NEURO ADAPTIVE QUIZ 1

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? A. Nausea B. Lethargy C. Sunset eyes D. Hyperthermia

B

A registered nurse (RN) must assess the body temperature of a client with a history of epilepsy. Which site for measuring temperature is contraindicated in this client? A. Skin B. Axilla C. Oral cavity D. Temporal artery

C

The nurse is performing a neurologic assessment on a client and is completing the Glasgow Coma Scale (GCS). What components make up this assessment tool? Select all that apply. A. Best verbal response B. Best pupillary response C. Best motor response D. Best eye-opening response E. Best cognitive response A. A, B, C B. D, E, C C. A, C, D D. A, B, E

C

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

C

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record? A. "Has intact plantar reflexes" B. "Exhibits a positive Babinski sign" C. "Demonstrates normal sensory function" D. "Able to perform active range of motion"

B

What therapeutic effect does the nurse expect to identify when mannitol is administered parenterally to a client with cerebral edema? A. Improved renal blood flow B. Decreased intracranial pressure C. Maintenance of circulatory volume D. Prevention of the development of thrombi

B

When caring for a client who has sustained a closed head injury, it is important that the nurse assess for which clinical indicator(s)? Select all that apply. A. Slowing of the heart rate B. Diminished carotid pulses C. Bleeding from the oral cavity D. Absence of deep tendon reflexes E. Increased pulse pressure F. Altered level of consciousness A. A, B, C, D, E, F B. A, B, E, F C. A, C, E, F D. A, C, D, E

C

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. Which diagnostic test result will the nurse check for confirmation of this diagnosis? A. Myelography B. Lumbar puncture C. Electromyography D. Computed tomography

D

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

After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which clinical indicators should the nurse monitor the client? Select all that apply. A. Polyuria B. Insomnia C. Bradycardia D. Increased weight E. Decreased serum sodium F. Decreased level of consciousness A. A, B, C B. D, E, F C. A, B, C, D, E, F D. A, B, E, F

B

A client who had a brain attack (stroke) is admitted to the hospital with right-sided hemiplegia. For what reason does the nurse recognize the importance of identifying restrictions of mobility or neuromuscular abnormalities? A. Shortening and eventual atrophy of the muscles will occur. B. Hypertrophy of the muscles eventually will result from disuse. C. Rigid extension can occur, making therapy painful and difficult. C. Decreased movement on the affected side predisposes the client to infection

A

A client with migraine headaches is admitted for an electroencephalogram (EEG). Which statement made by the client assures the nurse that preprocedure teaching has been effective? A. I will need to avoid caffeine. B. I will have a headache after the test C. I will need to avoid milk until the test is completed D. I will be able to take my sleeping pill before the test.

A

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take? A. Assess the client's airway. B. Place pads on the side rails C. Notify the healthcare provider. D. Leave and obtain the crash cart

A

The nurse is caring for a client who underwent surgery for a brain tumor. On assessment, the nurse suspects meningitis in the client. Which finding would help confirm the nurse's suspicion? A. Positive Kernig sign B. Glasgow coma score: 10 C. Absence of nuchal rigidity D. Negative Brudzinski sign

A

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, where does the nurse suspect the tumor is located? A. Cerebellum B. Parietal lobe C. Basal ganglia D. Occipital lobe

A

Which radiologic study is used to obtain radiographic images of the client's brain for three-dimensional intracranial contents? A. Electromyography B. Cerebral angiography C. Computed tomography (CT) D. Transcranial doppler

C

Which information should be included in the teaching plan for the client diagnosed with epilepsy? A. Antiseizure medication must be taken for life. B. People taking phenytoin must floss regularly. C. People with epilepsy can never be issued a driver's license. D. Loss of consciousness during a seizure requires emergency evaluation

B

What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? A. Place objects within the visual field. B. Teach passive range-of-motion exercises C. Instill artificial teardrops into the affected eye D. Reduce time client is positioned on the left side.

A

After interacting with a client, the nurse believes the client is in the prodromal phase of a migraine. Which statements made by the client led the nurse to reach this conclusion? Select all that apply. A. "I feel drowsy all the time." B. "I feel severe pain over my ear." C. "I feel a throbbing pain in my head." D. "I feel confused at this point in time." E. "I feel weakness in the left side of my body." A. A, B, C B. D, E, C C. A, D, E D. A, B, E

C

Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing? A. Lateral cerebral B. Middle cerebral C. Anterior cerebral D. Posterior cerebral

C

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure? A. Thready, weak pulse B. Narrowing pulse pressure C. Regular, shallow breathing D. Lowered level of consciousness

D

In caring for the client with burr holes for a subdural hematoma postoperatively on day 2, the nurse notes the client has an increased temperature to 101.3 F° (38.5° C). What does the nurse understand about this reaction? A. This is a normal assessment for the client with a subdural hematoma. B. This is a normal reaction day 2 postoperatively, and the nurse will administer acetaminophen as prescribed by the healthcare provider. C. Because the client has burr holes, this is not an accurate measurement. D. The client is exhibiting signs of an infection, and the healthcare provider needs to be notified.

D

Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care? A. Spinal shock B. Brain herniation C. Hypovolemic shock D. Increased intracranial pressure

D

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply. A. Vomiting B. Irritability C. Hypotension D. Increased respirations E. Decreased level of consciousness A. A, B, C B. D, E, C C. A, B, C, D, E D. A, B, E

D

A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which areas of paralysis should the nurse find upon assessment? Select all that apply. A. Left leg B. Left arm C. Right leg D. Right arm E. Left side of face A. A, B, C B. D, E, C C. A, C, D D. A, B, E

D

A client is admitted with head trauma after a fall. The client is being prepared for a supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication primarily is given to do what? A. Lower blood pressure B. Prevent hypoglycemia C. Increase cardiac output D. Decrease fluid in the brain

D