Neuro 1 MC

Which neurological check finding does the nurse recognize as an early indicator of declining neurologic status? A. Change in level of consciousness B. Nonreactive and dilated pupils C. Loss of remote memory D. Decorticate posturing

A. Change in level of consciousness

Which type of neuron is the nurse assessing when asking a client to lift one leg and then the other? A. Motor B. Sensory C. Afferent D. Synaptic knob

A. Motor

What is the nurse's best action when caring for a client after craniotomy and finding the dressing is saturated and the Hemovac drainage is 100 mL over 8 hours? A. Notify the surgeon immediately. B. Reinforce the dressing with sterile gauze. C. Record the Hemovac drainage on the intake and output sheet. D. Check the drainage on the dressing for a halo effect.

A. Notify the surgeon immediately.

With which interprofessional healthcare member will the nurse collaborate to assess a client's strength? A. Physical therapist B. Orthopedic surgeon C. Skin care specialist nurse D. Neurology technician

A. Physical therapist

Which issue does the nurse consider a priority when caring for a client diagnosed with atonic (akinetic) seizures? A. Possibility of injury related to falls B. Limited mobility related to lack of tonicity of muscles C. Confusion related to postictal period D. Organ ischemia related to decreased perfusion

A. Possibility of injury related to falls

Which assessment finding indicates to the nurse that a client's reticular activating system (RAS) is functioning normally? A. The client awakens from sleep in response to a loud noise. B. The client can move all four extremities. C. The client's respirations are within normal range. D. The client can sense sharp and dull stimuli

A. The client awakens from sleep in response to a loud noise.

What is the most important reason that the nurse asks a client whether he or she is right-handed or left-handed during neurologic assessment? A. The client may be stronger on the dominant side, which is expected. B. The client should be encouraged to strengthen and rely on the dominant side. C. Effects of a neurologic event will be worse if the nondominant side is involved. D. This information is part of all standard databases for older clients.

A. The client may be stronger on the dominant side, which is expected.

When assessing sensation, why does the nurse make a clinical judgment decision to forgo assessing pain sensation for a client with Guillain-Barré syndrome (GBS)? A. The client's temperature sensation is intact. B. Sensory function assessment is routinely completed at 4-hour intervals. C. Only clients with spinal trauma require completion of this assessment. D. Clients with GBS are often too confused to respond appropriately

A. The client's temperature sensation is intact.

What is the nurse's best first action when a client who had a craniotomy develops periorbital edema and ecchymosis? A. Immediately notify the surgeon. B. Apply cold compresses. C. Check pupillary response. D. Perform a focused neurologic assessment

B. Apply cold compresses.

For which client does the nurse avoid harm by not performing a sharp and dull sensory for pain assessment? A. Client with pulses that are not palpable in the distal extremities B. Client who is prescribed anticoagulant therapy and bruises easily C. Client who is sensitive to pain and temperature changes D. Client who is unable to move the affected or injured side

B. Client who is prescribed anticoagulant therapy and bruises easily

For which client would the healthcare provider avoid harm by not performing a lumbar puncture? A. Client who is unable to ambulate B. Client with severe increase in intracranial pressure C. Client with hyperactive deep tendon reflexes D. Client with muscle weakness in all four extremities

B. Client with severe increase in intracranial pressure

How does the nurse interpret a serum sodium finding of 126 mEq/L (126 mmol/L) for a client with bacterial meningitis? A. An early warning sign that the electrolyte imbalance will potentiate an acute myocardial infarction B. Evidence of syndrome of inappropriate antidiuretic hormone which is a complication of bacterial meningitis C. Within normal limits considering the diagnosis of bacterial meningitis but test should be repeated looking for downward trend D. A protective measure that causes increased urination and therefore reduces the risk of increased intracranial pressure

B. Evidence of syndrome of inappropriate antidiuretic hormone which is a complication of bacterial meningitis

Which change will the nurse expect to observe when a client's sympathetic nervous system is stimulated? A. Increased salivation B. Increased heart rate C. Myoclonus in the muscles D. Hyperactive deep tendon reflexes

B. Increased heart rate

Which concept is most directly related to the nurse's teaching a client about smoking cessation to maintain or improve nervous system health? A. Comfort B. Perfusion C. Mobility D. Cognition

B. Perfusion

Which action will the nurse consider the highest priority when caring for a client who is currently experiencing a migraine headache? A. Avoiding environmental triggers of migraine headaches B. Providing pain management for client C. Assessing the client for visual symptoms D. Detecting a pre-migraine aura

B. Providing pain management for client

Which statement by a client indicates understanding of the use of a disc-shaped wafer (car-mustine) as part of treatment for a brain tumor? A. "I'll place the wafer under my tongue and allow it to completely dissolve." B. "The wafer must be dissolved in water and taken with my morning meals." C. "The wafer will be placed directly into the cavity created during removal of my tumor." D. "The wafer will be taped to my chest and the drug absorbed through my skin

C. "The wafer will be placed directly into the cavity created during removal of my tumor."

Which teaching strategy is best for the nurse to use when instructing an older adult about medications and lifestyle changes? A. Relate the information to recent events. B. Provide teaching late in the afternoon. C. Allow extra time for teaching and questions. D. Give limited and simplified information.

C. Allow extra time for teaching and questions.

Which reaction indicates to the nurse that a client has a cerebral or brainstem reason for muscle weakness when asked to close his or her eyes and hold arms perpendicular to the body with palms up for 15 to 30 seconds? A. Arms, wrists, and fingers are flexed with internal rotation B. Abnormal movement with rigidity and extension of the arms C. Arm on client's weak side drifts with the palm turning inward D. Dorsiflexion of the thumb and spreading of the other fingers

C. Arm on client's weak side drifts with the palm turning inward

Which cranial nerve does the nurse suspect is involved when a client reports severe, intermittent facial pain? A. Cranial nerve I B. Cranial nerve III C. Cranial nerve V D. Cranial nerve VII

C. Cranial nerve V

Which laboratory result would the nurse notify the radiology department and health care provider about for a client who is scheduled to have a computed tomography (CT) scan with contrast media? A. Blood glucose higher than baseline B. Decreased white blood cell count C. Elevated creatinine level D. Abnormal urobilinogen level

C. Elevated creatinine level

Which intervention will the nurse implement for a client who has a migraine headache with phonophobia? A. Ensure that the staff knows that the client will need help with ambulation. B. Dim the lights in the client's room and close the curtains. C. Place the client in a quiet room and instruct the staff to minimize noise. D. Increase the amount of ambient light to make it easier for the client to see.

C. Place the client in a quiet room and instruct the staff to minimize noise.

What would be the priority concern when the nurse asks a client to stand with arms at the sides, feet and knees close together, and eyes open, then close his or her eyes and maintain position; and the nurse notes client swaying only when the eyes are closed? A. Difficulty with performance of activities of daily living B. Potential for brainstem injury C. Possible falls related to lack of awareness of body position D. Functional incontinence due to difficulty with ambulation

C. Possible falls related to lack of awareness of body position

What is the nurse's priority concern when a client has an ischemic brainstem stroke with damage to the medulla area of the brain? A. Increased intracranial pressure B. Seizure activity C. Respiratory arrest D. Brainstem herniation

C. Respiratory arrest

Which priority assessment should be addressed next after the emergency department (ED) staff has assessed airway, breathing, and circulation (ABCs) in a client who sustained a head trauma with multiple injuries? A. Check for peripheral sensation. B. Stabilize long bone fractures. C. Rule out cervical spine fracture. D. Determine cerebral artery blockage.

C. Rule out cervical spine fracture.

Which statement by a client indicates to the nurse lack of correct understanding about information provided regarding cerebral angiography? A. "I must not have anything to eat or drink for at least 4 to 6 hours before the procedure." B. "I will not be able to move my head during the procedure." C. "I will feel a warm sensation when the contrast dye is injected into my IV." D. "I will not be able to talk to anyone during the procedure

D. "I will not be able to talk to anyone during the procedure

Which client does the nurse find at the greatest disadvantage with regard to the blood-brain barrier (BBB)? A. Client with pneumonia who needs supplemental oxygen B. Client who is dehydrated and needs IV fluids to correct fluid status C. Client in need of major surgery and requires general anesthesia D. Client with bacterial meningitis in need of antibiotics

D. Client with bacterial meningitis in need of antibiotics

What is the nurse's first priority action when assessing a client and finding unilateral loss of motor function and sensation? A. Apply oxygen at 2 L per nasal cannula. B. Order a stat computed tomography scan. C. Place the client in semi-Fowler position. D. Immediately notify the health care provider

D. Immediately notify the health care provider

How will the nurse prepare a client for an electroencephalogram test? A. Encourage extra fluids during the evening before the test. B. Give the client a sedative before bedtime for sleep. C. Give nothing by mouth but ice chips after midnight. D. Instruct the assistive personnel to wash the client's hair

D. Instruct the assistive personnel to wash the client's hair

What priority teaching will the nurse provide for a client on migraine preventive therapy who is taking a beta blocker and a calcium channel blocker drug? A. Move slowly when getting out of bed. B. Use handrails whenever possible. C. Avoid calcium-based foods. D. Learn to check your pulse.

D. Learn to check your pulse.

Which diagnostic test does the emergency department nurse anticipate for a client admitted with headache, fever, nausea, and light sensitivity, and who has been living with two people recently diagnosed with meningitis? A. Skull x-rays B. Myelography C. Cerebral angiogram D. Lumbar puncture

D. Lumbar puncture

Which is the best interpretation of client neurological assessment documentation that reads PERRLA? A. Peripheral nervous system is reactive and responsive when activated. B. Parasympathetic nervous system is responsible for reproductive actions. C. Pulses are equal in right arm and right leg and client is ambulatory. D. Pupils are equal in size, round, regular, and react to light and accommodation.

D. Pupils are equal in size, round, regular, and react to light and accommodation.

What is the nurse's best action when a client is having a generalized tonic-clonic seizure and becomes cyanotic? A. Raise the head of the bed and apply oxygen by nasal cannula. B. Suction the client and alert the Rapid Response Team. C. Call the health care provider and obtain intubation equipment. D. Stay with the client because the cyanosis is usually self-limiting.

D. Stay with the client because the cyanosis is usually self-limiting.

Which medication prescription will the nurse clarify before administering it to a client? A. Gabapentin for a client who has partial seizures B. Diazepam rectal gel for a client with status epilepticus C. Carbamazepine for a client with tonic-clonic seizures D. Warfarin for a client who takes phenytoin for seizures

D. Warfarin for a client who takes phenytoin for seizures