Neuro 1 & 2

Question 0

The patient arrives at the clinic with a chief complaint of headache. He is irritable and inpatient to receive treatment, but he is alert and oriented, his speech is clear, and he is able and willing to answer the nurses questions. Which questions to the nurse asked to solicit additional relevant information about this patient’s headache?

Answer 0

1. When do the headaches occur
2. How often do the headaches occur
3. Do you experience other symptoms with the headache
4. Have there been any recent changes in your headache

Question 1

History of migraine headaches reports his current headache is my usual throbbing pain, but today it is behind my left eye. Which question does the nurse asked to elicit information about trigger factors?

Answer 1

Did you drink wine or coffee before the headache occurred?

Question 2

Which type of medication can be used to prevent migraines?

Answer 2

Propranolol (inderal)

Question 3

During the patients last visit, the nurse instructed the patient about headaches and techniques to manage his condition. Which statement by the patient indicates teaching has been successful?

Answer 3

I have been keeping track of when my headaches occur

Question 4

Patient with a history of migraine headaches reports of noise makes her head hurt worse. How much is a nurse document this objective finding

Answer 4

Patient reports phonophobia

Question 5

A patient is prescribed ergotamine with caffeine for migraine headaches. Which statement by the patient indicates the patient is experiencing a side effect of this drug?

Answer 5

My headache is initially relieved by the medication, but then it returns

Question 6

The patient has received a prescription for Imitrex for the treatment of migraine headaches. The patient tells the nurse that she elected not to tell the physician about all of her health conditions because I just wanted treatment for my headaches I didn’t want to go into anything else. What is the nurses response?

Answer 6

The drug is contraindicated in actual or suspected ischemic heart disease

Question 7

Tonic clonic seizure

Answer 7

Rigidity followed by rhythmic jerking

Question 8

Absence seizure

Answer 8

Brief period of staring or loss of consciousness

Question 9

Myoclonic seizure

Answer 9

Brief jerking of extremities, singly or in groups

Question 10

Atonic seizure

Answer 10

Sudden loss of body tone

Question 11

An elementary school teacher has just been informed that her students brother has absence seizures. The teacher is fearful that her student may have the same type of seizures and is unsure what to expect. What signs does the nurse advise teacher to look for?

Answer 11

Brief loss of consciousness that may appear as daydreaming or blank stare

Question 12

What is the priority patient problem for atonic seizures?

Answer 12

Potential for injury related to falls

Question 13

Which test is a nurse anticipate will be ordered for patient to confirm the suspected diagnosis of epilepsy?

Answer 13

Electroencephalogram and computed tomography

Question 14

The nursing students caring for a patient with absence seizures. Which statement by the student indicates an understanding of absence seizures?

Answer 14

The patient may repeatedly pick at the linens

Question 15

An older adult patient is brought to the emergency department from the local mall after by standard saw her having a seizure. The patient is currently responsive to voice, but is lethargic, confused, and unable to give accurate history. Which aspect of this patient’s health history is the most important to verify with the family?

Answer 15

General ability to answer questions accurately

Question 16

The patient is treated in the emergency department for status epileptic us and is admitted to the hospital the physicians ordered seizure precautions. What equipment does the nurse place in the room before the patient’s arrival?

Answer 16

Oxygen and suction equipment

Question 17

Bacterial meningitis

Answer 17

1. Cerebrospinal fluid is hazy

2. Outbreaks occur in crowded conditions such as dormitory

Question 18

Viral meningitis

Answer 18

1. Condition is usually self-limiting, full recovery is expected
2. No organisms grow from the CSF

Question 19

Fungal meningitis

Answer 19

1. Manifestations vary according to the state of the immune system

Question 20

The nurse is caring for a patient who was admitted for a diagnosis of meningococcal meningitis. Which nursing action is specific to this type of meningitis?

Answer 20

Place the patient in isolation per hospital procedure

Question 21

The nurse is reviewing the electrolyte values for patients with bacterial meningitis and notes that the serum sodium is 126 mEq. How does the nurse interpret the findings?

Answer 21

Evidence, inappropriate antidiuretic hormone which is a complication of bacterial meningitis

Question 22

The patient with meningitis reports a headache, and the nurse says the appropriate Iv push medication. Several hours later, the patient reports pain in the left hand, radial pulse is weak, and capillary refill is sluggish compared to the left . What does the nurse suspect is occurring in this patient?

Answer 22

Septic emboli causing vascular compromise

Question 23

The patient arrives in the emergency dept with a headache,, nausea, photosensitivity. The patient is been living in close proximity with two people were diagnosed with meningitis. Which diagnostic test is the nurse anticipate the physician will order to rule out meningitis?

Answer 23

Lumbar puncture

Question 24

The nurses caring for a patient in less symptoms and risk factors for bacterial meningitis. For which must the nurse alert the physician?

Answer 24

Inability to move eyes laterally

Question 25

Nurses carefully monitoring a patient with a severe case of encephalitis for signs of increased ICP. What Vital sign changes are associated with increased ICP?

Answer 25

Widened pulse pressure and bradycardia

Question 26

The student nurse is caring for a patient with encephalitis. Which action by the student nurse warrants intervention by the supervising nurse?

Answer 26

Elevation that head of the bed to 30° after a lumbar puncture

Question 27

The nurses taking a history on it older adult patient reports chronic back pain the nurse seeks to identify factors that are contributing to the pain. Which question is the most useful in eliciting this information?

Answer 27

Do you have a history of osteoarthritis?

Question 28

The nurse is preparing to physically assess the patient's subjective report of paresthesia in the lower extremities. In order to accomplish this assessment, which assessment technique does the nurse use?

Answer 28

Ask the patient to identify sharpen dull sensation by using a paperclip and cotton ball

Question 29

Which position is therapeutic and comfortable for a patient with lower back pain?

Answer 29

Semi Fowler's position with a pillow under the Knees to keep them flexed

Question 30

The patient has been talking to his physician about drugs that could potentially be used in the treatment of his chronic low back pain. Which statement by the patient indicates the need for additional teaching?

Answer 30

The doctor may prescribe hydromorphone and it may cause drowsiness, I should not drive or drink alcohol when I take it

Question 31

The nurse is assessing the patient who presented to the ED recording a cute onset of numbness and tingling in the right leg. How does the nurse document the subject of finding?

Answer 31

Paresthesia

Question 32

Patient has just undergone a spinal fusion and laminectomy and his return from the operating room. Which assessments are done in the first 24 hours?

Answer 32

1. Take vital signs every four hours and assessed for fever and hypotension 2. Perform a neurologic assessment every four hours with attention to movement and sensation 3. Monitor intake and output and assess for urinary retention 4. Observed for clear fluid on or around the dressing and test for glucose

Question 33

The patient has a long history of chronic back pain and has undergone several back surgeries in the past. At this point, the surgeon is recommending a surgical procedure for spine stabilization. Which procedure does the nurse anticipate this patient will need?

Answer 33

Spinal fusion

Question 34

The patient has just undergone a laminectomy and return from surgery at 1300 hrs. At 1530 hrs. the nurses performing the change of shift assessment. Which postoperative finding is reported to the surgeon immediately?

Answer 34

1. Swelling or bulging at the operative site | 2. Moderate clear drainage on the postoperative dressing

Question 35

The patient has just undergone spinal fusion surgery and return from the operating room 12 hours ago. Which task is best to delegate to the nursing assistant?

Answer 35

Logroll the patient every two hours

Question 36

The nurse reviews the discharge and homecare instructions with the patient who had back surgery. Which statement by the patient indicates further teaching is needed?

Answer 36

I will drive myself to my doctors office next week

Question 37

The patient has had an anterior cervical dissecting me with fusion and his return from the recovery room. What is the priority assessment?

Answer 37

Assess for patency of airway and respiratory effort

Question 38

The patient comes to the emergency department with back pain, but is alert and oriented and is not having any problems breathing. Her husband is very distraught and when the nurse tries to find out what is happened he yells just help her now stop asking me these stupid questions. Why is it important for the nurse to continue trying to obtain information from the husband?

Answer 38

Engaging the husband will help him to calm down and give him an active role

Question 39

Which statements about spinal shock are accurate?

Answer 39

1. It lasts for 48 hours up to a few week 2. There is temporary loss of motor and sensory function 3. There's temporary loss of reflex and autonomic function

Question 40

The nurses caring for a patient with a spinal cord injury who is experiencing neurogenic shock. The patient systolic blood pressure is 88 despite starting a dopamine drip two hours earlier. There's a new order to infuse 500 mL of dextran 40 over four hours. At what rate does the nurse at the infusion pump?

Answer 40

125 mL an hour

Question 41

The patient involved in a high-speed motor vehicle accident was sustained multiple injuries in active bleeding is transported to the emergency department by ambulance with immobilization devices in place. There is a high probability of cervical spine fracture, the patient has altered mental status and extremities are flaccid. What is the priority assessment for this patient?

Answer 41

Assess respiratory pattern and ensure a patent airway

Question 42

The emergency department nurse is assessing in Montring a patient with a gunshot wound to the middle of the back. Because the patient is at risk for spinal shock what does the nurse monitor for?

Answer 42

Decreased blood pressure, bradycardia, and flaccid paralysis

Question 43

Which neurologic assessment technique does the nurse used to test the patient for sensory function?

Answer 43

Touch the skin with a clean paperclip and ask whether it is sharp Or dull sensation

Question 44

Assessing the patient with a lower spinal cord injury confirms that the patient has process of the bilateral lower extremities. How does the nurse document the findings?

Answer 44

Paraplegia

Question 45

Spinal shock complications

Answer 45

1. Flaccid paralysis 2. Hypotension 3. Loss of reflexes below the injury

Question 46

Autonomic dysreflexia complications

Answer 46

1. Hypertension 2. Severe headache 3. Blurred vision

Question 47

The nurse is assessing a patient with spinal cord injury and recognizes that the patient is experiencing autonomic dysreflexia. What is the nurses priority action?

Answer 47

Raise the head of the bad

Question 48

The nurses providing discharge teaching for a patient with a spinal cord injury who will be performing intermit itself catheterizations at home. Which sign and symptoms will the nurse instructed patient to report immediately to the primary healthcare provider?

Answer 48

1. Fever | 2. Foul smelling urine

Question 49

The nurses preparing a quadriplegic patient for discharge and his top the patient spouse to assist the patient with the quad cock to prevent respiratory complications. Which observation indicates that the spouses understood what has been taught ?

Answer 49

The spouse places her hands below the patients diaphragm and pushes upward as the patient Exhales

Question 50

Patient with an upper spinal cord injury is at risk for autonomic dysreflexia. What is the priority problem for this patient?

Answer 50

Decreased cerebral tissue perfusion

Question 51

The nurses caring for a patient with a recent spinal cord injury. Which intervention does the nurse used to target and prevent the potential SCI complication of autonomic dysreflexia?

Answer 51

Keep the room warm and control environmental stimuli Monitors stool output and maintain a bowel program Monitor urinary output and check for bladder distention

Question 52

What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury?

Answer 52

Hypertensive crisis

Question 53

After suffering an SCI, a patient develops autonomic dysfunction, including a neurogenic bladder. What is the priority patient problem for this condition?

Answer 53

Risk for urinary tract infection

Question 54

The nurse and nursing students are working together to bathe every position a patient who is in the halo fixator device. Which action by the nursing student causes the supervising nurse to intervene?

Answer 54

Turns a patient by pulling on the top of the halo device

Question 55

The nurses caring for several patients with SEI. Which task is best to delegate to the nursing assistant?

Answer 55

Log roll the patient, maintain proper body alignment and place a bedpan for toileting

Question 56

The patient within SEI has paraplegia and paraparesis. The nurse has identified a priority patient problem of inability to ambulate. The nurse assesses the Area of both legs for swelling tenderness redness or possible complaints of pain. This assessment is specific to the patient's increased risk for which condition?

Answer 56

Deep vein thrombosis

Question 57

The nurse is caring for a patient who is been in long-term care facility for several months falling and SCI the patient has had issues with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. Which are expected outcomes of the training program?

Answer 57

1. Demonstrates a predictable pattern avoiding 2. Is able to empty the bladder completely 3. Does not experience a urinary tract infection

Question 58

Methyl prednisone

Answer 58

Reduces inflammation

Question 59

Dextran

Answer 59

Increases capillary blood flow

Question 60

Atropine

Answer 60

Increases heart rate

Question 61

Dopamine

Answer 61

Regulates blood pressure

Question 62

Dantrolene

Answer 62

Relieves spasticity

Question 63

What does the nurse due to implement bowel and bladder retraining for a patient with an SCI?

Answer 63

1. Ensure that the patient gets a sufficient quantity of fluid each day 2. Assisted patient in developing a schedule 3. Teach the patient about high-fiber foods 4. Teach the patient to stimulate avoiding by stroking the inner thigh 5. Measure bladder residual with the bladder ultrasound device

Question 64

The patient is an adolescent was quadriplegic as a result of a diving accident. The nursing assistant reports that the patient started yelling and spitting out her while she was trying to bathe him. He's angry and hostile, stating nobody's going to do anything else to me, I'm going to get this place. What is the priority patient problem?

Answer 64

Inability to cope with the situation

Question 65

The nurses giving homecare instructions to a patient who will be discharged with the halo device. What does the nurse instructed patient to avoid?

Answer 65

1. Swimming or contact sport | 2. Driving

Question 66

A client who is receiving Dilantin to control a seizure disorder questions the nurse regarding this medication after discharge. The nurses best response is this medication......

Answer 66

Will probably be continued for life

Question 67

A client with a history of seizures is admitted with a partial occlusion of the left common carotid artery. The client has been taking Dilantin for 10 years. When planning care for this client what should the nurse do first?

Answer 67

Obtain a history of seizure type an incident

Question 68

When entering a room on a medical unit, the nurse identifies the client is having a seizure. What should the nurse do in addition to protecting the client from self injury?

Answer 68

Monitor the seizure activity

Question 69

Dilantin suspension 200 mg is prescribed for a client with epilepsy. The suspension contains 125 mg/5 mL. How much solution should the nurse administer?

Answer 69

8 mL

Question 70

What is the primary responsibility of a nurse during the clients generalized motor seizure?

Answer 70

Clearing the immediate environment for client safety

Question 71

The client has a history of seizures is scheduled for an arterial gram at 10 AM and if you have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9 AM. What should the nurse do?

Answer 71

Ask healthcare provider if the drug can be given by IV

Question 72

I'm nurses providing instructions for a client who is receiving they land but has limited access to healthcare. What's side effect is the basis for the nurses emphasis on the two Gillis oral hygiene?

Answer 72

Hyperplasia of the gums, gingival hyperplasia is an adverse effect of long-term Dilantin therapy. Incidence can be decreased by maintaining therapeutic blood levels and meticulous oral hygiene

Question 73

The client is receiving Dilantin for seizure disorder and heparin for a deep vein thrombosis. Coumadin is added in preparation for discontinuing the heparin. Why must the nurse observed the client closely during the initial days of the treatment with Coumadin?

Answer 73

Warfarin affects the metabolism of phenytoin (Dilantin)

Question 74

Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disc?

Answer 74

Pain radiating to the hip and leg because of pressure on the sciatic nerve

Question 75

A nurse expect the client with a herniated intravertible disk to report a sudden increase in pain with which activities?

Answer 75

Coughing, sneezing, or straining when having a bowel movement

Question 76

For which clinical indicator should the nurse assessed the client who just had a micro dissected me for a herniated lumbar disc?

Answer 76

Sensory loss in legs

Question 77

What should the nurse include in the plan of care for a client who just had a posterior lumbar laminectomy?

Answer 77

Reposition the client by logrolling

Question 78

What does the nurse do for a client with a cervical laminectomy this differs from the nursing care for client with a lumbar laminectomy?

Answer 78

Assist with the removal of oral secretions

Question 79

A client with the spinal cord injury has paraplegia. The nurse assesses for which major problem the client may experience early in the recovery.?

Answer 79

Bladder control

Question 80

The nurse should expect a client with spinal cord injury to have some spasticity of the lower extremities. What should the nurse include in the plan of care for this client to prevent the development of lower extremity contractures?

Answer 80

Proper positioning

Question 81

A client has paraplegia a result of the motorcycle accident. What is the reason the nursing care plan should include turning the client every 1-2 hours?

Answer 81

To prevent pressure ulcers

Question 82

What problem is the nurse primarily attempting to prevent when encouraging a client with a spinal cord injury to increase oral fluid intake?

Answer 82

Urinary tract infection

Question 83

A client has a functional transection of the spinal cord at C7/A, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after injury?

Answer 83

1. Flaccid paralysis | 2. Lack of reflexes below the injury

Question 84

After a traumatic spinal cord severance, a young client is having difficulty accepting the paralysis. One day the client has severe leg spasms and says my strength is coming back, and I know I will walk again. The nurses response should be based on what understanding?

Answer 84

Spinal shock has subsided and the clients reflexes are hyperactive

Question 85

What should the nurse assessed for when a client with a cervical injury reports a severe headache and nasal congestion?

Answer 85

Suprapubic distention, these are symptoms of autonomic dysreflexia, which commonly are precipitated by a distended bladder

Question 86

A client with quadriplegia is placed on the tilt table daily. Each day the angle of the head of the table gradually it increased. What should the nurse identify as it's purpose the client asked the reason for the tilt table?

Answer 86

It limits loss of calcium from the bone

Question 87

A nurse in a rehabilitation center teaches clients would quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction?

Answer 87

They usually will never walk

Question 88

The client is in the intensive care unit after sustaining a T2 spinal cord injury. Which priority interventions should the nurse including the clients plan of care?

Answer 88

1. Assessing the respiratory complications | 2. Monitoring and maintaining blood pressure

Question 89

A nurses caring Brookline with the spinal cord injury during the immediate post injury period. what is the primary focus of the nursing care during this immediate phase?

Answer 89

Avoiding flexion or hyperextension of the spine