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NAME OF STUDENT: ________________________________ DATE: _____________SCORE: ______ /

"Whoever can be trusted with very little can also be trusted with much, and whoever is dishonest with very little
will also be dishonest with much." Luke 16:10 -(NIV)

1. What is the priority nursing diagnosis for a patient experiencing a migraine headache?
a. Acute pain related to biologic and chemical factors
b. Anxiety related to change in or threat to health status
c. Hopelessness related to deteriorating physiological condition
d. Risk for Side effects related to medical therapy

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?
a. Document the seizure.
b. Perform neurologic checks.
c. Take the patients vital signs.
d. Restrain the patient for protection.

4. You are preparing to admit a patient with a seizure disorder. Which of the following actions can you
delegate to LPN/LVN?
a. Complete admission assessment.
b. Set up oxygen and suction equipment.
c. Place a padded tongue blade at bedside.
d. Pad the side rails before patient arrives.
5. A nursing student is teaching a patient and family about epilepsy prior to the patients discharge. For
which statement should you intervene?
a. You should avoid consumption of all forms of alcohol.
b. Wear you medical alert bracelet at all times.
c. Protect your loved ones airway during a seizure.
d. Its OK to take over-the-counter medications.

6. A patient with Parkinsons disease has a nursing diagnosis of Impaired Physical Mobility related to
neuromuscular impairment. You observe a 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?
a. I will avoid exercise because the pain gets worse.
b. I will use heat or ice to help control the pain.
c. I will not wear high-heeled shoes at home or work.
d. I will purchase a firm mattress to replace my old one.

8. A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly
started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and
MI DTERM EXAMS
EXAMI NATI ONS





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decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you
take first?
a. Administer the ordered acetaminophen
(Tylenol).
b. Check the Foley tubing for kinks or
obstruction.
c. Adjust the temperature in the patients room.
d. Notify the physician about the change in status
.
9. Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to the
neurologic unit?
a. A 28-year-old newly admitted patient with spinal cord injury
b. A 67-year-old patient with stroke 3 days ago and left-sided weakness
c. An 85-year-old dementia patient to be transferred to long-term care today
d. A 54-year-old patient with Parkinsons who needs assistance with bathing

10.A patient with a spinal cord injury at level C3-4 is being cared for in the ER. What is the priority
assessment?
a. Determine the level at which the patient has intact sensation.
b. Assess the level at which the patient has retained mobility.
c. Check blood pressure and pulse for signs of spinal shock.
d. Monitor respiratory effort and oxygen saturation level.

11.You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursing
assistant when providing nursing acre for a patient with Spinal cord injury ?
a. Assess patients respiratory status every 4 hours.
b. Take patients vital signs and record every 4 hours.
c. Monitor nutritional status including calorie counts.
d. Have patient turn, cough, and deep breathe every 3 hours.

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).
a. Stroke the patients inner thigh.
b. Pull on the patients pubic hair.
c. Initiate intermittent straight catheterization.
d. Pour warm water over the perineum.
e. Tap the bladder to stimulate detrusor muscle.

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).
a. Check the patients skin for pressure form device.
b. Assess the patients neurologic status for changes.
c. Observe the halo insertion sites for signs of infection.
d. Clean the halo insertion sites with hydrogen peroxide.

14.You are preparing a nursing care plan for the patient with SCI including the nursing diagnoses
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?
a. Risk for Injury related to altered mobility
b. Imbalanced Nutrition, Less Than Body
Requirements
c. Impaired Adjustment to Spinal Cord Injury
d. Poor Body Image related to immobilization

15.Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has been
on the neurologic unit for 1 week?
a. A 34-year-old patient newly diagnosed with multiple sclerosis (MS)
b. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS)
c. A 56-year-old patient with Guillain-Barre syndrome (GBS) in respiratory distress
d. A 25-year-old patient admitted with CA level spinal cord injury (SCI)



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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?
a. Fatigue related to disease state
b. Activity Intolerance due to generalized weakness
c. Impaired Physical Mobility related to neuromuscular impairment
d. Self-care Deficit related to fatigue and neuromuscular weakness

17.The LPN, under your supervision, is providing nursing care for a patient with GBS. What observation
would you instruct the LPN to report immediately?
a. Complaints of numbness and tingling
b. Facial weakness and difficulty speaking
c. Rapid heart rate of 102 beats per minute
d. Shallow respirations and decreased breath
sounds

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?
a. Administer an acetaminophen suppository.
b. Notify the physician immediately.
c. Recheck vital signs in 1 hour.
d. Reschedule patients physical therapy.

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?
a. The student instructs the patient to sit up straight, resulting in the patients puzzled expression.
b. The student moves the patients tray to the right side of her over-bed tray.
c. The student assists the patient with passive range-of-motion (ROM) exercises.
d. The student combs the left side of the patients hair when the patient combs only the right side.

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).
a. Assist patient to reposition every 2 hours.
b. Reapply pneumatic compression boots.
c. Remind patient to perform active ROM.
d. Check extremities for redness and edema.

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?
a. Position the patient sitting up in bed before you feed her.
b. Check the patients gag and swallowing reflexes.
c. Feed the patient quickly because there are three more waiting.
d. Suction the patients secretions between bites of food.

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?
a. Administer codeine 15 mg orally for the patients headache.
b. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
c. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.
d. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.



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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.

25.A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new
onset generalized tonic-clonic seizures. Which nursing activities included in the patients care will be best
to delegate to an LPN/LVN whom you are supervising? (Choose all that apply).
a. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures.
b. Administer phenytoin (Dilantin) 200 mg PO daily.
c. Teach patient about the need for good oral hygiene.
d. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.

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?
a. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.
b. Administer lorazepam (Ativan) 1 mg IV.
c. Turn the patient to the side and protect airway.
d. Assess level of consciousness during and immediately after the seizure.

27.A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the
outpatient clinic. Which information obtained during his chart review and assessment will be of greatest
concern?
a. The gums appear enlarged and inflamed.
b. The white blood cell count is 2300/mm3.
c. Patient occasionally forgets to take the phenytoin until after lunch.
d. Patient wants to renew his drivers license in the next month.

28.After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first?
a. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching
b. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching
c. A 59-year-old with Parkinsons disease who will need a swallowing assessment before breakfast
d. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain

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).
a. Check for orthostatic changes in pulse and bloods pressure.
b. Monitor for improvement in tremor after levodopa (L-dopa) is given.
c. Remind the patient to allow adequate time for meals.
d. Monitor for abnormal involuntary jerky movements of extremities.
e. Assist the patient with prescribed strengthening exercises.
f. Adapt the patients preferred activities to his level of function.

30.As the manager in a long-term-care (LTC) facility, you are in charge of developing a standard plan of
care for residents with Alzheimers disease. Which of these nursing tasks is best to delegate to the LPN
team leaders working in the facility?
a. Check for improvement in resident memory after medication therapy is initiated.
b. Use the Mini-Mental State Examination to assess residents every 6 months.
c. Assist residents to toilet every 2 hours to decrease risk for urinary intolerance.
d. Develop individualized activity plans after consulting with residents and family.

31.A patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of



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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?
a. Decreased Cardiac Output related to poor myocardial contractility
b. Caregiver Role Strain related to continuous need for providing care
c. Ineffective Therapeutic Regimen Management related to poor patient memory
d. Risk for Falls related to patient wandering behavior during the night

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?
a. The patient does not recognize family
members.
b. The blood glucose level is 234 mg/dL.
c. The patient complains of a continued
headache.
d. The daily weight has increased 1 kg.

33.A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the
hospital ER. His wife tells you that he fell 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?
a. Place on the hospital alcohol withdrawal
protocol.
b. Transfer to radiology for a CT scan.
c. Insert a retention catheter to straight
drainage.
d. Give phenytoin (Dilantin) 100 mg PO.

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
35. Essential feature of glaucoma is:
a. Optic neuropathy
b. Raised intraocular pressure
c. Reduced vision
d. Painful eye
36. Which of these is not a feature of ocular hypertension?
a. Elevated intraocular pressure
b. Closed angle
c. Normal visual fields
d. Normal optic discs
37. Risk factors for glaucoma include:
a. Cardiovascular diseases
b. Family history of glaucoma
c. Hypothyroidism
d. All of the above

38. Which of these is not a likely cause of painful red eye in a patient?
a. Open angle glaucoma
b. Closed angle glaucoma
c. Conjunctivitis
d. Herpes simplex
39.
40.

1. ANSWER A The priority for interdisciplinary care for the patient experiencing a migraine headache
is pain management. All of the other nursing diagnoses are accurate, but none of them is as urgent
as the issue of pain, which is often incapacitating. Focus: Prioritization

2. ANSWERS A, B, C, D & E Medications such as estrogen supplements may actually trigger a



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migraine headache attack. All of the other statements are accurate. Focus: Prioritization

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 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.

5. ANSWER D A patient with a seizure disorder should not take over-the-counter medications
without consulting with the physician first. The other three statements are appropriate teaching
points for patients with seizures disorders and their families. 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

7. ANSWER A Exercises are used to strengthen the back, relieve pressure on compressed nerves
and protect the back from re-injury. Ice, heat, and firm mattresses are appropriate interventions
for back pain. People with chronic back pain should avoid wearing high-heeled shoes at al times.
Focus: Prioritization

8. ANSWER B These signs and symptoms are characteristic of autonomic dysreflexia, a
neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause
of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for
poor catheter drainage, bladder distention, or fecal impaction is the first action that should be
taken. Adjusting the room temperature may be helpful, since too cool a
temperature in the room may contribute to the problem. Tylenol will not decrease the autonomic
dysreflexia that is causing the patients headache. Notification of the physician may be necessary if
nursing actions do not resolve symptoms. Focus: Prioritization

9. ANSWER B The new graduate RN who is oriented to the unit should be assigned stable, non-
complex patients, such as the patient with stroke. The patient with Parkinsons disease needs
assistance with bathing, which is best delegated to the nursing assistant. The patient being
transferred to the nursing home and the newly admitted SCI should be assigned to experienced
nurses. Focus: Assignment




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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. 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

12. ANSWERS A, B, D & E- All of the strategies, except straight catheterization, may stimulate
voiding in patients with SCI. Intermittent bladder catheterization can be used to empty the
patients bladder, but it will not stimulate voiding. Focus: Prioritization

13. ANSWERS A, C & D Checking and observing for signs of pressure or infection are within the
scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo
insertion sites with hydrogen peroxide. Neurologic examination requires additional education and
skill appropriate to the professional RN. Focus: Delegation/supervision

14. ANSWER C The patients statement indicates impairment of adjustment to the limitations of
the injury and indicates the need for additional counseling, teaching, and support. The other three
nursing diagnoses may be appropriate to the patient with SCI, but they are not related to the
patients statement. Focus: Prioritization

15. ANSWER B The traveling is relatively new to neurologic nursing and should be assigned
patients whose conditions are stable and not complex. The newly diagnosed patient will need to be
transferred to the ICU. The patient with C4 SCI is at risk for respiratory arrest. All three of these
patients should be assigned to nurses experienced in neurologic nursing care. Focus: Assignment

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

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



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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

23. ANSWER B Untreated bacterial meningitis has a mortality are approaching 100%, so rapid
antibiotic treatment is essential. The other interventions will help reduce CNS stimulation and
irritation, and should be implemented as soon as possible. Focus: Prioritization

24. ANSWER A Meningococcal meningitis is spread through contact with respiratory secretions so
use of a mask and gown is required to prevent spread of the infection to staff members or other
patients. The other actions 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

25. ANSWER B Administration of medications is included in LPN education and scope of practice.



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Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes
initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient
started to seize. Documentation of the seizure, patient teaching, and planning of care are complex
activities that require RN level education and scope of practice. Focus: Delegation

26. ANSWER C The priority action during a generalized tonic-clonic seizure is to protect the
airway. Administration of lorazepam should be the next action, since it will act rapidly to control
the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during
tonic-clonic seizures is caused by apnea. Checking the level of consciousness is not appropriate
during the seizure, because generalized tonic-clonic seizures are associated with
a loss of consciousness. Focus: Prioritization

27. ANSWER B Leukopenia is a serious adverse effect of phenytoin and would require
discontinuation of the medication. The other data indicate a need for further assessment and/or
patient teaching, but will not require a change in medical treatment for the seizures. Focus:
Prioritization

28. ANSWER D Urinary tract infections are a frequent complication in patient with multiple
sclerosis because of the effect on bladder function. The elevated temperature and decreased breath
sounds suggest that this patient may have pyelonephritis. The physician should be notified
immediately so that antibiotic therapy can be started quickly. The other patients should be
assessed soon, but do not have needs as urgent and this patient. Focus: Prioritization

29. ANSWERS A, C and E NA education and scope of practice includes taking pulse and blood
pressure measurements. In addition, NAs can reinforce previous teaching or skills taught by the RN
or other disciplines, such as speech or physical therapists. Evaluation of patient response to
medication and development and individualizing the plan of care require RN-level education and
scope of practice. Focus: Delegation

30. ANSWER A LPN education and team leader responsibilities include checking for the
therapeutic and adverse effects of medications. Changes in the residents memory would be
communicated to the RN supervisor, who is responsible for overseeing the plan of care for each
resident. Assessment for changes on the Mini-Mental State Examination and developing the plan of
care are RN responsibilities. Assisting residents with personal care and hygiene would be delegated
to nursing assistants working the LTC facility. Focus: Delegation

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




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32. ANSWER A The inability to recognize a family member is a new neurologic deficit for this
patient, and indicates a possible increase in intracranial pressure (ICP). This change should be
ommunicated to the physician immediately so that treatment can be initiated. The continued
headache also indicates that the ICP may be elevated, but it is not a new problem. The glucose
elevation and weight gain are common adverse effects of dexamethasone that may
require treatment, but they are not emergencies. 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.
35. a. Optic neuropathy
36. b. Closed angle
37. d. All of the above
38. b. Closed angle glaucoma







. Kelly Smith complains that her headaches are
occurring more frequently despite medications.
Patients with a history of headaches should be
taught to avoid?
Chocolate
The nurse is caring for a male client
diagnosed with a cerebral aneurysm who
reports a severe headache. Which action
should the nurse perform?
Call the physician immediately.




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The client is seen in the clinic for treatment of
migraine headaches. The drug Imitrex
(sumatriptan succinate) is prescribed for the client.
Which of the following in the clients history
should be reported to the doctor?
Prinzmetals angina
The patient with migraine headaches has a
seizure. After the seizure, which action can
you delegate to the nursing assistant?
Take the patients vital signs.
The nurse answers a call bell and finds a
frightened mother whose child, the patient, is
having a seizure. Which of these actions
should the nurse take?
The nurse should clear the area and position the client safely
The client is experiencing seizure due to chemical imbalances. The following
are causes of seizure because of chemical imbalances EXCEPT:
Alkalosis
The nurse is preparing a diet plan for a patient experiencing seizures. What
plan of diet should the nurse prepare?
a diet high in fat and very low in carbohydrates and protein which can produced
Ketosis

In giving health teachngs to a patient experiencing seizures,the diet plan that
should be avoided includes:
Avoid excess sugar and caffeine

A patient is suddenly having seizure. As a nurse, an initial nursing
intervention should include:
Place the patient on side during a seizure
Assessment of Generalized tonic-clonic (grand mal) seizure includes all of the
following EXCEPT:
Loss of contact with environment for 5 to 30 seconds.
The following are complications related to seizure EXCEPT: Hypertension
A patient is admitted to the hospital for epeliptic seizure. Medications include
which of the following:
Anticonvulsants
A child is admitted to the hospital with an uncontrolled seizure disorder. The
admitting physician writes orders for actions to be taken in the event of a
seizure. Which of the following actions would NOT be included?
Restrain the patient's limbs
1. Which of the following best describes hydrocephalous? Abnormal accumulation of CSF in the ventricles

1. Which is not a symptom of acquired hydrocephalous? Delirium

1. All of the following are causes of acquired hydrocephalous except? Infection




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1. What procedure that involves the placement of a ventricular into the cerebral
ventricles to drain the excess fluid into the other body cavities?
VP shunt

1. Intra-axial tumors originate from the glial cells and arise from within the following
except?
Meninges

1. It is common in patients with intracranial tumors and may be the first
manifestation. It is also known as Choked Disc?
Papilledema

1. Patient Magangana was diagnosed with brain tumor. She was scheduled for
craniotomy. In preventing development of cerebral edema after surgery, the
nurse should expect the use of what medication?
Steroids

1. All but one is the best nursing responsibility of Nurse Magangana to take action
regarding monitoring for an increase ICP
Assess neurologic status and vital signs frequently

1. Patient MD had a head trauma. She experience loss of consciousness for 5
minutes and retrograde amnesia. There was no break in her skull or dura and
no visible damage as seen in MRI. Nurse GGV knows that this type of trauma
is________
Concussions

1. ___________ is the most severe form of head injury because there is no focal
lesion to remove.
Diffuse Axonal injury

1. The medical management of severely head-injured patients focuses on
supporting all organ system while recovery from the injury takes place. This
involves ___________
All of the above

1. A patient has loss of consciousness lasting 6 to 24 hours and has a short -term
disability. What type of diffuse axonal injury does the patient manifest?
Mild axonal injury

1. Clinical manifestations of arteriovenous malformation include all the following
except:
Focal neurologic lesions

1. A patient is admitted with essential arteriovenous malformation. The nurse
knows that most AVM are caused by an abnormality in embryonal
development that leads to:
Tangle arteries and veins in the brain that lacks in capillary bed.
The nurse advises Mr. Nathan to bed rest with sedation. This advice is based
on the knowledge that rest and sedation
Prevent agitation and stress

1. Doppler Ultrasonography of cerebrovascular system is used for arteriovenous
malformation that indicates:
Turbulent blood flow

1. All of the following are cause by cerebral aneurysm except: Alcoholism

This is the most common type of cerebral aneurysm
Saccular or berry aneurysm

Cerebral aneurysm most commonly occur at the bifurcations of the large
arteries at the base of the brain, what is the specific location?
Cerebral arterial circle




13

1. A female client with a suspected brain tumor is cheduled for computed
tomography (CT). what should the nurse do when preparing the client for this
test?
Determine whether the client is allergic to iodine, contrast dyes,
or shellfish

1. The nurse is caring for a child with spina bifida which of the following factors
determines the extent of sensory and motor function loss in the lower limbs of
the child?
Degree of spinal cord abnormality

1. Which assessment findings suggest hydrocephalus? Rapid increase in head size and irritability

1. Which technique is more important for diagnosing hydrocephalus?
Measurement of head circumference
All of the following are common etiology of spina bifida
None of the above

1. Where is the usual location of meningocele? Posterior vertebral arches

1. Which one of the following phrases most accurately describes
myelomeningocele?
Herniation of a portion of the spinal cord and meninges into a cyst.

1. A female patient is diagnosed with a CVA in the left hemisphere. The nurse
explains to the patient that her cerebral accidents (stroke) occurred in the left
hemisphere of her brain; therefore, she will have paresis (weakness) on
The right side of the body.

1. A male patient recovering from a CVA is receiving oxygen therapy. The action
the nurse should take before starting oxygen therapy is to?
Keep the patients head slightly elevated and clear his mouth of secretions
1. The most common motor dysfunction of a stroke is:
Hemiplegia
1. The degree of neurologic damage that occurs with the ischemic stroke depends
on the:
Combination of the above factors.

1. A patient suffered a spinal cord injury in a swimming accident that resulted in
quadriplegia. The nurse recognizes that the one major early problem for a
quadriplegia will be:
Learning to use mechanical aids

1. The rehabilitation nurse is admitting a client following spinal cord injury. The
nurse concludes that the client has developed Brown-Sequared syndrome
after noting which of the following in the client?
Ipsilateral proprioception loss below lesion

1. A client who is recovering from a spinal cord injury complains of blurred vision
and a severe headache. His blood pressure is 210/140. The most appropriate
initial action for the nurse to take is:
Check for bladder distention

1. When the nurse asks a male patient with parkinsons disease to undress, the
nurse observes that the patients upper arm tremors disappear as he
unbuttons his shirt. Which of the following statement would be the best to
guide the nurse when analyzing her observation?
This type of tremor usually disappears with purposeful and voluntary
movements.

1. A client with Parkinsons disease is receiving combination therapy with Levodopa
(L-dopa) and Carbidopa (Sinemet). Which of the following manifestations
indicate to the nurse that an adverse drug reaction is occurring?
Depression




14

1. A nurse is teaching a family of a client with Parkinsons disease. Which of the
following statements by the family reflects a need for more education?
We can buy lots of soups for dad.

1. The nurse is admitting a male patient with Parkinsons disease to the hospital
records that the patient has a shuffling and propulsive gait. If the nurse is
using the term propulsive gait correctly, she has observed that the patients
walk is characterized by:
slumping forward while walking
1. Signs and symptoms seen in Parkinsons Disease result from the fact that the
patients body suffer from a:
depletion of dopamine

1. Which of the following nursing goals is most realistic and appropriate in caring
for a patient with Parkinsons disease?
Cure the disease in three to five years

1. When the nurse asks a male patient with Parkinsons disease to undress, the
nurse observes that the patients upper arm tremors disappear as he
unbuttons his shirt. Which of the following statements would be best to guide
the nurse when analyzing his observation?
This type of tremors usually disappears with purposeful and voluntary
movements

1. This type of food should be avoided when taking Levodopa except: a. Apple

1. This is a diagnostic procedure in patients with spinal cord injury if a ligamentous
injury is suspected.
a. MRI

These are possible cause of hemorrhagic stroke, except Venous Thrombosis
1. A nurse is caring for a patient diagnosed with hemorrhagic stroke; the nurse
would be alert for this complication.
Seizure

1. IN relation to ischemic stroke, penumbra region is referred to: An area of low cerebral blood flow

. ____________ an autoimmune disorder caused by the destruction of
acetylcholine receptors.
Myasthenia Gravis
Myasthenic crisis and cholinergic crisis are the major complications of
myasthenia gravis. Which of the following is essential nursing
knowledge when caring for a client in crisis?
a. Weakness and paralysis of the muscles for
swallowing and breathing occur in either
crisis

3. A client is admitted to the medical-surgical
floor with an exacerbation of myasthenia gravis.
Which intervention is important for the nurse to
include in the plan of care for this client?
. Scheduling the client's care around periods of rest.
Karina, a client with myasthenia gravis is to receive immunosuppressive
therapy. The nurse understands that this therapy is effective because it:
Decreases the production of auto antibodies that attack the acetylcholine
receptors

The nurse is caring for a client admitted with suspected myasthenia gravis.
Which finding is usually associated with a diagnosis of myasthenia gravis?
Progressive weakness that is worse at the days end




15

1. All of the fallowing are clinical manifestation of Guillain Barre Syndrome except: Headache

1. It is not recommended for the treatment of GBS
Corticosteroids
1. In respiratory distress with Guillain Barre Syndrome, we monitor for the fallowing
except
Vital signs
1. The cell that produces myelin in the nerve
Schwann cell
1. Cerebral Palsy can be diagnosed as early as _____________?
4 months
1. Result in the damage or defects in the brains corticospinal pathways in either
one or both hemispheres?
a) Pyradimal/ spastic
1. 1. common The type of cerebral palsy a) Spastic cerebral palsy

1. In planning a diet for a client with cerebral palsy, what would be the most
appropriate
High calorie diet
. Which of the following pathophysiologic
processes are involved in Multiple Sclerosis ?
Developmental of demyelination of the
myelin sheath, interfering with nerve
transmission

Which of the following symptom usually occurs early in multiple sclerosis? Diplopia
The client with multiple sclerosis is experiencing dysphagia. Which of the
following foods is the most important for the client?
vanilla pudding
Which of following condition or activities may
exacerbate multiple sclerosis (MS)?
pregnancy
Which of the following client would be most
likely to develop multiple sclerosis (MS)?
A 35 years old white female teacher
1. The patient is suffering from herniated nucleus pulposus. Which of the
following does not aggravate the pain?
a. Bed rest

1. The patient is experiencing muscle spasm. All of the following but one
is not an appropriate intervention?
a. Narcotics

1. A pre-op patient who underwent a laminectomy needs further
instruction if she states that;
a. Im not allowed to drink for four days




16

1. A patient was admitted to the hospital. The physician diagnosed the
condition of the patient as herniated nucleus pulposus. The nurse
on duty knows that herniated nucleus pulposus is the;
a. Profusion of the central part of interverfebral disk with the spinal
canal casing compression of spinal nerve roots.


1. As a nurse, you know that herniated nucleus pulposus is dominant to
men due to the heavy lifting. It is common in the _______and less
common/rare in _______ vertebral _______.
a. Lumbar; cervical; space

1. A patient came into the emergency complaining of an increasing
throbbing headache that she characterized as a persistent aching
and burning pain. The nurse knows that the patient is suffering from
a temporal arteritis. All of these are associated factors of temporal
arteritis except?
Nausea and vomiting
1. Tension headache is the most common type of headache, as a nurse
you know that tension headaches can be treated with all of the
following except?
a. Corticosteriods

1. A patient complains of experiencing deep-seated, throbbing pain and
describes the pain as aching or bursting. The nurse knows that the
patient is suffering from headaches of brain tumor that causes
attacks of pain lasting a few minutes to an hour or more. All the
following are associated factors except one;
a. Loss of vision

1. Mr X was diagnosed with seizure. The affected part of his brain is the
frontal lobe. Nurse A would expect the pt. to have:
a. Tremors that begin in the hands with unimpaired LOC

1. Mrs Samantha has a history of seizure while gardening. The patient
suddenly losses consciousness and fell on the floor. Upon
assessment, the patient has minimal abrasions increase pulse rate
and perspiring. As a nurse, you know that the patient has a;
a. Grand mal Seizure

1. The physician ordered an anticonvulsant drug for a patient with seizure
one of the nursing consideration is;
a. An anticonvulsant should not be given with narcotic analgesics

1. Nurse Anna is monitoring the vital signs of the patient with seizures/
What are the important vital signs should nurse Anna take?
a. CV status, temperature and Respiration

1. Andie has bacterial meningitis, which of the following drug is most
likely to administer for early diagnosis.
a. Vancomycin HCI with cephalosporins

1. People in class contact with meningococcal meningitis should be
treated with antimicrobial prophylaxis. The medication should be
administered:
a. Within 24 hrs.

1. A patient who diagnose of meningitis can manifest a frequently initial
symtoms that the patient will experience throughout the course of
illness. Which of the ff. experiencing?
d. Headache and fever

1. Doctor Jonathan diagnosed Mr. Santiago to have intracranial
hemorrhage between cranium and outside the dura.The doctor is
correct if he interprets that Epidural Hemorrhage is frequently due
to:
c.Rupture of middle meningeal artery

17.Nurse Sarra is aware that Nuerological signs of
Intracranial Hemorrhage includes:EXCEPT
b.Increase in respiratory

18. This results from spontaneous rupture of a
small penetrating artery deep in the brain?
d. Intracerebral Hemorrhage




17

19. Mr. Reyes experienced pain when he flexed
and extend his thigh on his abdomen at right
angle. This situation is significantly positive to
what condition?
d. Kernigs Sign

20. Antifibrolytics are used in the management of
haemorrhagic lesion to:
b. prevent fibrin clot degeneration

1. After experiencing a transient ischemic attack, a
client is prescribed aspirin, 325 mg p.o. daily. The
nurse should teach the client that this medication
has been prescribed to:
d. Reduce platelet agglutination

2. A 70 year old client with a diagnosis of left
sided CVA is admitted to the facility. To prevent
the development of disuse osteoporosis, which of
the following objectives is most appropriate?
c. Promoting weight bearing exercises

3. Which nursing diagnosis takes highest priority
for a client with Parkinsons crisis?
b. Ineffective airway clearance

4. A client with a spinal cord injury and
subsequent urine retention receives intermittent
catheterization every 4 hours. The average
catheterized urine volume has been 550 ml. the
nurse should plan to:
a. Increase the frequency of the catheterizations

5. A client undergoes cerebral angiography for
nurse evaluation of neurologic deficits. Afterward,
the nurse checks frequently for signs and
symptoms of complications associated with this
procedure which findings indicate spasm or
occlusion of a cerebral vessel by a clot?
b. Hemiplegia, seizures, and decreased level of
consciousness

6. The nurse formulates a nursing diagnosis of risk
for altered body temperature for a client who
suffers a CVA after surgery. When developing
expected outcomes, the nurse incorporate
assessment of the clients temperature to detect
abnormalities. The thermoregulatory centers are
located in which part of the brain?
d. Hypothalamus

7. A client recovering from a CVA has right sided
hemiplegia and telegraphic speech and often
seems frustrated and agitated especially when
trying to communicate. However the chart
indicates that the clients auditory and reading
comprehension are intact. The nurse suspects that
the clients has:
b. Non-fluent aphasia




18

8. A client with parkinsons disease visits the
physicians office for a routine check-up. The
nurse notes that the client takes
benztropine(cogentin), 0.5 mg p.o. daily and asks
when the client takes the drug during each day.
Which response medicates that the client
understands when to take benztropine?
d. I take the medication at bedtime

9. After a CVA, a 75 yr old client is admitted to
the facility. The client has left sided weakness and
an absent gag reflex. Hes incontinent and has a
tarry stool. His blood pressure is 90/50 mmHg,
and his Hgb is 10g. Which of the following is a
priority for this client?
d. Elevating the head of the bed to 30 degrees

10. During recovery from CVA, a client is given
nothing by mouth to help prevent aspiration. To
determine when the client is ready for a liquid diet
, the nurse assesses the clients swallowing ability
once each shift. This assessment evaluates:
d. CN IX & X

11. The nurse is caring for a client with
hemiparesis caused by a CVA. Which intervention
takes the highest priority?
b. Placing the client on the affected side

12. A client injures the spinal cord in a diving
accident. The nurse knows that the client will be
unable to breathe spontaneously if the injury site
is above which vertebral level?
a. C4

13. A white female client is admitted to an acute
care facility with a diagnosis of CVA. Her history
reveals bronchial asthma, exogenous obesity and
iron deficiency anemia. Which history findigs is a
risk factor for CVA?
c. Obesity

14. When teaching a client about levodopa
carbidopa (sinemet) therapy for Parkinsons
disease, the nurse should include which
instruction?
d. be aware that your urine may appear darker than
usual

15. The physician prescribes several drugs for a
client with hemorrhagic stroke. Which drug order
should the nurse question?
a. Heparin sodium (heparin sodium injection)

16. A client who recently experienced a CVA tells
the nurse that he has double vision. Which nursing
intervention is the most appropriate?
b. Alternatively patch one eye every 2 hours

17. For a client who has had a CVA, which
nursing intervention can help prevent contractures
in the lower legs?
d. Attaching braces or splints to each foot and leg




19

18. If a client experienced a cerebrovascular
accident that damaged the hypothalamus, the
nurse would anticipate that the client has problems
with:
a. Body temperature control

19. Vince William, age 65 years old, is admitted
to the hospital with a diagnosis of Parkinsons
disease. Joels symptoms are caused by:
d. an imbalance in dopamine and
acetylcholine

20. Which clinical feature of the disease should
the nurse expect to see during admission
assessment?
b. mask like face and shuffling gait

1. The physician told that baby Megamind needs to undergo surgery that will create
an opening to allow CSF to drain through a shunt from ventricles of the brain
into cisterna magna. What is this surgical procedure?
a. Ventriculocisternostomy

1. It is a diagnostic procedure wherein a light is shone through a body area or
organ.
a. Transillumination

1. Patient megamind was diagnosed with non communicating or intraventricular
hydrocephalus, as a nurse we know that this problem can cause a non-
communicating hydrocephalus.
a. Arnold-Chiari Syndrome

1. Clarissia an 8y/o child that has been diagnosed to have brain tumor. The doctor
advised the parents of clarissa to get their child for treatment. You know as a
nurse that the best treatment for clarissa would be:
a. Chemotherapy

6. In relation to the question in no.1. Clarissas
parents ask what is the action of the treatment. As
a nurse your answer would be:
a. Its goal is to kill tumor cells with the aid of drugs.

7. Leren has breast cancer for 5 years, the cancer
has already metastasized through her body
reaching the brain . What do you call this
condition?
b. Secondary brain tumor

10. Patient Tin is classified as grade 3 in Spetzler
Martin Grading for microsurgery. What does it
implies?
a. She may or may not be amenable for a surgery
11. This is a type of stroke that is caused by
bleeding into the subarachnoid space in the area
between the brain and the skull which contain
CSF.
b. SAH

12. Mr. Q was diagnosed with AVM. What part of
the brain is removed if he is required to have a
supra tentorial surgery?
c. Above the tentorium

13. Mr. R, a 42 years old police officer was
diagnosed of having AVM and was ready to
undergo what appropriate type of surgery?
b. microsurgery




20

14. Baby Marco, a 7 months old is brought by his
mother to the hospital because of noticeable
enlargement of the head. As a student nurse you
know that baby Marco is suffering from
hydrocephalus because as you further assess the
symptom it shows the ff. except:
d. Nuchal rigidity

15. In relation to question #6 after the diagnostic
procedure is done, baby Marco have to undergo
surgery. Prior to surgery you do your nursing
management that include the ff. except:
d. Monitor for Signs and Symptoms or HCP and
infection

16. Mr. You was brought to the Emergency
Department by his wife due to the vehicular
accident. The patient undergone an immediate
Skull x-ray that reveals Mr. You has Depressed
Skull Fracture. As a nurse, you are aware the
characteristic of Depressed Skull Fracture is?
a. A break in a cranial bone or "crushed" portion of skull with
depression of the bone in toward the brain

17. Nurse Biwit is taking the history of his patient
experiencing head injury, he should know that the
most common symptom of concussion is
a. Headache

18. Nurse Biwit has a patient who has a historyof
head injury, during health teaching, nurse Biwit
includes all of the following regarding the
prevention of head injury except?
*c. Cap in construction

19. A 55 y/o male client was diagnosed with
fusiform cerebral aneurysm that needs an urgent
medical treatment . What should be the first
nursing intervention?
* b. Monitor V/S

20. A relative of a client with cerebral aneurysm
ask the nurse what does it means. The nurses
appropriate response would be:
*c. Is a dilation of the walls of the cerebral artery
that develops as a result of weakness in the arterial
wall.

1. You are about to administer 20 mg. of Capoxane to a patient with relapsing-
remitting Multiple Sclerosis, what is the only route used in administering this
drug?
a. Subcutaneous

1. Which of the following suggest why patients with Multiple Sclerosis develop
depression?
a. Depression is a side effect of some drugs used to treat MS
such as steroids and Interferon.

1. What is the virus most often associated with Guillaine-Barre Syndrome? a. Campylobacter Jejuni

1. Because Myasthenia Gravis may involve the muscle of respiration, what action
will you do to prevent a patient from experiencing dyspnea and ineffective
cough and swallow mechanism?
a. Encourage deep breathing and coughing.




21

1. This is an autoimmune disease that persists on muscular weakness and fatigue
that worsens with exercise and improves with rest?
a. Myasthenia Gravis

1. Brad Feet a 25 year old patient with Guillaine-Barre Syndrome is having a
respiratory distress which of the following will you expect to see connected to
the patient?
a. Mechanical Ventilator

1. Which of the following diagnoses is appropriate for a client with Multiple
Sclerosis?
a. Impaired urinary elimination related to bladder dysfunction.

1. Which of the following is a unique clinical manifestation of Guillaine-Barre
Syndrome?
a. Ascending weakness