Saunder’s Neurological Study Guide Questions and Answers with Rationales
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ATI Med Surg
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Chamberlain College Of Nursing
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Saunders Comprehensive Review for NCLEX-PN
Saunder’s Neurological Study Guide Questions and Answers with Rationales
1-The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use
which technique to test the client's peripheral response to pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on...
saunder’s neurological study guide questions and answers with rationales
neurological study guide questions and answers with rationales
the nurse is assessing the motor and sensory function of an unco
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SAUNDERS COMPREHENSIVE REVIEW FOR THE NCLEX-PN (SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX-PN) 7TH EDITION BY LINDA ANNE SILVESTRI PHD RN FAAN (AUTHOR), ANGELA SILVESTRI PHD APRN FNP-BC CNE (AUTHOR)
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Saunder’s Neurological Study Guide Questions and Answers with Rationales
1- The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use
which technique to test the client's peripheral response to pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle
Rationale: Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral responses
to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the
clavicle or sternocleidomastoid muscle.
2- The nurse is caring for the client with increased intracranial pressure. The nurse would note which
trend in vital signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing
blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing
blood pressure
Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trends include
increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory
irregularities also may occur.
3-A client recovering from a head injury is participating in care. The nurse determines that the client
understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing
which activity?
1. Blowing the nose
2. Isometric exercises
3. Coughing vigorously
4. Exhaling during repositioning
Rationale: Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation
of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver,
coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in
bed opens the glottis, which prevents intrathoracic pressure from rising.
4-A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert
the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
,3. Fluid clumps together on the dressing and has a pH of 7.
4. Fluid separates into concentric rings and tests positive for glucose.
Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull
fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody
and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for
glucose.
5-A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should
include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.
1. Keeping the linens wrinkle-free under the client
2. Preventing unnecessary pressure on the lower limbs
3. Limiting bladder catheterization to once every 12 hours
4. Turning and repositioning the client at least every 2 hours
5. Ensuring that the client has a bowel movement at least once a week
Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and
urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal
impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement
once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or
painful stimuli. The nurse administers care to minimize risk in these areas.
6- The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury.
Which observation indicates that spinal shock persists?
1. Hyperreflexia
2. Positive reflexes
3. Flaccid paralysis
4. Reflex emptying of the bladder
Rationale: Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to
noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the
bladder.
7- The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions
should the nurse take? Select all that apply.
1. Loosening restrictive clothing
2. Restraining the client's limbs
3. Removing the pillow and raising padded side rails
4. Positioning the client to the side, if possible, with the head flexed forward
5. Keeping the curtain around the client and the room door open so when help
arrives they can quickly enter to assist
Rationale: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing,
removing the pillow and raising padded side rails in the bed, and placing the client on one side with the
,head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are
never restrained because the strong muscle contractions could cause the client harm. If the client is not in
bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head
from injury; and moves furniture that may injure the client.
8- The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain
attack). Which characteristics are associated with this condition? Select all that apply.
1. The client is aphasic.
2. The client has weakness on the right side of the body.
3. The client has complete bilateral paralysis of the arms and legs.
4. The client has weakness on the right side of the face and tongue.
5. The client has lost the ability to move the right arm but is able to walk
independently.
6. The client has lost the ability to ambulate independently but is able to feed and
bathe himself or herself without assistance.
Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves
weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to
discriminate words and letters. They are generally very cautious and get anxious when attempting a new
task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis
has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.
9- The nurse has instructed the family of a client with stroke (brain attack) who has homonymous
hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the
family understands the measures to use when caring for the client?
1. "We need to discourage him from wearing eyeglasses."
2. "We need to place objects in his impaired field of vision."
3. "We need to approach him from the impaired field of vision."
4. "We need to remind him to turn his head to scan the lost visual field."
Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous
hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach
the client from the intact side. The nurse instructs the client to scan the environment to overcome the
visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use
of personal eyeglasses, if they are available.
10- The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain
attack). Which observation indicates to the nurse that the client is adapting most successfully?
1. Gets angry with family if they interrupt a task
2. Experiences bouts of depression and irritability
3. Has difficulty with using modified feeding utensils
4. Consistently uses adaptive equipment in dressing self
, Rationale: Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make
appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.
Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.
11- The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and
cholinergic crises. Which client activity suggests that teaching is most effective?
1. Taking medications as scheduled
2. Eating large, well-balanced meals
3. Doing muscle-strengthening exercises
4. Doing all chores early in the day while less fatigued
Rationale: Clients with myasthenia gravis are taught to space out activities over the day to conserve
energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too
low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client.
Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits,
and emotional stress.
12- The nurse is instructing a client with Parkinson's disease about preventing falls. Which client
statement reflects a need for further teaching?
1. "I can sit down to put on my pants and shoes."
2. "I try to exercise every day and rest when I'm tired."
3. "My son removed all loose rugs from my bedroom."
4. "I don't need to use my walker to get to the bathroom."
Rationale: The client with Parkinson's disease should be instructed regarding safety measures in the
home. The client should use his or her walker as support to get to the bathroom because of bradykinesia.
The client should sit down to put on pants and shoes to prevent falling. The client should exercise every
day in the morning when energy levels are highest. The client should have all loose rugs in the home
removed to prevent falling.
13- The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize
episodes of pain. The nurse determines that the client needs further teaching if the client makes which
statement?
1. "I will wash my face with cotton pads."
2. "I'll have to start chewing on my unaffected side."
3. "I should rinse my mouth if toothbrushing is painful."
4. "I'll try to eat my food either very warm or very cold."
Rationale: Facial pain can be minimized by using cotton pads to wash the face and using room
temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in
foods and beverages at room temperature. If brushing the teeth triggers pain, an oral rinse after meals
may be helpful instead.
14- The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical
history finding makes the client most at risk for this disease?
1. Meningitis or encephalitis during the last 5 years
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