Neuro

Question 1

Which of the following observations BEST indicates to the nurse that a client diagnosed with paraplegia can adequately carry out activities of daily living at home after discharge?

1. The client shaves and brushes his teeth.
2. The client transfers himself into and out of his wheelchair.
3. The client maneuvers the wheelchair without difficulty.
4. The client prepares well-balanced meals.

Answer 1

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Strategy: Think about the outcome of each answer.

(1) paraplegic has full use of his upper body, so this activity presents no problem
(2) correct—essential if client is to perform ADLs
(3) done with the arms and presents no real problem
(4) is a necessary requisite for living alone and performing ADLs but is not directly hindered by paraplegia

Question 2

A client is admitted diagnosed with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY?

1. Unequal and dilated pupils.
2. Decerebrate posturing.
3. Grand mal seizures.
4. Decreased level of consciousness.

Answer 2

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Strategy: All answers are assessments. Determine how each relates to increased intercranial pressure.

(1) indicates brainstem damage
(2) late sign of brainstem damage
(3) late sign of increased intracranial pressure
(4) correct—may be confused and stuporous

Question 3

The nurse cares for a client who has just returned to his room after a scleral buckling procedure was completed to repair a detached retina. Which of the following is the MOST important nursing action?

1. Remove reading material to decrease eyestrain.
2. Ask the client if he is nauseated.
3. Assess color of drainage from the affected eye.
4. Maintain sterility during q3h saline eye irrigations.

Answer 3

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Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Think about what the assessments mean.

(1) implementation; would be ineffective
(2) correct—assessment; is important to prevent nausea and vomiting, would increase intraocular pressure, could cause damage to area repaired
(3) assessment; refers to an eye infection, would be important after initial operative day
(4) implementation; eye irrigations are not commonly done following this procedure

Question 4

A 4-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5°C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding indicates an increase in intracranial pressure?

1. Positive Babinski.
2. High-pitched cry.
3. Bulging posterior fontanelle.
4. Pinpoint pupils.

Answer 4

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Strategy: Determine if each answer relates to increased ICP.

(1) normal for the first year of life
(2) correct—high-pitched cry is one of the first signs of an increase in the intracranial pressure in infants
(3) fontanelle should be closed by the third month
(4) with increased pressure, the pupil may respond to light slowly, rather than with the usual brisk response

Question 5

A client is diagnosed with a flaccid bladder following a spinal cord injury. The nurse teaches the client about dietary changes. Which of the following beverages, if selected by the client, indicates to the nurse that teaching is effective?

Select all that apply.

1. Lemonade.
2. Prune juice.
3. Milk.
4. Orange juice.
5. Cranberry juice.
6. Tomato juice.

Answer 5

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Strategy: “Teaching is effective” indicates a correct statement.

(1) promotes alkaline urine; should also avoid citrus juices, excessive amounts of milk, and carbonated beverages
(2) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon
(3) excessive amounts of milk promote alkaline urine
(4) promotes alkaline urine; should also avoid citrus juices, excessive amounts of milk, and carbonated beverages
(5) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon
(6) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon

Question 6

The nurse assesses a client diagnosed with a detached retina. Which of the following observations supports this diagnosis?

1. Loss of acuity in the peripheral visual field.
2. Increased lacrimation, blurred vision.
3. Conjunctivitis, dilated pupils bilaterally.
4. Photophobia, loss of a portion of the visual field.

Answer 6

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Strategy: Think about each answer choice.

(1) loss of peripheral vision occurs with glaucoma; loss of acuity occurs with cataracts
(2) occurs with ocular infections
(3) has no correlation with detached retina
(4) correct—bright flashes of light and client stating that portion of visual field is dark are classic symptoms

Question 7

A client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the maxillary branch of the affected nerve. When performing client teaching, it is MOST important for the nurse to include which of the following instructions?

1. "Report an increase in blurred vision."
2. "Eat soft, warm foods."
3. "Change positions slowly."
4. "Chew food on the affected side."

Answer 7

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Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired?

(1) unnecessary, does not occur with this condition
(2) correct—intense facial pain experienced along nerve tract is characteristic of this condition; nursing care should be directed toward preventing stimuli to the area and decreasing pain
(3) intervention for Ménière’s disease
(4) chewing food on unaffected side less likely to trigger an attack

Question 8

A client is transferred to the neurology unit after developing right-sided paralysis and aphasia. The nurse should include which of the following in the client’s plan of care?

1. Encourage client to shake head in response to questions.
2. Speak in a loud voice during interactions.
3. Speak using phrases and short sentences.
4. Encourage the use of radio to stimulate the client.

Answer 8

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Strategy: Topic of question is unstated. Read the answer choices for clues.

(1) does not encourage verbal communication
(2) inappropriate for the situation
(3) correct—will decrease tension and anxiety; client may understand some of the incoming communication if it is kept simple; speech may be relearned with appropriate support and interventions
(4) inappropriate for the situation

Question 9

A client comes to the clinic complaining of severe facial pain. To collect subjective data from the client, it is MOST important for the nurse to take which of the following actions?

1. Obtain the client's vital signs.
2. Interview the client.
3. Inspect the face for grimacing.
4. Administer pain medication.

Answer 9

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Strategy: Focus on the question.

(1) vital signs are objective data
(2) correct—subjective data is collected in the health history or interview
(3) objective data
(4) implementation, complete assessment to determine the problem