Nursing442 nclex Neuro Study Guide: Key Points for Neurological Nursing, Exams of Nursing

Download Nursing442 nclex Neuro Study Guide: Key Points for Neurological Nursing and more Exams Nursing in PDF only on Docsity! Nursing442 nclex neuro #2study guide. Download to score,  The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria? • Separates into concentric rings and tests positive for glucose  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? • The health care provider reviews the x- ray results.  The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide. Download to score, worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom? • Minor Headache  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  The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client? • Comparing the amount of prescribed weights with the amount in use Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide Select all that apply • Pad the bed's side rails. • Place an airway at the bedside. • Place oxygen equipment at the bedside. • Place suction equipment at the bedside.  The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising? • Increasing temperature, decreasing pulse, decreasing respirations, increasing BP  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 client recovering from a head injury is arousable and participating in care. The Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity? Exhaling during  The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take? • Raise the head of the bed and remove the noxious stimulus.  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 Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide short phrases and simple terms.  The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room? Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse should plan which approach as therapeutic in assisting the client to cope with the disease? • Encourage and praise perseverance in exercising and performing ADL.  The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement? • "I will try to eat my food either very warm or very cold."  A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety? Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide • Provide a clear path for ambulation without obstacles.  The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? • Bloody or clear drainage from the auditory canal  A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? • Walker  The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? • Encouraging multiple visitors at one time Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration? • Establishing a toileting schedule  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  A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which action by the family? • Encouraging the client to stand unassisted on the leg  The nurse is preparing a client who is scheduled to have cerebral angiography Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center which is located in which part of the brain? • Hypothalamus  A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client makes which statement? • "I can resume a full activity level immediately."  The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How should the nurse interpret the client's situation? Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide • It is possible the client can hear the family. Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  The nurse is providing care to a client with increased intracranial pressure (ICP). Which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply. • Reducing environmental noise • Maintaining a calm atmosphere • Allowing the client uninterrupted time for sleep  The nurse is preparing to give the postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not "something stronger." The nurse should formulate a response based on which understanding of codeine? • Codeine does not alter respirations or mask neurological signs as do other opioids. Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this? • Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.  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 with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide do which? • Wear the patch continuously, alternating eyes each day.  The nurse is planning care for a client in spinal shock. Which action would be least helpful in minimizing the effects of vasodilation below the level of the injury? • Moving the client quickly as one unit  The nursing instructor asks a nursing student about the points to document if the client has had a seizure. The instructor determines that the student needs to research seizures and related documentation points if the student states which assessment is important? • Client's diet in the 2 hours preceding seizure activity  The nurse is planning to institute seizure Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide 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? Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide myasthenia gravis about prevention of myasthenic and cholinergic crises. The Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide nurse tells the client that this is most effectively done by which activity? • Taking medications on time to maintain therapeutic blood levels  The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statements? • "Going to the beach will be a nice, relaxing form of activity."  A client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse should immediately place the client where? • In a quiet, dim room with respiratory and cardiac support available  The nurse has given instructions to the Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will perform which activity? • Rock back and forth to start movement with bradykinesia.  An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which is consistent with normal findings? • Red blood cells  The nurse is collecting data on a client with a diagnosis of meningitis and notes that the client is assuming this posture. (Refer to figure.) The nurse contacts the health care provider and reports that the client is exhibiting which? • Opisthotonos Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide • A lag in closing the bottom eyelid  An adult client with suspected meningitis has undergone lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis of a bacterial infection. The nurse checks for which value indicating a bacterial infection of the CSF? • Decreased glucose level  The nurse is monitoring a client with a head injury and notes that the client is assuming the posture shown in the figure. What is the client exhibiting that would require the nurse to notify the registered nurse immediately? Refer to the figure. • Decorticate posturing  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? Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide • Extension of the extremities and pronation of the arms  The nurse is caring for a client diagnosed with Bell's palsy 1 week ago. Which data would indicate a potential complication associated with Bell's palsy? • Excessive tearing  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? • Recent memory loss Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply. • Bowel sounds are absent. • The client's abdomen is distended. • Respiratory excursion is diminished. • Accessory muscles of respiration are areflexic.  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.  The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement? Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide • Monitoring the respiratory rate  A client with myasthenia gravis is experiencing prolonged periods of weakness. The health care provider prescribes a test dose of edrophonium (Enlon) and the client becomes weaker. The nurse interprets this outcome as indicative of which result? • Cholinergic crisis  The nurse is assisting in gathering data on cranial nerve XII of a client who sustained a brain attack (stroke). The nurse understands that the client should be asked to perform which action? • Extend the tongue. Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  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 caring for a client with a supratentorial lesion. The nurse monitors which criterion as the critical index of central nervous system (CNS) dysfunction? • Level of consciousness  The nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure (ICP). Which indicates an early sign of increased ICP? • Confusion  Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide The nurse monitors the client for effectiveness of this medication, knowing which is its primary action? • Decrease cerebrospinal fluid production  Which sign/symptom is observed in the clonic phase of a seizure? • Extension spasms of the body  The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply. • Suction machine • Oxygen administration Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  The nurse is caring for a client with a diagnosis of multiple sclerosis who has been prescribed oxybutynin (Ditropan). The nurse evaluates the effectiveness of the medication by asking the client which question? • "Are you getting up at night to urinate?"  The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. Which sign/symptom is considered a primary symptom of this syndrome? • Development of muscle weakness  A thymectomy via a median sternotomy approach is performed on a client with a diagnosis of myasthenia gravis. The nurse has assisted in developing a plan of care for the client and includes which nursing action in the plan? Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide • Monitor the chest tube drainage.  The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack (stroke). The nurse notes that the client is alert and oriented to time and place. Based on these findings, the nurse makes which determination? • The client may have perceptual and spatial disabilities.  The nurse is preparing to care for a client with a diagnosis of brain attack (stroke). The nurse notes in the client's record that the client has anosognosia. The nurse plans care, knowing which is a characteristic of anosognosia? • The client neglects the affected side. Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization? • Associated with poor comprehension  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 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. Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide alleviate this problem? • Consciously think about walking over imaginary lines on the floor.  The nurse is assisting in checking for Tinel's sign in a client suspected of having carpal tunnel syndrome (CTS). Which technique should the nurse expect to be used to elicit this sign? • Percuss the medial nerve at the wrist as it enters the carpal tunnel, and monitor for tingling sensations.  The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which assessment will provide the nurse with the best information about recovery from the spinal shock? Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide • Reflexes  The nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that an early sign of rupture is which? • A decline in the level of consciousness  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.  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? Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide • Foot drop  A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching? • "I will bend at the waist, keeping the halo vest straight to pick up items."  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? Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  The nurse is collecting data on a client diagnosed with Parkinson's disease. Which finding indicates a serious complication of this disorder? • Congested cough and coarse rhonchi heard during auscultation  The nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. Which method is the best way for the nurse to explore issues with the client regarding these behaviors? • Have the client express the feelings in writing.  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? Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide • Higher than normal, supporting the diagnosis of Guillain-Barré  A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which finding is indicative of this complication? • The client complains of a headache, and the blood pressure is elevated.  The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which sign is indicative of this complication of a spinal cord injury? • Areflexia below the level of injury Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  A client with tetraplegia complains bitterly about the nurse's slow response to the call light and the rigidity of the therapy schedule. Which interpretation of this behavior should serve as a basis for planning nursing care? • The client is reacting to loss of control.  A client with Parkinson's disease is developing dementia. Which action should the nurse plan to assist the client in maintaining self-care abilities? • Break down activities into small steps.  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 Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide  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 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 determines that motor function of which cranial nerve is intact if the client can perform this action? Refer to figure. • Facial  A client complains of pain in the lower back Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide 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 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  The nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse reviews the Nursing442 nclex neuro #2study guide Nursing442 nclex neuro #2study guide client's plan of care, expecting to note that the client should be maintained in which position? • Semi-Fowler's position  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 caring for a client that is comatose and notes in the client's chart that the client is exhibiting decerebrate posturing. The nurse understands that which definition describes decerebrate posturing? • The extension of the extremities and pronation of the arms Nursing442 nclex neuro #2study guide