NURSING 442 Neuro Nclex Questions, Exams of Nursing

Download NURSING 442 Neuro Nclex Questions and more Exams Nursing in PDF only on Docsity! 1 The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measure should the nurse avoid in planning for the client's safety? • Putting a padded tongue blade at the head of the bed A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle- strengthening benefit from which activity? • Doing active range of motion to finger joints A client who suffered a cervical spine injury had Crutchfield tongs applied in the emergency department. The nurse should avoid which action in the care of the client? • Removing the weights when repositioning the client The nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. This conclusion is based on which findings? Select all that apply. • Drainage from ear • Bruising around the eyes • Pink-tinged drainage from the nose A client with Guillain-Barré syndrome has been asking many questions about the condition, and the nursing staff feels that the client is very discouraged about her condition. It is important for the nurse to include which information in discussions with the client? • Generally, a vast number of people recover from this condition The nurse is caring for the client with a head injury secondary to a motor vehicle crash. The nurse observes the client's status 2 regularly, monitoring closely for which change in vital signs that could indicate increased intracranial pressure? • Decreasing pulse, decreasing respirations, increasing BP The nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data should focus on which characteristic of this disease? 5 A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) protein is 750 mg/dL. The nurse analyzes these results as which? • Higher than normal, supporting the diagnosis of Guillain- Barré The nurse is caring for a client with a spinal cord injury. High-top sneakers on the client's feet will prevent the occurrence of which? • Foot drop The nurse is collecting neurological data on an unconscious client. On application of a central noxious stimulus, the nurse observes this response. How should the nurse document this response on the client's record? Refer to figure. • Client demonstrated decerebrate posturing. The nurse is caring for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, which action does the nurse plan? • Increase the client's awareness of the affected side. The nurse suspects neurogenic shock in a client with complete transection of the spinal cord at the T3 (thoracic 3) level if which clinical symptoms are observed? • Hypotension and bradycardia The nurse is reinforcing instructions to the client who has just been fitted for a halo vest. Which statement by the client indicates the need for further teaching? • "I will avoid driving at night because the vest limits the ability to turn the head." 6 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? • Head of bed elevated 30 to 45 degrees, head and neck midline 7 A client complains of pain in the lower back and pain and spasms in the hamstrings when the nurse attempts to extend the client's leg. How should the nurse record this finding on the client's medical record? Refer to figure. • Positive Kernig's sign A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study (studies) to determine the cause of the complaints? Select all that apply. • Cerebral angiography • Lumbar puncture (LP) • Computed tomography The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives a test dose of edrophonium (Enlon). The nurse recalls that the client should have which reaction if the client has this disease? • An increase in muscle strength within 1 to 3 minutes A client with a stroke (brain attack) is experiencing residual dysphagia. The nurse should remove which food items that arrived on the client's meal tray from the dietary department? • Peas A client with myasthenia gravis becomes increasingly weaker. The health care provider injects a dose of edrophonium (Enlon) to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if the client is in cholinergic crisis? • A temporary worsening of the condition 10 The nurse is assisting in admitting a client who experienced seizure activity in the emergency department. The nurse avoids which action when managing this client's environment? • ? The nurse is collecting admission data on a client with Parkinson's disease. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which in the client's record? 11 • Positive Romberg's test A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse? • Acknowledge the client's anger and continue to encourage participation in care. Which symptoms would validate the diagnosis of a cluster headache? Select all that apply. • A runny nose • Burning sensation in the eye • Tearing on the affected eye A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which position will be used during the procedure? • Side-lying with the legs pulled up and the head bent down onto the chest The nurse is told in report that a client has a positive Chvostek's sign. Which other data should the nurse expect to find on data collection? Select all that apply. • Tetany • Diarrhea • Possible seizure activity • Positive Trousseau's sign The nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure (ICP). Which sign if noted in the client should the nurse report immediately? • The client vomits. 12 A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which signs and symptoms? Select all that apply. • Tachycardia • Photophobia • Red, macular rash • Positive Kernig's sign 15 The nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which intervention does the nurse document in the plan as the priority nursing intervention for this client? • Monitor urine output. The nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further teaching? • "I will not hear sounds clearly unless they are loud." The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems? • Allergy to pollen The nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which information? • Masklike facies is a component of Parkinson's disease. The nurse is assisting in admitting a client who experienced seizure activity in the emergency department. The nurse avoids which action when managing this client's environment? • Keeping the bed position raised to the nurse's waist level A client has just undergone lumbar puncture (LP). The nurse assists the client into which optimal position? • Prone, with a pillow under the abdomen 16 The nurse is reviewing the medical record of a client diagnosed with amyotrophic lateral sclerosis (ALS). Which initial sign/symptom of this disorder supports this diagnosis? • Mild clumsiness The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives a test dose of edrophonium (Enlon). The nurse recalls that the client should have which reaction if the client has this disease? 17 • An increase in muscle strength within 1 to 3 minutes A client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. Which suggestion should the nurse include in the client's plan of care to alleviate this problem? • Consciously think about walking over imaginary lines on the floor. A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which action to determine whether the client is ready to begin sitting up? • Compares the client's pulse and blood pressure when both flat and sitting The nurse is caring for a client who sustained a spinal cord injury. While administering morning care, the client developed signs and symptoms of autonomic dysreflexia. Which is the initial nursing action? • Elevate the head of the bed. The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply. • Face the client when talking. • Speak slowly and maintain eye contact. • Use gestures when talking to enhance words. • Give the client directions using short phrases and simple terms. A client is recovering at home after suffering a brain attack (stroke) 2 weeks ago. A home caregiver tells the home health nurse that the client has some difficulty swallowing food and fluids. Which nursing action would be appropriate? • Observe the client feeding himself or herself. 20 The nurse is ambulating a client with a known seizure disorder. The client says, "I'm seeing those flashing lights again," then loses consciousness and develops a clonic-tonic seizure. Which would be the nurse's initial action? • Assist the client to the floor. 21 The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse? • Head turned to the side The nurse reviews the health care provider's treatment plan for a client with Guillain-Barré syndrome. Which prescription noted in the client's record should the nurse question? • Clear liquid diet Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. The nurse monitors the client for effectiveness of this medication, knowing which is its primary action? • Decrease cerebrospinal fluid production The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? • Limiting bladder catheterization to once every 12 hours Which data collection finding supports the possible diagnosis of Bell's palsy? • Speech or chewing difficulties accompanied by facial droop A client has just undergone lumbar puncture (LP). The nurse assists the client into which optimal position? • Prone, with a pillow under the abdomen The nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle crash. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation? 22 • Extension of the extremities and pronation of the arms An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client's daughter. The daughter states that this is the first time that the client experienced confusion. The nurse determines from this piece of information that which is unlikely to be the cause of the client's disorientation? • Alzheimer's disease