Neurological-NCLEX

The client recovering from a head injury is arousable and 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? 1. blowing the nose 2. isometric exercises 3. coughing vigorously 4. exhaling during repositioning

4. exhaling during repositioning

Carbidopa-levodopa is prescribed for a client with Parkinson's disease, and the nurse monitors the client for adverse effects of the medication. Which sign/symptom indicates the client is experiencing an adverse effects? 1. pruritus 2. tachycardia 3. hypertension 4. impaired voluntary movements

4. impaired voluntary movements

Phenytoin 100 mg orally three times daily, has been prescribed for a client for seizure control. The nurse reinforce =s instructions regarding the medication to the client. which statement by the client indicates an understanding of the instructions? 1. I will use a soft toothbrush to brush my teeth 2. its alright to break the capsules to make it easier for me to swallow them 3. if I forget to take my medication, I can wait until the next dose and eliminate that dose 4. if my throat becomes sore, its a normal effect of the medication and its nothing to be concerned about

1. I will use a soft toothbrush to brush my teeth

The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care? 1. i should drink extra fluids for the remainder of the day 2. i should not take any medication for at least 4 hours 3. i should eat lightly for the remainder of the day 4. i should rest quietly for the remainder of the day

1. i should drink extra fluids for the remainder of the day

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? SELECT ALL THAT APPLY 1. pad the bed's side rails 2. place an airway at the bedside 3. place oxygen equipment at the bedside 4. place suction equipment at the bedside 5. tape a padded tongue blade to the wall at the head of the bed

1. pad the bed's side rails 2. place an airway at the bedside 3. place oxygen equipment at the bedside 4. place suction equipment at the bedside

The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take? 1. raise the head of the bed and remove the noxious stimulus 2. lower the head of the bed and remove the noxious stimulus 3. lower the head of the bed and administer an antihypertensive agent

1. raise the head of the bed and remove the noxious stimulus

The client is taking phenytoin for seizure control, and blood sample for a serum drug level is drawn. Which laboratory finding indicates a therapeutic serum drug result? 1. 5 mcg/ml 2. 15 mcg/ml 3. 25 mcg/ml 4. 30 mcg/ml

2. 15 mcg/ml

The nurse observes an unlicensed assistive personnel positioning the client with increased intracranial pressure. Which position would require intervention by the nurse? 1. head midline 2. head turned to the side 3. neck in neutral position 4. head of bed elevated 30 to 45 degrees

2. head turned to the side

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs FURTHER teaching if which statement is made? 1. i will use a straw for drinking 2. i will drive only during the daytime 3. i will use caution because the device alters balance 4. i will wash the skin daily under the lamb's wool liner of the vest

2. i will drive only during the daytime

The client is receiving meperidine hydrochloride for pain. Which signs/symptoms are side and adverse effects of this medication?SELECT ALL THAT APPLY 1. diarrhea 2. tremors 3. drowsiness 4. hypotension 5. urinary frequency 6. increased respiratory rate

2. tremors 3. drowsiness 4. hypotension

The client with myasthenia gravis is receiving pyridostigmine. The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs? 1. vitamin K 2. acetylcysteine 3. atropine sulfate 4. protamine sulfate

3. atropine sulfate

The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively? 1. head of bed flat, head and neck midline 2. head of bed flat, head turned to the nonoperative side 3. head of bed elevated 30 to 45 degrees, head and neck midline 4. head of bed elevated 30 to 45 degrees , head turned to the operative side

3. head of bed elevated 30 to 45 degrees, head and neck midline

The client with myasthenia gravis becomes increasingly weak. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication(cholinergic crisis) or increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which change in condition indicates that the client is in cholinergic crisis? 1. no change in the condition 2. complains of muscle spasms 3. an improvement of the weakness 4. a temporary worsening of the condition

4. a temporary worsening of the condition

The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom are side and adverse effects of this medication? 1. ataxia 2. mouth sores 3. hypothermia 4. hypertension

4. hypertension

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk if autonomic dysreflexia is which action? 1. strictly adhering to a bowl retraining program 2. keeping the linen wrinkle free under the client 3. avoiding unnecessary pressure on the lower limbs 4. limiting bladder cathererization to once every 12 hours

4. limiting bladder cathererization to once every 12 hours

The nurse is caring for a patient with increased intracranial pressure. Which change in vital signs would occur if ICP is rising? 1. increasing temp, increasing pulse, increasing respirations, decreasing bp 2. decreasing temp. decreasing pulse, decreasing respirations, decreasing bp 3. increasing temp, decreasing pulse, decreasing respirations, increasing bp

3. increasing temp, decreasing pulse, decreasing respirations, increasing bp

The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted? 1. sudden tachycardia 2. pallor of the face and neck 3. severe, throbbing headache 4. severe and sudden hypotension

3. severe, throbbing headache

The nurse is caring for a client who is taking phenytoin for control of seizures. During data collection, the nurse notes that the client is taking birth control pills. Which information should the nurse provide to the client ? 1. pregnancy should be avoided while taking phenytoin 2. the client may stop taking the phenytoin if it is causing severe gastrointestinal effects 3. the potential for decreased effectiveness of the birth control pills exists while taking phenytoin 4. the increased risk of thrombophlebitis exists while taking phenytoin and birth control pills

3. the potential for decreased effectiveness of the birth control pills exists while taking phenytoin

ibuprofen is prescribed for a client. Which instructions should the nurse give the client about taking this medication? 1. take with 8 oz of milk 2. take in the morning after arising 3. take 60 minutes before breakfast 4. take at bedtime on an empty stomach

1. take with 8 oz of milk

The client is having a lumbar puncture performed. The nurse should place the client in which position for the procedure? 1. supine, in semi-fowlers 2. prone, in slight trendelenbury 3. prone, with a pillow under the abdomen 4. side-laying , with legs pulled up and chin to the chest

4. side-laying , with legs pulled up and chin to the chest

The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? 1. the client is taken for spinal x-rays 2. the family comes to visit after surgery 3. the nurse needs to provide physical care 4. the primary health care provider reviews the x-ray results

4. the primary health care provider reviews the x-ray results

The client has clear fluid leaking from the nose after a basilar skull fracture.The nurse determines that this is cerebrospinal fluid if the fluid meets which criteria? 1. is grossly bloody in appearance and has a ph of 6 2. clumps together on the dressing and has a ph of 7 3. is clear in appearance and test negative for glucose 4. separates into concentric rings and tests positive for glucose

4. separates into concentric rings and tests positive for glucose

The client with trigeminal neuralgia is being treated with carbamazepine. Which laboratory results indicates that the client is experiencing an adverse effect of the medication? 1. sodium level, 140 2. uric acid level 5. 0 3. white blood cell count 3000 4. blood urea nitrogen

3. white blood cell count 3000

The client with a cervical spine injury has crutch-field tongs applied in the ER. The nurse should perform which essential action when caring for this client? 1. providing a standard bed frame 2. removing the weights to reposition the client 3. removing the weights if the client is uncomfortable 4. comparing the amount of prescribed weights with the amount in use

4. comparing the amount of prescribed weights with the amount in use