Med-Surg Success (Neuro)
posticatal
(occurring) after a seizure or attack
105. The client is in the terminal stage of ALS. Which intervention should the nurse implement? 1. Perform passive ROM every two (2) hours. 2. Maintain a negative nitrogen balance. 3. Encourage a low-protein, soft-mechanical diet. 4. Turn the client and have him cough and deep breathe every shift.
1
107. The client with end-stage ALS requires a gastrostomy tube feeding. Which finding would require the nurse to hold a bolus tube feeding? 1. A residual of 125 mL. 2. The abdomen is soft. 3. Three episodes of diarrhea. 4. The potassium level is 3.4 mEq/L.
1
112. The nurse is caring for a client diagnosed with encephalitis. Which is an expected outcome for the client? 1. The client will regain as much neurological function as possible. 2. The client will have no short-term memory loss. 3. The client will have improved renal function. 4. The client will apply hydrocortisone cream daily.
1
115. The public health department nurse is preparing a lecture on prevention of West Nile virus. Which information should the nurse include? 1. Change water daily in pet dishes and birdbaths. 2. Wear thick, dark clothing when outside to avoid bites. 3. Apply insect repellent over face and arms only. 4. Explain that mosquitoes are more prevalent in the morning.
1
117. The nurse is developing a plan of care for a client diagnosed with West Nile virus. Which intervention should the nurse include in this plan? 1. Monitor the client's respirations frequently. 2. Refer to a dermatologist for tx of maculopapular rash. 3. Treat hypothermia by using ice packs under the client's arms. 4. Teach the client to report any swollen lymph glands.
1
12. a client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener bid. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.
1
129. Which priority goal would the nurse identify for a client diagnosed with Parkinson's Disease (PD)? 1. The client will be able to maintain mobility and swallow without aspiration. 2. The client will verbalize feelings about the diagnosis of Parkinson's Disease. 3. The client will understand the purpose of medications administered for PD. 4. The client will have a home health agency for monitoring at home.
1
13. The client diagnosed with a mild concussion is being discharged from the ED. Which discharge instruction should the nurse teach client's significant other? 1. Awaken the client every two (2) hours. 2. Monitor for ICP. 3. Observe frequently for hypervigilance. 4. Offer the client food every three (3) to four (4) hours.
1
19. The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained 2 hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. Flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 mm in size and nonreactive on painful stimuli.
1
23. The client diagnosed with a closed head injury and is in coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included in the plan of care? 1. Position the client with the HOB elevated at intervals. 2. Perform ROM exercises every 4 hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.
1
26. In assessing a client with a Thoracic SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of neurogenic shock? 1. No reflex activity below the waist. 2. Inability to move upper extremities. 3. Complaints of a pounding headache. 4. Hypotension and bradycardia.
1
29. The home health nurse is caring for a 28-year-old client with a T10 SCI who says, "I can't do anything. Why am I so worthless?" Which statement by the nurse would be the most therapeutic? 1. "This must be very hard for you. You're feeling worthless?" 2. "You shouldn't feel worthless—you are still alive." 3. "Why do you feel worthless? You still have the use of your arms." 4. "If you attended a work rehab program you wouldn't feel worthless."
1
34. The nurse is caring for clients on the rehabilitation unit. Which clients should the nurse assess first after receiving the change-of-report? 1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. 2. The client with an L4 SCI who is crying and very upset about being discharged home. 3. The client with an L2 SCI who is complaining of a headache and feeling very hot. 4. The client with a T4 SCI who is unable to move the lower extremities.
1
38. The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement? 1. Ensure that helmets are worn in appropriate areas. 2. Implement daily exercise programs for the staff. 3. Provide healthy foods in the cafeteria. 4. Encourage employees to wear safety glasses.
1
40. The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first? 1. Note the first thing the client does in the seizure. 2. Assess the size of the client's pupils. 3. Determine if the client is incontinent of urine or stool. 4. Provide the client with privacy during the seizure.
1
43. The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication? 1. "I will brush my teeth after every meal." 2. "I will check my Dilantin level daily." 3. "My urine will turn orange while on Dilantin." 4. "I won't have any seizures while on this medication."
1
47. The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response? 1. "Some people have a warning that the seizure is about to start." 2. "Auras occur when you are physically and psychologically exhausted." 3. "You're concerned that you do not have auras before your seizures?" 4. "Auras usually cause you to be sleepy after you have a seizure."
1
53. The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make? 1. Social worker. 2. Chaplain. 3. Health-care provider. 4. Occupational therapist.
1
64. The nurse is assessing the client diagnosed with meningococcal meningitis. Which assessment data would warrant notifying the HCP? 1. Purpuric lesions on the face. 2. Complaints of light hurting the eyes. 3. Dull, aching, frontal headache. 4. Not remembering the day of the week.
1
68. The nurse is caring for a client dx with meningitis. Which collaborative intervention should be included in the plan of care? 1. Administer antibiotics. 2. Obtain a sputum culture. 3. Monitor the pulse oximeter. 4. Assess I&O's.
1
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. Anti-hyperuricemia medication. 4. A thrombolytic medication.
1
71. The client diagnosed with septic meningitis is admitted to the medical floor at noon. Which health-care provider's order would have the highest priority? 1. Administer an intravenous antibiotic. 2. Obtain the client's lunch tray. 3. Provide a quiet, calm, and dark room. 4. Weigh the client in hospital attire.
1
76. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? 1. Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing. 2. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson's disease. 3. Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities. 4. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson's disease.
1
77. The charge nurse is making assignments. Which client should be assigned to the new graduate nurse? 1. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes. 2. The client diagnosed with Parkinson's disease who fell during the night and is complaining of difficulty walking. 3. The client diagnosed with a cerebrovascular accident whose vitals signs are P 60, R 14, and BP 198/68. 4. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.
1
86. The chief executive officer (CEO) of a large manufacturing plant presents to the occupational health clinic with chronic rhinitis and requesting medication. On inspection, the nurse notices holes in the septum that separates the nasal passages. The nurse also notes dilated pupils and tachycardia. The facility has a "No Drug" policy. Which intervention should the nurse implement? 1. Prepare to complete a drug screen urine test. 2. Discuss the client's use of illegal drugs. 3. Notify the client's supervisor about the situation. 4. Give the client an antihistamine and say nothing.
1
87. The nurse is working with several clients in a substance abuse clinic. Client A tells the nurse another client, Client B, has "started using again." Which action should the nurse implement? 1. Tell Client A that nurse cannot discuss Client B with him. 2. Find out how Client A got this information. 3. Inform the HCP that Client B is using again. 4. Get in touch with Client B and have the Client come to the clinic.
1
91. The client diagnosed with delirium tremens when trying to quit drinking cold turkey is admitted to the medical unit. Which medications would the nurse anticipate administering? 1. Thiamine (vitamin B6 ) and librium, a benzodiazepine. 2. Dilantin, an anticonvulsant, and Feosol, an iron preparation. 3. Methadone, a synthetic narcotic, and Depakote, a mood stabilizer. 4. Mannitol, an osmotic diuretic, and Ritalin, a stimulant.
1
94. The nurse caring for a client who has been abusing amphetamines writes a problem of "cardiovascular compromise." Which nursing interventions should be implemented? 1. Monitor the telemetry and vital signs every four (4) hours. 2. Encourage the client to verbalize the reason for using drugs. 3. Provide a quiet, calm atmosphere for the client to rest. 4. Place the client on bedrest and a low-sodium diet.
1
98. The client is diagnosed with ALS. Which client problem would be most appropriate for this client? 1. Disuse syndrome. 2. Altered body image. 3. Fluid and electrolyte imbalance. 4. Alteration in pain.
1
123. The nurse identifies the concept of intracranial regulation disturbance in a client diagnosed with Parkinson's Disease. Which priority intervention should the nurse implement? 1. Keep the bed low and call light in reach. 2. Provide a regular diet of three (3) meals per day. 3. Obtain an order for home health to see the client. 4. Perform the Braden scale skin assessment.
1 (Safety)
109. The nurse is admitting the client for rule- out encephalitis. Which interventions should the nurse assess to support the diagnosis of encephalitis? Select all that apply. 1. Determine if the client has recently received any immunizations. 2. Ask the client if he or she has had a cold in the last week. 3. Check to see if the client has active herpes simplex 1. 4. Find out if the client has traveled to the Great Lakes region. 5. Assess for exposure to soil with fungal spores.
1, 2, 3
60. The client is being discharged following a transsphenoidal hypophysectomy. Which discharge instructions should the nurse teach the client? Select all that apply. 1. Sleep with the head of the bed elevated. 2. Keep a humidifier in the room. 3. Use caution when performing oral care. 4. Stay on a full liquid diet until seen by the HCP. 5. Notify the HCP if developing a cold or fever.
1, 2, 3, 5
67. The nurse is preparing a client to rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply. 1. Obtain an informed consent from the client or significant other. 2. Have the client empty the bladder prior to the procedure. 3. Place the client in a side-lying position with the back arched. 4. Instruct the client to breathe rapidly and deeply during the procedure. 5. Explain to the client what to expect during the procedure.
1, 2, 3, 5
4. The client diagnosed with a right-sided CVA is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent should adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers into a fist.
1, 3
45. The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply. 1. Keep a record of seizure activity. 2. Take tub baths only; do not take showers. 3. Avoid over-the-counter medications. 4. Have anticonvulsant medication serum levels checked regularly. 5. Do not drive alone; have someone in the car.
1, 3, 4
28. The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. 1. Monitor the pulse oximetry reading. 2. Provide pureed foods six times a day. 3. Encourage coughing and deep breathing. 4. Assess for autonomic dysreflexia. 5. Administer intravenous corticosteroids.
1, 3, 5
3. Which client would the nurse identify as most at risk for experiencing a CVA? 1. A 55 yr old African American male. 2. An 84 yr old Japanese female. 3. A 67 yr old Caucasian male. 4. A 39 yr old pregnant female.
1. African Americans have twice the rate of CVAs.
100. The client diagnosed with ALS asks the nurse, "I know this disease is going to kill me. What will happen to me in the end?" Which statement by the nurse would be most appropriate? 1. "You are afraid of how you will die?" 2. "Most people with ALS die of respiratory failure." 3. "Don't talk like that. You have to stay positive." 4. "ALS is not a killer. You can live a long life."
2
101. The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first? 1. Elevate the head of the bed 30 degrees. 2. Administer oxygen via nasal cannula. 3. Assess the client's lung sounds. 4. Obtain a pulse oximeter reading.
2
114. The nurse is caring for the client with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication? 1. Examine pupil reactions to light. 2. Assess LOC. 3. Observe for seizure activity. 4. Monitor VS every shift.
2
116. Which problem is the highest priority for the client diagnosed with West Nile virus? 1. Alteration in the body temperature. 2. Altered tissue perfusion. 3. Fluid volume excess. 4. Altered skin integrity.
2
122. The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first? 1. Schedule a STAT MRI of the brain. 2. Call a code STROKE. 3. Notify HCP 4. Have the client swallow a glass of water.
2
124. The client newly diagnosed with Parkinson's Disease (PD) asks the nurse, "Why can't I control these tremors?" Which is the nurse's best response? 1. "You can control the tremors when you learn to concentrate and focus on the cause." 2. "The tremors are caused by a lack of the chemical dopamine in the brain; medication may help." 3. "You have too much acetylcholine in your brain causing the tremors but they will get better with time." 4. "You are concerned about the tremors? If you want to talk I would like to hear how you feel."
2
135. Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? Select all that apply. 1. Position the client with the head of the bed up 30 degrees. 2. Cluster activities of care. 3. Suction the client every three (3) hours. 4. Administer soapsuds enemas until clear. 5. Place the client in Trendelenburg position.
2
14. The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steri-strips. Which s/s would warrant transferring the resident to the ED? 1. A 4-cm area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.
2
18. The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? 1. A subcutaneous anticoagulant. 2. An intravenous osmotic diuretic. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.
2
24. The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? 1. The client will return to work within six (6) months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain bowel and bladder control.
2
27. The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement? 1. Keep oxygen via nasal cannula on at all times. 2. Administer low-dose subcutaneous anticoagulants. 3. Perform active lower extremity ROM exercises. 4. Refer to a speech therapist for ventilator-assisted speech.
2
32. The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? 1. Discuss how to correctly remove the insertion pins. 2. Instruct the client to report reddened or irritated skin areas. 3. Inform the client that the vest liner cannot be changed. 4. Encourage the client to remain in the recliner as much as possible.
2
36. The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement? 1. Refer the client to the American Spinal Cord Injury Association (ASIA). 2. Refer the client to the state rehabilitation commission. 3. Ask the social worker about applying for disability. 4. Suggest that the client talk with his significant other about this concern.
2
42. The UAP is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take? 1. Help the UAP to insert the oral airway in the mouth. 2. Tell the UAP to stop trying to insert anything in the mouth. 3. Take no action because the UAP is handling the situation. 4. Notify the charge nurse of the situation immediately.
2
49. The client is being admitted to rule out a brain tumor. Which classic triad of symptoms supports a dx of a brain tumor? 1. Nervousness, metastasis to the lungs, and seizures. 2. Headache, vomiting, and papilledema. 3. Hypotension, tachycardia, and tachypnea. 4. Abrupt loss of motor function, diarrhea, and change in taste.
2
51. The male client diagnosed with a brain tumor is scheduled for a magnetic resonance imaging (MRI) scan in the morning. The client tells the nurse that he is scared. Which response by the nurse indicates an appropriate therapeutic response? 1. "MRIs are loud but there will not be any invasive procedure done." 2. "You're scared. Tell me about what is scaring you." 3. "This is the least thing to be scared about—there will be worse." 4. "I can call the MRI tech to come and talk to you about the scan."
2
57. The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery? 1. The client complains of a headache at "3" to "4" on a 1-to-10 scale. 2. The client has an intake of 1,000 mL and an output of 3,500 mL. 3. The client complains of a raspy sore throat. 4. The client experiences dizziness when trying to get up too quickly.
2
59. The client is diagnosed with a metastatic brain tumor, and radiation therapy is scheduled. The client asks the nurse, "Why not try chemotherapy first? It has helped my other tumors." The nurse's response is based on which scientific rationale? 1. Chemotherapy is only used as a last resort in caring for clients with brain tumors. 2. The blood-brain barrier prevents medications from reaching the brain. 3. Radiation therapy will have fewer side effects than chemotherapy. 4. Metastatic tumors become resistant to chemotherapy and it becomes useless.
2
62. The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak? 1. Clients recently discharged from the hospital. 2. Residents of a college dormitory. 3. Individuals who visit a third world country. 4. Employees in a high-rise office building.
2
66. The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem "altered cerebral tissue perfusion"? 1. The client will be able to complete activities of daily living. 2. The client will be protected from injury if seizure activity occurs. 3. The client will be afebrile for 48 hours prior to discharge. 4. The client will have elastic tissue turgor with ready recoil.
2
69. The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home? 1. The Haemophilus influenzae vaccine. 2. Antimicrobial chemoprophylaxis. 3. A 10-day dose pack of corticosteroids. 4. A gamma globulin injection.
2
70. Which statement best describes the scientific rationale for alternating a nonnarcotic antipyretic and a nonsteroidal anti-inflammatory drug (NSAID) every two (2) hours to a female client diagnosed with bacterial meningitis? 1. This regimen helps to decrease the purulent exudate surrounding the meninges. 2. These medications will decrease intracranial pressure and brain metabolism. 3. These medications will increase the client's memory and orientation. 4. This will help prevent a yeast infection secondary to antibiotic therapy.
2
83. The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? 1. The client should discuss feelings about being placed on a ventilator. 2. The client may have rapid mood swings and become easily upset. 3. Pill-rolling tremors will become worse when the medication is wearing off. 4. The client may automatically start to repeat what another person says.
2
88. A 20-year-old female client who tried lysergic acid diethylamide (LSD) as a teen tells the nurse that she has bad dreams that make her want to kill herself. Which is the explanation for this occurrence? 1. These occurrences are referred to as "holdover reactions" to the drug. 2. These are flashbacks to a time when the client had a "bad trip." 3. The drug is still in the client's body and causing these reactions. 4. The client is suicidal and should be on one-to-one precautions.
2
9. The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.
2
95. The client diagnosed with substance abuse is being discharged from a drug and alcohol rehabilitation facility. Which information should the nurse teach the client? 1. "Do not go anyplace where you can be tempted to use again." 2. "It is important that you attend a 12-step meeting regularly." 3. "Now that you are clean, your family will be willing to see you again." 4. "You should explain to all your coworkers what has happened."
2
97. Which diagnostic test is used to confirm the diagnosis of ALS? 1. Electromyogram (EMG). 2. Muscle biopsy. 3. Serum creatine kinase (CK). 4. Pulmonary function test.
2
128. Which diagnostic evaluation tool would the nurse use to assess the client's cognitive functioning? Select all that apply. 1. The Geriatric Depression Scale (GDS) 2. The St. Louis University Mental Status (SLUMS) scale. 3. The Mini-Mental Status Examination (MMSE) scale. 4. The Manic Depression vs Elderly Depression (MDED) scale. 5. The Functional Independence Measurement Scale (FIMS).
2, 3
127. The 28-year-old client is on the rehab unit post SCI at the level of T10. Which collaborative team members should participate with the nurse at the case conference? Select all that apply. 1. OT 2. PT 3. Registered Dietician 4. Rehabilitation Physician 5. Social Worker 6. PCT
2, 3, 4, 5
20. The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? 1. Maintain the HOB at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure the pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every 2 hours. 5. Administer mild sedatives.
2, 3, 5
113. Which intervention should the nurse implement when caring for the client diagnosed with encephalitis? Select all that apply. 1. Turn the client every 2 hours. 2. Encourage the client to increase fluids. 3. Keep the client in the supine position. 4. Assess for DVT. 5. Assess for any alterations in elimination.
2, 4, 5
2. The nurse is assessing a client experiencing motor loss as a result of a left-sided CVA. Which clinical manifestation would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.
2. The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA will affect the right side. Ataxia is an impaired ability to coordinate movement.
102. The client is to receive a 100-mL intravenous antibiotic over 30 minutes via an intravenous pump. At what rate should the nurse set the IV pump? ___________
200 mL/hr
10. 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 mm Hg. 4. The presence of bronchogenic carcinoma.
3
103. The nurse is caring for the (several) following clients on a medical unit. Which client should the nurse assess first? 1. The client with ALS who is refusing to turn every two (2) hours. 2. The client with abdominal pain who is complaining of nausea. 3. The client with pneumonia who has a pulse oximeter reading of 90%. 4. The client who is complaining about not receiving any pain medication.
3
104. The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement? 1. Discuss the need to be placed in a long-term care facility. 2. Explain how to care for a sigmoid colostomy. 3. Assist the client to prepare an advance directive. 4. Teach the client how to use a motorized wheelchair.
3
106. The son of a client diagnosed with ALS asks the nurse, "Is there any chance that I could get this disease?" Which statement by the nurse would be most appropriate? 1. "It must be scary to think you might get this disease." 2. "No, this disease is not genetic or contagious." 3. "ALS does have a genetic factor and runs in families." 4. "If you are exposed to the same virus, you may get the disease."
3
111. The client admitted to the hospital to rule out encephalitis is being prepared for a lumbar puncture. Which instructions should the nurse teach the client regarding care postprocedural? 1. Instruct that all invasive procedures require a written permission. 2. Explain that this allows analysis of a sample of the CSF. 3. Tell the client to increase fluid intake to 300 mL for the next 48 hours. 4. Discuss that lying supine with the head flat will prevent all hematomas.
3
126. The 80-year-old male client on an Alzheimer's unit is agitated and asking the nurse to get his father to come and see him. Which is the best response? 1. Tell the client his father is dead and cannot come see him. 2. Give the client the phone and have him attempt to call his father. 3. Ask the client to talk about his father with the nurse. 4. Call the family so they can tell the client why his father cannot come to see him.
3
132. The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first? 1. Set the ventilator to hyperventilate the client in preparation for suctioning. 2. Assess the client's lung sounds and check for peripheral cyanosis. 3. Turn the client to the side to allow the secretions to drain from the mouth. 4. Suction the client using the in-line suction, wait 30 seconds, and repeat.
3
15. The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report? 1. The 22-yr old male client diagnosed with a concussion who is complaining someone is waking him up every 2 hours. 2. The 36-yr old female client admitted with complaints of left-sided weakness who is scheduled for a MRI scan. 3. The 45-yr old client admitted with blunt trauma to the head after a motorcycle accident with a Glasgow Coma Scale (GCS) score of 6. 4. The 62-yr old client diagnosed with CVA who has expressive aphasia.
3
16. The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead." Which data support that the client is brain dead? 1. When the client's head is turned to the right, the eyes turn to the right. 2. The electroencephalogram (EEG) has identifiable waveforms. 3. There is no eye activity when the cold caloric test is performed. 4. The client assumes decorticate posturing when painful stimuli are applied.
3
21. The client with a closed head injury has a clear fluid drainage from the nose. Which action should the nurse implement first? 1. Notify the HCP immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for the presence of glucose. 4. Place a 2 x 2 gauze under the nose to collect drainage.
3
25. The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next? 1. Carefully remove the driver from the car. 2. Assess the client's pupils for reaction. 3. Assess the client's airway. 4. Attempt to wake the client up by shaking him.
3
31. The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement? 1. Keep the client flat in bed. 2. Dim the lights in the room. 3. Assess for bladder distention. 4. Administer a narcotic analgesic.
3
35. Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? 1. Teach Credé's maneuver to the client needing to void. 2. Administer the tube feeding to the client who is quadriplegic. 3. Assist with bowel training by placing the client on the bedside commode. 4. Observe the client demonstrating self-catheterization technique.
3
39. The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedural teaching should the nurse implement? 1. Tell the client to take any routine ant-seizure medication prior to the EEG. 2. Tell the client not to eat anything for eight (8) hours prior to the procedure. 3. Instruct the client to stay awake for 24 hours prior to the EEG. 4. Explain to the client that there will be some discomfort during the procedure.
3
41. The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement? 1. Perform a complete neurological assessment. 2. Awaken the client every 30 minutes. 3. Turn the client to the side and allow the client to sleep. 4. Interview the client to find out what caused the seizure.
3
44. The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate? 1. Assess the client's neurological status every hour. 2. Monitor the client's heart rhythm via telemetry. 3. Administer an anticonvulsant medication by intravenous push. 4. Prepare to administer a Glucocorticosteroids orally.
3
46. Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? 1. "It is all right for me to drink coffee for breakfast." 2. "My menstrual cycle will not affect my seizure disorder." 3. "I am going to take a class in stress management." 4. "I should wear dark glasses when I am out in the sun."
3
48. The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly? 1. Alzheimer's disease. 2. Parkinson's disease. 3. Cerebral vascular accident (stroke). 4. Brain atrophy due to aging.
3
52. The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement? 1. Institute aspiration precautions. 2. Refer the client to Reach to Recovery. 3. Initiate seizure precautions. 4. Teach the client about mastectomy care.
3
54. The nurse has written a care plan for a client diagnosed with a brain tumor. Which is an important goal regarding self-care deficit? 1. The client will maintain body weight within two (2) pounds. 2. The client will execute an advance directive. 3. The client will be able to perform three (3) ADLs with assistance. 4. The client will verbalize feeling of loss by the end of the shift.
3
56. The client is diagnosed with a pituitary tumor and is scheduled for a transsphenoidal hypophysectomy. Which preoperative instruction is important for the nurse to teach? 1. There will be a large turban dressing around the skull after surgery. 2. The client will not be able to eat for four (4) or five (5) days postop. 3. The client should not blow the nose for two (2) weeks after surgery. 4. The client will have to lie flat for 24 hours following the surgery.
3
6. The nurse and an UAP are caring for an client with a 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 a hand under the client's right axilla to move up in the bed. 4. The assistant praises the client for attempting to perform ADL's independently.
3
61. The wife of the client diagnosed with septic meningitis asks the nurse, "I am so scared. What is meningitis?" Which statement would be the most appropriate response by the nurse? 1. "There is bleeding into his brain causing irritation of the meninges." 2. "A virus has infected the brain and meninges, causing inflammation." 3. "This is a bacterial infection of the tissues that cover the brain and spinal cord." 4. "This is an inflammation of the brain parenchyma caused by a mosquito bite."
3
63. The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis? 1. Positive Babinski's sign and peripheral paresthesia. 2. Negative Chvostek's sign and facial tingling. 3. Positive Kernig's sign and nuchal rigidity. 4. Negative Trousseau's sign and nystagmus.
3
73. The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is scientific rationale for combining these medications? 1. There will be fewer side effects with this combination than with carbidopa alone. 2. Dopamine D requires the presence of both of these medications to work. 3. Carbidopa makes more levodopa available to the brain. 4. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.
3
80. The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? 1. "All of my spouse's emotions will slow down now just like his body movements." 2. "My spouse may experience hallucinations until the medication starts working." 3. "I will schedule appointments late in the morning after his morning bath." 4. "It is fine if we don't follow a strict medication schedule on weekends."
3
82. Which is a common cognitive problem associated with Parkinson's disease? 1. Emotional lability. 2. Depression. 3. Memory deficits. 4. Paranoia.
3
84. The nurse caring for clients on med-surg floor. Which clients should be assessed first? 1. The 65-yr old client dx w/ seizures who is complaining of a headache that is a 2/10 scale. 2. The 24-yr old client dx w/ a T10 spinal cord injury (SCI) who cannot move his toes. 3. The 58-yr old client dx with PD who is crying and worried about her facial appearance. 4. The 62-yr old client dx w/ a CVA who has a resolving left hemiparesis.
3
89. The nurse observes a coworker acting erratically. The clients assigned to this coworker don't seem to get relief when pain medications are administered. Which action should the nurse take? 1. Try to help the coworker by confronting the coworker with the nurse's suspicions. 2. Tell the coworker that the nurse will give all narcotic medications from now on. 3. Report the nurse's suspicions to the nurse's supervisor or the facility's peer review. 4. Do nothing until the nurse can prove the coworker has been using drugs.
3
96. The nurse is working with clients and their families regarding substance abuse. Which statement is the scientific rationale for teaching the children new coping mechanisms? 1. The child needs to realize that the parent will be changing behaviors. 2. The child will need to point out to the parent when the parent is not coping. 3. Children tend to mimic behaviors of parents when faced with similar situations. 4. Children need to feel like they are a part of the parent's recovery.
3
92. The client is withdrawing from a heroin addiction. Which interventions should the nurse implement? Select all that apply. 1. Initiate seizure precautions. 2. Check vital signs every eight (8) hours. 3. Place the client in a quiet, calm atmosphere. 4. Have a consent form signed for HIV testing. 5. Provide the client with sterile needles.
3, 4
1. A 78-yr-old client is admitted to the ED with numbness and weakness of the left arm and slurred speech. Which nursing intervention is 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- CT scan of the head. 4. Notify the speech pathologist for an emergency consult.
3. STAT- CT scan (determine if a stroke, brain tumor, or other neurological disorder is present.
108. The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client? 1. Take the medication with food. 2. Do not eat green, leafy vegetables. 3. Use SPF 30 when going out in the sun. 4. Report any febrile illness.
4
11. The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.
4
110. The nurse is assessing the client admitted with encephalitis. Which data require immediate nursing intervention? The client has bilateral facial palsies. 1. The client has bilateral facial palsies. 2. The client has a recurrent temperature of 100.6*F. 2. The client has a decreased complaint of headache. 3. The client comments that the meal has no taste.
4
125. The concept of intracranial regulation is identified for a client diagnosed with a brain tumor. Which intervention should the nurse include in the client's plan of care? 1. Tell the client to remain on bedrest. 2. Maintain the IV rate at 150 mL/hr. 3. Provide a soft, bland diet with 3 snacks per day. 4. Place the client on seizure precautions.
4
17. The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess neurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.
4
22. The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first? 1. Assess the client's level of consciousness. 2. Organize onlookers to remove the client from the lake. 3. Perform a head-to-toe assessment to determine injuries. 4. Stabilize the client's cervical spine.
4
30. The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? 1. "Do you have trouble hearing?" 2. "Are you allergic to any type of dairy products?" 3. "Have you eaten anything in the last eight hours?" 4. "Are you uncomfortable in closed spaces?"
4
33. The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of lightheadedness and dizziness. The client's vital signs are T 99.2˚F, P 98, R 24, and BP 84/40. Which action should the nurse implement? 1. Notify the health-care provider ASAP. 2. Calm the client down by talking therapeutically. 3. Increase the IV rate by 50 mL/hour. 4. Lower the head of the bed immediately.
4
37. The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? 1. Push aside any furniture. 2. Place the client on his side. 3. Assess the client's vital signs. 4. Ease the client to the floor.
4
5. The nurse is planning care for a client experiencing agnosia secondary to a CVA. Which collaborative intervention will be included into the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.
4
50. The client has been diagnosed with a brain tumor. Which presenting signs and symptoms help to localize the tumor position? 1. Widening pulse pressure and bounding pulse. 2. Diplopia and decreased visual acuity. 3. Bradykinesia and scanning speech. 4. Hemiparesis and personality changes.
4
55. The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client's condition is becoming worse? 1. The client has purposeful movement with painful stimuli. 2. The client has assumed adduction of the upper extremities. 3. The client is aimlessly thrashing in the bed. 4. The client has become flaccid and does not respond to stimuli.
4
58. The client diagnosed with a brain tumor has a diminished gag response. Which intervention should the nurse implement? 1. Make the client NPO until seen by the health-care provider. 2. Position the client in low Fowler's position for all meals. 3. Place the client on a mechanically ground diet. 4. Teach the client to direct food and fluid toward the unaffected side.
4
65. Which type of precautions should the nurse implement for the client diagnosed with septic meningitis? 1. Standard Precautions. 2. Airborne Precautions. 3. Contact Precautions. 4. Droplet Precautions.
4
72. The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority? 1. Assess lung sounds. 2. Assess the six cardinal fields of gaze. 3. Assess apical pulse. 4. Assess level of consciousness.
4
78. The nurse is planning the care for a client dx with PD. Which would be a therapeutic goal of treatment for disease process? 1. The client will experience periods of akinesia throughout the day. 2. The client will take the prescribed medications correctly. 3. The client will be able to enjoy a family outing with the spouse. 4. The client will be able to carry out ADLs.
4
79. The nurse researcher is working with clients diagnosed with Parkinson's disease. Which is an example of an experimental therapy? 1. Stereotactic pallidotomy/thalamotomy. 2. Dopamine receptor agonist medication. 3. Physical therapy for muscle strengthening. 4. Fetal tissue transplantation.
4
8. The client has been diagnosed with CVA (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for client's bathroom.
4
81. The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? 1. Crackles in the upper lung fields and jugular vein distention. 2. Muscle weakness in the upper extremities and ptosis. 3. Exaggerated arm swinging and scanning speech. 4. Masklike facies and a shuffling gait.
4
85. The friend of an 18-year-old male client brings the client to the emergency department (ED). The client is unconscious and his breathing is slow and shallow. Which action should the nurse implement first? 1. Ask the friend what drugs the client has been taking. 2. Initiate an IV infusion at a keep-open rate. 3. Call for a ventilator to be brought to the ED. 4. Apply oxygen at 100% via nasal cannula.
4
90. The client is diagnosed with Wernicke-Korsakoff syndrome as a result of chronic alcoholism. For which symptoms would the nurse assess? 1. Insomnia and anxiety. 2. Visual or auditory hallucinations. 3. Extreme tremors and agitation. 4. Ataxia and confabulation.
4
93. The wife of the client diagnosed with chronic alcoholism tells the nurse, "I have to call his work just about every Monday to let them know he is ill or he will lose his job." Which would be the nurse's best response? 1. "I am sure that this must be hard for you. Tell me about your concerns." 2. "You are afraid he will lose his source of income." 3. "Why would you call in for your husband? Can't he do this?" 4. "Are you aware that when you do this you are enabling him?"
4
99. The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis? 1. Muscle atrophy and flaccidity. 2. Fatigue and malnutrition. 3. Slurred speech and dysphagia. 4. Weakness and paralysis.
4
133. The nurse is performing a Glasgow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client's GCS one (1) hour ago was scored at 10. Which datum indicates the client is improving? 1. The current GSC rating is 3. 2. The current GSC rating is 9. 3. The current GSC rating is 10. 4. The current GSC rating is 12.
4 (Remember, GCS rating goes up then client is improving)
121. The male client is admitted to ED following a motorcycle accident. The client is not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the ED nurse implement in the first 5 minutes? 1. Stabilize the client's neck and spine. 2. Contact the organ procurement organization to speak with the family. 3. Elevate the HOB to 70 degrees. 4. Perform a Glasgow Coma Scale (GCS) assessment. 5. Ensure the client has a patent peripheral venous catheter in place. 6. Check the client's driver's license to see if he will accept blood.
4, 5
134. The client diagnosed with a brain abscess is experiencing a tonic-clonic seizure. Which interventions should the nurse implement? Rank in order of performance. 1. Assess the client's mouth. 2. Loosen restrictive clothing. 3. Administer phenytoin IVP. 4. Turn the client to the side. 5. Protect the client's head from injury.
4, 5, 2, 3, 1
75. The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? 1. Consult the occupational therapist for adaptive appliances for eating. 2. Request a low-fat, low-sodium diet from the dietary department. 3. Provide three (3) meals per day that include nuts and whole-grain breads. 4. Offer six (6) meals per day with a soft consistency.
5
Epilepsy
A disorder of the central nervous system characterized by loss of consciousness and convulsions. (chronic brain disorder-recurrent seizure activity)
Activity of Daily Living (ADL)
Any basic self-care task, including grooming, bathing, and eating
Echolalia
The uncontrollable and immediate repetition of words spoken by another person
Parkinson's disease
a progressive disease that destroys brain cells and is identified by muscular tremors, slowing of movement, and partial facial paralysis A disorder of the central nervous system that affects movement, often including tremors.
computed tomography (CT)
a series of x-ray images are taken in multiple views (especially cross section) a scanning technique using multiple X-rays to construct three-dimensional images
paroxysms
a sudden attack or violent expression of a particular emotion or activity
paresthesia
abnormal sensation of numbness and tingling without objective cause
Areflexia
absence of reflexes
Transient Ischemic Attack (TIA)
brief episode of loss of blood flow to the brain, usually caused by a partial occlusion that results in temporary neurologic deficit (impairment); often precedes a CVA Minor stroke; where neurological function is regained quickly with time
amyotrophic lateral sclerosis (ALS)
degenerative disorder of motor neurons in the spinal cord and brainstem (progressive- atrophy and muscular weakness)
cerebrovascular accident
disruption in the normal blood supply to the brain; stroke
diplopia
double vision
Decarboxylase
enzyme that removes the decarboxyl group of an amino acid to yield an amine and CO2
ELISA
enzyme-linked immunosorbent assay (test to detect anti-HIV antibodies)
Apraxia
impaired ability to carry out motor activities despite intact motor function
Aphasia
impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding).
Akinesia
inability to initiate movement
ICP
intracranial pressure (normal pressure is 5 to 15 mm Hg)
Ataxia
lack of muscle coordination
Traumatic Brain Injury
mild or severe trauma that can result from a violent impact to the head (blow to the head)
Autonomic Dysreflexia
patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) (potentially life-threatening emergency)
bradykinesia
slowness of movement
Papilledema
swelling and inflammation of the optic nerve at the point of entrance into the eye through the optic disk
paralysis
temporary or permanent loss of motor control
Agnosia
the inability to recognize familiar objects.
Dysarthria
the inability to use speech that is distinct and connected because of a loss of muscle control after damage to the peripheral or central nervous system (slurred speech/difficulty forming words)
penumbra
the lighter part of a shadow where light is partially blocked