Neurologic 2
22. A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Self-care deficit: Dressing/grooming
Answer: B. Ineffective breathing pattern Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation.
11. Nurse Mary witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to opens the airway in this victim by using which method? A. Flexed position B. Head tilt-chin lift C. Jaw-thrust maneuver D. Modified head tilt-chin lift
Answer: C. Jaw-thrust maneuver If a neck injury is suspected, the jaw thrust maneuver is used to open the airway.
16. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? A. A private room down the hall from the nurses' station B. An isolation room three doors from the nurses' station C. A semi private room with a 32-year-old client who has viral meningitis D. A two-bed room with a client who previously had bacterial meningitis
Answer: B. An isolation room three doors from the nurses' station A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission.
20. Nurse Marty is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? A. Excessive tearing B. Urine retention C. Muscle weakness D. Slurred speech
Answer: C. Muscle weakness The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis.
3. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? A. Give him a barbiturate. B. Place him on mechanical ventilation. C. Perform a lumbar puncture. D. Elevate the head of his bed.
Answer: C. Perform a lumbar puncture. The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system and, thereby, cause additional damage.
24. A female client who was found unconscious at home is brought to the hospital by a rescue squaD. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: A. Introducing ice water into the external auditory canal. B. Touching the cornea with a wisp of cotton. C. Turning the client's head suddenly while holding the eyelids open. D. Shining a bright light into the pupil.
Answer: C. Turning the client's head suddenly while holding the eyelids open. To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed.
19. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? A. "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." B. "Try to ambulate independently after about 24 hours." C. "Shampoo your hair every day for ten (10) days to help prevent ear infection." D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
Answer: D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." For 30 days after a stapedectomy, the client should avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes).
25. While reviewing a client's chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? A. The client may be less sensitive to the effects of a neuromuscular blocking agent. B. Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage. C. Pancuronium shouldn't be used; succinylcholine may be used in a lower dosage. D. Pancuronium and succinylcholine both require cautious administration.
Answer: D. Pancuronium and succinylcholine both require cautious administration. The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis.
27. A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of: A. Seizures or trauma to the brain B. Meningitis during the last five (5 years C. Back injury or trauma to the spinal cord D. Respiratory or gastrointestinal infection during the previous month.
Answer: D. Respiratory or gastrointestinal infection during the previous month. Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery.
19. The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: A. The client has complete bilateral paralysis of the arms and legs. B. The client has weakness on the right side of the body, including the face and tongue. C. The client has lost the ability to move the right arm but can walk independently. D. The client has lost the ability to move the right arm but can walk independently.
Answer: B. The client has weakness on the right side of the body, including the face and tongue. Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is a weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition.
25. A male client with Bell's Palsy asks the nurse what has caused this problem. The nurse's response is based on an understanding that the cause is: A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem B. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia C. Primary genetic in origin, triggered by exposure to meningitis D. Primarily genetic in origin, triggered by exposure to neurotoxins
Answer: A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem Bell's palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown but may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors.
18. A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière's disease. When assessing this client, the nurse expects to note: A. Vertigo, tinnitus, and hearing loss. B. Vertigo, vomiting, and nystagmus C. Vertigo, pain, and hearing impairment. D. Vertigo, blurred vision, and fever.
Answer: A. Vertigo, tinnitus, and hearing loss. Ménière's disease, an inner ear disease, is characterized by the symptom triad of vertigo, tinnitus, and hearing loss. The combination of vertigo, vomiting, and nystagmus suggests labyrinthitis. Ménière's disease rarely causes pain, blurred vision, or fever.
30. A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client's behavior. A. Is disoriented to person, place, and time B. Affect is flat, with periods of emotional lability C. Cannot recall what was eaten for breakfast today D. Demonstrate inability to add and subtract; does not know who is the president
Answer: B. Affect is flat, with periods of emotional lability The limbic system is responsible for feelings (affect) and emotions.
11. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by: A. Increasing the exudative reaction of ocular tissue. B. Decreasing leukocyte infiltration at the site of ocular inflammation. C. Inhibiting the action of carbonic anhydrase. D. Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris.
Answer: B. Decreasing leukocyte infiltration at the site of ocular inflammation. Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring.
15. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? A. Head midline B. Head turned to the side C. Neck in neutral position D. Head of bed elevated 30 to 45 degrees
Answer: B. Head turned to the side The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.
8. Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam, if needed and prescribed? A. In 30 to 45 seconds B. In 10 to 15 minutes C. In 30 to 45 minutes D. In 1 to 2 hours
Answer: B. In 10 to 15 minutes When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn't exceed 100 mg in 24 hours.
5. Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination D. Risk for injury
Answer: B. Ineffective airway clearance In Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they aren't immediately life-threatening.
13. After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: A. Instilling one drop of pilocarpine 0.25% into both eyes daily. B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily. C. Instilling one drop of pilocarpine 0.25% into the right eye daily. D. Instilling one drop of pilocarpine 0.25% into the left eye four times daily.
Answer: B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily. The abbreviation "gtt" stands for drop, "i" is the apothecary symbol for the number 1, OU signifies both eyes, and "q.i.d." means four times a day. Therefore, one drop of pilocarpine 0.25% should be instilled into both eyes four times daily.
2. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: A. Take a hot bath. B. Rest in an air-conditioned room. C. Increase the dose of muscle relaxants. D. Avoid naps during the day.
Answer: B. Rest in an air-conditioned room. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.
18. The nurse is caring for the male client who begins to experience seizure activity while in beD. Which of the following actions by the nurse would be contraindicated? A. Loosening restrictive clothing B. Restraining the client's limbs C. Removing the pillow and raising padded side rails D. Positioning the client to side, if possible, with the head flexed forward
Answer: B. Restraining the client's limbs The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.
14. A female client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? A. The client leaves the side rails down. B. The client uses a mirror to inspect the skin. C. The client repositions only after being reminded to do so. D. The client hangs the left arm over the side of the wheelchair.
Answer: B. The client uses a mirror to inspect the skin. Using a mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members.
22. Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? A. Speaking to the client at a slower rate B. Allowing plenty of time for the client to respond C. Completing the sentences that the client cannot finish D. Looking directly at the client during attempts at speech
Answer: C. Completing the sentences that the client cannot finish Clients with aphasia after brain attack (stroke) often fatigue easily and have a short attention span. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all the responses for the client.
17. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine? A. Ulcerative colitis B. Blood dyscrasia C. Intestinal obstruction D. Spinal cord injury
Answer: C. Intestinal obstruction Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents.
2. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? A. Phenytoin (Dilantin) B. Mannitol (Osmitrol) C. Lidocaine (Xylocaine) D. Furosemide (Lasix)
Answer: C. Lidocaine (Xylocaine) Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning.
27. A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? A. Diencephalon B. Medulla C. Midbrain D. Cortex
Answer: C. Midbrain Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain.
1. A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? A. Caucasian race B. Female sex C. Obesity D. Bronchial asthma
Answer: C. Obesity Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age.
23. A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: A. Getting too little exercise B. Taking excess medication C. Omitting doses of medication D. Increasing intake of fatty foods
Answer: C. Omitting doses of medication Myasthenic crisis often is caused by under medication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Option B: Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Options A and D: Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger
13. A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of: A. Hypertension B. Heart failure C. Prosthetic valve replacement D. Chronic obstructive pulmonary disorder
Answer: C. Prosthetic valve replacement The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if a significant risk exists.
28. A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? A. Giving client full control over care decisions and restricting visitors B. Providing positive feedback and encouraging active range of motion C. Providing information, giving positive feedback and encouraging relaxation D. Providing intravenously administered sedatives, reducing distractions and limiting visitors
Answer: C. Providing information, giving positive feedback, and encouraging relaxation The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.
29. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the physician immediately.
Answer: D. Call the physician immediately. A headache may be an indication that an aneurysm is leaking. The nurse should notify the physician immediately.
17. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program B. Keeping the linen wrinkle-free under the client C. Preventing unnecessary pressure on the lower limbs D. Limiting bladder catheterization to once every 12 hours
Answer: D. Limiting bladder catheterization to once every 12 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every four (4) to six (6) hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
16. A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: A. Is clear and tests negative for glucose B. Is grossly bloody in appearance and has a pH of 6 C. Clumps together on the dressing and has a pH of 7 D. Separates into concentric rings and test positive of glucose
Answer: D. Separates into concentric rings and test positive of glucose Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.
14. A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? A. Side-lying, with a pillow under the hip B. Prone, with a pillow under the abdomen C. Prone, in slight-Trendelenburg's position D. Side-lying, with the legs, pulled up and head bent down onto the chest.
Answer: D. Side-lying, with the 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 the head bent down onto the chest. This position helps open the spaces between the vertebrae.
24. The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: A. Eating large, well-balanced meals B. Doing muscle-strengthening exercises C. Doing all chores early in the day while less fatigued D. Taking medications on time to maintain therapeutic blood levels
Answer: D. Taking medications on time to maintain therapeutic blood levels Taking medications correctly to maintain blood levels that are not too low or too high is important.
10. For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: A. Prevent respiratory alkalosis. B. Lower arterial pH. C. Promote carbon dioxide elimination. D. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg
Answer: C. Promote carbon dioxide elimination. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP.
1. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: A. Body temperature control. B. Balance and equilibrium. C. Visual acuity. D. Thinking and reasoning.
Answer: A. Body temperature control. The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control.
6. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? A. Immobilize the neck before the client is moved onto a stretcher. B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. C. Place a cap on the client's head. D. Administer a sedative as ordered.
Answer: B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Because CT commonly involves the use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish.
4. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? A. "You may have difficulty believing this, but the paralysis caused by this disease is temporary." B. "You'll have to accept the fact that you're permanently paralyzeD. However, you won't have any sensory loss." C. "It must be hard to accept the permanency of your paralysis." D. "You'll first regain use of your legs and then your arms."
Answer: A. "You may have difficulty believing this, but the paralysis caused by this disease is temporary." The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.
26. The nurse has given the male client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: A. Exposure to cold and drafts B. Massage the face with a gentle upward motion C. Perform facial exercises D. Wrinkle the forehead, blow out the cheeks, and whistle
Answer: A. Exposure to cold and drafts Exposure to cold or drafts is avoided. Local application of heat to the face may improve blood flow and provide comfort.
12. Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal? A. More back pain than the first postoperative day B. Paresthesia in the dermatomes near the wounds C. Urine retention or incontinence D. Temperature of 99.2° F (37.3° C)
Answer: C. Urine retention or incontinence Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery.
20. The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? A. Giving the client thin liquids B. Thickening liquids to the consistency of oatmeal C. Placing food on the unaffected side of the mouth D. Allowing plenty of time for chewing and swallowing
Answer: A. Giving the client thin liquids Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned.
29. A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client to ensure client safety? A. Speak loudly to the client B. Test the temperature of the shower water C. Check the temperature of the food on the delivery tray. D. Provide a clear path for ambulation without obstacles
Answer: D. Provide a clear path for ambulation without obstacles Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating.
28. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? A. Vision changes B. Absent deep tendon reflexes C. Tremors at rest D. Flaccid muscles
Answer: A. Vision changes Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis.
7. During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: A. Use the pointed end of the reflex hammer when striking the Achilles' tendon. B. Support the joint where the tendon is being tested. C. Tap the tendon slowly and softly D. Hold the reflex hammer tightly.
Answer: B. Support the joint where the tendon is being tested. To prevent the attached muscle from contracting, the nurse should support the joint where the tendon is being tested.
30. During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment evaluates: A. Cranial nerves I and II. B. Cranial nerves III and V. C. Cranial nerves VI and VIII. D. Cranial nerves IX and X.
Answer: D. Cranial nerves IX and X. Swallowing is a motor function of cranial nerves IX and X.
23. A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), two (2) mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, Diazepam also is recommended for: A. long-term treatment of epilepsy. B. postoperative pain management of laminectomy clients. C. postoperative pain management of diskectomy clients D. treatment of spasticity associated with spinal cord lesions.
Answer: D. Treatment of spasticity associated with spinal cord lesions. In addition to relieving painful muscle spasms, Diazepam also is recommended for treatment of spasticity associated with spinal cord lesions. Diazepam's use is limited by its central nervous system effects and the tolerance that develops with prolonged use.
12. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Nail bed pressure C. Pressure on the orbital rim D. Squeezing of the sternocleidomastoid muscle
12. Answer: B. Nail bed pressure Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Options A, C, and D: Cerebral responses to pain are tested using
21. The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: A. Gets angry with family if they interrupt a task B. Experiences bouts of depression and irritability C. Has difficulty with using modified feeding utensils D. Consistently uses adaptive equipment in dressing self
Answer: D. Consistently uses adaptive equipment in dressing self Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.
10. Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag." Which intervention by the nurse has the highest priority? A. Assessing the left leg B. Assessing the pupils C. Placing the client in Trendelenburg's position D. Assessing level of consciousness
Answer: A. Assessing the left leg In the scenario, airway and breathing are established so the nurse's next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site.
5. The nurse is working on a surgical floor. The nurse must log roll a male client following a: A. Laminectomy. B. Thoracotomy. C. Hemorrhoidectomy. D. Cystectomy.
Answer: A. Laminectomy. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning.
4. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: A. Light flashes and floaters in front of the eye. B. A recent driving accident while changing lanes. C. Headaches, nausea, and redness of the eyes. D. Frequent episodes of double vision.
Answer: A. Light flashes and floaters in front of the eye. The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment.
26. A male client is color blind. The nurse understands that this client has a problem with: A. Rods. B. Cones. C. Lens. D. Aqueous humor.
Answer: B. Cones. Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs.
7. The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? A. Cerebellar function B. Intellectual function C. Cerebral function D. Sensory function
Answer: C. Cerebral function The mental status examination assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning.
9. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client's therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? A. Parasympathomimetic agent B. Sympatholytic agent C. Adrenergic blocker D. Cholinergic blocker
Answer: D. Cholinergic blocker Atropine sulfate is a cholinergic blocker. It isn't a parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker.
8. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority for this client's plan of care? A. Disturbed sensory perception (visual) B. Self-care deficient: Dressing/grooming C. Impaired verbal communication D. Risk for injury
Answer: D. Risk for injury Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury.
15. A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term? A. Ataxic B. Dystrophic C. Helicopod D. Steppage
Answer: C. Helicopod A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step.
6. To encourage adequate nutritional intake for a female client with Alzheimer's disease, the nurse should: A. Stay with the client and encourage him to eat. B. Help the client fill out his menu. C. Give the client privacy during meals. D. Fill out the menu for the client.
Answer: A. Stay with the client and encourage him to eat. Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat.
21. The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? A. Tachycardia B. Increased salivation C. Hypotension D. Apnea
Answer: A. Tachycardia Systemic absorption of atropine sulfate can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops.
3. A male client is having tonic-clonic seizures. What should the nurse do first? A. Elevate the head of the bed. B. Restrain the client's arms and legs. C. Place a tongue blade in the client's mouth. D. Take measures to prevent injury.
Answer: D. Take measures to prevent injury. Protecting the client from injury is the immediate priority during a seizure.
9. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrateD. I can't do anything without help!" This comment best supports which nursing diagnosis? A. Anxiety B. Powerlessness C. Ineffective denial D. Risk for disuse syndrome
Answer: B. Powerlessness This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that can't perform even simple daily tasks.
