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Neuro Quiz
Neuro Quiz
2. You are creating a teaching plan for a patient with newly diagnosed
migraine headaches. Which key items should be included in the teaching
plan? (Choose all that apply).
a. Avoid foods that contain tyramine, such as alcohol and aged cheese.
b. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.
c. Abortive therapy is aimed at eliminating the pain during the aura.
d. A potential side effect of medications is rebound headache.
e. Complementary therapies such as relaxation may be helpful.
f. Continue taking estrogen as prescribed by your physician.
3. The patient with migraine headaches has a seizure. After the seizure,
which action can you delegate to the nursing assistant?
4. You are preparing to admit a patient with a seizure disorder. Which of the
following actions can you delegate to LPN/LVN?
nursing assistant performing all of these actions. For which action must you
intervene?
a. The NA assists the patient to ambulate to the bathroom and back to bed.
b. The NA reminds the patient not to look at his feet when he is walking.
c. The NA performs the patients complete bath and oral care.
d. The NA sets up the patients tray and encourages patient to feed himself.
7. The nurse is preparing to discharge a patient with chronic low back pain.
Which statement by the patient indicates that additional teaching is
necessary?
10. A patient with a spinal cord injury at level C3-4 is being cared for in the
ED. What is the priority assessment?
11. You are pulled from the ED to the neurologic floor. Which action should
you delegate to the nursing assistant when providing nursing care for a
patient with SCI?
12. You are helping the patient with an SCI to establish a bladder-retraining
program. What strategies may stimulate the patient to void? (Choose all that
apply).
13. The patient with a cervical SCI has been placed in fixed skeletal traction
with a halo fixation device. When caring for this patient the nurse may
delegate which action (s) to the LPN/LVN? (Choose all that apply).
14. You are preparing a nursing care plan for the patient with SCI including
the nursing diagnosis Impaired Physical Mobility and Self-Care Deficit. The
patient tells you, I dont know why were doing all this. My lifes over. What
additional nursing diagnosis takes priority based on this statement?
16. The patient with multiple sclerosis tells the nursing assistant that after
physical therapy she is too tired to take a bath. What is your priority nursing
diagnosis at this time?
17. The LPN/LVN, under your supervision, is providing nursing care for a
patient with GBS. What observation would you instruct the LPN/LVN to report
immediately?
18. The nursing assistant reports to you, the RN, that the patient with
myasthenia gravis (MG) has an elevated temperature (102.20 F), heart rate
of 120/minute, rise in blood pressure (158/94), and was incontinent off urine
and stool. What is your best first action at this time?
19. You are providing care for a patient with an acute hemorrhage stroke.
The patients husband has been reading a lot about strokes and asks why his
wife did not receive alteplase. What is your best response?
a. Your wife was not admitted within the time frame that alteplase is usually
given.
b. This drug is used primarily for patients who experience an acute heart
attack.
c. Alteplase dissolves clots and may cause more bleeding into your wifes
brain.
d. Your wife had gallbladder surgery just 6 months ago and this prevents the
use of alteplase.
20. You are supervising a senior nursing student who is caring for a patient
with a right hemisphere stroke. Which action by the student nurse requires
that you intervene?
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21. Which action (s) should you delegate to the experienced nursing
assistant when caring for a patient with a thrombotic stroke with residual
left-sided weakness? (Choose all that apply).
22.The patient who had a stroke needs to be fed. What instruction should
you give to the nursing assistant who will feed the patient?
23. You have just admitted a patient with bacterial meningitis to the medical-
surgical unit. The patient complains of a severe headache with photophobia
and has a temperature of 102.60 F orally. Which collaborative intervention
must be accomplished first?
24. You are mentoring a student nurse in the intensive care unit (ICU) while
caring for a patient with meningococcal meningitis. Which action by the
student requires that you intervene immediately?
a. The student enters the room without putting on a mask and gown.
b. The student instructs the family that visits are restricted to 10 minutes.
c. The student gives the patient a warm blanket when he says he feels cold.
d. The student checks the patients pupil response to light every 30 minutes.
26.While working in the ICU, you are assigned to care for a patient with a
seizure disorder. Which of these nursing actions will you implement first if
the patient has a seizure?
29. All of these nursing activities are included in the care plan for a 78-year-
old man with Parkinsons disease who has been referred to your home health
agency. Which ones will you delegate to a nursing assistant (NA)? (Choose all
that apply).
31. A patient who has been admitted to the medical unit with new-onset
angina also has a diagnosis of Alzheimers disease. Her husband tells you
that he rarely gets a good nights sleep because he needs to be sure she
does not wander during the night. He insists on checking each of the
medications you give her to be sure they are the same as the ones she takes
at home. Based on this information, which nursing diagnosis is most
appropriate for this patient?
32. You are caring for a patient with a recurrent glioblastoma who is receiving
dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of
right arm weakness and headache. Which assessment information concerns
you the most?
down the stairs about a month ago, but he didnt have a scratch afterward.
She feels that he has become gradually less active and sleepier over the last
10 days or so. Which of the following collaborative interventions will you
implement first?
34. Which of these patients in the neurologic ICU will be best to assign to an
RN who has floated from the medical unit?
a. A 26-year-old patient with a basilar skull structure who has clear drainage
coming out of the nose
b. A 42-year-old patient admitted several hours ago with a headache and
diagnosed with a ruptured berry aneurysm.
c. A 46-year-old patient who was admitted 48 hours ago with bacterial
meningitis and has an antibiotic dose due
d. A 65-year-old patient with a astrocytoma who has just returned to the unit
after having a craniotomy
Here are the answers and rationale for this exam. Counter check your
answers to those below and tell us your scores. If you have any disputes or
need more clarification to a certain question, please direct them to the
comments section.
3. Answer: C Taking vital signs is within the education and scope of practice
for a nursing assistant. The nurse should perform neurologic checks and
document the seizure. Patients with seizures should not be restrained;
however, the nurse may guide the patients movements as necessary. Focus:
Delegation/supervision
4. Answer: B The LPN/LVN can set up the equipment for oxygen and
suctioning. The RN should perform the complete initial assessment. Padded
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side rails are controversial in terms of whether they actually provide safety
and ay embarrass the patient and family. Tongue blades should not be at the
bedside and should never be inserted into the patients mouth after a seizure
begins. Focus: Delegation/supervision.
6. Answer: C The nursing assistant should assist the patient with morning
care as needed, but the goal is to keep this patient as independent and
mobile as possible. Assisting the patient to ambulate, reminding the patient
not to look at his feet (to prevent falls), and encouraging the patient to feed
himself are all appropriate to goal of maintaining independence. Focus:
Delegation/supervision
10. Answer: D The first priority for the patient with an SCI is assessing
respiratory patterns and ensuring an adequate airway. The patient with a
high cervical injury is at risk for respiratory compromise because the spinal
nerves (C3 5) innervate the phrenic nerve, which controls the diaphragm.
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The other assessments are also necessary, but not as high priority. Focus:
Prioritization
11. Answer: B The nursing assistants training and education include taking
and recording patients vital signs. The nursing assistant may assist with
turning and repositioning the patient and may remind the patient to cough
and deep breathe but does not teach the patient how to perform these
actions. Assessing and monitoring patients require additional education and
are appropriate to the scope of practice for professional nurses. Focus:
Delegation/supervision
16. Answer: D At this time, based on the patients statement, the priority is
Self-Care Deficit related to fatigue after physical therapy. The other three
nursing diagnoses are appropriate to a patient with MS, but they are not
related to the patients statement. Focus: Prioritization
17. Answer: D The priority interventions for the patient with GBS are aimed
at maintaining adequate respiratory function. These patients are risk for
respiratory failure, which is urgent. The other findings are important and
should be reported to the nurse, but they are not life-threatening. Focus:
Prioritization, delegation/supervision
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18. Answer: B The changes that the nursing assistant is reporting are
characteristics of myasthenia crisis, which often follows some type of
infection. The patient is at risk for inadequate respiratory function. In
addition to notifying the physician, the nurse should carefully monitor the
patients respiratory status. The patient may need incubation and
mechanical ventilation. The nurse would notify the physician before giving
the suppository because there may be orders for cultures before giving
acetaminophen. This patients vital signs need to be re-checked sooner than
1 hour. Rescheduling the physical therapy can be delegated to the unit clerk
and is not urgent. Focus: Prioritization
19. Answer: C Alteplase is a clot buster. With patient who has experienced
hemorrhagic stroke, there is already bleeding into the brain. A drug like
alteplase can worsen the bleeding. The other statements are also accurate
about use of alteplase, but they are not pertinent to this patients diagnosis.
Focus: Prioritization
20. Answer: A Patients with right cerebral hemisphere stroke often present
with neglect syndrome. They lean to the left and when asked, respond that
they believe they are sitting up straight. They often neglect the left side of
their bodies and ignore food on the left side of their food trays. The nurse
would need to remind the student of this phenomenon and discuss the
appropriate interventions. Focus: Delegation/supervision
21. Answer: A, B and C The experienced nursing assistant would know how
to reposition the patient and how to reapply compression boots, and would
remind the patient to perform activities he has been taught to perform.
Assessing for redness and swelling (signs of deep venous thrombosis {DVT})
requires additional education and still appropriate to the professional nurse.
Focus: Delegation/supervision
22. Answer: A Positioning the patient in a sitting position decreases the risk
of aspiration. The nursing assistant is not trained to assess gag or swallowing
reflexes. The patient should not be rushed during feeding. A patient who
needs to be suctioned between bites of food is not handling secretions and is
at risk for aspiration. This patient should be assessed further before feeding.
Focus: Delegation/supervision
may not be appropriate but they do not require intervention as rapidly. The
presence of a family member at the bedside may decrease patient confusion
and agitation. Patients with hyperthermia frequently complain of feeling
chilled, but warming the patient is not an appropriate intervention. Checking
the pupil response to light is appropriate, but it is not needed every 30
minutes and is uncomfortable for a patient with photophobia. Focus:
Prioritization
31. Answer: B The husbands statement about lack of sleep and anxiety
over whether the patient is receiving the correct medications are behaviors
that support this diagnosis. There is no evidence that the patients cardiac
output is decreased. The husbands statements about how he monitors the
patient and his concern with medication administration indicate that the Risk
for Ineffective Therapeutic Regimen Management and falls are not priorities
at this time. Focus: Prioritization
33. Answer: B The patients history and assessment data indicate that he
may have a chronic subdural hematoma. The priority goal is to obtain a rapid
diagnosis and send the patient to surgery to have the hematoma evacuated.
The other interventions also should be implemented as soon as possible, but
the initial nursing activities should be directed toward treatment of any
intracranial lesion. Focus: Prioritization
34. Answer: C This patient is the most stable of the patients listed. An RN
from the medical unit would be familiar with administration of IV antibiotics.
The other patients require assessments and care from RNs more experienced
in caring for patients with neurologic diagnoses. Focus: Assignment.
1. Regular oral hygiene is an essential intervention for the client who has had
a stroke. Which of the following nursing measures is inappropriate when
providing oral hygiene?
1. Placing the client on the back with a small pillow under the head.
2. Keeping portable suctioning equipment at the bedside.
3. Opening the clients mouth with a padded tongue blade.
4. Cleaning the clients mouth and teeth with a toothbrush.
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1. Current medications.
2. Complete physical and history.
3. Time of onset of current stroke.
4. Upcoming surgical procedures.
4. During the first 24 hours after thrombolytic therapy for ischemic stroke,
the primary goal is to control the clients:
1. Pulse
2. Respirations
3. Blood pressure
4. Temperature
1. Cholesterol level
2. Pupil size and pupillary response
3. Bowel sounds
4. Echocardiogram
8. Which client would the nurse identify as being most at risk for
experiencing a CVA?
9. Which assessment data would indicate to the nurse that the client would
be at risk for a hemorrhagic stroke?
10. The nurse and unlicensed assistive personnel (UAP) are caring for a client
with right-sided paralysis. Which action by the UAP requires the nurse to
intervene?
1. The assistant places a gait belt around the clients waist prior to
ambulating.
2. The assistant places the client on the back with the clients head to the
side.
3. The assistant places her hand under the clients right axilla to help
him/her move up in bed.
4. The assistant praises the client for attempting to perform ADLs
independently.
1. Answer: 1. Placing the client on the back with a small pillow under the
head.
A helpless client should be positioned on the side, not on the back. This
lateral position helps secretions escape from the throat and mouth,
minimizing the risk of aspiration.
A CT scan will determine if the client is having a stroke or has a brain tumor
or another neurological disorder. This would also determine if it is a
hemorrhagic or ischemic accident and guide the treatment because only an
ischemic stroke can use rt-PA. This would make (1) not the priority since if a
stroke was determined to be hemorrhagic, rt-PA is contraindicated.
Option A: Current medications are relevant, but the onset of current stroke
takes priority.
Option B: A complete history is not possible in emergency care.
Option D: Upcoming surgical procedures will need to be delay if t-PA is
administered.
4. Answer: 3. Blood pressure
Option B: Beta blockers slow the heart rate and lower the blood pressure.
Option C: Anti-hyperuricemic medication is given to clients with gout.
Option D: Thrombolytic medication might have been given at initial
presentation but would not be a drug prescribed at discharge.
8. Answer: 1. A 55-year-old African American male.
African Americans have twice the rate of CVAs as Caucasians; males are
more likely to have strokes than females except in advanced years.
Option B: Orientals have a lower risk, possibly due to their high omega-3
fatty acids.
Option D: Pregnancy is a minimal risk factor for CVA.
9. Answer: 3. A blood pressure of 220/120 mmHg.
3. 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?
7. A client comes into the ER after hitting his head in an MVA. Hes alert and
oriented. Which of the following nursing interventions should be done first?
8. A client with a C6 spinal injury would most likely have which of the
following symptoms?
1. Aphasia
2. Hemiparesis
3. Paraplegia
4. Tetraplegia
1. Bladder distension
2. Neurological deficit
3. Pulse ox readings
4. The clients feelings about the injury
10. 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?
1. Autonomic dysreflexia
2. Hemorrhagic shock
3. Neurogenic shock
4. Pulmonary embolism
11. 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?
1. Acetazolamide (Diamox)
2. Furosemide (Lasix)
3. Methylprednisolone (Solu-Medrol)
4. Sodium bicarbonate
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13. A client with a cervical spine injury has Gardner-Wells tongs inserted for
which of the following reasons?
16. 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?
17. 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?
18. Which of the following clients on the rehab unit is most likely to develop
autonomic dysreflexia?
19. Which of the following conditions indicates that spinal shock is resolving
in a client with C7 quadriplegia?
1. Headache
2. Lumbar spinal cord injury
3. Neurogenic shock
4. Noxious stimuli
22. A client with a T1 spinal cord injury arrives at the emergency department
with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower
extremities. Which of the following conditions would most likely be
suspected?
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1. Autonomic dysreflexia
2. Hypervolemia
3. Neurogenic shock
4. Sepsis
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?
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?
1. Dopamine
2. GABA
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3. Histamine
4. Norepinephrine
29. A client arrives at the ER after slipping on a patch of ice and hitting her
head. A CT scan of the head shows a collection of blood between the skull
and dura mater. Which type of head injury does this finding suggest?
1. Subdural hematoma
2. Subarachnoid hemorrhage
3. Epidural hematoma
4. 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?
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.
33. The client with a head injury has been urinating copious amounts of
dilute urine through the Foley catheter. The clients urine output for the
previous shift was 3000 ml. The nurse implements a new physician order to
administer:
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 consciousness again. The nurse takes
quick action, knowing this is compatible with:
1. Skull fracture
2. Concussion
3. Subdural hematoma
4. Epidural hematoma
35. The nurse is caring for a client who suffered a spinal cord injury 48 hours
ago. The nurse monitors for GI complications by assessing for:
1. A flattened abdomen
2. Hematest positive nasogastric tube drainage
3. Hyperactive bowel sounds
4. A history of diarrhea
37. The nurse is planning care for the client in spinal shock. Which of the
following actions would be least helpful in minimizing the effects of
vasodilation below the level of the injury?
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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:
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?
1. Positive reflexes
2. Hyperreflexia
3. Inability to elicit a Babinskis reflex
4. Reflex emptying of the bladder
41. A client is at risk for increased ICP. Which of the following would be a
priority for the nurse to monitor?
42. Which of the following respiratory patterns indicate increasing ICP in the
brain stem?
44. A client has signs of increased ICP. Which of the following is an early
indicator of deterioration in the clients condition?
1. Internal rotation and adduction of arms with flexion of elbows, wrists, and
fingers
2. Back hunched over, rigid flexion of all four extremities with supination of
arms and plantar flexion of the feet
3. Supination of arms, dorsiflexion of feet
4. Back arched; rigid extension of all four extremities.
1. Count the rate to be sure the ventilations are deep enough to be sufficient
2. Call the physician while another nurse checks the vital signs and
ascertains the patients Glasgow Coma score.
3. Call the physician to adjust the ventilator settings.
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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?
49. A client has been pronounced brain dead. Which findings would the nurse
assess? Check all that apply.
1. Decerebrate posturing
2. Dilated nonreactive pupils
3. Deep tendon reflexes
4. Absent corneal reflex
Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure
of the pituitary to produce the anti-diuretic hormone. This may occur with
increased intracranial pressure and head trauma; the nurse evaluates for low
urine specific gravity, increased serum osmolarity, and dehydration.
Frequent swallowing after brain surgery may indicate fluid or blood leaking
from the sinuses into the oropharynx.
Option A: Blood or fluid draining from the ear may indicate a basilar skull
fracture.
6. Answer: 4. To replace antidiuretic hormone (ADH) normally secreted by the
pituitary.
All clients with a head injury are treated as if a cervical spine injury is present
until x-rays confirm their absence. The airway doesnt need to be opened
since the client appears alert and not in respiratory distress.
After a spinal cord injury, ascending cord edema may cause a higher level of
injury. The diaphragm is innervated at the level of C4, so assessment of
adequate oxygenation and ventilation is necessary.
High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce
cord swelling and limit neurological deficit. The other drugs arent indicated
in this circumstance.
Option A: Putting the client flat will cause the blood pressure to increase
even more.
Option B: The indwelling urinary catheter should be assessed immediately
after the HOB is raised.
Option C: Nitroglycerin is given to reduce chest pain and reduce preload; it
isnt used for hypertension or dysreflexia.
13. Answer: 2. To immobilize the cervical spine
Clear fluid from the nose or ear can be determined to be cerebral spinal fluid
or mucous by the presence of dextrose.
Option A: Placing the client flat in bed may increase ICP and promote
pulmonary aspiration.
Option C: The nose wouldnt be suctioned because of the risk for suctioning
brain tissue through the sinuses.
Option D: Nothing is inserted into the ears or nose of a client with a skull
fracture because of the risk of infection.
17. Answer: 3. An interval when the client is oriented but then becomes
somnolent
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Option A: The absence of pain sensation in the chest doesnt apply to spinal
shock.
Option C: Spinal shock descends from the injury, and respiratory difficulties
occur at C4 and above.
20. Answer: 4. Noxious stimuli
Putting the client in the high-Fowlers position will decrease cerebral blood
flow, decreasing hypertension.
Options A, B, and C: Elevating the clients legs, putting the client flat in bed,
or putting the bed in the Trendelenburgs position places the client in
positions that improve cerebral blood flow, worsening hypertension.
22. Answer: 3. Neurogenic shock
Loss of sympathetic control and unopposed vagal stimulation below the level
of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis,
and warm, dry skin in the client in neurogenic shock.
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The diaphragm is stimulated by nerves at the level of C4. Initially, this client
may need mechanical ventilation due to cord edema. This may resolve in
time.
The frontal lobe primarily functions to regulate thinking, planning, and affect.
Dopamine is known to circulate widely throughout this lobe, which is why its
such an important neurotransmitter in schizophrenia.
Options A and B: Extent of intracranial bleeding and location of the injury site
would be determined by CT or MRI.
Option D: Percent of functional brain tissue would be determined by a series
of tests.
29. Answer: 3. Epidural hematoma
An epidural hematoma occurs when blood collects between the skull and the
dura mater.
Options A and B: If the tongue or relaxed throat muscles are obstructing the
airway, a nasopharyngeal or oropharyngeal airway can be inserted; however,
the client must have spontaneous respirations when the airway is open.
Option D: The head-tilt, chin-lift maneuver requires neck hyperextension,
which can worsen the cervical spine injury.
32. Answer: 1, 2, 4, 5.
The client has signs and symptoms of autonomic dysreflexia. The potentially
life-threatening condition is caused by an uninhibited response from the
sympathetic nervous system resulting from a lack of control over the
autonomic nervous system. The nurse should immediately elevate the HOB
to 90 degrees and place extremities dependently to decrease venous return
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to the heart and increase venous return from the brain. Because tactile
stimuli can trigger autonomic dysreflexia, any constrictive clothing should be
loosened. The nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and correct any
problems. Elevated blood pressure is the most life-threatening complication
of autonomic dysreflexia because it can cause stroke, MI, or seizures. If
removing the triggering event doesnt reduce the clients blood pressure, IV
antihypertensives should be administered.
Option C: A fan shouldnt be used because cold drafts may trigger autonomic
dysreflexia.
33. Answer: 1. Desmopressin (DDAVP, stimate)
Options A and C: After spinal cord injury, the client can develop paralytic
ileus, which is characterized by the absence of bowel sounds and abdominal
distention.
Option D: A history of diarrhea is irrelevant.
36. Answer: 2. Limiting bladder catheterization to once every 12 hours
Reflex vasodilation below the level of the spinal cord injury places the client
at risk for orthostatic hypotension, which may be profound.
Option A: Measures to minimize this include measuring vital signs before and
during position changes, use of a tilt-table with early mobilization, and
changing the clients position slowly.
Option B: Vasopressor medications are administered per protocol.
Option D: Venous pooling can be reduced by using Teds (compression
stockings) or pneumatic boots.
38. Answer: 4. Placing the client on a Stryker frame
40. Answer: 2, 4, 1, 3, 5.
Neural control of respiration takes place in the brain stem. Deterioration and
pressure produce irregular respiratory patterns.
It is best for the client to wear mitts which help prevent the client from
pulling on the IV without causing additional agitation.
Option A: Internal rotation and adduction of arms with flexion of the elbows,
wrists, and fingers described decorticate posturing, which indicates damage
to corticospinal tracts and cerebral hemispheres.
47. Answer: 2. Call the physician while another nurse checks the vital signs
and ascertains the patients Glasgow Coma score.
49. Answers: 2, 3, 4.
1. Vomiting continues
2. Intracranial pressure (ICP) is increased
3. The client needs mechanical ventilation
4. Blood is anticipated in the cerebrospinal fluid (CSF)
1. 0 to 15 mm Hg
2. 25 mm Hg
3. 35 to 45 mm Hg
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4. 120/80 mm Hg
6. 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
3. Restlessness and confusion
4. Widened pulse pressure
7. Problems with memory and learning would relate to which of the following
lobes?
1. Frontal
2. Occipital
3. Parietal
4. Temporal
8. While cooking, your client couldnt feel the temperature of a hot oven.
Which lobe could be dysfunctional?
1. Frontal
2. Occipital
3. Parietal
4. Temporal
1. Sternal rub
2. Pressure on the orbital rim
3. Squeezing the sternocleidomastoid muscle
4. Nail bed pressure
10. The client is having a lumbar puncture performed. The nurse would plan
to place the client in which position for the procedure?
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1. Side-lying, with legs pulled up and head bent down onto the chest
2. Side-lying, with a pillow under the hip
3. Prone, in a slight Trendelenburgs position
4. Prone, with a pillow under the abdomen.
1. A cerebral lesion
2. A temporal lesion
3. An intact brainstem
4. 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?
13. The nurse is evaluating the status of a client who had a craniotomy 3
days ago. The nurse would suspect the client is developing meningitis as a
complication of surgery if the client exhibits:
14. A client is arousing from a coma and keeps saying, Just stop the pain.
The nurse responds based on the knowledge that the human body typically
and automatically responds to pain first with attempts to:
15. During the acute stage of meningitis, a 3-year-old child is restless and
irritable. Which of the following would be most appropriate to institute?
16. Which of the following would lead the nurse to suspect that a child with
meningitis has developed disseminated intravascular coagulation?
1. Bladder infection
2. Middle ear infection
3. Fractured clavicle
4. Septic arthritis
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
20. A nurse is planning care for a child with acute bacterial meningitis. Based
on the mode of transmission of this infection, which of the following would be
included in the plan of care?
21. A nurse is reviewing the record of a child with increased ICP and notes
that the child has exhibited signs of decerebrate posturing. On assessment of
the child, the nurse would expect to note which of the following if this type of
posturing was present?
25. You are preparing to admit a patient with a seizure disorder. Which of the
following actions can you delegate to LPN/LVN?
Sudden removal of CSF results in pressures lower in the lumbar area than the
brain and favors herniation of the brain; therefore, LP is contraindicated with
increased ICP.
Option B: Fixed and dilated pupils are symptoms of increased ICP or cranial
nerve damage.
Options C and D: No information is given about abnormal BUN and creatinine
levels or that mannitol is being given for renal dysfunction or blood pressure
maintenance.
4. Answer: 1. 0 to 15 mm Hg
The parietal lobe regulates sensory function, which would include the ability
to sense hot or cold objects.
Motor testing on the unconscious client can be done only by testing response
to painful stimuli. Nail Bed pressure tests a basic peripheral response.
Cerebral responses to pain are testing using
Options A, B, and C: Cerebral responses to pain are testing using sternal rub,
placing upward pressure on the orbital rim, or squeezing the clavicle or
sternocleidomastoid muscle.
10. Answer: 1. Side-lying, with legs pulled up and head bent down onto the
chest
The client undergoing lumbar puncture is positioned lying on the side, with
the legs pulled up to the abdomen, and with the head bent down onto the
chest. This position helps to open the spaces between the vertebrae.
Option B: Kernigs sign is positive when the client feels pain and spasm of the
hamstring muscles when the knee and thigh are extended from a flexed-right
angle position.
Option C: Nuchal rigidity is characterized by a stiff neck and soreness, which
is especially noticeable when the neck is fixed.
Option D: A Glasgow Coma Scale of 15 is a perfect score and indicates the
client is awake and alert with no neurological deficits.
14. Answer: 3. Escape the source of pain
The clients innate responses to pain are directed initially toward escaping
from the source of pain.
Option A: There is no need to limit conversations with the child. However, the
nurse should speak in a calm, gentle, reassuring voice.
Option C: The child needs gentle and calm bathing. Because of the acuteness
of the infection, sponge baths would be more appropriate than tub baths.
Option D: Although treatments need to be completed as quickly as possible
to prevent overstressing the child, any treatments should be performed
carefully and at a pace that avoids sudden movements to prevent startling
the child and subsequently increasing intracranial pressure.
16. Answer: 1. Hemorrhagic skin rash
18. Answer: 1, 2, 4.
Head tilt, vomiting, and lethargy are classic signs assessed in a child with a
brain tumor. Clinical manifestations are the result of location and size of the
tumor.
21. Answer: 2. Rigid extension and pronation of the arms and legs
NEURO
The LPN/LVN can set up the equipment for oxygen and suctioning. Focus:
Delegation/supervision.