Nursing442 nclex neuro revision questions with answers, Exams of Nursing

Download Nursing442 nclex neuro revision questions with answers and more Exams Nursing in PDF only on Docsity! Nursing442 nclex neuro revision questions with answers 1) The nurse is assisting with caring for a client after a craniotomy. Which is the best position for the client to be placed? • Semi-Fowler's position 2) The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to Figures. • A 3) A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply • Pad the bed's side rails. • Place an airway at the bedside. • Place oxygen equipment at the bedside. • Place suction equipment at the bedside. 4) 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 5) 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 6) The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity? • Exhaling during repositioning • "I will drive only during the daytime." 13) The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted? • Severe, throbbing headache 14) 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 15) 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. 16) 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. 17) 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? • Electrocardiographic monitoring electrodes and intubation tray 18) The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which finding should be an early indication that the level of consciousness (LOC) is deteriorating? • Drowsiness 19) The nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item should be included as part of the precautions? • Maintaining the head of the bed at 15 degrees 20) The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated? • Restrain the client's limbs. 21) The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client? • Within the client's reach, on the left side 22) The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which? • Remind the client to turn the head to scan the lost visual field. 23) A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor? • Omitted doses of medication 24) 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. 25) 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." 26) A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety? • Provide a clear path for ambulation without obstacles. 27) 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 28) 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 29) 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 • It is possible the client can hear the family. 42) 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 43) 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. 44) 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." 45) The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance? • Indicates that facial puffiness will be a permanent problem 46) 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. • Putting a padded tongue blade at the head of the bed 53) The nurse has given medication instructions to the client receiving phenytoin (Dilantin). The nurse determines that the client understands the instructions if the client makes which comment? • "Good oral hygiene is needed, including brushing and flossing." 54) A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the should nurse avoid which action? • Giving the client thin liquids 55) The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client? • Completing the sentences that the client cannot finish 56) A client receives a dose of edrophonium (Enlon). The client shows improvement in muscle strength for a period of time following the injection. The nurse should interpret this finding as indicative of which disease process? • Myasthenia gravis 57)A client with myasthenia gravis is having difficulty speaking. The client's speech is dysarthric and has a nasal tone. The nurse should use which communication strategies when working with this client? Select all that apply. • Listening attentively • Asking yes and no questions when able • Using a communication board when necessary • Repeating what the client said to verify the message 58) The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by which activity? • Taking medications on time to maintain therapeutic blood levels 59) 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." 60) 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 61) The nurse has given instructions to the 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. 62) 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 63) 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 75) 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. 76)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. 77)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? • "I can't swallow very well today." 78)Which information will the nurse reinforce to the client scheduled for a lumbar puncture? • An informed consent will be required. 79)The nurse is reinforcing instructions to a client taking divalproex sodium (Depakote). The nurse tells the client to return to the clinic for follow-up laboratory studies related to which test? • Liver function studies 80)Which data collection finding supports the possible diagnosis of Bell's palsy? • Speech or chewing difficulties accompanied by facial droop 81)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 82)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 83)A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client? • Monitoring the respiratory rate 84)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 85)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. 86)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 87)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 88)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 89)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 90)Which sign/symptom is observed in the clonic phase of a seizure? • Extension spasms of the body 91)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 102) 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 103) 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. 104) 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. 105) A female client with myasthenia gravis comes to the health care provider's office for a scheduled office visit. The client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. Which is the appropriate nursing response? • "Have you thought about sharing your feelings with your husband?" 106) 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. 107) The nurse is collecting neurological data on a poststroke adult client. Which technique should the nurse perform to adequately check proprioception? • Hold the sides of the client's great toe, and while moving it, ask what position it is in. 108) The nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply. • Monitor the client's ability to void. • Maintain the client in a flat position. • Monitor the client's ability to move the extremities. • Inspect the puncture site for swelling, redness, and drainage. 109) 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. 110) 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. 111) 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? • Reflexes 112) 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 113) 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. 114) 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 115) 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." 116) 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? 126) 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. 127) 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. 128) 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 129) A client recovering from a craniotomy complains of a "runny nose." Based on the interpretation of the client's complaint, which action should the nurse take? • Notify the registered nurse. 130) The nurse is planning care for a client with Bell's palsy. Which measure should be included in the plan? • Instill artificial tears and wear a patch over the affected eye at night. 131) 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. 132) 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 133) 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 134) When the nurse taps at the level of the client's facial nerve, the following response is noted. How should the nurse document this finding on the client record? Refer to figure. • Positive Chvostek's sign 135) 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. 136) 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 137) 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 138) The nurse determines that motor function of which cranial nerve is intact if the client can perform this action? Refer to figure. • Facial 139) 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 140) 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 141) The nurse is caring for a client following craniotomy who has a supratentorial incision. The