Neurologic 1
18. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. 1. Head tilt 2. Vomiting 3. Polydipsia 4. Lethargy 5. Increased appetite 6. Increased pulse
Answer: 1, 2, 4. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.
4. Which of the following values is considered normal for ICP? 1. 0 to 15 mm Hg 2. 25 mm Hg 3. 35 to 45 mm Hg 4. 120/80 mm Hg
Answer: 1. 0 to 15 mm Hg
8. Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.
Answer: 1. A 55-year-old African American male. African Americans have twice the rate of CVA's as Caucasians; males are more likely to have strokes than females except in advanced years.
13. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: 1. A positive Brudzinski's sign 2. A negative Kernig's sign 3. Absence of nuchal rigidity 4. A Glascow Coma Scale score of 15
Answer: 1. A positive Brudzinski's sign Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest.
7. Problems with memory and learning would relate to which of the following lobes? 1. Frontal 2. Occipital 3. Parietal 4. Temporal
Answer: 4. Temporal The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus.
7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta-blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.
Answer: 1. An oral anticoagulant medication. Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge versus intravenous.
5. Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? 1. Ataxia and confusion 2. Sodium depletion 3. Tonic-clonic seizure 4. Urinary incontinence
Answer: 1. Ataxia and confusion A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia.
16. Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? 1. Hemorrhagic skin rash 2. Edema 3. Cyanosis 4. Dyspnea on exertion
Answer: 1. Hemorrhagic skin rash DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.
1. Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.
Answer: 1. Placing the client on the back with a small pillow under the head. A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration.
22. Which of the following assessment data indicated nuchal rigidity? 1. Positive Kernig's sign 2. Negative Brudzinski's sign 3. Positive homan's sign 4. Negative Kernig's sign
Answer: 1. Positive Kernig's sign A positive Kernig's sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space. Brudzinski's sign is also indicative of the condition.
10. The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? 1. Side-lying, with legs pulled up and head bent down onto the chest 2. Side-lying, with a pillow under the hip 3. Prone, in a slight Trendelenburg's position 4. Prone, with a pillow under the abdomen.
Answer: 1. Side-lying, with legs pulled up and head bent down onto the chest The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae.
3. A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? 1. Urine output increases 2. Pupils are 8 mm and nonreactive 3. Systolic blood pressure remains at 150 mm Hg 4. BUN and creatinine levels return to normal
Answer: 1. Urine output increases Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes.
24. Which of the following pathologic processes is often associated with aseptic meningitis? 1. Ischemic infarction of cerebral tissue 2. Childhood diseases of viral causation such as mumps 3. Brain abscesses caused by a variety of pyogenic organisms 4. Cerebral ventricular irritation from a traumatic brain injury
Answer: 2. Childhood diseases of viral causation such as mumps Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles, mumps, herpes, and leukemia.
19. A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? 1. Cloudy CSF, decreased protein, and decreased glucose 2. Cloudy CSF, elevated protein, and decreased glucose 3. Clear CSF, elevated protein, and decreased glucose 4. Clear CSF, decreased pressure, and elevated protein
Answer: 2. Cloudy CSF, elevated protein, and decreased glucose A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.
12. The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
Answer: 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.
1. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? 1. Vomiting continues 2. Intracranial pressure (ICP) is increased 3. The client needs mechanical ventilation 4. Blood is anticipated in the cerebrospinal fluid (CSF)
Answer: 2. Intracranial pressure (ICP) is increased Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP.
15. During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? 1. Limiting conversation with the child 2. Keeping extraneous noise to a minimum 3. Allowing the child to play in the bathtub 4. Performing treatments quickly
Answer: 2. Keeping extraneous noise to a minimum A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible.
23. Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? 1. Congenital anatomic abnormality of the meninges 2. Lack of acquired resistance to the various etiologic organisms 3. Occlusion or narrowing of the CSF pathway 4. Natural affinity of the CNS to certain pathogens
Answer: 2. Lack of acquired resistance to the various etiologic organisms Extension of a variety of bacterial infections is a major causative factor of meningitis and occurs as a result of a lack of acquired resistance to the etiologic organisms. Preexisting CNS anomalies are factors that contribute to susceptibility.
17. When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? 1. Bladder infection 2. Middle ear infection 3. Fractured clavicle 4. Septic arthritis
Answer: 2. Middle ear infection Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumococcus. A chronically draining ear is frequently also found.
5. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Cholesterol level 2. Pupil size and pupillary response 3. Bowel sounds 4. Echocardiogram
Answer: 2. Pupil size and pupillary response It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.
21. A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? 1. Abnormal flexion of the upper extremities and extension of the lower extremities 2. Rigid extension and pronation of the arms and legs 3. Rigid pronation of all extremities 4. Flaccid paralysis of all extremities
Answer: 2. Rigid extension and pronation of the arms and legs Decerebrate posturing is characterized by the rigid extension and pronation of the arms and legs.
25. You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN? 1. Complete admission assessment. 2. Set up oxygen and suction equipment. 3. Place a padded tongue blade at bedside. 4. Pad the side rails before patient arrives.
Answer: 2. Set up oxygen and suction equipment. The LPN/LVN can set up the equipment for oxygen and suctioning. Focus: Delegation/supervision.
9. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dl. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mmHg. 4. The presence of bronchogenic carcinoma.
Answer: 3. A blood pressure of 220/120 mmHg. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel in the cranium.
11. A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: 1. A cerebral lesion 2. A temporal lesion 3. An intact brainstem 4. Brain death
Answer: 3. An intact brainstem Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or disconjugate eye movements indicate brainstem damage.
4. During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: 1. Pulse 2. Respirations 3. Blood pressure 4. Temperature
Answer: 3. Blood pressure Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the priority is blood pressure.
6. What is the expected outcome of thrombolytic drug therapy? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage
Answer: 3. Dissolved emboli. Thrombolytic therapy is used to dissolve emboli and reestablish cerebral perfusion
14. A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: 1. Tolerate the pain 2. Decrease the perception of pain 3. Escape the source of pain 4. Divert attention from the source of pain.
Answer: 3. Escape the source of pain The client's innate responses to pain are directed initially toward escaping from the source of pain.
20. A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? 1. No precautions are required as long as antibiotics have been started 2. Maintain enteric precautions 3. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics 4. Maintain neutropenic precautions
Answer: 3. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.
8. While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? 1. Frontal 2. Occipital 3. Parietal 4. Temporal
Answer: 3. Parietal The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects.
6. Which of the following signs and symptoms of increased ICP after head trauma would appear first? 1. Bradycardia 2. Large amounts of very dilute urine 3. Restlessness and confusion 4. Widened pulse pressure
Answer: 3. Restlessness and confusion The earliest symptom of elevated ICP is a change in mental status.
2. A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for A STAT computer tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.
Answer: 3. Schedule for A STAT computer tomography (CT) scan of the head. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use rt-PA. This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated.
10. The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places her hand under the client's right axilla to help him/her move up in bed. 4. The assistant praises the client for attempting to perform ADL's independently.
Answer: 3. The assistant places her hand under the client's right axilla to help him/her move up in bed. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety.
3. A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? 1. Current medications. 2. Complete physical and history. 3. Time of onset of current stroke. 4. Upcoming surgical procedures.
Answer: 3. Time of onset of current stroke. The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes.
2. A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? 1. To reduce intraocular pressure 2. To prevent acute tubular necrosis 3. To promote osmotic diuresis to decrease ICP 4. To draw water into the vascular system to increase blood pressure
Answer: 3. To promote osmotic diuresis to decrease ICP Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.
9. The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? 1. Sternal rub 2. Pressure on the orbital rim 3. Squeezing the sternocleidomastoid muscle 4. Nail bed pressure
Answer: 4. Nail bed pressure Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nail Bed pressure tests a basic peripheral response. Cerebral responses to pain are testing using
