RN NCLEX Neuro adult health questions

RN NCLEX Neuro adult health questions Leave the first rating Terms in this set (81) Science MedicineNursing Save A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate?

• Document the amount of emesis
• Lower the head of the bed
• Notify the health care provider

(HCP)

• Offer anti-nausea medication.

Notify the health care provider Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a history. The unexpected vomiting is related to pressure changes in the cranium. The vomiting can be associated with headache and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg.The health care provider prescribes as-needed anti-hypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate?

• Give the antihypertensive

medication

• Monitor the blood pressure
• Notify the health care provider
• Question the prescription.

Monitor the blood pressure The nurse is assessing the cranial nerves and begins testing the facial nerve (cranial nerve VII). Which direction should the nurse give the client to test this cranial nerve?

• Close your eyes and identify this

smell

• Follow my finger with your eyes

without moving your head

• Look straight ahead and let me

know when you can see my finger

• Raise your eyebrows, smile, and

frown.Raise your eyebrows, smile, and frown

The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin.Which of the following should the nurse include in client teaching?Select all that apply

• Avoid drinking alcoholic beverages
• Do not abruptly stop taking your

phenytoin

• Go to the emergency department

every time a seizure occurs

• Wear an epilepsy medical

identification bracelet

• You may need to start using

nonhormonal birth control method.

• Avoid drinking alcoholic beverages
• Do not abruptly stop taking your phenytoin
• Wear an epilepsy medical alert bracelet
• You may need to start using a nonhormonal birth

control method.The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect? Select all that apply.

• Diarrhea
• Difficulty breathing
• Difficulty swallowing
• Muscle weakness
• Resting tremor.

Difficulty breathing Difficulty swallowing Muscle weakness

A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which interventions should the nurse perform? Select all that apply

• Administer an analgesic as needed
• Determine if there is bladder

distention

• Measure the client's blood pressure
• Place the client in the Sim's position
• Remove constrictive clothing.

Determine if there is bladder distention Measure the client's blood pressure Remove constrictive clothing A client with a history of headaches is scheduled for a lumbar puncture to assess the cerebrospinal fluid pressure. The nurse is preparing the client for the procedure. Which statement by the client indicates a need for further teaching by the nurse/

• I may feel a sharp pain that shoots

to my leg, but it should pass soon

• I will go to the bathroom and try to

urinate before the procedure

• I will need to lie on my stomach

during the procedure

• The physician will insert a needle

between the bones in my lower spine I will need to lie on my stomach during the procedure.