MedSurg Neurological Disorders NCLEX Questions

MedSurg Neurological Disorders NCLEX Questions 4.5 (2 reviews) Students also studied Terms in this set (110) Science MedicineNursing Save Neurological NCLEX Questions 55 terms marissaxxcarol Preview NUR 211 Neurological Disorders NC...13 terms christa_hintonPreview Neurological disorders NCLEX 34 terms clairessister2Preview Endocr 121 terms awe Regular oral hygiene is an essential intervention for a client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene?

• Placing the client on the back with a small pillow under

the head.

• Keeping portable suctioning equipment at the bedside.
• Opening the client's mouth with a padded tongue

blade.

• Cleaning the client's mouth and teeth with a

toothbrush.A.client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration.A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?

• Prepare to administer recombinant tissue plasminogen

activator (rt-PA).

• Discuss the precipitating factors that caused the

symptoms.

• Schedule for A STAT computer tomography (CT) scan

of the head.

• Notify the speech pathologist for an emergency

consultation.C.A CT scan will determine if the client is having a stroke or has a brain tumour or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use tPA.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?

• Time of onset of current stroke
• Complete physical and history
• Current medications
• Upcoming surgical procedures

A.The time of onset of a stroke to t-PA administration is critical. Administration within

• hours has better outcomes. Tissue plasminogen activator (tPA) is classified as a

serine protease (enzymes that cleave peptide bonds in proteins). It is thus one of the essential components of the dissolution of blood clots. Its primary function includes catalyzing the conversion of plasminogen to plasmin, the primary enzyme involved in dissolving blood clots.During the first 24 hours after thrombolytic therapy for

ischemic stroke, the primary goal is to control the client's:

• Pulse
• Respirations
• Blood pressure
• Temperature

C.Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to the physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment.What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

• Cholesterol level
• Pupil size and pupillary response
• Bowel sounds
• Echocardiogram

B.It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact. Pupil size and equality is determined by a balance between parasympathetic and sympathetic innervation. Response to light reflects the combined function of the optic (II) and oculomotor (III) cranial nerves.What is the expected outcome of thrombolytic drug therapy?

• Increased vascular permeability
• Vasoconstriction
• Dissolved emboli
• Prevention of hemorrhage

C.Thrombolytic therapy is used to dissolve emboli and reestablish cerebral perfusion. Thrombolytic treatment is also known as fibrinolytic or thrombolysis, to dissolve dangerous intravascular clots to prevent ischemic damage by improving blood flow. Thrombosis is a significant physiological response that limits hemorrhage caused by large or tiny vascular injury.The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

• A thrombolytic medication
• A beta-blocker medication
• An anti-hyperuricemic medication
• An oral anticoagulant medication

D.Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be anticipated to prevent thrombus formation; and oral (warfarin [Coumadin]) at discharge versus intravenous. Oral anticoagulation is indicated for patients with atrial fibrillation or other sources of cardioembolic sources of TIA.Which client would the nurse identify as being most at risk for experiencing a CVA?

• A 39-year-old pregnant female.
• A 67-year-old Caucasian male.
• An 84-year-old Japanese female.
• A 55-year-old African American male.

D.African Americans have twice the rate of CVAs as Caucasians; males are more likely to have strokes than females except in advanced years. Of all the risk factors, hypertension is the most common modifiable risk factor for stroke.Hypertension is most prevalent in African-Americans and also occurs earlier in life.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

• A blood glucose level of 480 mg/dl.
• A right-sided carotid bruit.
• A blood pressure of 220/120 mmHg.
• The presence of bronchogenic carcinoma.

C.Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel in the cranium. Hypertension is the most common cause of hemorrhagic stroke. Long standing hypertension produces degeneration of media, breakage of the elastic lamina, and fragmentation of smooth muscles of arteries.The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?

• The assistant places a gait belt around the client's waist

prior to ambulating.

• The assistant places the client on the back with the

client's head to the side.

• The assistant places her hand under the client's right

axilla to help him/her move up in bed.

• The assistant praises the client for attempting to

perform ADLs independently.C.This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety. Avoid pulling the affected arm. Place a hand behind the scapula when moving the upper extremity instead of pulling from the arm; Utilize a lift sheet during bed repositioning. When the patient is sitting provide the arm with a firm support surface A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?

• Vomiting continues.
• Intracranial pressure (ICP) is increased.
• The client needs mechanical ventilation.
• Blood is anticipated in the cerebrospinal fluid (CSF).

B.Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favours herniation of the brain; therefore, LP is contraindicated with increased ICP.A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?

• To reduce intraocular pressure.
• To prevent acute tubular necrosis.
• To promote osmotic diuresis to decrease ICP.
• To draw water into the vascular system to increase

blood pressure.C.Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern. The mannitol causes the cells in the brain to dehydrate mildly. The water inside the brain cells (intracellular water) leaves the cells and enters the bloodstream as the mannitol draws it out of the cells and into the bloodstream. Once in the bloodstream, the extra water is whisked out of the skull. When the mannitol gets to the kidneys, the kidneys filter the mannitol into the urine.A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?

• Urine output increases.
• Pupils are 8 mm and nonreactive.
• Systolic blood pressure remains at 150 mm Hg.
• BUN and creatinine levels return to normal.

A.Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. The mannitol causes the cells in the brain to dehydrate mildly. The water inside the brain cells (intracellular water) leaves the cells and enters the bloodstream as the mannitol draws it out of the cells and into the bloodstream.Once in the bloodstream, the extra water is whisked out of the skull. When the mannitol gets to the kidneys, the kidneys filter the mannitol into the urine.

Which of the following values is considered normal for ICP?

• 0 to 15 mm Hg
• 25 mm Hg
• 35 to 45 mm Hg
• 120/80 mm Hg

A.Normal ICP is 0-15 mm Hg. Intracranial hypertension (IH) is a clinical condition that is associated with an elevation of the pressures within the cranium. The pressure in the cranial vault is measured in millimeters of mercury (mm Hg) and is normally less than 20 mm Hg.Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?

• Ataxia and confusion
• Sodium depletion
• Tonic-clonic seizure
• Urinary incontinence

A.A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia. The neurotoxic effects are concentration dependent and can range from mild nystagmus to ataxia, slurred speech, vomiting, lethargy and eventually coma and death. Paradoxically, at very high concentrations, phenytoin can lead to seizures.Which of the following signs and symptoms of increased ICP after head trauma would appear first?

• Bradycardia
• Large amounts of very dilute urine
• Restlessness and confusion
• Widened pulse pressure

C.The earliest symptom of elevated ICP is a change in mental status. Following the neurological exam closely is very important. Usually, there is an altered mental status and development of a fixed and dilated pupil. Patients presenting with findings suggestive of cerebral insult should undergo computed tomography (CT) scan of the brain; this can show the edema, which is visible as areas of low density and loss of gray/white matter differentiation, on an unenhanced image.Problems with memory and learning would relate to which of the following lobes?

• Frontal
• Occipital
• Parietal
• Temporal

D.The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The hippocampus is responsible for creating declarative memories-those that can be consciously thought of and verbalized. Declarative memory can be episodic and semantic. Episodic memory is the ability to remember a specific occasion in the past in its specific time and place. Meanwhile, semantic memory is the ability to recall general facts about the world.While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional?

• Frontal
• Occipital
• Parietal
• Temporal

C.The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects.The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?

• Sternal rub
• Pressure on the orbital rim
• Squeezing the sternocleidomastoid muscle
• Nail bed pressure

D.Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Using peripheral pain to elicit a response isn't an effective test of brain function. A response may indicate that the patient feels the stimulus, but the response is from the spinal cord. If the patient didn't respond at all to central stimuli, apply a peripheral stimulus to all four extremities to establish a baseline. If all but one of his extremities responded to a central stimulus, test only the nonresponsive extremity. Pressing on his nail plate with a pencil is an acceptable technique.