures to maintain skin integrity. Which instruction will be most helpful to the client?

Shift weight every 2 hours while in a wheelchair.

The nurse is caring for a client with Parkinson's disease. Which finding about gait would the nurse expect to note in the client?

Shuffling and propulsive

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure?

Spasms of the entire body

A client who had a brain attack (stroke) has suffered damage to Broca's area of the brain. Which priority assessment would the nurse perform?

Speech

The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What would the nurse anticipate to promote during the bowel retraining program?

Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) needs to be placed at the child's bedside?

Suctioning equipment and oxygen

A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse determines that the client's clinical manifestations are due to what type of physiological response?

Sympathetic nervous system

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?

Taking medications as scheduled

A client who had a stroke (brain attack) has right-sided hemianopsia. What would the nurse plan to do to help the client adapt to this problem?

Teach the client to scan the environment.

The nurse caring for a client notes that the client has become disoriented and is displaying inappropriate behavior. The nurse is concerned about this new finding because of its sudden onset. The nurse recognizes that which condition is most likely occurring?

The client is experiencing delirium.

The nurse is caring for a client who was admitted for a stroke (brain attack) of the temporal lobe. Which clinical manifestations would the nurse expect to note in the client?

The client will have difficulty understanding language.

The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse would document which desired outcome in the plan of care?

The client's fingers and toes are warm to touch.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition would the nurse document?

The intracranial pressure reading is normal.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area?

The left side of the body

The nurse is caring for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care?

Use strict aseptic technique when touching the monitoring system.

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. On the basis of these findings, the nurse determines that the client is experiencing parasympathetic stimulation of which cranial nerve?

Vagus (CN X)

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The client asks for a snack and something to drink. The nurse would plan to offer which best snack to the client?

Vanilla wafers and room-temperature water

A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment?

Vision

An older client is brought to the hospital emergency department by a neighbor who heard the client talking and found him wandering in the street at 3 a.m. The nurse would first determine which data about the client?

Whether this is a change in usual level of orientation

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse would place the client with an incision in the anterior or middle fossa in which position?

With the head of the bed elevated at least 30 degrees

The nurse is testing the spinal reflexes of a client during neurological assessment. Which assessment by the nurse would help to determine the adequacy of the spinal reflex?

Withdrawal reflex