Neuro Exam 5

A nurse is caring for a client who is having a seizure. Place the following actions in the appropriate order: 1. Note the length of the seizure and any factors that may have caused it 2. Stay with the client and call for help 3. administer anti-seizure medications 4. protect the clients head and loosen restrictive clothing 5. Document the seizure and the clients condition

2. Stay with the client and call for help 4. protect the clients head and loosen restrictive clothing 3. administer anti-seizure medications 1. Note the length of the seizure and any factors that may have caused it 5. Document the seizure and the clients condition

A nurse is caring for a client who has an order for gabapentin (Neurontin) 0.3 g orally BID (twice daily). Each capsule is 100 mg. How many capsules should the nurse administer in the morning? Enter the numeric value only.

3

A nurse is caring for a client with neuropathic pain who has an analgesic prescribed at a dose of 24 mg orally twice a day. The available stock is 16 mg / 5ml. Calculate the amount of dose in milliliters that will be administered for one dose for this client. (Fill in the blank with the numeric value only to one decimal point. Lead with a 0 if less than 1) Answer: ____mL

7.5 mL

The nurse is caring for an older adult client with visual disturbances. At what mark on the drawing of the right cerebral hemisphere of the brain is the visual association area located?

A. The primary visual area is located at the posterior tip of the occipital lobe (A), mainly on the medial surface of the cerebral hemisphere. Visual disturbance is a general terminology that implies the different conditions that occur in relation to visual impairment. Decreased visual acuity, blurring, and dulling are some examples of symptoms related to visual impairment

A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following pieces of information should the nurse include? A. "You might need glasses after the surgery." B. "You may drive home after the procedure." C. "Continue to wear your contact lenses until the day of the surgery." D. "Expect complete healing and clear vision in about a week."

A. "You might need glasses after the surgery." Rationale: LASIK is a type of refractive laser eye surgery that ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, overcorrection or undercorrection of refractive errors is possible, so some clients will need prescription eyeglasses despite having had LASIK surgery.

An RN is caring for an elderly client who has blindness as a result of glaucoma. The nurse knows to implement which of the following interventions when caring for this client (select all that apply)? A. Announce entry and exit from the room B. Instruct the client to use a cane with the nondominant hand C. Orient the client to the placement of items on the meal tray by using a clock-face description D. Stand close to the client and speak loudly to ensure comprehension E. Ask the client's spouse about the client's preferred arrangement of hygiene items

A. Announce entry and exit from the room C. Orient the client to the placement of items on the meal tray by using a clock-face description

A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement? A. Dysphagia B. Positive Babinski sign C. Decreased deep-tendon reflexes D. Ataxia

A. Dysphagia

A nurse is caring for a pediatric client with increased intracranial pressure (ICP) who begins to have a seizure. Which of the following is the nurse's priority action? A. Ensuring the client's safety B. Calling the healthcare provider C. Administering anticonvulsants D. Perform a neurological assessment

A. Ensuring the client's safety

A nurse is caring for a client who had a cerebrovascular accident (CVA). The client appears alert and engaged during a visit but does not respond verbally to questions. The nurse should document this as which of the following alterations? A. Expressive aphasia B. Dysarthria C. Receptive aphasia D. Dysphagia

A. Expressive aphasia Rationale: A client who has expressive aphasia understands speech but has difficulty speaking and writing. This typically occurs as a result of a lesion at Broca's area of the frontal lobe

A nurse is assessing a client with new onset of slurred speech and right sided weakness. Which of the following lab tests would the nurse expect the physician to order for evaluation of a client with suspected stroke? A. Fingerstick glucose B. Urine culture and sensitivity C. Serum folate D. Blood arsenic levels

A. Fingerstick glucose Signs of stroke include sudden onset of one or more of the following: numbness or weakness of the face, arms, or legs; confusion; difficulty speaking or understanding others (aphasia); vision changes; ataxia, dizziness; or loss of coordination or balance. Stroke or suspected stroke is an emergency. Initial tests include fingerstick glucose and non-contrast CT scan of the brain. Hypoglycemia must be ruled out, as it can cause stroke-like symptoms.

Which of the following best describes an appropriate desired outcome for a client with a traumatic head injury who has a nursing diagnosis of decreased adaptive capacity? A. Glasgow Coma Scale will be 13 or higher B. Intracranial pressure will be 50 mmHg or greater C. Cerebral perfusion pressure will be less than 20 mmHg D. Mean systolic arterial pressure will be 40 mmHg or less

A. Glasgow Coma Scale will be 13 or higher

A nurse is teaching a client who has a new prescription for pramipexole to treat Parkinson's disease. The nurse should instruct the client to monitor for which of the following adverse effects? A. Hallucinations B. Increased salivation C. Diarrhea D. Urinary retention

A. Hallucinations Rationale: Pramipexole can cause hallucinations within 9 months of the initial dose and might require discontinuation.

A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use? A. Have the client open his mouth and say, "aah" B. Ask the client to identify the scent of coffee C. Use a tongue blade to provoke a gag reflex D. Have the client smile and raise his eyebrows

A. Have the client open his mouth and say, "aah"

A nurse is caring for a client who had a stroke (CVA) who frequently cries when family members visit. The family is upset by the crying. The nurse explains to the family members that the client is: A. Having difficulty controlling emotions B. Demonstrating a premorbid personality C. Mourning the loss of functional abilities D. Conveying unhappiness about the situation

A. Having difficulty controlling emotions A common complication of a stroke (CVA) is the inability to control emotional effect. Clients may be depressed or apathetic and experience lability of mood.

A nurse is caring for a hospitalized adult client who was injured in a motor vehicle accident and suffered a spinal cord injury 3 days ago. The client has been paralyzed below the level of T5 on the spinal cord. Based on the information provided, which of the following nursing interventions is most important? A. Increase the client's activity level as quickly as possible B. Teach the client to promote circulation through ankle rotation and foot pumping C. Administer vasodilator medications as ordered D. Place an abdominal binder on the client and remove it every 24 hours

A. Increase the client's activity level as quickly as possible

A nurse is caring for a client with Parkinson's disease who has a prescription for selegiline (Eldepryl). Which of the following is true about this medication? (Select all that apply) A. It causes dizziness B. It affects sleep patterns C. It is taken intravenously only D. It can be administered with MAOI (monoamine oxidase inhibitor) E. It is ototoxic F. It's best to administer when symptoms occur

A. It causes dizziness B. It affects sleep patterns Common side effects are dizziness, dry mouth, insomnia or difficulty falling asleep, myalgia or muscle pain, rashes, nausea, and constipation. Adverse reactions from this type of drug include arrhythmia, dyspnea, chorea, and hallucinations. Selegiline should not be administered in combination with another MAOI (monoamine oxidase inhibitor) or fluoxetine, as the effects are strengthened and may lead to a toxic reaction.

Why is a tilt table with an increased angle at the head of the table used each day to treat a client with quadriplegia? A. It increases tolerance to exercise. B. It promotes hyperextension of the spine. C. It helps the nurse with transfers from bed. D. It reduces the loss of muscle and bone mass.

A. It increases tolerance to exercise.

A nurse is caring for a client transported to the ED by ambulance after a motorcycle accident. The client has a Glasgow Coma Scale score of 13 and suspected cervical spinal cord injury. There is a cervical collar in place. Which of the following nursing interventions is a priority intervention? A. Place the client on a backboard B. Avoid moving the client C. Turn client on side in case of seizure D. Obtain an order for a Foley catheter

A. Place the client on a backboard Vital Concept: When a client has suspected traumatic cervical spinal cord injury, the healthcare team implements procedures to support alignment of the spine in an anatomically neutral position, including logrolling of the client when repositioning for comfort or procedures; use of transfer techniques to move the client from surface to surface; application and maintenance of C-spine collar; skincare; placing the client on an appropriate surface as ordered by the responsible healthcare provider and monitoring spinal signs.

A nurse is caring for a client with a seizure disorder. Which of the following should the nurse include when seizure precautions are prescribed by the healthcare provider? (Select all that apply.) A. Prepare suction equipment at the bedside. B. Insert a urinary catheter. C. Place pads on the side rails of the bed. D. Elevate the bed to a high position. E. Place the client in restraints.

A. Prepare suction equipment at the bedside. C. Place pads on the side rails of the bed.

A nurse is caring for a client who sustained a severe spinal cord injury (SCI) 2 days ago involving a T12 fracture. The client has no muscle control of the lower limbs, bowel, or bladder. In planning the client's care, which of the following outcomes should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of urinary tract infections (UTIs) C. Prevention of skin breakdown of areas that lack sensation D. Prevention of contractures to the lower extremities

A. Prevention of further damage to the spinal cord

A nurse is providing discharge teaching to a client who has had a transient ischemic attack (TIA). Which of the following instructions should the nurse include? A. Reduce dietary sodium B. Decrease dietary potassium C. Restrict intake of insoluble fiber D. Limit alcohol intake to ≤3 servings per day

A. Reduce dietary sodium

A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? A. The client's ability to clear oral secretions B. The client's ability to communicate verbally C. The client's ability to move all extremities D. The client's ability to remain continent of urine

A. The Client's ability to clear oral secretions Rationale: The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to check the client's ability to clear secretions in order to protect the airway and reduce the risk of aspiration.

A nurse and unlicensed assistive personnel are caring for a client in the intensive care unit with increased intracranial pressure after rupture of a cerebral aneurysm. Which of the following actions by the UAP will prompt intervention by the nurse? A. The UAP assists the client to a prone position. B. The UAP uses the lift sheet to move the client. C. The UAP encourages the client when he attempts to brush his teeth. D. The UAP performs passive range of motion exercises.

A. The UAP assists the client to a prone position. A client who is experiencing increased intracranial pressure should not be placed in a prone position. Clients with increased intracranial pressure should generally be placed in a position with the head elevated, to reduce intracranial swelling.

A nurse is caring for a client in the ICU who was hospitalized after rupture of cerebral aneurysm. The client was responsive to painful stimuli, with decorticate posturing, on initial assessment by the nurse. Which of the following findings 4 hours later would require immediate intervention by the nurse? A. The client extends all extremities in response to sternal rub. B. The client responds to sternal rub by localizing movement. C. The client responds purposefully to verbal stimuli. D. The client opens eyes in response to sternal rub.

A. The client extends all extremities in response to sternal rub. Decorticate posture is an abnormal posturing in which the client is stiff with flexion of the upper extremities and extension of the lower extremities. This posture is a sign of severe damage in the brain. Decerebrate posturing refers to extension of all extremities.

A nurse in the emergency department is caring for a client with a score of 11 on the Glasgow Scale. What does this score indicate? A. The client has a moderate brain injury B. The client has a high level of consciousness C. The client is at risk for falls and injuries D. The client is at risk for skin breakdown

A. The client has a moderate brain injury

A nurse in an emergency department is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following findings are indicative of increased intracranial pressure (ICP)? (Select all that apply.) A. Vomiting. B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A. Vomiting. B. Dilated pupils D. Decorticate posturing

The nurse is assessing a client with a closed head injury. In what order should the nurse do the following pieces of the assessment? 1. LOC 2. Vital Signs 3. Motor Strength 4. Urine output

Answer: LOC Motor strength VS Urine Output

Although providing an obstacle-free path is a safety precaution for all clients, it is especially crucial for this client. Cranial nerve II is the optic nerve; therefore, the client has at least some visual challenges and will need an obstacle-free path for ambulation. A. "You can expect your vision to return immediately after the procedure." B. "You should avoid reading for 1 week." C. "You can remove eye shields when you're sleeping." D. "You should not lift objects that weigh more than 25 lb."

B. "You should avoid reading for 1 week." Rationale: The client should avoid reading and any activity that can cause rapid movement of the eye due to the risk of detachment of the retina.

A nurse is preparing a client for an electroencephalogram (EEG). Which of the following pieces of information should the nurse share with the client? A. "Expect the test to take about 3 hr." B. "You'll begin by lying still with your eyes closed." C. "You'll sleep for the duration of the procedure." D. "Expect some mild electrical shocks during the test."

B. "You'll begin by lying still with your eyes closed."

When testing extraocular movements (EOM), the nurse is testing which cranial nerve(s)? (Select all that apply) A. 2- Optic B. 3- Oculomotor C. 4- Trochlear D. 5- Trigeminal E. 6- Abducens

B. 3- Oculomotor C. 4- Trochlear E. 6- Abducens

A nurse is caring for a client who has received sedation. When the nurse applies nailbed pressure, the client withdraws his hand. The nurse should document this response as indicating which of the following? A. Confusion B. Arousal C. Orientation D. Attention

B. Arousal Rationale: The nurse should document that the client is demonstrating some degree of arousal. Withdrawing the hand in response to nailbed pressure indicates responsiveness to sensory stimulation.

A nurse is caring for a client who is post-op lumbar laminectomy. Which of the following is appropriate when caring for this client? A. Encourage the client to cough frequently and deep-breathe B. Assist with repositioning by using the draw sheet and logrolling the client C. Assess the client for symptoms of peritonitis D. Instruct the client to bend the knees while turning

B. Assist with repositioning by using the draw sheet and logrolling the client

A nurse is caring for a client with a spinal cord injury. The nurse understands that which of the following spinal cord injury complications is accurately paired with its description? A. Poikilothermia: A type of neurogenic shock that occurs in clients with a spinal cord injury above T 6 B. Autonomic dysreflexia: A life-threatening complication that occurs in clients with a spinal cord injury above T 6 C. Autonomic dysreflexia: Poikilothermia is the body's loss of ability to control and regulate body temperature D. Neutropenia: An abnormally low neutrophil count

B. Autonomic dysreflexia: A life-threatening complication that occurs in clients with a spinal cord injury above T 6

A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul

B. Cheyne-Stokes Rationale: Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.

A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nares C. Motor loss on one side of the body D. Bleeding from the top of the scalp

B. Clear fluid coming from the nares Rationale: Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture.

A client with myasthenia gravis is undergoing assessment. Which of the following symptoms does the nurse expect? (Select all that apply) A. Hyperkalemia B. Double vision C. Moon faces D. Anuria E. Dysphagia

B. Double vision E. Dysphagia Myasthenia gravis is an autoimmune neuromuscular disorder. Auto-antibodies destroy and block the neuromuscular junction receptor sites, giving rise to the symptoms associated with this condition, including diplopia or double vision, ptosis, facial weakness, dysphagia, dysarthria, weakness, fatigue, decreased function of the lower extremities, weakened intercostal muscles, grimacing, poor gas exchange, dyspnea, and decrease in diaphragmatic movement. Myasthenia gravis is treated with anticholinesterase medications that increase acetylcholine levels at the neuromuscular junction, facilitating muscular contraction. Myasthenic crisis results in sudden exacerbation of motor weakness, increasing the risk of respiratory failure. A crisis is usually caused by under-medication or missed medication and/or infection.

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? A. Elevated glucose B. Elevated protein C. Presence of RBCs D. Presence of D-dimer

B. Elevated protein

A nurse is caring for a client who has absence seizures. The nurse should recognize that which of the following medications are indicated for the treatment of absence seizures? (Select all that apply.) A. Phenytoin B. Ethosuximide C. Gabapentin D. Primidone E. Valproic acid F. Lamotrigine

B. Ethosuximide E. Valproic acid F. Lamotrigine

A nurse is reviewing the medical records of a client who takes herbal supplements for migraine headaches. The nurse should identify that which of the following herbal supplements is used prophylactically for migraine headaches? A. Echinacea B. Feverfew C. Saw palmetto D. Valerian

B. Feverfew The nurse should identify that feverfew is administered to prevent migraine headaches, arthritis, and to stimulate digestion. Feverfew has no effect if administered after a migraine headache has begun.

A nurse is caring for a client with a traumatic spinal cord injury as a result of a diving accident. The client has lost motor function below the injury but has some preserved sensory function at and below the level of the injury. How is this injury classified according to the American Spinal Injury Association's ASIA scale? A. Grade A spinal cord injury B. Grade B spinal cord injury C. Grade C spinal cord injury D. Grade D spinal cord injury

B. Grade B spinal cord injury The American Spinal Injury Association classifies spinal cord injuries according to the ASIA scale, from Grade A to Grade E. Grade B is characterized by a lack of motor function, but some preserved sensory function at and below the level of the injury. Grade A spinal cord injuries are complete injuries with the lack of all sensory and motor function; Grade C reflects the some motor function but impaired sensory function below the level of the injury; and Grade E reflects normal sensory and motor function.

A college student is asking the nurse about his grandfather, who just received a diagnosis of Huntington's disease. The student wants to know if he will also have the disease. What should the nurse tell the student? (Select all that apply.) A. Huntington's disease affects men more than women B. Huntington's disease is an autosomal dominant disease C. Huntington's disease does not skip a generation D. Huntington's disease is a curable disease E. There is a 75% chance you will have the disease

B. Huntington's disease is an autosomal dominant disease C. Huntington's disease does not skip a generation

A nurse is assessing a client who is seeking care for frequent headaches and blurred vision. The nurse asks the client to follow a moving object with his eyes. This test assesses the functions of which set of cranial nerves? A. I, II B. III, IV, VI C. IX, X, XI D. VIII, XII

B. III, IV, VI

Why is a client with myasthenia gravis likely to have a higher risk of respiratory complications? A. Reduced immunity B. Ineffective coughing C. Increased mucous viscosity D. Airway hyperreactivity

B. Ineffective coughing Vital Concept: Myasthenia gravis is an autoimmune disease that affects the neuromuscular junction. It causes periods of fluctuating weakness that most commonly affects skeletal muscles involved in eye movement, eyelids, swallowing, and respiration. Weakness of swallow, cough reflex and respiratory muscles increases the risk of pulmonary infection.

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? A. Visualizing the eardrum before irrigating B. Instilling 50 mL of fluid with each irrigation C. Using firm, continuous pressure while irrigating D. Warming the irrigation fluid to at least 37°C (98°F)

B. Instilling 50 mL of fluid with each irrigation Rationale: When irrigating a client's ear, the nurse should use no more than 5 to 10 mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear, which would result in nausea, vomiting, or dizziness. The nurse should stop irrigating if the client experiences pain, nausea, vomiting, or dizziness.

A nurse is caring for a client in the Intensive Care Unit (ICU) who has suffered a head injury and requires a monitor to check intracranial pressure. Which of the following are late signs of increased intracranial pressure? (Select all that apply.) A. Contracted extremities B. Loss of reflexes C. Tachycardia D. Hyper-response to painful stimuli E. Arm drift

B. Loss of reflexes E. Arm drift Late signs of increased intracranial pressure in a patient may include loss of reflexes, arm drift, changes in the level of consciousness, paralysis, and seizures.

A nurse is creating a plan of care for an infant who has an endotracheal (ET) tube in place due to increased intracranial pressure (ICP). Which of the following interventions should the nurse include in the plan of care to reduce ICP? (Select all that apply.) A. Suction the ET tube every 2 hr. B. Maintain a quiet environment. C. Use two pillows to elevate the infant's head. D. Administer a stool softener. E. Place the infant in the Trendelenburg position.

B. Maintain a quiet environment. D. Administer a stool softener.

The nurse is assessing a client with trigeminal neuralgia. Which of the following are true with this condition? (Select all that apply) A. Hypotension occurs B. Ophthalmic sensory division is affected C. Frequent falls occur D. Slurred speech occurs E. Pain occurs

B. Ophthalmic sensory division is affected E. Pain occurs

A nurse is caring for a client who is unconscious. When positioning the client, the nurse understands that compression of which of the following structures will result in wrist drop? A. Lateral cord of brachial plexus B. Radial nerve C. Median nerve D. Ulnar nerve

B. Radial nerve

The nurse should document that the client is demonstrating some degree of arousal. Withdrawing the hand in response to nailbed pressure indicates responsiveness to sensory stimulation. A. Glaucoma B. Retinal Detachment C. Macular Degeneration D. Cataracts

B. Retinal detachment Rationale: A flash of light and a sudden loss of vision are manifestations of retinal detachment. Clients report the event of vision loss as sudden and painless.

A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. Which of the following positions should the nurse place the child? A. Knee-chest B. Semi-Fowler's C. Prone D. Supine

B. Semi-Fowler's

A nurse is admitting a client who is being evaluated for increased seizure activity at home. Which of the following tasks can the nurse delegate to the unlicensed assistive personnel (UAP) during admission of this client? A. Setting up the client's room with supplies and equipment needed for seizure precautions, including the sterile field B. Setting up the client's room with supplies and equipment needed for seizure precautions C. Receiving report on the client from the emergency department and transporting the client to her room D. Setting up the client's room with supplies and equipment needed for seizure precautions including a vest restraint for emergency use during a possible seizure

B. Setting up the client's room with supplies and equipment needed for seizure precautions

A nurse is observing a student nurse's performance of a neurological assessment. The student nurse checks all reflexes on the left side from head to toe and then checks all the reflexes on the right side from head to toe in an orderly, systematic, and complete manner. Has the student nurse correctly performed the assessment of reflexes? A. The student nurse failed to use a stopwatch. B. The student nurse did not perform the reflex assessment in the proper sequence C. The student nurse has correctly and completely performed the physical assessment of the neurological system's reflexes D. The student nurse completed the reflex assessment in the proper sequence

B. The student nurse did not perform the reflex assessment in the proper sequence Each reflex should be assessed bilaterally in a short sequence to determine if each reflex is equal or unequal on the right and left side. For example, the plantar reflex is checked on the right extremity and then immediately checked on the left extremity.

Select the type of stroke that is accurately paired with its etiology. A. Embolic stroke: The rupture of an aneurysm B. Thrombotic stroke: Clotting on cerebral artery plaque C. Hemorrhagic stroke: An occlusion of the cerebral artery D. Cerebral stroke: The rupture of a nerve

B. Thrombotic stroke: Clotting on cerebral artery plaque Rationale: The etiology, or cause, of a thrombotic stroke is the clotting of blood on the plaque of the cerebral artery. The occlusion of this vital artery caused by the clot can cause a thrombotic stroke. An embolic stroke occurs as the result of a clot in another part of the body that travels to and occludes the cerebral artery. A hemorrhagic stroke is caused by the rupture of an aneurysm or an artery in the brain. All of these types of strokes are cerebral strokes.

A nurse is caring for a client with Lewy body dementia who becomes agitated and accuses the nurse of failing to provide food to satisfy his hunger and nutritional needs within 30 minutes after eating a meal. What is the appropriate response by the nurse? A. Have another witness confirm that the client consumed his meal. B. Withhold a portion of meals in the future to offer if the client asks for his meal soon after eating. C. Tell the client that he has already eaten but another meal will be served soon. D. Remind the client calmly during the course of the day that he has eaten.

B. Withhold a portion of meals in the future to offer if the client asks for his meal soon after eating.

A nurse is providing teaching to a client who has a new prescription for levodopa/carbidopa to treat Parkinson's disease. Which of the following statements should the nurse include in the teaching? A. "This medication will cause you to urinate more frequently." B. "Expect muscle twitching to occur." C. "Take this medication with food." D. "Relief of symptoms should occur within 24 hours."

C. "Take this medication with food." The client should take this medication with food to reduce adverse gastrointestinal effects, such as nausea and vomiting. However, the client should avoid high-protein meals.

A nurse is teaching a client who has seizures about going home with her new vagal nerve stimulator. Which of the following statements should the nurse include in the teaching? A. "You should use hypoallergenic lotion on your skin in the area of the device." B. "Notify your provider if you experience hiccups." C. "You should place the special magnet over the device when you feel an aura occurring." D. "It is recommended that you use ultrasound diathermy for pain management."

C. "You should place the special magnet over the device when you feel an aura occurring."

Which of the following clients in a neurology unit should be assigned to the most experienced nurse? A. A client with Guillain-Barre syndrome who complains of difficulty walking B. A client with Alzheimer's dementia who is restless C. A client with a stroke that is evolving D. A client who experienced a transient ischemic attack 24 hours earlier

C. A client with a stroke that is evolving The client with an evolving stroke is experiencing a change that is potentially life-threatening, which makes this client a priority

A client in the intensive care unit after head trauma develops diabetes insipidus. Which of the following nursing actions is appropriate? A. Monitor glucose and use sliding-scale insulin B. Place the client in the Trendelenburg position C. Administer desmopressin D. Ensure fluid restriction

C. Administer desmopressin

A client is admitted after an MVC resulting in spinal cord injury with paraplegia. The nurse recognizes that which of the following will be an early problem for this client? A. Nutrition B. Use of assistive device for ambulation C. Bladder control D. Need for rehabilitation of quadriceps muscles

C. Bladder control

A nurse is teaching a client about newly diagnosed Parkinson's disease. The nurse tells the client's family that the disease is caused by which of the following? A. Cholesterol plaques causing reduced blood flow to the brain B. Antibodies to myelin on the nerve sheath C. Breakdown of neurons in the basal ganglia D. Vitamin B12 deficiency

C. Breakdown of neurons in the basal ganglia

A nurse is caring for a school-age child who has a concussion. Which of the following manifestations are late indications of increased intracranial pressure (ICP)? (Select all that apply.) A. Report of headache B. Nausea C. Decreased motor response D. Increased sleeping E. Bradycardia

C. Decreased motor response E. Bradycardia

A nurse is caring for an elderly female client who developed pneumonia after a hip replacement surgery. The client had been alert and oriented, but today she appears confused and less responsive. She is not oriented to place or time. Which of the following does the nurse suspect in this client? A. Dementia B. Amnesia C. Delirium D. Depressive psychosis

C. Delirium Vital Concept: Delirium refers to an acute change in mental status that occurs as a result of an underlying disease or condition. Elderly clients are at greater risk of delirium than the general population. Clients with delirium experience global memory impairment, disorientation, and confusion. They may experience hallucinations or appear agitated. The priority nursing task is to ensure the client's safety.

A nurse is preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affects the manner in which the nurse will prepare the client for the scan? A. No food or fluids consumed for 4 hr B. Difficulty recalling recent events C. Development of hives when eating shrimp D. Paresthesias in both hands

C. Development of hives when eating shrimp

A nurse is assessing for silent aspiration for a client who has a neurogenic disorder and is experiencing dysphagia. Which of the following manifestations should indicate to the nurse that the client has silent aspiration? A. Displays continual tongue rolling while eating B. Attempts to rapidly swallow with each bite C. Displays no coughing when food enters the airway D. Attempts to regurgitate food after swallowing

C. Displays no coughing when food enters the airway

A nurse is caring for a client during the first 72 hr following a cerebrovascular accident (CVA). Which of the following actions should the nurse take? A. Turn the client's head to the side with the head of the bed elevated 60° B. Place the head of the bed flat with pillows under the client's neck and feet C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position D. Position the client in a dorsal recumbent position with pillows under the head and knees

C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? A. Occipital B. Temporal C. Frontal D. Limbic

C. Frontal

When caring for a client who is within 72 hours of onset of a hemorrhagic stroke, the nurse knows the client should be placed in which of the following positions? A. Trendelenburg B. Dorsal recumbent position C. Head of the bed elevated to 30 degrees with the client's head in midline D. Left lateral decubitus with the head elevated 45 degrees

C. Head of the bed elevated to 30 degrees with the client's head in midline

A nurse is assessing a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment? A. Inability to remember current age B. Inability to count backward C. Inability to locate eyeglasses D. Inability to recall names of family members

C. Inability to locate eyeglasses

A nurse is assessing a client who has increased intracranial pressure and has received intravenous mannitol. Which of the following findings indicates a therapeutic effect of this medication? A. Decreased blood glucose B. Decreased bronchospasms C. Increased urine output D. Increased temperature

C. Increased urine output Mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys. Increased urine output and decreased intracranial pressure are therapeutic effects of this medication.

While performing an initial physical assessment on a client who was brought in following a motor vehicle accident, the nurse notes that the client is exhibiting decerebrate posturing. Which best describes this posture? A. Legs and feet extended, arms pulled up and tucked into chest B. Legs and feet flaccid, arms rigid and flexed at the elbows C. Legs, feet, and arms stiffly extended, hands turned outward and flexed D. Legs, feet, and arms flaccid with no motor response

C. Legs, feet, and arms stiffly extended, hands turned outward and flexed

The nurse is caring for a client with an injury to the thalamus. Which of the following nursing interventions is appropriate when caring for this client? A. Give higher doses of pain medication B. Keep patches on the eyes to prevent corneal abrasion C. Monitor the temperature of the bathwater D. Avoid turning the client

C. Monitor the temperature of the bathwater

A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote the client's safety? A. Initiate seizure precautions. B. Ensure the client receives a soft diet. C. Provide an obstacle-free path for ambulation. D. Instruct the client to use lukewarm water when showering.

C. Provide an obstacle-free path for ambulation. Rationale: Although providing an obstacle-free path is a safety precaution for all clients, it is especially crucial for this client. Cranial nerve II is the optic nerve; therefore, the client has at least some visual challenges and will need an obstacle-free path for ambulation.

A nurse in a long-term care facility is giving an inservice presentation to a group of nurses about the management of clients who have Alzheimer's disease (AD). When the nurse describes the plan of care for a client who is in the moderate stage of AD, which of the following interventions should the nurse include in the plan? A. Offer memory training activities. B. Limit instructions to two to three steps at a time. C. Provide protective undergarments. D. Perform ADLs for the client.

C. Provide protective undergarments.

A nurse is providing information to a client with bipolar disorder who has a new prescription for valproic acid (Depakene). Which of the following side effects of valproic acid will the nurse discuss with the client? A. Increased urination B. Hair growth C. Sedation D. Weight loss

C. Sedation Valproic acid can result in sedation as well as headache, nausea, vomiting, and indigestion. It also causes tremor and thrombocytopenia, which can result in bruising.

A nurse is assessing a client transported to the emergency department with a traumatic head injury following a motor vehicle accident. The nurse determines that the client has a score of 8 on the Glasgow Coma Scale. This score is consistent with which of the following? A. Mild head injury B. Moderate head injury C. Severe head injury D. Vegetative state

C. Severe head injury

A nurse is caring for a client who has experienced a left-sided CVA. The nurse knows to intervene when the unlicensed nursing person assigned to help with feeding does which of the following? A. Assists the client to sit upright at 90 degrees B. Tilts the client's neck downward slightly during feeding C. Thins pureed food with some milk to ease swallowing D. Places food on the stronger side of the client's mouth

C. Thins pureed food with some milk to ease swallowing

The nurse is assessing a client with Parkinson's disease who experiences unsteadiness when turning. According to this finding, which stage of the disease is the client experiencing? A. Second B. First C. Third D. Fourth

C. Third

A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching? A. Remain NPO 6 to 8 hr prior to the EEG B. Take a sedative the night prior to the EEG C. Thoroughly shampoo her hair prior to the EEG D. Sleep for at least 8 hr during the night prior to the test

C. Thoroughly shampoo her hair prior to the EEG Rationale: The nurse should instruct the client to thoroughly wash her hair prior to the EEG because hairsprays, oils, and other hair preparations interfere with recording results of the EEG.

A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect? A. Tonic-clonic seizures B. Report of a severe headache C. Weakness of the lower extremities D. Decreased level of consciousness

C. Weakness of the lower extremities

Which of the following situations would contribute to sensorineural hearing loss? Select all that apply. A. Cerumen impaction B. Chronic ear infections C. Exposure to loud noise D. Acoustic neuroma E. Use of ototoxic medications

Correct Answers: C. Exposure to loud noise D. Acoustic neuroma E. Use of ototoxic medications Sensorineural hearing loss is a type of hearing loss that develops because of damage to the structures of the inner ear, such as the cochlea, vestibular duct, or the utricle. Alternatively, conductive hearing loss develops because of something that prevents sound from reaching the inner ear, not actual damage to the inner structures. Causes of sensorineural hearing loss include:

A nurse is preparing a client for an electroencephalogram (EEG). When the client asks the nurse what this test does, which of the following responses should the nurse provide? A. "An EEG measures the electric signals to your brain from hearing, sight, and touch." B. "An EEG measures the electrical activity in your muscles." C. "An EEG identifies the magnetic fields produced by electrical activity in your brain." D. "An EEG records the electrical activity of your brain cells."

D. "An EEG records the electrical activity of your brain cells."

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching? A. A TIA can cause irreversible hemiparesis. B. A TIA can be the result of cerebral bleeding. C. A TIA can cause cerebral edema. D. A TIA can precede an ischemic stroke.

D. A TIA can precede an ischemic stroke. Rationale: TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include the loss of vision in an eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness.

A nurse is performing an assessment of an unconscious client. The nurse knows that the Glasgow Coma Scale is designed to: A. Assess muscle strength B. Assess the performance of activities of daily living C. Assess the pain level D. Assess the level of consciousness

D. Assess the level of consciousness

Which of the following nursing diagnoses is the highest priority for a client who has presented to the emergency department with a depressed skull fracture? A. At risk for acute confusion related to a depressed skull fracture B. At risk for disturbed sensory perception related to a depressed skull fracture C. At risk for permanent dysfunction related to a depressed skull fracture D. At risk for respiratory compromise related to a depressed skull fracture

D. At risk for respiratory compromise related to a depressed skull fracture

A nurse is completing a neurological examination on a client who is recovering from a traumatic brain injury. The nurse should perform which of the following actions to assess cranial nerve III? A. Test visual acuity. B. Observe for facial symmetry. C. Monitor the client's ability to hear the spoken word. D. Check the client's pupillary response to light.

D. Check the client's pupillary response to light.

A nurse is caring for a client who has a cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected? A. Wernicke's area B. Cerebral cortex C. Basal ganglia D. Hypothalamus

D. Hypothalamus Rationale: The nurse should identify that the hypothalamus, located below the cerebrum of the brain, is responsible for the regulation of body temperature.

A nurse in the emergency department is caring for a client with a spinal cord injury. Which intervention should the nurse prioritize? A. Place a small pillow under the client's head for comfort B. Move the client gently to decrease pain C. Restrain the client's arms and legs to limit movement D. Immobilize the client's head and neck

D. Immobilize the client's head and neck

A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? A. Question the clients coworkers about the mechanism of Injury B. Check the patients pupils for equality and reactions to light C. Measure the clients alertness using the Glasglow Coma scale D. Immobilize the clients cervical spine.

D. Immobilize the clients cervical spine Rationale: The greatest risk to this client is an injury from a cervical spine dislocation and spinal cord compression following a traumatic head injury. Therefore, the priority action the nurse should take after assessing the client's ABC is immobilizing the client's neck with a cervical collar. A client who has head trauma might also have damage to the cervical spine. This is an essential component of the initial stabilization of a client who has a head injury.

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions should the nurse include in the plan of care? A. Assist the client in supine position. B. Keep the client's room well lit. C. Measure head circumference every shift. D. Implement seizure precautions.

D. Implement seizure precautions.

A nurse is preparing a client for lumbar puncture. To which of the following positions will the nurse assist the client? A. Prone position with knees flexed B. Fowler's position with head and neck flexed C. Supine position with knees flexed D. Lateral position with head and neck flexed

D. Lateral position with head and neck flexed

A nurse is assessing a client who was transported to the ER with neurological deficits after falling off a ladder. What client assessment is included in the Glasgow Coma Scale? A. Breathing patterns B. Deep tendon reflexes C. Eye accommodation to light D. Motor response to a stimulus

D. Motor response to a stimulus The three areas of assessment to determine the level of unconsciousness using the Glasgow Coma Scale are motor, verbal, and eye response to stimuli.

A nurse is caring for a client who had a cervical spine injury 24 hr ago. Which of the following prescribed medications should the nurse clarify with the provider? A. Calcium supplements B. Plasma expanders C. H2 antagonists D. Muscle relaxants

D. Muscle relaxants The nurse should clarify the need for the client to receive muscle relaxants with the provider. The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

A nurse is caring for a client status post craniotomy who has clear wound drainage of 60 mL during one shift from a drain placed during the procedure. Which of the following is the priority nursing intervention? A. Log-roll the client with the operative side up. B. Cleanse the wound site using sterile saline and apply a new dressing. C. Mark the drainage saturation of the dressing and monitor q 12 hours. D. Notify the healthcare provider of the amount and color of drainage.

D. Notify the healthcare provider of the amount and color of drainage. Drainage of 50 mL or more per shift or drainage that saturates dressings during the shift suggest the possibility of a leak of cerebral spinal fluid as a result of an injury to the dura during surgery

A client falls to the floor while ambulating and appears to experience a tonic-clonic seizure. Which of the following is the most appropriate immediate intervention by the nurse during the seizure? A. Document timing and symptoms B. Insert a tongue blade into the client's mouth C. Restrain the client to prevent injury D. Place the client in the left lateral position

D. Place the client in the left lateral position

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. Flushing of the lower extremities B. Hypotension C. Tachycardia D. Report of a headache

D. Report of a headache

A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? A. Spasticity of the left foot B. Negative Babinski reflex C. Ocular hypertension D. Right-sided hemiplegia

D. Right-sided hemiplegia Rationale: The nurse should expect right-sided hemiplegia following intracranial bleeding in the left hemisphere of the brain.

A nurse is caring for a client who has undergone craniotomy. Which of the following nursing interventions is appropriate for this client? A. Keep the client in the supine position B. Encourage the client to cough and take deep breaths every hour C. Encourage the client to perform active range of motion exercises D. Use the Glasgow Coma Scale to monitor the client's mental status

D. Use the Glasgow Coma Scale to monitor the client's mental status

A 22-year-old male comes to the emergency department following a motor vehicle accident. His eyes open to speech, he is confused, and he localizes to pain. What is his Glasgow Coma Scale (GCS) score? A. 10 B. 3 C. 7 D. 15 E. 12

E. 12

When caring for a client with delirium and a history of cerebrovascular accident (CVA) that resulted in right-sided weakness, implementation of which of the following interventions is indicated to prevent injury? A. Place the client in a room that is quiet, preferably away from the nursing station B. Raise bed rails to prevent the client from getting out of bed without help C. Place a bedside commode on the right side (side of weakness) D. Use restraints to prevent increased risk of injury if the client attempts to get up without notifying the nurse E. Use a bed alarm that will alert the staff if the client attempts to get up

E. Use a bed alarm that will alert the staff if the client attempts to get up