RN NCLEX NEURO ADULT HEALTH QUESTIONS AND ANSWERS PRCATICE

RN NCLEX NEURO ADULT HEALTH QUESTIONS AND ANSWERS PRCATICE

EXAM SOLUTION

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.

The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer's disease. What instructions should the nurse include? Select all that apply

• Arrange furniture to allow for free movement
• Keep frequently used items within easy reach
• Lock doors leading to stairwells and outside areas.
• Place an identifying symbol on the bathroom door
• Provide a dark room free of shadows for sleeping - - Arrange furniture to allow for free

movement

• Keep frequently used items within easy reach
• Lock doors leading to stairwells and outside areas
• Place an identifying symbol on the bathroom door.

A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke team is initiated. The nurse takes which priority action?

• Determine onset of symptoms
• Ensure that the client has 2 large-bore intravenous IV lines
• Maintain patent airway
• Prepare for head CT scan - Maintain patent airway

A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what action first/

• Check for Kernig's and Brudzinski's signs
• Establish IV access
• Place the client on droplet precautions
• Prepare the client for lumbar puncture - Place the client on droplet precautions

The emergency department nurse receives several prescriptions for a client who was found unresponsive after drinking beer and consuming unidentified pills. Which prescription should the nurse implement first?

Exhibit: Vital signs

T: 96.4 F

BP: 90/62

HR: 53/min

RR: 6/min

O2 sat: 92%

• Administer IV push naloxone once now
• Draw specimen for blood alcohol content testing STAT
• Initiate continuous lactated ringer solution infusion
• Obtain urine sample for drug abuse screening ASAP - Administer IV push naloxone

once now.

The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? Select all that apply.

• Call for help
• Hold down the client's arms
• Insert a tongue depressor to move the tongue
• Prepare for suctioning
• Turn the client on the side. - - Call for help
• Prepare for suctioning
• Turn the client on the side.

The emergency department nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury. Which assessment finding is consistent with injury to the occipital lobe?'

• Decreased rate and depth of respirations
• Deficits in visual perception

• Expressive aphasia
• inability to recognize touch - Deficits in visual perception

A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care?Select all that apply

• Administer PRN stool softeners daily
• Administer scheduled enoxaparin injection
• Implement seizure precautions
• Keep client NPO until swallow screen is performed
• Perform frequent neurological assessments. - Administer PRN stool softeners daily
• Implement seizure precautions
• Keep client NPO until swallow screen is performed
• Perform frequent neurological assessments

The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a headache. The nurse documents the confusion and headache as which phase of the client's seizure activity?

• Aural phase
• Ictal phase
• Postictal phase
• Prodromal phase. - Postictal phase

The client comes to the emergency department status post fall. The client is squinting both eyes and reports sudden blurry vision. The nurse is aware that this deficit reflects injury to which area of the brain? - The occipital lobe receives visual images. The frontal lobe controls executive function and personality. The temporal lobe receives auditory input. The parietal lobe receives sensory input.

The occipital lobe is the most posterior lobe.

The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse?

• I will raise the head of the bed so it is easier to see the television
• I will turn down the lights when I leave
• Let me move your belongings closer so you can reach them
• You should do deep breathing and coughing exercises. - You should do deep

breathing and coughing exercises.

The nurse assesses a newly admitted adult client on a neurological inpatient unit. Which assessment findings require immediate follow-up by the nurse? Select all that apply

• Cannot flex the chin toward the chest
• Eyes move in opposite direction of head when head is turned to side