1. A client is admitted to the hospital for severe headaches. The client has a history
of increased intracranial pressure (ICP), which has required lumbar punctures to
relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and
states, "That's weird, I didn't even feel n...
1. A client is admitted to the hospital for severe headaches. The client has a history
of increased intracranial pressure (ICP), which has required lumbar punctures to
relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and
states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the
most appropriate?
1. Document the amount of emesis
2. Lower the head of the bed
3. Notify the health care provider (HCP)
4. Offer anti-nausea medication
Answer: 3
2. The nurse in the outpatient clinic is speaking with a client diagnosed with
cerebral arteriovenous malformation. Which statement would be a priority for the
nurse to report to the health care provider?
1. "I got short of breath this morning when I worked out."
2. "I have cut down on smoking to 1/2 pack per day."
3. "I haven't been feeling well, so I have been sleeping a lot."
4. "I took an acetaminophen in the waiting room for this bad headache."
Answer: 4
3. A nurse working in a neurology clinic receives the following telephone messages.
Which client should the nurse call back first?
1. Client prescribed sumatriptan who has throbbing left temple pain preceded by
an aura
2. Client taking carbidopa-levodopa who has dizziness when rising from a sitting
or lying position
3. Client with myasthenia gravis who has a fever and increasing difficulty
swallowing
4. Client with trigeminal neuralgia who reports burning cheek pain after eating ice
cream
Answer: 3
4. A nurse cares for a client with impairment of cranial nerve VIII. What instructions
will the nurse provide the unlicensed assistive personnel prior to delegating
interventions related to the client's activities of daily living?
1. "Be aware of the client's shoulder weakness and provide support as needed."
2. "Ensure that the client sits upright and tucks the chin when swallowing food."
3. "Explain all procedures in step-by-step detail before performing them."
4. "Make sure the items needed by the client are within reach."
Answer: 4
,5. An 86-year-old client with diabetes and gastroparesis has had repeated
hospitalizations for aspiration pneumonia following a stroke and is now hospitalized
with altered level of consciousness. Which nursing action is most appropriate to
decrease the client's risk for developing aspiration pneumonia?
1. Assessing client's breath sounds every 2 hours
2. Placing client in the side lying position in bed
3. Titrating client's oxygen to maintain saturation ≥93%
4. Turning and repositioning the client every 2 hours
Answer: 2
6. The nurse is planning care for a client with suspected stroke who has just arrived
at the emergency department with slurred speech, facial drooping, and right arm
weakness that began 1 hour ago. Which of the following interventions should the
nurse anticipate including in the initial plan of care? Select all that apply.
1. Arrange for a speech pathologist consult
2. Discuss community resources with family
3. Obtain a STAT CT scan of the head
4. Perform a baseline neurologic assessment
5. Prepare to initiate alteplase within the next 3 hours
Answer: 3,4,5
7. The nurse is caring for a client with left-sided weakness from a stroke. When
assisting the client to a chair, what should the nurse do?
1. Bend at the waist
2. Keep the feet close together
3. Pivot on the foot proximal to the chair
4. Use a transfer belt
Answer: 4
8. A client with a C3 spinal cord injury has a headache and nausea. The client's
blood pressure is 170/100 mm Hg. How should the nurse respond initially?
1. Administer PRN analgesic medication
2. Administer PRN antihypertensive medication
3. Lower the head of the bed
4. Palpate the client's bladder
Answer: 4
9. A highly intoxicated client was brought to the emergency department after found
lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and
blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is
48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse
anticipate taking next?
, NEURO ADULT 3
1. Administer atropine for bradycardia
2. Administer nifedipine for hypertension
3. Have CT scan performed to rule out an intracranial bleed
4. Perform hourly neurologic checks with Glasgow coma scale (GCS)
Answer: 3
10. The nurse educates the caregiver of a client with Alzheimer disease about
maintaining the client's safety. Current symptoms include occasional confusion and
wandering. Which of the following responses by the caregiver show correct
understanding? Select all that apply.
1. "Grab bars should be installed in the shower and beside the toilet."
2. "I will place a safe return bracelet on the client's wrist."
3. "Keyed deadbolts should be placed on all exterior doors."
4. "Medications will be placed in a weekly pill dispenser."
5. "Throw rugs and clutter will be removed from the floors."
Answer: 1,2,3,5
11. A client sustained a concussion after falling off a ladder. What are essential
instructions for the nurse to provide when the client is discharged from the hospital?
Select all that apply.
1. Client should abstain from alcohol
2. Client should remain awake all night
3. Client should return if having difficulty walking
4. Responsible adult should be taught neurological examination
5. Responsible adult should stay with the client
Answer: 1,3,5
12. An adult client with altered mental status and fever has suspected bacterial
meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed
intervention should the nurse implement first?
1. Administer IV antibiotics
2. Infuse bolus of IV normal saline
3. Prepare to assist with lumbar puncture
4. Transport client for head CT scan
Answer: 2
13. The nurse is caring for a client after a lumbar puncture (spinal tap). Which
client assessment is most concerning and requires a nursing response?
1. Consumes 600 mL liquid over 4 hours
2. Insertion site dressing saturated with clear fluid
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