1.

If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: a. body temperature control. 2. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? c. lidocaine (Xylocaine)

10. Emergency medical technicians transport a 27-yearold iron worker to the emergency department. They tell the nurse, He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and hes comatose. We intubated him and hes maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag. Which intervention by the nurse has the highest priority? a. Assessing the left leg

3. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. Hes unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?. c. Perform a lumbar puncture. 4. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: a. light flashes and floaters in front of the eye. . 5. Which nursing diagnosis takes highest priority for a client with Parkinsons crisis? b. Ineffective airway clearance

11. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by: b. decreasing leukocyte infiltration at the site of ocular inflammation. 12. Nurse April is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal? c. Urine retention or incontinence 13. After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: b. instilling one drop of pilocarpine 0.25% into both eyes four times daily. 14. A female client whos paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? b. The client uses a mirror to inspect the. 15. A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the clients feet make a half circle. To document the clients gait, the nurse should use which term? c. Helicopod 16. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? b. An isolation room three doors from the nurses station

6. To encourage adequate nutritional intake for a female client with Alzheimers disease, the nurse should: a. stay with the client and encourage him to eat.

7. The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses which of the following? c. Cerebral function

8. Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed? b. In 10 to 15 minutes

9. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil a condition resulting from acute iris inflammation (iritis). As part of the clients therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? d. Cholinergic blocker

17. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the clients history. Which preexisting condition would contraindicate the use of pyridostigmi c. Intestinal obstruction 18. A female client is admitted to the facility for investigation of balance and coordination problems, including possible Mnires disease. When assessing this client, the nurse expects to note: a. vertigo, tinnitus, and hearing loss. . 19. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? d. Dont fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days. 20. Nurse Oliver is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? c. Muscle weakness 21. The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? a. Tachycardia 22. A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this clients care, the nurse should assign highest priority to which nursing diagnosis? b. Ineffective breathing pattern 23. A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for: d. treatment of spasticity associated with spinal cord lesions. 24. A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the clients oculocephalic (dolls eye) response by: c. turning the clients head suddenly while holding the eyelids open.

25. While reviewing a clients chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? d. Pancuronium and succinylcholine both require cautious administration. 26. A male client is color blind. The nurse understands that this client has a problem with: b. cones.. 27. A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? c. Midbrain

28. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? a. Vision changes 29. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? d. Call the physician immediately. 30. During recovery from a cerebrovascular accident (CVA), a female 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. cranial nerves IX and X.

1.

A white female client is admitted to an acute care

9.

A female client with amyotrophic lateral sclerosis

facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? c. 2. Obesity

(ALS) tells the nurse, Sometimes I feel so frustrated. I cant do anything without help! This comment best supports which nursing diagnosis? b. Powerlessness

10. For a male client with suspected increased intracranial The nurse is teaching a female client with multiple pressure (ICP), a most appropriate respiratory goal is to: c. 11. promote carbon dioxide elimination. Nurse Maureen witnesses a neighbors husband sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: b. 3. d. 4. rest in an air-conditioned room A male client is having a tonic-clonic seizures. What Take measures to prevent injury. A female client with Guillain-Barr syndrome has sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to opens the airway in this victim by using which method? c. 12. Jaw thrust maneuver The nurse is assessing the motor function of an should the nurse do first?.

paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? a. You may have difficulty believing this, but the paralysis caused by this disease is temporary.

unconscious male client. The nurse would plan to use which plan to use which of the following to test the clients peripheral response to pain? b. 13. Nail bed pressure A female client admitted to the hospital with a

5. a. . 6.

The nurse is working on a surgical floor. The nurse laminectomy. A female client with a suspected brain tumor is

neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the clients history of: c. 14. d. Prosthetic valve replacement A male client is having a lumbar puncture performed. Side-lying, with the legs pulled up and head bent

must logroll a male client following a:

scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. 7. to:. b. 8. support the joint where the tendon is being tested. A female client is admitted in a disoriented and restless 16. A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: d. Separates into concentric rings and test positive of glucose During a routine physical examination to assess a male 15. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? b. state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this clients plan of care? d. Risk for injury Head turned to the side The nurse would plan to place the client in which position? down onto chest. clients deep tendon reflexes, the nurse should make sure

17.

A male client with a spinal cord injury is prone to

d.

Taking medications on time to maintain therapeutic

experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? d. Limiting bladder catheterization to once every 12 hours 18. The nurse is caring for the male client who begins to

blood levels 25. A male client with Bells palsy asks the nurse what

has caused this problem. The nurses response is based on an understanding that the cause is: a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem 26. The nurse has given the male client with Bells palsy

experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? B. 19. Restraining the clients limbs The nurse is assigned to care for a female client with instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: a. 27. Exposure to cold and drafts Female client is admitted to the hospital with a complete right-sided hemiparesis. The nurse plans care knowing that this condition: b. The client has weakness on the right side of the diagnosis of Guillain-Barre syndrome. The nurse inquires 20. The client with a brain attack (stroke) has residual during the nursing admission interview if the client has history of: d. Respiratory or gastrointestinal infection during the previous month. 28. A female client with Guillian-Barre syndrome has dysphagia. When a dietorder is initiated, the nurse avoids doing which of the following? a. 21. Giving the client thin liquids The nurse is assessing the adaptation of the female body, including the face and tongue.

client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: d. self 22. Nurse Kristine is trying to communicate with a client Consistently uses adaptive equipment in dressing

ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? c. Providing information, giving positive feedback, and encouraging relaxation

with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? c. Completing the sentences that the client cannot finish 23. A female client has experienced an episode of

29.

A male client has an impairment of cranial nerve II.

Specific to this impairment, the nurse would plan to do which of the following to ensure client to ensure client safety?. d. Provide a clear path for ambulation without obstacles

myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: c. 24. Omitting doses of medication The nurse is teaching the female client with

30.

A female client has a neurological deficit involving

the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the clients behavior. B. Affect is flat, with periods of emotional lability

myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: