NUR 211 Neurological Disorders Exam
- A nurse would use which standardized tool as a guide in assessing a client with a
head injury and increased intracranial pressure (ICP)?
A. Snellen chart
B. Pulse oximetry graph
C. Visual Analogue Scale
D. Glasgow Coma Scale
Rationale:
GCS is a method of assessing consciousness. The Visual Analogue Scale can be used
to determine pain rating. A pulse oximetry graph would be used to document pulse ox
readings. A Snellen chart would be used to assess visual acuity. - A nurse is caring for a client with a neurological disorder is planning care to maintain
nutritional status. The nurse is concerned about the client’s swallowing ability. Which of
the following food items would the nurse plan to avoid in this client’s diet?
A. Spinach
B. Custard
C. Scrambled eggs
D. Mashed potatoes
Rationale:
Flavorful, warm, or well-chilled foods with texture stimulate the swallowing reflex. Soft
and semisoft foods, such as custards or puddings, egg dishes, and potatoes, are
usually effective Raw vegetables, chunky vegetables, such as diced beets, and stringy
vegetables, such as spinach, corn, and peas are foods commonly excluded from the
diet of a client with a poor swallowing reflex. - A client experiences an episode of Bell’s palsy and complains about increasing
clumsiness. The nurse should prepare the client for which diagnostic study(ies) to
determine the cause of the assessment findings?
A. Serum sodium level
B. Cerebral angiography
C. Lumbar puncture (LP)
D. Oculovestibular reflex
E. Electroencephalogram
F. Computed tomography
Rationale:
The most sensitive and specific tests that provide relevant diagnostic information for
these types of pathology are cerebral angiography, LP, and CT. The imaging studies
potentially illustrate central nervous system lesions and the LP enables the care
provider to analyze cerebrospinal fluid for immunoglobulins (antibodies) and other
components. Because the client’s neurological problem unlikely to be metabolic, the
sodium level is unlikely to be helpful (option A). Usually electroencephalogram and
oculovestibular reflex are tests that are reserved to evaluate electrical activity of the
brain in seizure disorders and to determine brain death (options D and E). In addition,
the oculovestibular reflex is not performed on a client who is conscious.
- A clients with Parkinson’s disease is experiencing tremors, rigidity, and bradykinesia.
The nurse anticipates that the physician will prescribe which medication to control these
symptoms?
A. Phenytoin (Dilantin)
B. Carbidopa-levodopa (Sinemet)
C. Pyridostigmine (Mestinon)
D. Warfarin (Coumadin)
Rationale:
Carbidopa-levodopa is an antiparkinsonian agent and is used to control symptoms of
Parkinson’s disease. Phenytoin is an anticonvulsant and antidysrhythmic.
Pyridostigmine is a cholinergic medication often used to treat myasthenia gravis.
Warfarin is an anticoagulant. - A client recovering from a craniotomy complains of a “runny nose”. Which of the
following nursing actions should be immediately implemented?
A. Notify the physician
B. Provide the client with soft tissues
C. Monitor the client for signs of a cold
D. Tell the client to use soft tissues to soak up the drainage
Rationale:
If the client has sustained a craniocerebral injury or is recovering from a craniotomy,
careful observation of any drainage from the eyes, ears, nose or traumatic area is
critical because this may indicate leakage of cerebrospinal fluid. Cerebrospinal fluid is
colorless and generally nonpurulent, and its presence indicates a serious breach of
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