Neuro NCLEX Questions from Class 4 on exam

Neuro NCLEX Questions from Class (4 on exam) Leave the first rating Students also studied Terms in this set (48) Science MedicineNursing Save Neurological NCLEX Questions 55 terms marissaxxcarol Preview Readiness 1/23 37 terms aubreykrizkaPreview NCLEX practice questions- STROKE...21 terms samanthalohneiss Preview Neuro 34 terms kuk Your patient who had a stroke has issues with understanding speech. What type of aphasia is this patient experiencing and what area of the brain is affected?

• Expressive; Wernicke's area
• Receptive, Broca's area
• Expressive; Hippocampus
• Receptive; Wernicke's area

D The nurse is caring for a client who has been admitted to the hospital with a diagnosis of Guillain-Barre syndrome, which past medical history finding makes the client most at risk for this disease?

• Meningitis or encephalitis during the last 5 years
• Seizures or trauma to the brain within the last year
• Back injury or trauma to the spinal cord during the last
• years
• Respiratory or gastrointestinal infection during the

previous month D The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient's cerebral perfusion pressure, and how do you interpret this as the nurse?

• 90 mmHg, normal
• 62 mmHg, abnormal
• 36 mmHg, abnormal
• 56 mmHg, normal

A

Your patient has a history of epilepsy. While helping the patient to the restroom, the patient reports having this feeling of déjà vu and seeing spots in their visual field.Your next nursing action is to?

• Continue assisting the patient to the restroom and let

them sit down.

• Initiate the emergency response system.
• Lay the patient down on their side with a pillow

underneath the head.

• Assess the patient's medication history.

C A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?

• Bradycardia
• Decerebrate posturing
• Restlessness
• Unequal pupil size

C The nurse is assessing a client with a traumatic head injury and suspects increased intracranial pressure​ (IICP). Which assessment finding supports this​ suspicion? (Select all that​ apply.)

• Hemiparesis
• Blurred vision
• Double vision
• Increased heart rate
• Drowsiness

A, B, C, E

A nurse educator is teaching students about the risk for stroke. Which of the following would place the patient most at risk for hemorrhagic stroke?

• Presence of atrial fibrillation
• Use of oral contraceptives
• Blood pressure 160/100 mmHg
• Resting heart rate of 78 bpm

C A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?

• Coughing
• Sneezing
• Talking
• Valsalva maneuver
• Vomiting

A, B, D, E

The nurse is caring for the client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?

• Increasing temperature, increasing pulse, increasing

respirations, decreasing blood pressure

• Increasing temperature, decreasing pulse, decreasing

respirations, increasing blood pressure.

• Decreasing temperature, decreasing pulse, increasing

respirations, decreasing blood pressure.

• decreasing temperature, increasing pulse, decreasing

respirations, increasing blood pressure.B The nurse is assessing the client after sustaining a closed head injury. When applying nail bed pressure, the client's body suddenly stiffens, the eyes roll upward, and there is increased salvation and loss of swallowing reflexes.Which observation should the nurse document?

• Decerebrate posturing observed
• Decorticate posturing observed
• Positive Kernig's sign observed
• Tonic seizure activity observed

D You're providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority?

• Keeping the head of the bed greater than 45 degrees

at all times

• Repositioning the patient every thirty minutes
• Keeping the patient's spine immobilized
• Avoid log-rolling the patient during transport

C Which patient below with ICP is experiencing Cushing's

Triad? A patient with the following:

A. BP 150/112, HR 110, RR 8

B. BP 90/60, HR 80, RR 22

C. BP 200/60, HR 50, RR 8

D. BP 80/40, HR 49, RR 12

C Which of the following patients are at most risk for a subdural hematoma?

• A 30-year-old female with polycystic kidney disease
• A 6-year-old boy that hit his head after jumping off the

swings at the playground

• The 80-year-old male who is an alcoholic
• The 46-year-old who has hypertension and is a smoker

B

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?

• Reposition the client to avoid neck flexion
• Administer 1 g Mannitol IV as ordered
• Increase the ventilator's respiratory rate to 20

breaths/minute

• Administer 100 mg of pentobarbital IV as ordered.

A A patient's MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding?

• Vision problems
• Balance impairment
• Language difficulty
• Impaired short-term memory

B A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?

• Bladder distention
• Neurological deficit
• Pulse ox readings
• Client's feelings about the injury

C The nurse is teaching a client about the cause of a transient ischemic attack​ (TIA). Which should the nurse​ include?

• Sudden intracranial bleed
• Vascular blockage
• Brief period of a neurologic deficit
• Formation of a clot in a blood vessel

C A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?

• Assess full ROM to determine extent of injuries
• Call for an immediate chest x-ray
• Immobilize the client's head and neck
• Open the airway with the head-tilt-chin-lift maneuver

C You're providing an in-service to a group of new nurse graduates on the causes of autonomic dysreflexia. Select the most common causes you would discuss during the in-service. (SATA)

• Hypoglycemia
• Distended bladder
• Sacral pressure injury
• Fecal impaction
• Urinary tract infection

B, C, D, E