Neuro Exam 1 (NCLEX)
A client has slight weakness in the right leg. On the basis of this assessment finding, the nurse determines that the client would benefit most from the use of which item?
straight leg cane A straight leg cane is useful for the client with slight weakness in one leg as a result of a stroke. A walker is beneficial to the client with greater or bilateral weakness or one who is at risk for falls. Wooden crutches often are used by clients with a leg cast. Lofstrand crutches aid clients who need crutches but have limited arm strength.
A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse would include which interventions in the plan of care to maintain client safety after this procedure? Select all that apply.
Keep the head of the bed flat Place pillows under the length of the legs Use a logrolling technique for repositioning Assist the client with eating meals and drinking fluids
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.
Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Turning and repositioning the client at least every 2 hours
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions would the nurse take? Select all that apply.
Loosening restrictive clothing Removing the pillow and raising padded side rails Positioning the client to the side, if possible, with the head flexed forward
The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition?
Muscle spasm in the area of the herniated disk
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?
"I don't need to use my walker to get to the bathroom."
A client is somewhat nervous about undergoing magnetic resonance imaging (MRI). Which statement by the nurse would provide the most reassurance to the client about the procedure?
"The MRI machine is a long, narrow, hollow tube and may make you feel somewhat claustrophobic."
A new registered nurse (RN) is assisting the RN in admitting a client who has a diagnosis of hypothermia. The RN provides education to the new RN on anticipated vital signs in the client with hypothermia. Which statement by the new RN indicates that the teaching has been effective?
"The client will likely exhibit decreased heart rate and decreased blood pressure." Rationale: The heart rate and blood pressure are decreased because the metabolic needs of the body are reduced with hypothermia. With fewer metabolic needs, the workload of the heart decreases. Therefore, the vital sign changes in the remaining options are incorrect
The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client?
A cervical spinal cord injury
A client with a herniated disk who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to which member of the health care team?
A social worker
The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client who sustained a head injury. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How would the nurse document these findings?
Abnormal Rationale: In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses in‐ clude movement of the eyes in the same direction as the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. C
A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse would perform which action?
Acknowledge the client's anger and continue to encourage participation in care.
A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?
Affect is flat, with periods of emotional lability
A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem?
Altered breathing pattern
The nurse is assessing the client's gait and notes that it is unsteady and staggering. Which description would the nurse use when documenting the assessment finding?
Ataxic
A client is complaining of low back pain that radiates down the left posterior thigh. The nurse would ask the client if the pain is worsened or aggravated by which factor?
Bending or lifting
The nurse in the neurological unit is monitoring a client with a head injury for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item?
Blood pressure
The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate?
Contact the primary health care provider (PHCP).
A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client?
Decreased heart rate and decreased blood pressure Rationale: Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, resulting in decreased heart rate and blood pressure. Therefore, the remaining options are incorrect
The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse would bring which most essential items into the client's room?
Electrocardiographic monitoring electrodes and intubation tray
A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration?
Establishing a toileting schedule
. A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?
Exhaling during repositioning
The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention would the nurse plan to incorporate into the care routine for the client and family?
Explaining equipment and procedures on an ongoing basis
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?
Flaccid paralysis
The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse would place the client in which position postoperatively?
Head of bed elevated 30 to 45 degrees, head and neck midline
The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest in Williams' position to minimize the pain. The nurse would put the bed in what position?
In semi-Fowler's position, with the knees slightly flexed
The nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath sounds. Which judgment would the nurse formulate for the client?
Increased risk for aspiration
The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action?
Indicates that facial puffiness will be a permanent problem
The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action?
Initiating a bowel movement every other day, 45 minutes after the largest meal of the day
Members of the family of an unconscious client with increased intracranial pressure from a head injury are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation?
It is possible the client can hear the family.
The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply
Keep suction equipment at the bedside Elevate the head of the bed 30 degrees. Keep the head and neck in good alignment. Administer prescribed respiratory treatments as needed
The nurse is evaluating the use of a cane for a client who sustained a stroke who has residual left-sided weakness. The nurse would intervene and correct the client if the nurse observed that the client performs which action?
Moves the cane when the right leg is moved
The nurse is monitoring a client with a suspected intervertebral disc problem who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the primary health care provider (PHCP)?
Neck stiffness
The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate?
Notify the primary health care provider (PHCP).
The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" The nurse would plan to make which appropriate response to the client?
Pain is due to stimulation of the affected nerve by pressure and temperature."
The nurse is administering mouth care to an unconscious client. The nurse would perform which actions in the care of this person? Select all that apply.
Position the client on his or her side Brush the teeth with a small, soft toothbrush. Cleanse the mucous membranes with soft sponges.
The nurse is preparing to care for a client with suspected meningitis after a lumbar puncture. The nurse would plan to place the client in which best position following the procedure?
Prone with a small pillow under the abdomen
The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply
Provide physical aspects of care. Prevent pushing or straining activities Maintain the head of the bed at 15 degrees.
A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness?
Providing information, giving positive feedback, and encouraging relaxation
The nurse is planning care for a client who displays confusion secondary to a brain attack (stroke). Which approaches by the nurse would be helpful in assisting this client? Select all that apply.
Providing sensory cues Giving simple, clear directions Providing a stable environment Keeping family pictures at the bedside
. A client who has experienced a stroke has partial hemiplegia of the left leg. The nurse interprets that the client could benefit from the support and stability provided by which item?
Quad cane Rationale: A quad cane may be used by the client requiring greater support and stability than is provided by a straight leg cane. The quad cane provides a four-point base of sup‐ port and is indicated for use by clients with partial or complete hemiplegia. Neither crutches nor a wheelchair is indicated for use with a client such as the one described in the question.
The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures would the nurse include in planning for the client's safety? Select all that apply.
Rationale: Seizure precautions may vary from agency to agency, but they generally have some common features. - Usually, airway, oxygen, and suctioning equipment are kept available at the bedside. - The side rails of the bed are padded, - and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse needs to be - checking patency of the catheter. The use of padded tongue blades is highly controversial, and they would not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begin
The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan?
Restrict fluid intake for a period of 2 hours.
The nurse is assessing fluid balance in a client with a head injury who has undergone a craniotomy. The nurse would assess for which finding as a sign of overhydration, which would aggravate cerebral edema?
Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)
The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction?
Sounds will not be heard clearly unless they are loud
A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply.
Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering ac‐ etaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure.
The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What would the nurse anticipate to promote during the bowel retraining program?
Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord Rationale: The principal reflex center for defecation is located in the parasympathetic center at the S1 to S4 level of the spinal cord. This center is most active after the first meal of the day. Other factors that contribute to satisfactory stool passage are sufficient fluid and roughage in the diet and the Valsalva maneuver (which is lost with SCI). During defecation, the anal sphincter relaxes.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.
The client is aphasic has weakness on the right side of the body weakness on the right side of the face and tongue.
The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition would the nurse document?
The intracranial pressure reading is normal
The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional?
neuropsychologist
