UW Neuro
A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain? A. expressive speech, vision B. Light touch, hearing C. Sense of position, graphesthesia D. Weber tuning fork test, Cranial nerve I
ANS: A
An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, a UAP takes the client's vital signs, but when the UAP goes back to assist the client with a shower, the client curses at and tries to hit the UAP. Which of the following is the most appropriate response by the Registered nurse? Vital Signs: Temp 98.7, BP 110/64, Pulse 92, Resp 22, O2 sat 90% RA A. "I need to assess the client." B. "It sounds like the client is not satisfied with the care provided. I'll see if we can make the client more comfortable." C. "Just leave the client alone now and try again later." D. "The client probably has dementia and is under a lot of stress with the change of the environment."
ANS: A
The ED nurse receives prescriptions for a client who was found unresponsive after drinking beer and consuming unidentified pills. Which prescription should the nurse implement first? Vital signs Temp 96.4 F BP 90/62 HR 53 Resp 6/min SPO2 92%. A. Administer IV push naloxone once now B. Draw specimen for blood alcohol content testing STAT C. Initiate continuous lactated ringers solution infusion D. Obtain urine sample for drug abuse screening ASAP
ANS: A
The client has increased ICP with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occuring? A. Auscultate breath sounds to assess for crackles B. Monitor for >50 mL/hr urine output C. Monitor GCS increasing from 8/15-9/15. D. Press over the tibia to assess for pitting edema
ANS: A
The nurse assesses several clients using the Glascow Coma Scale. Which scenario best demonstrates a correct application of this scale? A. The nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away. The nurse scores motor response as "localization of pain." B. The nurse asks the client what day it is and the client says "banana". The nurse scores verbal response as "confused". C. The nurse speaks with the client and then the client's eyes open. The nurse scores eye opening as "spontaneous". D. The nurse walks in the room and the client states, "Hi honey, how are you?" The nurse scores verbal response as "oriented".
ANS: A
The nurse is caring for a client with absence seizures. The UAP asks if the client will "shake and jerk" when having a seizure. Which response from the nurse is most helpful? A. "No, absence seizures can look like daydreaming or staring off into space." B. "No, you are wrong. Don't worry about that." C. "Yes, so please let me know if you see the client do that." D. "You don't have to monitor the client for seizures."
ANS: A
The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions? A. "I have a leftover prescription at home I can use if I have pain." B. "I will cancel the wine tasting I have planned for this weekend." C. "I will have someone drive me home and will take a couple of days off work." D. "I will have someone stay with me and make sure I am okay."
ANS: A
The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves. The nurse understands that damage has occurred to cranial nerve IX based on which assessment? A. A tongue blade is used to touch the client's pharynx; gag reflex is absent. B. Only one side of the mouth moves when the client is asked to smile and frown. C. The absence of light touch and pain sensation on the left side of the client's face D. When the client shrugs against resistance, the left shoulder is weaker than the right.
ANS: A Cranial nerves IX (glossopharyngeal) and X (vagus) are related to the movement of the pharynx and tongue. To evaluate cranial nerves IX and X, the nurse assesses for the presence of a gag reflex and symmetrical movements of the uvula and soft palate, and listens to voice quality. A tongue blade can be used to touch the posterior pharyngeal wall to assess for a gag reflex. Asking the client to say "ahhh" will allow assessment of the uvula and soft palate. Harsh or brassy voice quality indicates dysfunction with the vagus nerve (X).
The home health nurse teaches an elderly client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching? A. "I have to remember to raise my chin slightly upward when I swallow." B. "I have to remember to swallow 2 times before taking another bite of food." C. "I should avoid taking over-the-counter cold medications when I'm sick." D. "I should sit upright for at least 30-40 minutes after I eat."
ANS: A Dysphagia increases the risk for aspiration of oropharyngeal secretions, gastric content, food, and/or fluid into the lungs. Aspiration of foreign material into the lungs increases the risk for developing aspiration pneumonia. Interventions to help decrease aspiration and resulting aspiration pneumonia in susceptible clients, include the following: Swallowing 2 times before taking another bite of food. This clears food from the pharynx. Thickening liquids to assist swallowing Avoiding over-the-counter cold medications. Antihistamine cold preparation medications also have some anticholinergic properties, such as causing drowsiness, decreasing saliva (xerostomia) production, and making the mouth dry. Saliva is a lubricant, and it helps bind food together to facilitate swallowing. Sitting upright for at least 30-40 minutes after meals. This uses gravity to move food or fluid through the alimentary tract, decreases gastroesophageal reflux, and helps decrease the risk for aspiration. Brushing teeth and using antiseptic mouthwash before and after meals. This reduces the bacterial count before eating because bacteria as well as food can be aspirated. After-meal use removes particles of food that can be aspirated later. Smoking cessation. Smoking decreases mucociliary clearance and increases bacterial count in the mouth.
The nurse is caring for a young adult who is considering becoming pregnant. The client expresses concern, stating, "One of my parents has Huntington disease, and I am afraid my child will get it." How should the nurse respond? A. "Genetic counseling is recommended. You will receive a referral before you leave." B. "Huntington disease inheritance requires both biological parents to carry the gene." C. "There are other ways to grow your family. You should consider adoption." D. "This disease occurs spontaneously and is not likely to affect your children."
ANS: A Huntington disease is an incurable autosomal dominant disease that causes progressive nerve degeneration, which results in impaired movement, swallowing, speech, and cognitive abilities. Chorea (involuntary, tic-like movement) is a hallmark sign. The onset of active disease is usually at age 30-50, and death from neuromuscular and respiratory complications typically occurs within 20 years of diagnosis. Huntington disease is confirmed by genetic testing. Clients who have a parent with HD and are considering having biological children should receive genetic counseling.
The nurse is planning care for a client being admitted with newly diagnosed quadriplegia (tetraplegia). Which action should the nurse prioritize? A. Frequent focused respiratory assessments. B. Monitoring for autonomic dysreflexia C. Passive range-of-motion exercises every 4 hours. D. Repositioning the client every 2 hours
ANS: A Quadriplegia occurs when the lower extremities are completely paralyzed and the upper extremities are completely or partially paralyzed, usually due to cervical spinal cord injury. The client is at risk for: Impaired respiratory function, depending on the level of injury. In cervical and high thoracic injuries clients can experience decreased reserve volume. Injuries above C4 can cause diaphragm paralysis and/or increasing spinal edema within the first 48 hours. Atelectasis and pneumonia due to immobility. Respiratory status is the priority in the client with newly diagnosed quadriplegia. Regular or continuous assessment includes airway patency, breath sounds, oxygenation and spirometry.
The daughter of an 80-year-old client recently diagnosed with Alzheimer's disease (AD) says to the nurse, "I guess I can anticipate getting this disease myself at some point." What is an appropriate response by the nurse? A. "Engaging in regular exercise decreases the risk of AD." B. "Having a family history of AD is not a risk factor." C. "Try not to worry about this now as you can't do anything to prevent AD." D. "You should avoid aluminum cans and cookware to prevent AD."
ANS: A The development of Alzheimer's disease is related to a combination of genetic, lifestyle, and environmental factors. Clients with AD are usually diagnosed at age > 65. Early onset AD is a rare form of the disease that develops before age 60 and is strongly related to genetics. Children of clients with early-onset AD have a 50% chance of developing the disease. For late-onset AD, the strongest known risk factor is advancing age. Having a first-degree relative with late-onset AD also increases the risk of developing AD. Trauma to the brain has been associated witht he development of AD in the future. Brain trauma may be prevented by wearing seat belts and sports helmets and taking measures to prevent falls. Research suggests that healthy lifestyle choices reduce the risk for developing AD.
A client with an acute head injury cannot accurately identify the sensation felt when the nurse touches the intact skin with a cotton ball or paperclip. The nurse is aware that the deficit reflects injury to which area of the brain? A. Parietal B. Occipital C. Frontal D. Temporal
ANS: A The parietal lobe of the brain integrates somatic and sensory input. Injury to the parietal lobe could result in a deficit with sensation. The nurse would verify the client's injuries and documented imaging studies to confirm that this was an expected deficit and document it accordingly. If it is a new or unexpected deficit, the nurse should inform the health care provider immediately. The frontal lobe controls higher-order processing, such as executive function and personality. Injury to the frontal lobe often results in behavioral changes. The temporal lobe integrates visual and auditory input and past experiences. Temporal lobe injury clients cannot understand verbal or written language. The occipital lobe of the brain registers visual images. Injury to the occipital lobe could result in a deficit with vision.
The emergency department nurse is assessing a client brought in after a car accident in which the client's head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? SATA A. Breath smells of alcohol B. Client disoriented to place C. Client reports eyes burning D. History of multiple sclerosis E. Point tenderness over spine
ANS: A, B E Spinal immobilization is not a benign procedure. An acronym to help determine the need for a spinal immobilization is NSAIDs: N- neurological examination. Focal deficits include numbness and decreased strength S- Significant traumatic mechanism of injury A- Alertness. The client may be disoriented or have an altered LOC I- Intoxication D-distracting injury. Another significant injury could distract the client from spinal pain S-Spinal examination. Point tenderness over the spine or neck pain on movement may be present.
The nurse is preparing teaching for a client with Parkinson's disease. Which of the following techniques are appropriate when communicating with a client with Parkinson's disease? SATA A. Encourage the client to speak slowly and pause to take deep breaths periodically. B. Identify and promote the client's capabilities and strengths throughout the sessions C. Provide client teaching during times of day when the client has the most energy D. Reserve discussion of important or complex teaching for the client's caregiver E. Schedule teaching sessions at times with low risk of rushing or interruptions
ANS: A, B, C, E
The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? SATA A. Add a thickening agent to the fluids B. Avoid administering sedating medications before meals C. Place the client in an upright position during meals D. Restrict visitors who show signs of illness E. Teach the client to flex the neck while swallowing
ANS: A, B, C, E Aspiration pneumonia develops when aspirated material (eg., food, emesis, gastric reflux)causes an inflammatory response and provides a medium for bacterial growth. At-risk conditions include cognitive changes (dementia, head injury, stroke, sedation), difficulty swallowing, compromised gag reflex, and tube feeding. Aspiration-prevention measures include: 1. Thicken liquids 2. ensure client is fully awake while before eating 3. elevate the head of the bed to 90 degrees during and for 30 minutes after eating 4. encourage the client to facilitate swallowing by flexing the neck (chin to chest) 5. Administer prescribed antiemetics as needed 6. monitor for coughing, gagging and pocketing food
The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? SATA A. "Avoid drinking alcoholic beverages." B. "Do not abruptly stop taking your phenytoin." C. "Go to the ED every time a seizure occurs." D. "Wear an epilepsy medical identification bracelet." E. "You may need to start using a nonhormonal birth control method."
ANS: A, B, D, E Epilepsy is characterized by chronic seizure activity. Clients typically require lifelong anticonvulsant medication. The nurse should provide education about identifying and avoiding seizure triggers, such as excessive alcohol intake, sleep deprivation, and stress. Practicing relaxation techniques may help reduce the number of episodes. The client should also be encouraged to wear an epilepsy medical identification bracelet in case of emergency. Phenytoin, a hydantoin anticonvulsant, may decrease the effectiveness of some medications due to stimulation of hepatic metabolism. An alternate, nonhormonal birth control method should be used in addition to or instead of oral contraceptives. Clients should discuss pregnancy plans with their health care provider, as phenytoin can cause fetal abnormalities. Clients taking phenytoin should also receive education about practicing good oral hygiene as gingival hyperplasia is a potential complication. Anticonvulsants should not be stopped abruptly, as this increases the risk of seizure.
The nurse is educating a client with myasthenia gravis about avoiding acute symptom exacerbation (ie., myasthenic crisis). Which of the following client statements indicate a correct understanding of the teaching? SATA A. "I should eat semisolid foods instead of solid foods." B. "I should still receive a flu vaccine annually." C. "I should use a bladder training schedule to prevent incontinence." D. "I will plan to get my errands done in the evening." E. "I will take my medication before meals."
ANS: A, B, E Pathophysiology: Antibodies against acetylcholine receptors at motor endplate. Thymus involved in autoimmunity. Thymic hyperplasia. Thymoma S/SX: fluctuating and fatigable proximal muscle weakness; worse later in the day. Ocular (eg., diplopia, ptosis) Bulbar (eg., dysphagia, dysarthria) Respiratory muscles ( eg., myasthenic crisis) Treatment: acetylcholinesterase inhibitors (eg. pyridostigmine); Thymectomy Myasthenia gravis is an autoimmune neuromuscular disease that involves the attack of acetylcholine receptors by autoantibodies at the neuromuscular junction. The deficit acetylcholine receptors cause fluctuating skeletal muscle weakness ad fatigue. Myasthenic crisis is an exacerbation of myasthenia gravis due to disease progression, deficiency in anticholinesterase, illness or stress. Interventions to manage myasthenia gravis and prevent myasthenic crisis at home include: 1. Eating semisolid foods instead of solids or liquids to conserve energy and prevent choking/ aspiration 2. Receiving an annual flu vaccine to prevent infection and undue stress on the respiratory system and muscles. 3. Taking acetylcholinesterase inhibitors (eg., pyridostigmine, neostigmine) before meals so that peak effects of the medication help the client to eat and swallow food.
A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? SATA A. Applying a patch to the right eye B. Avoid driving C. Chew on the left side D. Maintain meticulous oral hygiene E. Use a can on the left side
ANS: A, C, D
The nurse assesses a newly admitted adult client on a neurological inpatient unit. Which assessment findings require immediate follow-up by the nurse? SATA A. Cannot flex the chin toward the chest B. Eyes move in opposite direction of head when head is turned to side C. New onset of right arm drift D. Pupils 8 mm in diameter bilaterally E. Toes point downward when sole of foot is stimulated
ANS: A, C, D
The nurse is caring for a client who had a stroke 2 weeks ago and has moderate receptive aphasia. Which interventions should the nurse include in the plan of care to help the client follow simple commands regarding ADLs? SATA A. Ask simple questions that require "yes" or "no" answers B. If the client becomes frustrated, seek a different care provider to complete ADL C. Remain calm and allow the client time to understand each instruction D. Show the client pictures of ADL or use gestures E. Speak slowly but loudly while looking directly at the client
ANS: A, C, D
The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct which client to avoid the Valsalva maneuver when defecating? Select all that apply. A. 22-year-old man with a head injury sustained during a college football game B. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty C. 56-year-old man 2 weeks post myocardial infarction D. 68-year-old woman recently diagnosed with pancreatic cancer E. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis F. 82-year-old woman 1 week post cataract surgery
ANS: A, C, E, F The valsalva maneuver involves holding the breath while bearing down on the perineum to pass a stool. Straining to have a bowel movement is to be avoided in clients recently diagnosed with increased intracranial pressure, stroke, or head injury as straining increases intra-abdominal and intrathoracic pressure, which raises the intracranial pressure. The vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease. Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension related to cirrhosis due to the risk of variceal bleeding. The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery.
The graduate nurse cares for several poststroke clients. Which of the following nursing interventions are appropriate?SATA A. Implement fall precautions for the client with cerebellar stroke B. Increase lighting for the client with cranial nerve VII affected C. Initiate swallow precautions for the client with the cranial nerves IX and X affected D. Place spoon within field of vision for the client with homonymous and hemianopsia E. Speak louder in front of the client who has receptive aphasia
ANS: A, C,D
A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care? SATA A. Administer PRN stool softeners daily B. Administer scheduled enoxaparin injection C. Implement seizure precautions D. Keep client NPO until swallow screen is performed E. Perform frequent neurological assessments
ANS: A, C,D, E
The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? SATA A. Call for help B. Hold down the client's arms C. Insert a tongue depressor to move the tongue D. Prepare for suctioning E. Turn the client on the side
ANS: A, D, E
The nurse reinforces education and about safety modifications in the home for the spouse of a client diagnosed with alzheimer disease. What instructions should the nurse include?SATA A. Arrange furniture to allow for free movement B. Keep frequently used items within reach C. Lock doors leading to stairwells and outside areas D. Place an identifying symbol on the bathroom door E. Provide a dark room free of shadows for sleeping
ANS: A,B,C,D
The nurse is caring for a client in the medical-surgical unit who has delirium according to the Confusion Assessment Method assessment tool. Which of the following assessment findings are likely contributing to the client's delirium? SATA A. Multiple doses of IV hydromorphone administered in the past 12 hours. B. Serum sodium of 123 mEq/L C. SpO2 of 82% on room air D. Temperature of 103.1 F E. Urine culture positive for gram-positive cocci in chains
ANS: A,B,C,D,E
The nurse educates the caregiver of a client with Alzheimer's disease about maintaining the client's safety. Current symptoms include occasional confusion and wandering. Which of the following responses by the caregiver show correct understanding? SATA A. "Grab bars should be installed in the shower and beside the toilet." B. "I will place a safe return bracelet on the client's wrist." C. "Keyed deadbolts should be placed on all exterior doors." D. "Medications will be placed in a weekly pill dispenser." E. "Throw rugs and clutter will be removed from the floors,"
ANS: A,B,C,E
The nurse is caring for a client with Bell Palsy. Which of the following assessment findings does the nurse expect? SATA A. Change in lacrimation on the affected side B. Electric shock-like pain in the lips and gums C. Flattening of the nasolabial fold D. Inability to smile symmetrically E. Severe pain along the cheekbone
ANS: A,C,D
A client sustained a concussion after falling a ladder. What are essential instructions for the nurse to provide when the client discharged from the hospital? SATA A. Client should abstain from alcohol B. Client should remain awake all night C. Client should return if having difficulty walking D. Responsible adult should be taught neurological examination E. Responsible adult should stay with the client
ANS: A,C,E
A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current GCS score is a "10". Which client assessment is most important for reporting nurse to include? A. Belief that the current surroundings are a racetrack B. GCS sor was "11" one hour ago C. Recent vital signs show blood pressure of 120/80 and pulse of 82. D. Reported allergy to penicillin and vancomycin
ANS: B
An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia? A. Assessing client's breath sounds every 2 hours B. Placing the client in a side lying position in the bed C. Titrating client's oxygen to maintain saturation D. Turning and repositioning the client every 2 hours
ANS: B
An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60. Which prescribed interventions should the nurse implement first? A. Administer IV antibiotics B. Infuse bolus of IV normal saline C. Prepare to assist with lumbar puncture D. Transport client for head CT scan
ANS: B
The ED nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury. Which assessment finding is consistent with injury to the occipital lobe? A. Decreased rate and depth of respirations B. Deficits in visual perception C. Expressive aphasia D. Inability to recognize touch
ANS: B
The nurse is caring for 75-year-old client admitted to the hospital with pneumonia. What assessment finding is most consistent with the diagnosis of delirium? A. Client has muscle stiffness and resting hand tremors B. Client appears to be inattentive and disoriented C. Client reports decreased enjoyment in hobbies D. Family reports client's gradual inability to recall recent events
ANS: B
The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200. Which action by the nurse is most appropriate? A. Give the antihypertensive medication B. Monitor the blood pressure C. Notify the HCP D. Question the prescription
ANS: B
The nurse is giving a presentation at a community health event. The nurse should provide which instruction on how to prevent botulism? A. Boil water if unsure of its source B. Discard canned food with a bulging end C. Keep milk cold D. Wash hands
ANS: B
The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is most concerning and requires a nursing response? A. Consumes 600 mL liquid over 4 hours B. Insertion site dressing saturated with clear fluid C. Observed lying in the right-sided Sim's position D. Reports a headache rated 6/10
ANS: B A lumbar puncture involves removing a sample of cerebrospinal fluid through a needle inserted between vertebrae. Elevated intracranial pressure is a contraindication to performing a lumbar puncture. The client is placed in the fetal position or sitting and leaning over a table. Continued leaking fluid indicated that the site did not seal off and a blood patch (autologous blood into the epidural space) is required.
A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform? SATA A. Administer an analgesic as needed B. Determine if there is bladder distention C. Measure the client's BP D. Place the client in the Sims' position E. Remove constrictive clothing
ANS: B, C, E Clients with a high (T6 or above) spinal cord injury are at risk for autonomic dysreflexia (autonomic hyperreflexia). It is an uncompensated sympathetic nervous system stimulation. Classic signs include hypertension (up to 300 mmHg systolic), throbbing headache, diaphoresis above the level of injury, bradycardia (30-40/min), piloerection, flushing, and nausea. This is a life-threatening condition that requires immediate intervention to prevent complications. Client's with a spinal cord injury should have their blood pressure checked when they report a headache. The most common cause of the autonomic dysreflexia is bladder irritation due to distention. The client needs to be catheterized or the possibility of a kink in the existing catheter must be assessed. Bowel impaction can also be a cause, a digital rectal examination should be performed. Constrictive clothing should be removed to decrease skin stimulation. The PCP should be notified. An alpha-adrenergic blocker or an arteriolar vasodilator (e.g. nifedipine) may be prescribed.
The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? SATA A. Client coughs and gasps when swallowing food and liquids B. Client is easily frustrated while attempting to speak C. Client is unable to understand speech and is completely non-verbal D. Client misunderstands and inappropriately responds to verbal instruction E. Client's speech is limited to short phrases that require effort
ANS: B, E
The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect? SATA A. Diarrhea B. Difficulty breathing C. Difficulty swallowing D. Muscle weakness E. Resting tumor
ANS: B,C,D
The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? SATA A. Complete activities such as bathing and dressing as quickly as possible B. Decrease the client's anxiety by limiting the number of choices offered C. Redirect the client if agitated by asking for help with a task or going for a walk. D. Remember to interact with the client as an adult, regardless of childlike affect E. Use open-ended questions when communicating with the client
ANS: B,C,D
The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion. SATA A. Asymmetrical pupillary constriction B. Brief loss of consciousness C. Headache D. Loss of vision E. Retrograde amnesia
ANS: B,C,E
The nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes. Which cranial nerves is the nurse assessing? SATA A. II B. III C. IV D. V E. VI
ANS: B,C,E The oculomotor(III), Trochlear (IV), and abducens (VI) are motor nerves of the eye that are tested by having the client track an object, such as a finger, through the fields of vision. The oculomotor nerve is also tested by checking for pupillary constriction and accommodation (constriction with near vision). Deficits in cranial nerves III, IV, and VI can include disconjugate gaze (eyes do not move together), nystagmus (fine, rapid jerking eye movements), or ptosis (drooping of the eyelid).
A client is brought to the ED by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action? A. Determine onset of symptoms B. Ensure that the client has 2 large-bore IV lines C. Maintain patent airway D. Prepare for head CT scan
ANS: C
A nurse working in a neurology clinic receives the following telephone messages. Which client should the nurse call back first? A. Client prescribed sumatriptan who has throbbing left temple pain preceded by an aura. B. Client taking carbidopa-levodopa who has dizziness when rising from a sitting or lying position C. Client with myasthenia gravis who has a fever and increasing difficulty swallowing D. Client with trigeminal neuralgia who reports burning cheek pain after eating ice cream
ANS: C
The nurse admits a client who fell off a 20-ft ladder. On arrival in the ED, the client is arousable but lethargic. What is the nurse's priority action? A. Ask about the client's chronic medical conditions B. Assess for level and duration of pain C. Obtain a GCS score D. Perform a head-to-toe assessment
ANS: C
The nurse is caring for a client diagnosed with Guillain-Barre syndrome (GBS) after a recent gastrointestinal illness. Monitoring for which of the following is a nursing care priority for this client? A. Diaphoresis with facial flushing B. Hypoactive or absent bowel sounds C. Inability to cough or lift the head D. Warm, tender, and swollen leg
ANS: C
The nurse is caring for a client in the immediate postoperative period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the healthcare provider immediately? A. diminished gag reflex after endotracheal tube removal B. Increased agitation level and pulling at linens C. Left arm drift during bilateral arm extension D. Responds to verbal commands with eyes closed
ANS: C
The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a terrible headache. The nurse documents the confusion and headache as which phase of the client's seizure activity? A. Aural phase B. Ictal phase C. Postictal phase D. Prodromal phase
ANS: C
The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time? A. Client admitted with Guillain-Barre syndrome yesterday is paralyzed to the knees. B. Client admitted with MS exacerbation has scanning speech C. Client with epilepsy puts on call light and reports having an aura D. Clients with fibromyalgia reports pain in the neck and shoulders.
ANS: C
A client with stroke symptoms has a blood pressure of 240/124. The nurse prepares the prescribed nicardipine IV infusion solution correctly to yield 0.1 mg/mL. The nurse then administers the initial prescription to infuse at 5 mg/mL. The nurse then administers the initial prescription to infuse at 5 mg/hr by setting the infusion pump at 50 mL/hr. What is the nurse's priority action at this time? A. Assess hourly urine output B. Increase pump setting to correct administration rate to 100 mL/hr C. Keep systolic BP above 170 mm Hg D. Monitor for a widening QT interval
ANS: C A client with an acute stroke presentation (brain attack) requires "permissive hypertension" during the first 24-48 hours to allow for adequate perfusion through the damaged cerebral tissues. However, the blood-brain barrier is no longer intact once the BP is >220/120 mmHg. Therefore, "mild" lowering is required, usually to a systolic pressure that is not below 170 mmHg. Nicardipine is a prototype of nifedipine and is a potent calcium channel blocking vasodilator. It takes effect within 1 minute of IV administration. It is essential to monitor that the BP is not being lowered too quickly or too slowly as this would extend the stroke. Hypotension can occur with or without reflex tachycardia. The drug must be discontinued if hypotension or reflex tachycardia occurs.
The nurse receives the assigned clients for today on a neurology unit. The nurse should check on which client first? A. Client with a history of head injury whose Glascow Coma Scale changes from 13-14. B. Client with history of myasthenia gravis who had ptosis in the evening. C. Client with a history of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension. D. Client with history of transverse myelitis with 2+ bilateral lower extremity muscle strength.
ANS: C Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction by the sympathetic nervous system in a spinal injury at T6 or higher. Due to the injury, the parasympathetic nervous system cannot counteract the SNS stimulation below the injury. Classic triggers are distended bladder or rectum. Classic manifestations include severe hypertension, throbbing headache, marked diaphoresis above the level of injury, bradycardia, piloerection (goosebumps), and flushing. This is an emergency condition requiring immediate intervention. Management includes raising the head of the bed and then treating the cause.
A client with a history of headaches is scheduled for a lumbar puncture to assess the cerebrospinal fluid pressure. The nurse is preparing the client for the procedure. Which statement by the client indicates a need for further teaching by the nurse? A. "I may feel a sharp pain that shoots to my leg, but it should pass soon." B. "I will go to the bathroom and try to urinate before the procedure." C. "I will need to lie on my stomach during the procedure." D. "The physician will insert a needle between the bones in my lower spine."
ANS: C CSF is assessed for color, contents, and pressure. Normal CSF is clear and colorless, and contains a little protein, a little glucose, minimal WBCs, no RBCs, and no microorganisms. Normal CSF pressure is 60-150 mm H2O. Abnormal CSF pressure or contents can help diagnose the cause of headaches in complicated cases. CSF is collected via lumbar puncture or ventriculostomy.
The HCP prescribes a multivitamin regimen that includes thiamine for a client with a history of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose? A. To lower the blood alcohol level B. To prevent gross tremors C. To prevent Wernicke encephalopathy D. To treat seizures related to acute alcohol withdrawal.
ANS: C Clients with chronic alcohol abuse suffer from poor nutrition related to improper diet and altered nutrient absorption. Poor thiamine intake and/or absorption can lead to Wernicke encephalopathy, a serious complication that manifests as altered mental status, oculomotor dysfunction, and ataxia. Clients are prescribed thiamine to prevent this condition.
A highly intoxicated client was brought to the ED after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and a BP of 160/80 mmHg. An hour later, the client is lethargic, pulse is 48/min, and BP is 200/80 mmHg. Which action does the nurse anticipate taking next? A. Administer atropine for bradycardia B. Administer nifedipine for hypertension C. Have a CT scan performed to rule out an intracranial bleed D. Perform hourly neurologic checks with Glascow coma scale
ANS: C Cushing's triad is related to ICP. Early signs include change in LOC. Later signs include bradycardia, increased systolic BP with a widening pulse pressure, and a slowed irregular (Cheyne-Stokes) respirations. Cushing's triad is a later sign that does not appear until the ICP is increased for some time. It indicates brain stem compression. The skull cannot expand after the fontanels close at age 18 months, so anything taking up more space inside the skull is a concern for causing pressure on the brain tissue/ brain stem and potential herniation. In this scenario, hidden head trauma causing an intracranial bleed must be ruled out with diagnostic testing. The client's intoxication could blunt an accurate history or presentation of a head injury.
The nurse is providing care for a client with Alzheimer's disease who often becomes angry and agitated 20 minutes or more after eating. The client accuses the nurse of not providing food, saying, "I'm hungry. You didn't feed me." The nurse should take which action? A. Give the client gentle reminders that the client has already eaten. B. Say that the client can have a snack in a couple of hours. C. Serve the client half of the meal initially and offer the other half later. D. Take a picture of the client having a meal and show it when the client becomes upset.
ANS: C Early stages: Forgetting that a meal was consumed due to short-term memory loss. Anorexia and weight loss secondary to depression &/or recognition of the disease Middle stages: Forgetting to eat at all, Not recognizing the sensations of hunger and thirst, forgetting how to use utensils, consuming non-food items, refusing to eat, restlessness: inability to sit long enough to consume a meal Later stages: Inability to feed oneself, dysphagia
A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what action first? A. Check for Kernig's and Brudzinski's signs B. Establish IV access C. Place the client on droplet precautions D. Prepare the client for lumbar puncture
ANS: C The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative agent has been identified and appropriate treatment is initiated. Meningococcal meningitis and Haemophilus influenzae type B meningitis are highly transmissible to others, and the client must remain on droplet isolation until these can be ruled out. Precautions can usually be discontinued 24 hours after beginning antibiotic therapy. Viral meningitis and other types of bacterial meningitis usually do not require droplet precautions.
A client is admitted to the hospital for severe headaches. The client has a history of ICP, which has required lumbar punctures to relieve the pressure by draining cerebral spinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate? A. Document the amount of emesis B. Lower the head of the bed C. Notify the HCP D. Offer anti-nausea medication
ANS: C Unexpected and projectile vomiting without nausea can be a sign of ICP, especially in the client with a history of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting can be associated with headache and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately.
The nurse is planning care for a client with suspected stroke who has just arrived at the emergency department with slurred speech, facial drooping, and right arm weakness that began 1 hour ago. Which of the following interventions should the nurse anticipate including in the initial plan of care. SATA A. Arrange for a speech pathologist consult B. Discuss community resources with family C. Obtain a STAT CT scan of the head D. Perform a baseline neurologic assessment E. Prepare to initiate alteplase within the next 3 hours
ANS: C, D, E
A client comes to the ED with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency? A. "I am very tired, and it's hard for me to keep my eyes open." B. "I don't feel good, and I want to be seen." C. "I have not taken my BP medicine in over a week." D. "I have the worst headache I've ever had in my life."
ANS: D
A client with MS is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time? A. "Avoid excess stretching of your lower extremities." B. "Build strength by increasing the duration of daily exercise." C. "Let me speak with your HCP about getting a wheelchair." D. "You should keep your feet apart and use a cane when walking."
ANS: D
A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100. How should the nurse respond initially? A. Administer PRN analgesic medication B. Administer PRN antihypertensive medication C. Lower the head of the bed D. Palpate the client's bladder
ANS: D
A nurse cares for a client with impairment of cranial nerve VIII. What instructions will the nurse provide the unlicensed assistive personnel prior to delegating interventions related to the client's activities of daily living? A. "Be aware of the client's shoulder weakness and provide support as needed." B. "Ensure that the client sits upright and tucks the chin when swallowing food." C. "Explain all procedures in step-by-step detail before performing them." D. "Make sure the items needed by the client are within reach."
ANS: D
The clinic nurse is assessing a previously healthy 60-year-old client says, "My hand has been shaking when I try to cut food. I did some online research. Could I have Parkinson's disease?" Which response from the nurse is the most helpful? A. "It can't be Parkinson's disease because you aren't old enough." B. "Make sure you tell the physician about your concerns." C. "Parkinson's disease does not cause that kind of hand shaking." D. "Tell me more about your symptoms. When did they start?"
ANS: D
The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the HCP? A. "I got short of breath this morning when I worked out." B. "I have cut down on smoking to 1/2 pack per day." C. "I haven't been feeling well, so I have been sleeping a lot." D. "I took an acetaminophen in the waiting room for this bad headache."
ANS: D
The nurse is caring for a client with increased ICP. Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse? A. "I will raise the head of the bed so it is easier to see the television." B. "I will turn down the lights when I leave." C. "Let me move your belongings closer so you can reach them." D. " You should do deep breathing and coughing exercises."
ANS: D
The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do? A. Bend at the waist B. Keep the feet close together C. Pivot on the foot proximal to the chair D. Use a transfer belt
ANS: D
The nurse receives report for 4 clients in the emergency department. Which client should be seen first? A. 30-year-old with a spinal cord injury at L3 sustained in a motorcycle accident who reports lower abdominal pain and difficulty urinating B. 33-year-old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait C. 65-year-old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL D. 70-year-old with Afib and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL
ANS: D
The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the HCP said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? A. "I will ask the HCP to explain the consequences of your procedure." B. "This is a common complication that will require you to have a hearing test every year. C. "This is a common complication; your HCP will order a consult for the speech pathologist." D. "This is the reason you are using a special swallowing technique when you eat and drink."
ANS: D Cranial nerve IX (Glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. Clients are instructed to : 1. Inhale deeply 2. Hold breath tightly to close the vocal cords 3. Place food in mouth and swallow while continuing to hold breath. 4. Cough to dispel remaining food from vocal cords 5. Swallow a second time before breathing.
The ED nurse is triaging clients. Which neurological presentation is most concerning for a serious etiology and should be given priority for definitive treatment? A. History of Bell's Palsy with unilateral facial droop and drooling B. History of multiple sclerosis and reporting recent blurred vision C. Reports unilateral facial pain when consuming hot foods D. Temple region hit by ball, loss of consciousness, but Glascow Coma Scale score is now 14.
ANS: D Epidural hematoma is an accumulation of blood between the skull bone and dura mater. The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal artery. The bleed is arterial in origin, and so hematoma develops quickly. The clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress into coma and death.
The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke? A. Consume a low-fat, low-salt diet B. Do not smoke cigarettes C. Exercise and lose weight D. Take prescribed antihypertensive medications
ANS: D Risk factors for stroke include diabetes, high cholesterol HTN, smoking, obesity (particularly in the abdomen), older age, and genetic susceptibility. The single most important modifiable risk factor is hypertension. Stroke risk can be reduced up to 50% with appropriate treatment of HTN. Because clients often experience side effects from the antihypertensive medications and don't feel bad with untreated HTN, they may not realize that it is essential to continue the medications. The nurse should therefore emphasize this point.
The nurse is assessing the cranial nerves and begins testing the facial nerve (cranial nerve VII). Which direction should the nurse give the client to test this cranial nerve? A. "Close your eyes and identify this smell." B. "Follow my finger with your eyes without moving your head." C. "Look straight ahead and let me know when you can see my finger." D. "Raise your eyebrows, smile, and frown."
ANS: D The facial nerve VII, is tested by assessing exaggerated facial movements. The client is directed to raise the eyebrows, furrow the eyebrows, draw up the cheeks in a large smile, pull the cheeks down in a frown, and open the lips to show the teeth. Any asymmetrical movements are documented, and if unexpected, the HCP is notified.
The client comes to the ED status post fall. The client is squinting both eyes and reports sudden blurry vision. The nurse is aware that this deficit reflects injury to which area of the brain? A. Parietal B. Frontal C. Temporal D. Occipital
ANS: D The occipital lobe of the brain registers visual images. Injury to the occipital lobe could result in a deficit with vision. The nurse should notify the health care provider immediately and document this finding. The frontal lobe controls higher-order processing, such as executive function and personality. Injury to the frontal lobe often results in behavioral changes. The temporal lobe integrates visual and auditory input and past experiences. The parietal lobe integrates somatic and sensory input.
A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? SATA A. Identify the number "8" traced on the palm B. Shrug the shoulders against resistance C. Swallow water D. Touch each finger of one hand to the hand's thumb E. Walk heel-to-toe
ANS: D, E
A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 1:00 am, the client reports a headache; the nurse obtains a normal neurological assessment and administers the PRN acetaminophen. At 2:00 am, the client appears to be sleeping. Which action should the nurse take? A. Arouse the client and ask what the current month is. B. Document "relief apparently obtained" and recheck at 3:00 am C. Let the client sleep but verify respiratory rate D. Wake the client up and check for paresthesia
ANS: A
The nurse is caring for a client following a transsphenoidal hypophysectomy. Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus? SATA A. Decreased serum sodium B. Excessive oral water intake C. High urine output D. Increased serum osmolality E. Increased urine specific gravity
ANS: B,C,D
A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first? A. Administer rectal diazepam B. Assess for neck stiffness and Brudzinski sign C. Draw blood for laboratory studies D. Transport the client to CT for assessment of shunt malfunction
ANS: A
Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit? A. Aphasia B. Apraxia C. Dysarthria D. Dysphagia
Ans: A
