neuro - HESI (evolve)

A nurse is evaluating sensory changes in a client whose spinal cord was severed at the level of T6 and T7. What does this evaluation process require? Client squeezing the nurse's hand Nurse monitoring the client's vital signs Client stating where the pinching sensation is felt Nurse observing the skin for color changes below the lesion

Client stating where the pinching sensation is felt

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

Low-Fowler

Which cranial nerve damage may lead to a decrease in the client's olfactory acuity? Cranial nerve I Cranial nerve X Cranial nerve V Cranial nerve VIII

Cranial nerve I

While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which condition should the nurse record in the assessment findings? Decortication Pronator drift Babinski's sign Decerebration

Decerebration

A client is admitted to the hospital after sustaining a head injury. Which is the most reliable sign of increased intracranial pressure the nurse can monitor for? Rise in respiratory rate Narrowing of pulse pressure Decrease in the level of consciousness Increase in the diastolic blood pressure

Decrease in the level of consciousness

A client comes into the emergency room (ER) after hitting his head while playing basketball. He is alert and oriented. Which is a priority nursing intervention? Assess full range of motion (ROM) to determine extent of injuries. Call for an immediate head computed tomography (CT). Immobilize the client's head and neck. Open the airway with the head-tilt chin-lift maneuver.

Immobilize the client's head and neck.

After a cerebrovascular accident (also known as brain attack) a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected? Frontal Parietal Occipital Temporal

Parietal

A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment? The injury results in loss of the reflex arc. The injury is above the sixth thoracic vertebra. There has been a partial transection of the cord. There is a flaccid paralysis of the lower extremities.

The injury is above the sixth thoracic vertebra.

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? Best verbal response Best pupillary response Best motor response Best eye-opening response

Best verbal response Best motor response Best eye-opening response

A client who had a cerebrovascular accident (also known as a "brain attack") becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program? Using medication to induce elimination Adhering to a definite time for attempted evacuations Considering previous habits associated with defecation Timing of elimination to take advantage of the gastrocolic reflex

Adhering to a definite time for attempted evacuations

A client who has a history of seizures is scheduled for an arteriogram at 10:00 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9:00 AM. What should the nurse do? Omit the 9:00 AM dose of the drug. Give the same dosage of the drug rectally. Administer the drug with 30 mL of water at 9:00 AM. Ask the healthcare provider if the drug can be given intravenously.

Ask the healthcare provider if the drug can be given intravenously.

A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex. Which position does the nurse recognize is the most appropriate for this client postoperatively? Semi-Fowler with knee gatch elevated Flat on one side with the neck maintained in alignment with a small pillow Head of the bed elevated 30 to 45 degrees with the neck in neutral alignment Head of the bed elevated 20 degrees with the head turned to the operative side

Head of the bed elevated 30 to 45 degrees with the neck in neutral alignment

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

Inability to execute coordinated movements

Bed rest is prescribed after a client's cerebrovascular accident (CVA, "brain attack") results in right hemiplegia. Which exercises should the nurse incorporate into the client's plan of care 24 hours after the brain attack? Passive range-of-motion exercises Active exercises of the extremities Light weight-lifting exercises of the right side Isotonic exercises that will capitalize on returning muscle function

Passive range-of-motion exercises

The nurse is caring for a client who underwent a contrast-based cerebral angiography. Which nursing interventions will be beneficial after the procedure? Provide oral or intravenous fluids Encourage deep or moderate sedation Maintain pressure dressing at the injection site Evaluate kidney function 24 hours after the test Have the client ambulate immediately after the procedure

Provide oral or intravenous fluids Maintain pressure dressing at the injection site Evaluate kidney function 24 hours after the test

A client reports a severe, sharp, stabbing headache and intense pain in and around the eye that lasts for up to 1 hour. History reveals that the client had similar episodes of headaches previously which lasted for ten weeks. What other symptoms may be manifested by the client? . Vertigo Rhinorrhea Lacrimation Phonophobia Pupillary constriction

Rhinorrhea Lacrimation Pupillary constriction

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? This is a normal assessment for the client with a subdural hematoma. This is a normal reaction day 2 postoperatively, and the nurse will administer acetaminophen as prescribed by the healthcare provider. Because the client has burr holes, this is not an accurate measurement. The client is exhibiting signs of an infection, and the healthcare provider needs to be notified.

The client is exhibiting signs of an infection, and the healthcare provider needs to be notified.

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? These seizures are associated with amnesia. These seizures increase the risk of injuries due to fall. These seizures are most resistant to drug therapy. These seizures are preceded by perception of an offensive smell. These seizures cause one sided movement of extremities in the client.

These seizures increase the risk of injuries due to fall. These seizures are most resistant to drug therapy.

A client with quadriplegia is placed on a tilt table daily. The client asks why the angle of the head of the table is gradually increased. How should the nurse respond? It facilitates turning. This prevents pressure ulcers. It promotes hyperextension of the spine. This limits loss of calcium from the bones.

This limits loss of calcium from the bones.

A client is going for a magnetic resonance imaging (MRI). What should the nurse ascertain before taking the client to the procedure? Scheduled medications have been given. All metal, such as jewelry and hair ornaments, has been removed. Adequate prehydration has been given. The client has emptied the bladder.

All metal, such as jewelry and hair ornaments, has been removed.

A client comes into the emergency department with neurologic deficits after falling off a ladder. Which client assessment will the nurse perform for the Glasgow Coma Scale? Breathing patterns Deep tendon reflexes Eye accommodation to light Motor response to verbal commands

Motor response to verbal commands

A client asks for information about glaucoma. How should the nurse explain glaucoma to the client? An increase in the pressure within the eyeball An opacity of the crystalline lens or its capsule A curvature of the cornea that becomes unequal A separation of the neural retina from the pigmented retina

An increase in the pressure within the eyeball

A male client with a brain attack (cerebrovascular accident) has regained control of bowel movements but still is incontinent of urine. To help reestablish bladder control, what should the nurse encourage the client to do? Assume a standing position for voiding. Void every four hours and attempt to hold urine between set times. Attempt to void more frequently in the afternoon than in the morning. Drink a minimum of 4 L of fluid daily and divide it equally among the hours while awake.

Assume a standing position for voiding.

What is the function of a client's cranial nerve VI? Movement of the eye with levator muscle Movement of the eye with lateral rectus muscles Movement of the eye with medial rectus muscles Movement of the eye with superior oblique muscles

Movement of the eye with lateral rectus muscles

After sustaining a head trauma, a client reports hearing ringing noises. Which area should the nurse assess further? Frontal lobe Occipital lobe Sixth cranial nerve (abducens) Eighth cranial nerve (vestibulocochlear)

Eighth cranial nerve (vestibulocochlear)

A client has had a carotid endarterectomy. To monitor for the complication of cranial nerve dysfunction, the nurse assesses the client for which finding? Labored breathing Edema of the neck Difficulty in swallowing Alteration in blood pressure

difficulty in swallowing

A client has a history of diabetes mellitus. After assessing the client, the primary healthcare provider confirms damage to the sensory limb of the bladder spinal reflex arc. Which clinical manifestations could confirm this condition? Incomplete voiding Overdistention of bladder Lack of control on micturition Infrequent voiding of large residual volumes

Infrequent voiding of large residual volumes

When performing a neurologic check on a client with a head injury, the nurse identifies a diminished corneal reflex in the left eye. What does appropriate nursing care for a client with an absent corneal reflex include? Irrigating the eye routinely Instilling artificial tears frequently Checking the corneal reflex every hour Taping the eyelids open during the day

Instilling artificial tears frequently

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure? Maintaining the client in the supine position for several hours Encouraging the client to ambulate every hour for at least 6 hours Keeping the client in the Trendelenburg position for at least 2 hours Placing the client in the high-Fowler position immediately after the procedure

Maintaining the client in the supine position for several hours

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma? Monitor the client for signs of brain injury. Check for hemorrhaging from the oral and nasal cavities. Elevate the foot of the bed if the client develops symptoms of shock. Observe for clinical indicators of decreased intracranial pressure and temperature.

Monitor the client for signs of brain injury.

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? Difficulty breathing Inability to move the lower arms Normal biceps reflexes in the arms Loss of pain sensation in the hands

Normal biceps reflexes in the arms

A client who had an infratentorial craniotomy is admitted to the intensive care unit after discharge from the postanesthesia care unit. Frequent assessments reveal that the client's intracranial pressure is increasing. What should the nurse do first? Notify the healthcare provider. Elevate the head of the bed. Reduce the flow rate of intravenous (IV) fluid. Administer the next dose of osmotic diuretic early.

Notify the healthcare provider.

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? Ptosis and dysphagia Paresthesias and paralysis Atrophy and fasciculations Muscle weakness and drooling

Paresthesias and paralysis