NURSING 403100 NEURO NCLEX LATEST Questions Answers Best Guaranteed Success 2024 Graded A+, Exams of Nursing

Download NURSING 403100 NEURO NCLEX LATEST Questions Answers Best Guaranteed Success 2024 Graded A+ and more Exams Nursing in PDF only on Docsity! NURSING 403 100 NEURO NCLEX LATEST Questions Answers Best Guaranteed Success 2024 Graded A+ 1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?  • Administer 1 g Mannitol IV as ordered • Increase the ventilator’s respiratory rate to 20 breaths/minute  Administer 100 mg of pentobarbital IV as ordered. p g . 1 Reposition the client to avoid neck flexion 2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. arrhythmias.  Dilantin should be mixed in dextrose in water before administration. • Dilantin should be administered through an IV catheter in the client’s hand. 3 While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? p g . 2 2. Rapid Dilantin administration can cause cardiac He’s alert and oriented. Which of the following nursing interventions should be done first? • Assess full ROM to determine extent of injuries • Call for an immediate chest x-ray  • Open the airway with the head-tilt-chin-lift maneuver 8. A client with a C6 spinal injury would most likely have which of the following symptoms? • Aphasia • Hemiparesis  Paraplegia a Tetraplegia 9. . . . A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, p g . 5 Immobilize the client’s head and neck 4. and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? • Autonomic dysreflexia  Hypervolemia  • Sepsis 10. The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?   Side-lying, with a pillow under the hip  Prone , in a slight Trendelenburg’s position  Prone, with a pillow under the abdomen. p g . 6 Neurogenic shock Side-lying, with legs pulled up and head bent down onto the chest 11. A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: • A cerebral lesion • A temporal lesion  • Brain death 12. The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? • Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. p g . 7 An intact brainstem • Allowing the child to play in the bathtub • Performing treatments quickly 16. Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?  • Edema • Cyanosis • Dyspnea on exertion 17. When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? • Bladde r infection  infection p g . 1 0 Hemorrhagic skin rash Middle ear • Fractured clavicle • Septic arthritis p g . 1 1 18. The nurse is assessing a child diagnosed with a brain tumor . Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. 1.Head tilt 2.Vomiting 3.Polydipsia 4.Lethargy 5.Increased appetite 6.Increased pulse 1,2,4 19. A lumbar puncture is performed on a child suspected of having bacteria l meningitis . CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? p g . 1 2 initiation of antibiotics 4.Maintain neutropenic precautions 21. During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? • Elevate the client’s legs • Put the client flat in bed Put the client in the Trendelenburg’s position  position 22 A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? p g . 1 5 Put the client in the high- Fowler’s • Bladder distension • Neurological deficit  Pulse ox readings • The client’s feelings about the injury 23. A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? • Absent corneal reflex • Decerebrate posturing • Movement of only the right or left half of the body  24. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? p g . 1 6 The need for mechanical l ventilation • Decreased urine output or oliguria  • Respiratory depression • Symptoms of shock 25. A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? • “Clean the meatus from back to front.” • “Measure the quantity of urine.”  “Gently rotate the catheter during removal.”  water.” 26. An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? p g . 1 7 Hypertension and bradycardia “Clean the meatus with soap and • Contusion 30. After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect?  • Quadriplegia and loss of respiratory function • Paraplegia with intercostal muscle loss • Loss of bowel and bladder control 31. A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine injury is suspected. How should the first- responder open the client’s airway for rescue breathing? p g . 2 0 Quadriplegia with gross arm movement and diaphragmatic breathing • By inserting a nasopharyngeal airway • By inserting a oropharyngeal airway  maneuver • By performing the head-tilt, chin-lift maneuver 32. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. 1.Elevate the HOB to 90 degrees 2.Loosen constrictive clothing 3.Use a fan to reduce diaphoresis p g . 2 1 By performing a jaw- thrust 4.Assess for bladder distention and bowel impaction 5.Administer antihypertensive medication 6.Place the client in a supine position with legs elevated 1,2,4,5 33. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client’s urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer:  • Dexamethasone (Decadron) • Ethacrynic acid (Educing) • Manito (Osmitrol) 34. The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost p g . 2 2 Decompressing (DDAVP, Estimate) • Applying Teds or compression stockings. 38. The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: • Keeping the client on a stretcher • Logrolling the client on a firm mattress  Logrolling the client on a soft mattress  frame 39. The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? • Positive reflexes  Hyperreflexia p g . 2 5 Placing the client on a Stryker  • Reflex emptying of the bladder 40. A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client’s vital signs, list in order of priority, the nurse’s actions (Number 1 being the first priority and number 5 being the last priority). • Check for bladder distention • Raise the head of the bed • Contact the physician • Loosen tight clothing on the client • Administer an antihypertensive medication 2,4,1,3,5 41. A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? p g . 2 6 Inability to elicit a Babinski’s reflex  • Decreasing systolic blood pressure • Tachycardia • Decreasing body temperature 42. Which of the following respiratory patterns indicate increasing ICP in the brain stem?  • Rapid, shallow respirations • Asymmetric chest expansion  Nasal flaring 43. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? • Give the client a warming blanket • Administer low-dose barbiturate  p g . 2 7 Unequal pupil size Slow, irregular respirations Encourage the client to hyperventilate  and ascertains the patient’s Glasgow Coma score. • Call the physician to adjust the ventilator settings. • Check deep tendon reflexes to determine the best motor response 48. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? • Keeping the client flat on one side or the other  degrees • Log rolling or turning as a unit when turning • Keeping the head in neutral position p g . 3 0 Call the physician while another nurse checks the vital signs Elevating the head of the bed to 30 49. A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply. • Decerebrate posturing • Dilated nonreactive pupils • Deep tendon reflexes • Absent corneal reflex 2,3,4 50. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? • Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. p g . 3 1  • Teach patient about the need for good oral hygiene.  Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation. 51. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: A. Ba lance and equilibrium. Visual acuity. Thinking and reasoning. 52. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a p g . 3 2 Administer phenytoin (Dilantin) 200 mg PO daily. Body temperature control. C. Impaired urinary elimination D. Risk for injury 56. To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the nurse should: A. Help the client fill out his menu. Give the client privacy during meals. D.Phil. out the menu for the client. 57. The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? A.Cerebellar function Intellectual function p g . 3 5 Stay with the client and encourage him to eat. C. Cerebral function D. Sensory function 58. Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam, if needed and prescribed? A. In 30 to 45 seconds 15 minutes C. In 30 to 45 minutes D. In 1 to 2 hours 59. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. p g . 3 6 B. In 10 to Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? A.Parasympathomimetic agent B.Sympatholytic agent adrenergic blocker Cholinergic blocker 60. Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, “He fell from a two- story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s p g . 3 7 D. Armored back pain than the first postoperative day Paresthesia in the dermatomes near the wounds D. Temperature of 99.2° F (37.3° C) 63. After an eye examination, a male client is diagnosed with open- angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Palomar), 0.25% get i, OU quid. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: A.Instilling one drop of pilocarpine 0.25% into both eyes daily. B. In sti p g . 4 0 C. Urine e retention or incontinence Instilling one drop of pilocarpine 0.25% into both eyes four times daily . lling one drop of pilocarpine 0.25% into the right eye daily. Distilling one drop of pilocarpine 0.25% into the left eye four times daily. 64. A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? Althea client leaves the side rails down. B. Ca ther client repositions only after being reminded to do so. Dither client hangs the left arm over the side of the wheelchair. 65. A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client’s p g . 4 1 The client uses a mirror to inspect the skin. feet make a half circle. To document the client’s gait, the nurse should use which term? A.Ataxic B.Dystroph Ice Helicopter D. Steppage 66. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? A. A private room down the hall from the nurses’ station nurses’ station p g . 4 2 C. B. An isolation room three doors from the B. “Try to ambulate independently after about 24 hours.” C.“Shampoo your hair every day for ten (10) days to help prevent ear infection.” D. movements, 70. Nurse Marty is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? A.Excessive tearing B.Urine retention Musk l e weakness D. Slurred speech p g . 4 5 “Don’t fly in an airplane, climb to high altitudes, make sudden or expose yourself to loud sounds for 30 days.” C. 71. The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? A.Tachycardia B.Increased salivation C. Hypotension D. Apnea 72. A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s care, the nurse should assign the highest priority to which nursing diagnosis? A. Impaired physica l mobility p g . 4 6 B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Self-care deficit : Dressing/grooming 73. A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), two (2) mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, Diazepam also is recommended for: A.long-term treatment of epilepsy. B.postoperative pain management of laminectomy clients. C.postoperative pain management of diskectomy clients D. 74. A female client who was found unconscious at home is brought to the hospital by a rescue squaD. In the intensive p g . 4 7 treatment of spasticity associated with spinal cord lesions. 77. A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? A.Diencephalon B.Medulla C. Midbrain D. Cortex 78. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? A. B. Absent deep tendon reflexes p g . 5 0 Vision changes C.Tremors at rest D.Flaccid muscles 79. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? A.Sit with the client for a few minutes. Administer an analgesic. Inform the nurse manager . D. 80. During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing ability once each shift. This assessment evaluates: p g . 5 1 Call the physician immediately. A.Cranial nerves I and II. Cranial nerves III and V. Cranial nerves VI and VIII. and X. 81. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? 1. V o miting continues 2. 3.The client needs mechanical l ventilation 4. Blood is anticipated in the cerebrospinal l fluid (CSF) p g . 5 2 D. Cranial nerves IX Intracranial pressure (ICP) is increased 4. Urinary incontinence 86. Which of the following signs and symptoms of increased ICP after head trauma would appear first? 1.Bradycardia 2.Large amounts of very dilute urine confusion 4. Widened pulse pressure 87. Problems with memory and learning would relate to which of the following lobes? 1.Frontal 2. Occipital 3.Parietal p g . 5 5 3. Restlessness and 4. Temporal 88. While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional? 1. Frontal 2.Occipit al Parietal 4. Temporal 89. The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain? • Sternal rub p g . 5 6 3. • Pressure on the orbital rim • Squeezing the sternocleidomastoid muscle  90. . . . A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?  • Anticipate treatment for renal failure • Provide emollients to the skin to prevent breakdown • Slow down the IV fluids and notify the physician 91. A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? p g . 5 7 Na i l bed pressure Evaluate urine specific gravity hematoma is usually related to which of the following conditions?  • Rupture of the carotid artery • Thromboembolism from a carotid artery • Venous bleeding from the arachnoid space 96. A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? • Position the client flat in bed  • Suction the nose to maintain airway patency p g . 6 0 Laceration of the middle meningeal artery Check the fluid for dextrose with a dipstick • Insert nasal and ear packing with sterile gauze 97 . When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? • An interval when the client’s speech is garbled • An interval when the client is alert but can’t recall recent events  • An interval when the client has a “warning” symptom, such as an odor or visual disturbance. p g . 6 1 An interval when the client is oriented but then becomes somnolen t 98. Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?  A client with a brain injury  A client with a herniated nucleus pulposus cervical spine injury 4. A client with a stroke 99. Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? • Absence of pain sensation in chest • Spasticity • Spontaneous respirations • Urinary continence p g . 6 2 3. A client with a high