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Neurological Disorders NCLEX Practice | Quiz
#2: 50 Questions
UPDATED ON JUNE 18, 2023 BY MATT VERA BSN, R.N.
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1. Question
To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the nurse
should:
A. Stay with the client and encourage him to eat.
B. Help the client fill out his menu.
C. Give the client privacy during meals.
D. Fill out the menu for the client.
Incorrect
Correct Answer: A. Stay with the client and encourage him to eat.
Staying with the client and encouraging him to feed himself will ensure adequate food
intake. A client with Alzheimer’s disease can forget how to eat. Offer sweet and salt
substitutes. Helps satisfy desire for these tastes as taste buds decrease with aging
without compromising diet. Allow for interaction during mealtime to promote interest in
eating.
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Option B: During the middle stages of Alzheimer’s, distractions, too many
choices, and changes in perception, taste, and smell can make eating more
difficult. Be flexible with food preferences. It is possible the person may suddenly
develop certain food preferences or reject foods he or she may have liked in the
past.
Option C: Eat together. Give the person the opportunity to eat with others.
Keeping mealtimes social can encourage the person to eat. Limit distractions.
Serve meals in quiet surroundings, away from the television and other
distractions.
Option D: Offer one food item at a time. The person may be unable to decide
among the foods on his or her plate. Serve only one or two items at a time. For
example, serve mashed potatoes followed by the main entree.
2. Question
The nurse is performing a mental status examination on a male client diagnosed with a subdural
hematoma. This test assesses which of the following?
A. Cerebellar function
B. Intellectual function
C. Cerebral function
D. Sensory function
Incorrect
Correct Answer: C. Cerebral function
The mental status examination assesses functions governed by the cerebrum. Some of
these are orientation, attention span, judgment, and abstract reasoning. Cerebrum is the
largest part of the brain and is composed of right and left hemispheres. It performs
higher functions like interpreting touch, vision, and hearing, as well as speech, reasoning,
emotions, learning, and fine control of movement.
Option A: Cerebellar function testing assesses coordination, equilibrium, and fine
motor movement. Cerebellum is located under the cerebrum. Its function is to
coordinate muscle movements, maintain posture, and balance.
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Option B: Intellectual functioning isn’t the only cerebral activity. When assessing
intelligence to make decisions about individuals, attention has been paid almost
exclusively to general intelligence, as reflected in a composite intelligence
quotient, or IQ. That is, a single number, embodied in the IQ, is used to portray an
individual’s mental ability.
Option D: Sensory function testing involves assessment of pain, light-touch
sensation, and temperature discrimination. Assessment of sensory function helps
to identify the different pathways for light touch, proprioception, vibration, and
pain. Use a pinprick to evaluate pain sensation.
3. Question
Shortly after admission to an acute care facility, a male client with a seizure disorder develops
status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the
nurse administer the second dose of diazepam, if needed and prescribed?
A. In 30 to 45 seconds
B. In 10 to 15 minutes
C. In 30 to 45 minutes
D. In 1 to 2 hours
Incorrect
Correct Answer: B. In 10 to 15 minutes
When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as
needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours,
if necessary, but the total dose shouldn’t exceed 100 mg in 24 hours. It is crucial to
monitor respiratory and cardiovascular status, blood pressure, heart rate, and symptoms
of anxiety in patients taking diazepam.
Option A: The nurse must not administer I.V. diazepam faster than 5 mg/minute.
Therefore, the dose can’t be repeated in 30 to 45 seconds because the first dose
wouldn’t have been administered completely by that time. 0.15 to 0.20 mg/kg IV
per dose, and may be repeated once if needed. Do not exceed 10 mg per single
dose. Rectal administration of 0.2 to 0.5 mg/kg administered one time. Do not
exceed 20 mg per dose.
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Option C: Waiting longer than 15 minutes to repeat the dose would increase the
client’s risk of complications associated with status epilepticus. When
administered intravenously, diazepam actS within 1 to 3 minutes, while oral
dosing onset ranges between 15 to 60 minutes. Diazepam is long-lasting with a
duration of action of more than 12 hours.
Option D: Diazepam is a fast-acting potent anxiolytic popular in use due to its
broad therapeutic index, low toxicity, and improved safety profile. Nonetheless,
diazepam is still a drug with high potential for use disorder associated with severe
adverse/toxic effects.
4. Question
A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her
right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a
condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic
regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the
right eye twice daily. Atropine sulfate belongs to which drug classification?
A. Parasympathomimetic agent
B. Sympatholytic agent
C. Adrenergic blocker
D. Cholinergic blocker
Incorrect
Correct Answer: D. Cholinergic blocker
Atropine sulfate is a cholinergic blocker. It isn’t a parasympathomimetic agent, a
sympatholytic agent, or an adrenergic blocker. Atropine is an antimuscarinic that works
through competitive inhibition of postganglionic acetylcholine receptors and direct
vagolytic action, which leads to parasympathetic inhibition of the acetylcholine receptors
in smooth muscle.
Option A: Parasympathomimetics are a class of pharmacological agents that
activate the parasympathetic division of the autonomic nervous system. These
drugs work by mimicking or modifying the effects of acetylcholine (ACh), the
primary neurotransmitter of the parasympathetic nervous system.
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Parasympathomimetic medications are classified into two main categories based
on whether they are direct agonists or indirect agonists of ACh.
Option B: Methyldopa is a centrally acting sympatholytic agent used in the
treatment of hypertension. Alpha-methyldopa is converted to methyl
norepinephrine centrally to decrease the adrenergic outflow by alpha-2 agonist
action from the central nervous system, leading to reduced total peripheral
resistance and decreased systemic blood pressure.
Option C: The effects of the sympathetic nervous system can be blocked either
by decreasing sympathetic outflow from the brain, suppressing release of
norepinephrine from terminals, or by blocking postsynaptic receptors. Adrenergic
antagonists reduce the effectiveness of sympathetic nerve stimulation and the
effects of exogenously applied agonists, such as isoproterenol. Most often the
receptor antagonists are divided into ?-receptor antagonists and ?-receptor
antagonists.
5. Question
Emergency medical technicians transport a 27-year-old ironworker to the emergency
department. They tell the nurse, “He fell from a two-story building. He has a large contusion on
his left chest and a hematoma in the left parietal area. He has a compound fracture of his left
femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation
of 92% by pulse oximeter with a manual resuscitation bag.” Which intervention by the nurse has
the highest priority?
A. Assessing the left leg.
B. Assessing the pupils.
C. Placing the client in Trendelenburg’s position.
D. Assessing level of consciousness.
Incorrect
Correct Answer: A. Assessing the left leg.
In the scenario, airway and breathing are established so the nurse’s next priority should
be circulation. With a compound fracture of the femur, there is a high risk of profuse
bleeding; therefore, the nurse should assess the site. Monitor vital signs. Note signs of
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general pallor, cyanosis, cool skin, changes in mentation. Inadequate circulating volume
compromises systemic tissue perfusion.
Option B: Test sensation of peroneal nerve by pinch or pinprick in the dorsal web
between the first and second toe, and assess the ability to dorsiflex toes if
indicated. Length and position of peroneal nerve increase risk of its injury in the
presence of leg fracture, edema or compartment syndrome, or malposition of
traction apparatus.
Option C: The nurse doesn’t have enough data to warrant putting the client in
Trendelenburg’s position. Handle injured tissues and bones gently, especially
during the first several days. This may prevent the development of fat emboli
(usually seen in the first 12–72 hr), which are closely associated with fractures,
especially of the long bones and pelvis.
Option D: Neurologic assessment is a secondary concern to airway, breathing,
and circulation. Perform neurovascular assessments, noting changes in motor and
sensory function. Ask the patient to localize pain and discomfort. Impaired
feeling, numbness, tingling, increased or diffuse pain occurs when circulation to
nerves is inadequate or nerves are damaged.
6. Question
An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his
eyes with water for 20 minutes, and then take him to the emergency department of a nearby
hospital, where he receives emergency care for the corneal injury. The physician prescribes
dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled
initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin
Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours.
Dexamethasone exerts its therapeutic effect by:
A. Increasing the exudative reaction of ocular tissue.
B. Decreasing leukocyte infiltration at the site of ocular inflammation.
C. Inhibiting the action of carbonic anhydrase.
D. Producing a miotic reaction by stimulating and contracting the sphincter muscles
of the iris.
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Incorrect
Correct Answer: B. Decreasing leukocyte infiltration at the site of ocular
inflammation.
Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the
site of ocular inflammation. This reduces the exudative reaction of diseased tissue,
lessening edema, redness, and scarring. Dexamethasone is a widely prescribed drug by
many healthcare professionals, including the nurse practitioner. However, it is essential
to know that this potent steroid has many adverse effects, and patient monitoring is
critical.
Option A: Dexamethasone is a potent glucocorticoid with very little, if any,
mineralocorticoid activity. Dexamethasone’s effect on the body occurs in a variety
of ways. It works by suppressing the migration of neutrophils and decreasing
lymphocyte colony proliferation. The capillary membrane becomes less
permeable, as well. Lysosomal membranes have increased stability.
Option C: There are higher concentrations of vitamin A compounds in the serum,
and prostaglandin, and some cytokines (interleukin-1, interleukin-12, interleukin18, tumor necrosis factor, interferon-gamma, and granulocyte-macrophage
colony-stimulating factor) become inhibited.
Option D: Dexamethasone and other anti-inflammatory agents don’t produce
any type of miotic reaction. In the treatment of inflammation, it is advisable to
start with low doses of 0.75 mg/day, which may titrate to 9 mg/day, with dosing
divided into 2 to 4 doses throughout the day. This applies to intravenous,
intramuscular, and oral administrations. Less may be used when directly
administered to the lesion or tissue with dosing ranging from 0.2 to 6 mg per day.
7. Question
Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago.
Which of the following findings should the nurse consider abnormal?
A. More back pain than the first postoperative day.
B. Paresthesia in the dermatomes near the wounds.
C. Urine retention or incontinence.
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D. Temperature of 99.2° F (37.3° C).
Incorrect
Correct Answer: C. Urine retention or incontinence.
Urine retention or incontinence may indicate cauda equina syndrome, which requires
immediate surgery. Cauda equina syndrome (CES) results from compression and
disruption of the function of these nerves and can be inclusive of the conus medullaris or
distal to it, and most often occurs when damage occurs to the L3-L5 nerve roots.
Option A: An increase in pain on the second postoperative day is common
because the long-acting local anesthetic, which may have been injected during
surgery, will wear off. The role of the nurse in the postoperative period should
include finite management of intravenous fluids, foley catheter care until
ambulating, administering antibiotics, pain control, wound/dressing care,
encouraging patient ambulation, and advance diet when appropriate.
Option B: While paresthesia is common after surgery, progressive weakness or
paralysis may indicate spinal nerve compression. Related-technique complications
are associated with the underlying structures covered by the laminae, being the
dural sac tear and nerve roots injury the most common. These complications
occur more often in elderly patients due to the fragility of the dural sac. Also, the
severity of compression could be a factor that increases the rate of a dural tear;
the most common risk factor for dural tear is the reoperation due to the presence
of scar tissue.
Option D: A mild fever is also common after surgery but is considered significant
only if it reaches 101° F (38.3° C). Postoperative wound infection and wound
dehiscence are other complications to consider, the presence of wound erythema,
increased pain, or swelling may raise the suspicion of wound infection.
8. Question
After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician
prescribes Pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this
prescription, the nurse should teach the client or a family member to administer the drug by:
A. Instilling one drop of pilocarpine 0.25% into both eyes daily.
B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily.
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C. Instilling one drop of pilocarpine 0.25% into the right eye daily.
D. Instilling one drop of pilocarpine 0.25% into the left eye four times daily.
Incorrect
Correct Answer: B. Instilling one drop of pilocarpine 0.25% into both eyes four
times daily.
The abbreviation “gtt” stands for drop, “i” is the apothecary symbol for the number 1,
OU signifies both eyes, and “q.i.d.” means four times a day. Therefore, one drop of
pilocarpine 0.25% should be instilled into both eyes four times daily. Pilocarpine is a
muscarinic acetylcholine agonist that is effective in the treatment and management of
acute angle-closure glaucoma and radiation-induced xerostomia. Although not a firstline treatment for glaucoma, it is useful as an adjunct medication in the form of
ophthalmic drops.
Option A: Pilocarpine is approved for use as an agent to decrease IOP in cases of
glaucoma, as well as in the management of xerostomia resulting from radiation
exposure and Sjogren disease. Its mechanism of action includes both full and
partial agonism of the muscarinic M3 receptor, which is an acetylcholine receptor.
It is important to note that pilocarpine may have effects on the M1-M3 receptor
subtypes, which causes parasympathetic side effects later discussed in this paper.
The M3 receptor is an excitatory receptor expressed in gastric glands, salivary
glands, and smooth muscle cells, such as those present in the pupillary sphincter
and ciliary bodies.
Option C: By stimulating the Gq receptor, the M3 receptor can activate
phospholipase C. This leads to the creation of the second messenger’s inositol
trisphosphate and diacylglycerol, as well as calcium and protein kinase. M3
cholinergic agonists, therefore, result in the upregulation of calcium, and
ultimately smooth muscle contraction such as in the pupillary sphincter muscle.
Option D: When used as a miotic agent, pilocarpine is available in the form of
ophthalmologic eye drops. This dose form will result in ciliary contraction (a
contraction of the iris), which will increase aqueous humor outflow, miosis, and
accommodation. The ciliary body connects to the zonular fibers that control the
accommodation of the lens. Contraction of the ciliary body will relax the zonular
fibers, which results in a more spherical shape of the lens and therefore allowing
aqueous outflow to occur. This conformational change is helpful to decrease
intraocular pressure in glaucoma.
9. Question
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A female client who’s paralyzed on the left side has been receiving physical therapy and
attending teaching sessions about safety. Which behavior indicates that the client accurately
understands safety measures related to paralysis?
A. The client leaves the side rails down.
B. The client uses a mirror to inspect the skin.
C. The client repositions only after being reminded to do so.
D. The client hangs the left arm over the side of the wheelchair.
Incorrect
Correct Answer: B. The client uses a mirror to inspect the skin.
Using a mirror enables the client to inspect all areas of the skin for signs of breakdown
without the help of staff or family members. Inspect skin daily. Observe for pressure
areas, and provide meticulous skincare. Teach the patient to inspect skin surfaces and to
use a mirror to look at hard-to-see-areas. Altered circulation, loss of sensation, and
paralysis potentiate pressure sore formation. This is a lifelong consideration.
Option A: The client should keep the side rails up to help with repositioning and
to prevent falls. Perform and assist with full ROM exercises on all extremities and
joints, using slow, smooth movements. Hyperextend hips periodically. Enhances
circulation, restores and maintains muscle tone and joint mobility, and prevents
disuse contractures and muscle atrophy.
Option C: The paralyzed client should take responsibility for repositioning or for
reminding the staff to assist with it if needed. Reposition periodically even when
sitting in a chair. Teach the patient how to use weight-shifting techniques.
Reduces pressure areas, promotes peripheral circulation.
Option D: A client with left-side paralysis may not realize that the left arm is
hanging over the side of the wheelchair. However, the nurse should call this to the
client’s attention because the arm can get caught in the wheel spokes or develop
impaired circulation from being in a dependent position for too long.
10. Question
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A male client in the emergency department has a suspected neurologic disorder. To assess gait,
the nurse asks the client to take a few steps; with each step, the client’s feet make a half-circle.
To document the client’s gait, the nurse should use which term?
A. Ataxic
B. Dystrophic
C. Helicopod
D. Steppage
Incorrect
Correct Answer: C. Helicopod
A helicopod gait is an abnormal gait in which the client’s feet make a half circle with
each step. A gait seen in some conversion reactions or hysteric disorders, in which the
feet describe half circles.
Option A: An ataxic gait is staggering and unsteady. Most commonly seen in
cerebellar disease, this gait is described as clumsy, staggering movements with a
wide-based gait. While standing still, the patient’s body may swagger back and
forth and from side to side, known as titubation. Patients will not be able to walk
from heel to toe or in a straight line.
Option B: In a dystrophic gait, the client waddles with the legs far apart.
Movement of the trunk is exaggerated to produce a waddling, duck-like walk.
Progressive muscular dystrophy or hip dislocation present from birth can produce
a waddling gait.
Option D: In a steppage gait, the feet, and toes raise high off the floor and the
heel comes down heavily with each step. Seen in patients with foot drop
(weakness of foot dorsiflexion), the cause of this gait is due to an attempt to lift
the leg high enough during walking so that the foot does not drag on the floor.
11. Question
A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best
choice for this client?
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A. A private room down the hall from the nurses’ station.
B. An isolation room three doors from the nurses’ station.
C. A semi-private room with a 32-year-old client who has viral meningitis.
D. A two-bedroom with a client who previously had bacterial meningitis.
Incorrect
Correct Answer: B. An isolation room three doors from the nurses’ station
A client with bacterial meningitis should be kept in isolation for at least 24 hours after
admission. Patients suspected of having meningococcal meningitis should be placed in
droplet precautions until they have received 24 hours of antibiotics. Close contacts
should also be treated prophylactically. Ciprofloxacin, rifampin, or ceftriaxone may be
used. Close contacts are defined as people within 3 feet of the patient for more than 8
hours during the seven days before and 24 hours after receiving antibiotics. People
exposed to the patient’s oral secretions during this time should also be treated.
Option A: During the initial acute phase, should be as close to the nurses’ station
as possible to allow maximal observation. The mortality for bacterial meningitis
varies from 10-15%. Survival depends on early recognition of acute bacterial
meningitis, followed by administration of appropriate antibiotic therapy. Delay in
treatment can result in increased intracranial pressure causing decreased cerebral
perfusion and may rapidly lead to loss of consciousness and death.
Option C: Placing the client in a room with a client who has viral meningitis may
cause harm to both clients because the organisms causing viral and bacterial
meningitis differ; either client may contract the other’s disease. These patients
need inpatient treatment until all symptoms have disappeared, therefore the
nursing staff will be responsible for administration as well as monitoring for
therapeutic effectiveness and adverse drug events, reporting any concerns to the
team.
Option D: Immunity to Bacterial meningitis can’t be acquired; therefore, a client
who previously had bacterial meningitis shouldn’t be put at risk by rooming with
a client who has just been diagnosed with this disease. Vaccines are available to
help prevent bacterial meningitis. Children can get a meningitis vaccine around
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ages 11 to 12, followed by a booster vaccine at age 16. Bacterial meningitis is
more common in infants under 1 year of age and young people ages 16 to 21.
12. Question
A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon),
60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews
the client’s history. Which preexisting condition would contraindicate the use of
pyridostigmine?
A. Ulcerative colitis
B. Blood dyscrasia
C. Intestinal obstruction
D. Spinal cord injury
Incorrect
Correct Answer: C. Intestinal obstruction
Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a
mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to
anticholinesterase agents. Pyridostigmine bromide is preferred over neostigmine
because of its longer duration of action. In those with bromide intolerance that leads to
gastrointestinal effects, ambenonium chloride can be used. Patients with MuSK MG
respond poorly to these drugs and hence may require higher doses.
Option A: Ulcerative colitis is not a contraindication to pyridostigmine. The
mainstay of treatment in MG involves cholinesterase enzyme inhibitors and
immunosuppressive agents. Symptoms that are resistant to primary treatment
modalities or those requiring rapid resolution of symptoms (myasthenic crisis),
plasmapheresis, or intravenous immunoglobulins can be used.
Option B: Blood dyscrasia is not a contraindication to pyridostigmine. Agricultural
employees who handle organophosphates for a prolonged period should have
medical monitoring. Appropriate testing is recommended to identify
overexposure before the occurrence of clinical illness. Both serum and RBC
cholinesterase must be determined.
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Option D: The contraction of the smooth muscle in various organs of the body
gets mediated through M3 receptors. Tone and peristalsis in the gastrointestinal
tract increase and sphincters relax, causing abdominal cramps and evacuation of
the bowel. The detrusor muscle contracts while the bladder trigone and sphincter
relax, leading to the voiding of the bladder.
13. Question
A female client is admitted to the facility for investigation of balance and coordination
problems, including possible Ménière’s disease. When assessing this client, the nurse expects to
note:
A. Vertigo, tinnitus, and hearing loss.
B. Vertigo, vomiting, and nystagmus.
C. Vertigo, pain, and hearing impairment.
D. Vertigo, blurred vision, and fever.
Incorrect
Correct Answer: A. Vertigo, tinnitus, and hearing loss.
Ménière’s disease, an inner ear disease, is characterized by the symptom triad of vertigo,
tinnitus, and hearing loss. The combination of vertigo, vomiting, and nystagmus
suggests labyrinthitis. Ménière’s disease rarely causes pain, blurred vision, or fever.
Meniere disease is a disorder of the inner ear characterized by hearing loss, tinnitus, and
vertigo. In most cases, it is slowly progressive and has a significant impact on the social
functioning of the individual affected.
Option B: Patients with a definite Meniere disease according to the Barany
Society have two or more spontaneous episodes of vertigo with each lasting 20
minutes to 12 hours; audiometrically documented low- to medium- frequency
sensorineural hearing loss in one ear, defining and locating to the affected ear on
in at least one instance prior, during or after one of the episodes of vertigo;
fluctuating aural symptoms (fullness, hearing, tinnitus) located in the affected ear;
and not better accounted for by any other vestibular diagnosis.
Option C: Probable Meniere disease can include the following clinical findings:
two or more episodes of dizziness or vertigo, each lasting 20 minutes to 24 hours;
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fluctuating aural symptoms (fullness, hearing, or tinnitus) in the affected ear; and
the condition is better explained by another vestibular diagnosis.
Option D: At the emergency room or in the general practice the physician will
differentiate between vertigo of central, peripheral, and cardiovascular cause. Red
flags for a central origin of vertigo, according to Harcourt et al., are neurological
symptoms or signs, acute deafness, new type or onset of headache, or
vertical/torsional/rotatory nystagmus.
14. Question
A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval
window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a
prosthesis. After the stapedectomy, the nurse should provide which client instruction?
A. “Lie in bed with your head elevated, and refrain from blowing your nose for 24
hours.”
B. “Try to ambulate independently after about 24 hours.”
C. “Shampoo your hair every day for ten (10) days to help prevent ear infection.”
D. “Don’t fly in an airplane, climb to high altitudes, make sudden movements, or
expose yourself to loud sounds for 30 days.”
Incorrect
Correct Answer: D. “Don’t fly in an airplane, climb to high altitudes, make sudden
movements, or expose yourself to loud sounds for 30 days.”
For 30 days after a stapedectomy, the client should avoid air travel, sudden movements
that may cause trauma, and exposure to loud sounds and pressure changes (such as
from high altitudes). The goal of any stapes procedure is to restore the vibration of fluids
within the cochlea; increasing communication secondary to increasing sound
amplification, bringing hearing levels to acceptable thresholds.
Option A: Immediately after surgery, the client should lie flat with the surgical ear
facing upward; nose blowing is permitted but should be done gently and on one
side at a time. The primary goal when operating on the stapes is to re-establish
sound transmission through an ossicular chain that has likely been stiffened
through the disease process known as otosclerosis. Otosclerosis, an otic capsule
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disease that involves absorption of compact bone and the redeposition of
spongy-appearing, or spongiotic, bone, is the most common cause of acquired
conductive hearing loss (CHL) as a result of stapes fixation.
Option B: The client’s first attempt at postoperative ambulation should be
supervised to prevent falls caused by vertigo and light-headedness. Skilled postanesthesia care unit nurses are invaluable in the immediate postoperative period,
as stapedectomy patients may experience pain, vertigo with nausea and vomiting
(the latter posing a risk to prosthesis dislodgement), and facial nerve weakness.
These nurses play a crucial role in notifying the surgeon of any early-onset
complications associated with the procedure.
Option C: The client must avoid shampooing and swimming to keep the dressing
and the ear dry. A terrible complication of stapes surgery is the formation of
reactive granulation tissue in and around the oval window. There are many ideas
on what causes such a reaction, but it is believed that the use of powderless
gloves, the avoidance of Gelfoam, or washing the prosthesis before introducing it
into the middle ear space has reduced granulomatous formations,
postoperatively.
15. Question
Nurse Marty is monitoring a client for adverse reactions to dantrolene (Dantrium). Which
adverse reaction is most common?
A. Excessive tearing
B. Urine retention
C. Muscle weakness
D. Slurred speech
Incorrect
Correct Answer: C. Muscle weakness
The most common adverse reaction to dantrolene is muscle weakness. The drug also
may depress liver function or cause idiosyncratic hepatitis. The intravenous
administration of dantrolene in healthy volunteers has resulted in skeletal muscle
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weakness, dyspnea, respiratory muscle weakness, and decreased inspiratory capacity.
These are expected symptoms given the mechanism of action of the medication.
Option A: For those taking the oral capsule for muscle spasticity, liver function
tests require monitoring, and dantrolene discontinued if signs and symptoms of
liver injury appear. These include elevated LFTs, jaundice, right upper quadrant
pain, etc. These symptoms typically resolve upon the discontinuation of
dantrolene. If dantrolene is to be reinstated, per recommendations, the patient
should be inpatient, and the drug initiated in very small doses with gradual
increases.
Option B: Although urine retention is an adverse reaction associated with
dantrolene use; they aren’t as common as muscle weakness. When using the
lyophilized form of dantrolene, large volumes of sterile water are administered
with the medication. Although mannitol is included with the dantrolene,
monitoring fluid status and output is paramount to the ongoing care of
resuscitation of these patients.
Option D: Muscle weakness is rarely severe enough to cause slurring of speech,
drooling, and enuresis. Oral dantrolene carries a black box warning for the
potential for hepatotoxicity, including overt hepatitis. Hepatic function should be
evaluated before the administration of the oral capsule form and require
monitoring throughout the course of treatment. The medication should stop
immediately if liver function becomes impaired.
16. Question
The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care)
eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which
adverse reaction?
A. Tachycardia
B. Increased salivation
C. Hypotension
D. Apnea
Incorrect
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Correct Answer: A. Tachycardia
Systemic absorption of atropine sulfate can cause tachycardia, palpitations, flushing, dry
skin, ataxia, and confusion. To minimize systemic absorption, the client should apply
digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling
the drops. Tachycardia is the most common side effect; titrate dose to effect when
treating bradyarrhythmia in patients with coronary artery disease. Atropine may
precipitate acute angle glaucoma, pyloric obstruction, urinary retention due to benign
prostatic hyperplasia, or viscid plugs in patients with chronic lung diseases.
Option B: The drug also may cause dry mouth. The most common adverse effects
are related to the drug’s antimuscarinic properties, including xerostomia, blurred
vision, photophobia, tachycardia, flushing, and hot skin. Constipation, difficulty
with urination, and anhidrosis can occur, especially in at-risk populations (most
notably, the elderly).
Option C: Atropine is an antimuscarinic that works through competitive inhibition
of postganglionic acetylcholine receptors and direct vagolytic action, which leads
to parasympathetic inhibition of the acetylcholine receptors in smooth muscle.
The end effect of increased parasympathetic inhibition allows for preexisting
sympathetic stimulation to predominate, creating increased cardiac output and
other associated antimuscarinic side effects as described herein.
Option D: It isn’t known to cause apnea. Overdose can lead to increased
antimuscarinic side effects presenting with dilated pupils, warm, dry skin,
tachycardia, tremor, ataxia, delirium, and coma. In extreme toxicity, circulatory
collapse secondary to respiratory failure may occur after paralysis and coma. Ten
milligrams or less may be fatal to a child, while there is no known adult lethal
dose.
17. Question
A male client is admitted with a cervical spine injury sustained during a diving accident. When
planning this client’s care, the nurse should assign the highest priority to which nursing
diagnosis?
A. Impaired physical mobility
B. Ineffective breathing pattern
C. Disturbed sensory perception (tactile)
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D. Self-care deficit: Dressing/grooming
Incorrect
Correct Answer: B. Ineffective breathing pattern
Because a cervical spine injury can cause respiratory distress, the nurse should take
immediate action to maintain a patent airway and provide adequate oxygenation.
Maintain patent airway: keep head in neutral position, elevate head of bed slightly if
tolerated, use airway adjuncts as indicated. Patients with high cervical injury and
impaired gag and cough reflexes require assistance in preventing aspiration and
maintaining patient airway.
Option A: Continually assess motor function (as spinal shock or edema resolves)
by requesting the patient to perform certain actions such as shrug shoulders,
spread fingers, squeeze, release examiner’s hands. Evaluates status of individual
situation (motor-sensory impairment may be mixed or not clear) for a specific
level of injury, affecting type and choice of interventions.
Option C: Assess and document sensory function or deficit (by means of touch,
pinprick, hot or cold, etc.), progressing from an area of deficit to a neurologically
intact area. Changes may not occur during acute phase, but as spinal shock
resolves, changes should be documented by dermatome charts or anatomical
landmarks (“2 in above nipple line”). Provide tactile stimulation, touching the
patient in intact sensory areas (shoulders, face, head).
Option D: The other options may be appropriate for a client with a spinal cord
injury — particularly during the course of recovery — but don’t take precedence
over a diagnosis of ineffective breathing pattern. Plan activities to provide
uninterrupted rest periods. Encourage involvement within individual tolerance
and ability. Prevents fatigue, allowing opportunity for maximal efforts and
participation by patient.
18. Question
A male client has a history of painful, continuous muscle spasms. He has taken several skeletal
muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), two (2)
mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, Diazepam also is
recommended for:
A. Long-term treatment of epilepsy.
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B. Postoperative pain management of laminectomy clients.
C. Postoperative pain management of diskectomy clients.
D. Treatment of spasticity associated with spinal cord lesions.
Incorrect
Correct Answer: D. Treatment of spasticity associated with spinal cord lesions.
In addition to relieving painful muscle spasms, Diazepam also is recommended for
treatment of spasticity associated with spinal cord lesions. Diazepam’s use is limited by
its central nervous system effects and the tolerance that develops with prolonged use. It
is a fast-acting, long-lasting benzodiazepine commonly used in the treatment of anxiety
disorders, as well as alcohol detoxification, acute recurrent seizures, severe muscle
spasm, and spasticity associated with neurologic disorders.
Option A: The parenteral form of diazepam can treat status epilepticus, but the
drug’s sedating properties make it an unsuitable choice for long-term
management of epilepsy. Diazepam HAs FDA approval for the management of
anxiety disorders, short-term relief of anxiety symptoms, spasticity associated with
upper motor neuron disorders, adjunct therapy for muscle spasms, preoperative
anxiety relief, management of certain refractory epilepsy patients and adjunct in
severe recurrent convulsive seizures, and an adjunct in status epilepticus.
Option B: Diazepam is not used for pain management. Specifically, the allosteric
binding within the limbic system leads to the anxiolytic effects seen with
diazepam. Allosteric binding within the spinal cord and motor neurons is the
primary mediator of the myorelaxant effects seen with diazepam. Mediation of
the sedative, amnestic, and anticonvulsant effects of diazepam is through
receptor binding within the cortex, thalamus, and cerebellum.
Option C: Diazepam isn’t an analgesic agent. Benzodiazepines have largely
replaced barbiturates in the treatment of anxiety and sleep disorders because of
their improved safety profile, fewer side effects, and the availability of the
antagonist flumazenil to reverse oversedation and benzodiazepine intoxication.
19. Question
A female client who was found unconscious at home is brought to the hospital by a rescue
squad. In the intensive care unit, the nurse checks the client’s oculocephalic (doll’s eye)
response by:
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A. Introducing ice water into the external auditory canal.
B. Touching the cornea with a wisp of cotton.
C. Turning the client’s head suddenly while holding the eyelids open.
D. Shining a bright light into the pupil.
Incorrect
Correct Answer: C. Turning the client’s head suddenly while holding the eyelids
open.
To elicit the oculocephalic response, which detects cranial nerve compression, the nurse
turns the client’s head suddenly while holding the eyelids open. Normally, the eyes move
from side to side when the head is turned; in an abnormal response, the eyes remain
fixed. The oculocephalic reflex (doll’s eyes reflex) is an application of the vestibularocular reflex (VOR) used for neurologic examination of cranial nerves 3, 6, and 8, the
reflex arc including brainstem nuclei, and overall gross brainstem function.
Option A: The nurse introduces ice water into the external auditory canal when
testing the oculovestibular response; normally, the client’s eyes deviate to the side
of ice water introduction. Vestibulo–ocular reflex is an involuntary reflex that
stabilizes the visual field and retinal image during head motion by producing eye
movements in a counter direction.
Option B: The nurse touches the client’s cornea with a wisp of cotton to elicit the
corneal reflex response, which reveals brain stem function; blinking is the normal
response. The corneal blink reflex is caused by a loop between the trigeminal
sensory nerves and the facial motor (VII) nerve innervation of the orbicularis oculi
muscles. The reflex activates when sensory stimulus contacts either free nerve
endings or mechanoreceptors within the epithelium of the cornea.
Option D: Shining a bright light into the client’s pupil helps evaluate brain stem
and cranial nerve III functions; normally, the pupil responds by constricting. The
oculomotor nerve helps to adjust and coordinate eye position during movement.
Several movements assist with this process: saccades, smooth pursuit, fixation,
accommodation, vestibulo-ocular reflex, and optokinetic reflex.
20. Question
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While reviewing a client’s chart, the nurse notices that the female client has myasthenia gravis.
Which of the following statements about neuromuscular blocking agents is true for a client with
this condition?
A. The client may be less sensitive to the effects of a neuromuscular blocking agent.
B. Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage.
C. Pancuronium shouldn’t be used; succinylcholine may be used in a lower dosage.
D. Pancuronium and succinylcholine both require cautious administration.
Incorrect
Correct Answer: D. Pancuronium and succinylcholine both require cautious
administration.
The nurse must cautiously administer pancuronium, succinylcholine, and any other
neuromuscular blocking agent to a client with myasthenia gravis. Patients on NMDA are
usually in the intensive care unit. Monitoring of patients on NMDA includes pulse
oximetry for oxygen saturation, continuous end-tidal C02. The rise in the level of carbon
dioxide might show the development of malignant hyperthermia.
Option A: Such a client isn’t less sensitive to the effects of a neuromuscular
blocking agent. Succinylcholine administration correlates to a significant rise in
the serum potassium. Therefore, it is recommended to avoid use of
succinylcholine in patients with chronic renal disease, burn patients, patients with
crush injuries, and rhabdomyolysis. Elevated potassium level can lead to fatal
arrhythmia.
Option B: Succinylcholine is also associated with bradycardia especially in the
pediatric population. The stimulation of the nicotinic receptor activates a
muscarinic receptor that produces bradycardia. The effect can be blunted by
administering atropine or glycopyrrolate.
Option C: Either succinylcholine or pancuronium can be administered in the usual
adult dosage to a client with myasthenia gravis. When an electric impulse
transmits along the motor neuron, it causes the release of acetylcholine (ACh)
from the presynaptic membrane which travels across the synaptic cleft and acts
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on the nicotinic receptors on the postsynaptic membrane, causing muscle
contraction.
21. Question
A male client is color blind. The nurse understands that this client has a problem with:
A. Rods.
B. Cones.
C. Lens.
D. Aqueous humor.
Incorrect
Correct Answer: B. Cones.
Cones provide daylight color vision, and their stimulation is interpreted as color. If one
or more types of cones are absent or defective, color blindness occurs. Very few
individuals are truly color blind, but instead, see a disrupted range of colors. The most
common forms are protanopia and deuteranopia, conditions arising from loss of
function of one of the cones, leading to dichromic vision.
Option A: Rods are sensitive to low levels of illumination but can’t discriminate
color. Rods are the cells primarily responsible for scotopic vision, or low-light
vision. Rods are the more abundant cell-type of the retina and reach their
maximum density approximately 15 to 20 degrees from the fovea, a small
depression in the retina of the eye where visual acuity is highest. There are
approximately 90 million rod cells in the human retina.
Option C: The lens is responsible for focusing images. The lens is the adjustable
component of the refractive system: its shape is altered by the contraction or
relaxation of the ciliary muscle to focus on objects that are near or far.
Option D: Aqueous humor is a clear watery fluid and isn’t involved in color
perception. Aqueous humor is a low viscosity fluid secreted from plasma
components by the ciliary body into the posterior chamber of the eye. The humor
then travels to the anterior chamber and proceeds to drain into the systemic
cardiovascular circulation by an incompletely understood mechanism. Aqueous
humor circulation forms the basis of intraocular pressure (IOP), which is
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associated with glaucoma; this is how the synthesis, circulation, and drainage of
aqueous humor become clinically significant.
22. Question
A female client who was trapped inside a car for hours after a head-on collision is rushed to the
emergency department with multiple injuries. During the neurologic examination, the client
responds to painful stimuli with decerebrate posturing. This finding indicates damage to which
part of the brain?
A. Diencephalon
B. Medulla
C. Midbrain
D. Cortex
Incorrect
Correct Answer: C. Midbrain
Decerebrate posturing, characterized by abnormal extension in response to painful
stimuli, indicates damage to the midbrain. Decerebrate posturing can be seen in patients
with large bilateral forebrain lesions with progression caudally into the diencephalon and
midbrain. It can also be caused by a posterior fossa lesion compressing the midbrain or
rostral pons.
Option A: Extensive lesions involving the forebrain, diencephalon, or rostral
midbrain are known to cause decorticate posturing. This includes the motor
cortex, premotor cortex, corona radiata, internal capsule, and thalamus.
Decorticate posturing is described as abnormal flexion of the arms with the
extension of the legs. Specifically, it involves slow flexion of the elbow, wrist, and
fingers with adduction and internal rotation at the shoulder. The lower limbs show
extension and internal rotation at the hip, with the extension of the knee and
plantar flexion of the feet. Toes are typically abducted and hyperextended.
Option B: Damage to the medulla results in flaccidity. Small changes or injury to
the medulla can lead to paraplegia, cardiovascular and respiratory dysfunction, or
vagus nerve injury. The medulla oblongata is the connection between the
brainstem and the spinal cord, carrying multiple important functional centers. It
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comprises the cardiovascular-respiratory regulation system, descending motor
tracts, ascending sensory tracts, and origin of cranial nerves IX, X, XI, and XII.
Option D: With damage to the diencephalon or cortex, abnormal flexion
(decorticate posturing) occurs when a painful stimulus is applied. Synonymous
terms for decorticate posturing include abnormal flexion, decorticate rigidity,
flexor posturing, or decorticate response. Brain lesions of several anatomical
regions may cause both postures, though they do usually involve some degree of
brainstem injury. It is, however, accepted that decorticate typically requires an
injury more rostral than decerebrate posturing.
23. Question
The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the
following symptoms would the nurse expect to find?
A. Vision changes
B. Absent deep tendon reflexes
C. Tremors at rest
D. Flaccid muscles
Incorrect
Correct Answer: A. Vision changes
Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of
multiple sclerosis. Multiple sclerosis (MS) is a chronic autoimmune disease of the central
nervous system (CNS) characterized by inflammation, demyelination, gliosis, and
neuronal loss. Neurological symptoms vary and can include vision impairment,
numbness and tingling, focal weakness, bladder and bowel incontinence, and cognitive
dysfunction. Symptoms vary depending on lesion location.
Option B: Deep tendon reflexes may be increased or hyperactive — not absent.
Babinski’s sign may be positive. The diagnosis of RR MS is made with at least two
CNS inflammatory events. Although different diagnostic criteria have been used
for MS, the general principle of diagnosing the RR course has involved
establishing episodes separated in “time and space.”
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Option C: Tremors at rest aren’t characteristic of multiple sclerosis; however,
intentional tremors, or those occurring with purposeful voluntary movement, are
common in clients with multiple sclerosis. Symptoms from relapses frequently
resolve, however over time, residual symptoms relating to episodes of
exacerbation accrue. This accrual of symptoms, generally after 10 to 15 years,
results in long-term disability over time. Neurologic manifestations are
heterogeneous in severity and degree of recovery.
Option D: Affected muscles are spastic, rather than flaccid. Clinical symptoms
characterized by acute relapses typically first develop in young adults. A gradually
progressive course then ensues with permanent disability in 10 to 15 years.
Relapses often recover either partially or completely over weeks and months,
frequently without treatment. Over time, residual symptoms from relapses
without complete recovery accumulate and contribute to general disability.
24. Question
The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe
headache. Which action should the nurse perform?
A. Sit with the client for a few minutes.
B. Administer an analgesic.
C. Inform the nurse manager.
D. Call the physician immediately.
Incorrect
Correct Answer: D. Call the physician immediately.
A headache may be an indication that an aneurysm is leaking. The nurse should notify
the physician immediately. Unruptured cerebral aneurysms are asymptomatic and are
therefore unable to be detected based on history and physical exam alone. However,
when ruptured, they commonly present with a sudden onset, severe headache. This is
classically described as a “thunderclap headache” or “worst headache of my life.” In 30%
of patients, the pain is lateralized to the side of the aneurysm.
Option A: Sitting with the client is appropriate but only after the physician has
been notified of the change in the client’s condition. A headache may be
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accompanied by a brief loss of consciousness, meningismus, or nausea and
vomiting. Seizures are rare, occurring in less than 10% of patients. Sudden death
may also occur in 10% to 15% of patients.
Option B: The physician will decide whether or not an administration of an
analgesic is indicated. The decision to treat is multifactorial and depends on the
size, location, age, and comorbidities of the patient, as well as whether or not
there is a rupture. The treatment can be divided into 2 categories: surgical and
endovascular.
Option C: Informing the nurse manager isn’t necessary. Interestingly, 30% to 50%
of patients with major SAH report a sudden and severe headache 6 to 20 days
prior. This is referred to as a “sentinel headache,” which represents a minor
hemorrhage or “warning leak.”
25. Question
During recovery from a cerebrovascular accident (CVA), a female client is given nothing by
mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the
nurse assesses the client’s swallowing ability once each shift. This assessment evaluates:
A. Cranial nerves I and II.
B. Cranial nerves III and V.
C. Cranial nerves VI and VIII.
D. Cranial nerves IX and X.
Incorrect
Correct Answer: D. Cranial nerves IX and X.
Swallowing is a motor function of cranial nerves IX and X. Cranial nerve IX
(glossopharyngeal nerve), is responsible for motor (SVE) innervation of the
stylopharyngeus and the pharyngeal constrictor muscles by the nucleus ambiguus.
Damage to the recurrent laryngeal branch of the vagus nerve can result in vocal
hoarseness or acute dyspnea with bilateral avulsion.
Option A: Cranial nerves I, II, and VIII don’t possess motor functions. Cranial
nerve I, the olfactory nerve, is composed of special visceral afferents (SVA).
Chemo-sensory receptors in the olfactory mucosal lining bind to odorant
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molecules and conduct a signal through the nerves traveling through the
cribriform plate of the ethmoid bone to synapse on the neurons of the olfactory
bulb within the cranial vault. Cranial nerve II, the optic nerve, conveys special
somatic afferent (SSA) visual sensory information from the rods and cones retinal
sensory receptors to the thalamus, especially the lateral geniculate nucleus (LGN),
and the superior colliculus (SC). Cranial nerve III innervates most of the eye
muscles, by splitting into a superior and an inferior branch to innervate the
remaining three recti muscles, the inferior oblique, and the skeletal muscle
component of levator palpebrae superiors.
Option B: The motor functions of cranial nerve III include extraocular eye
movement, eyelid elevation, and pupil constriction. Cranial nerve III innervates
most of the eye muscles, by splitting into a superior and an inferior branch to
innervate the remaining three recti muscles, the inferior oblique, and the skeletal
muscle component of levator palpebrae superioris. While no autonomic fibers
travel with the fifth cranial nerve as it exits the pons, parasympathetic fibers from
the other mixed cranial nerves will join with peripheral branches of cranial nerve V
to innervate their respective target structures, such as the lacrimal, parotid,
submandibular, and sublingual glands.
Option C: The motor function of cranial nerve V is chewing. Cranial nerve VI
controls lateral eye movement. The abducens nerve innervates the lateral rectus
muscles only; thereby this nerve can be tested by evaluating the abduction of the
eye gaze. Cranial nerve VIII, the vestibulocochlear nerve, is responsible for the
auditory sense and the vestibular sense of orientation of the head.
26. Question
A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular
accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency
anemia. Which history finding is a risk factor for CVA?
A. Caucasian race
B. Female sex
C. Obesity
D. Bronchial asthma
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Incorrect
Correct Answer: C. Obesity
Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes,
cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels,
hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use,
emotional stress, family history of CVA, and advancing age.
Option A: 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. According to JNC8, the recommended blood pressure
targets in patients with stroke should be less than 140/90 mm Hg.
Option B: One-third of the adults in the USA have elevated low-density
lipoprotein (LDL), leading to plaque formation in the intracerebral vasculature.
Eventually, due to the excessive plaque build-up thrombotic strokes occur.
Option D: Ischemic etiologies can further be divided into embolic, thrombotic,
and lacunar. In general, the common risk factors for stroke include hypertension,
diabetes, smoking, obesity, atrial fibrillation, and drug use.
27. Question
The nurse is teaching a female client with multiple sclerosis. When teaching the client how to
reduce fatigue, the nurse should tell the client to:
A. Take a hot bath.
B. Rest in an air-conditioned room.
C. Increase the dose of muscle relaxants.
D. Avoid naps during the day.
Incorrect
Correct Answer: B. Rest in an air-conditioned room.
Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body
temperature by resting in an air-conditioned room may relieve fatigue; however,
extreme cold should be avoided. Other measures to reduce fatigue in the client with
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multiple sclerosis include treating depression, using occupational therapy to learn
energy conservation techniques, and reducing spasticity.
Option A: A hot bath or shower can increase body temperature, producing
fatigue. Assist with physical therapy. Increase patient comfort with massages and
relaxing baths. Reduces fatigue and promotes a sense of wellness.
Option C: Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness
and fatigue. Amantadine (Symmetrel) and pemoline (Cylert) are useful in
treatment of fatigue. Positive antiviral drug effect in 30%–50% of patients. Use
may be limited by side effects of increased spasticity, insomnia, paresthesias of
hands and feet.
Option D: Planning for frequent rest periods and naps can relieve fatigue. Plan
care consistent rest periods between activities. Encourage afternoon naps.
Reduces fatigue, aggravation of muscle weakness.
28. Question
A male client is having tonic-clonic seizures. What should the nurse do first?
A. Elevate the head of the bed.
B. Restrain the client’s arms and legs.
C. Place a tongue blade in the client’s mouth.
D. Take measures to prevent injury.
Incorrect
Correct Answer: D. Take measures to prevent injury.
Protecting the client from injury is the immediate priority during a seizure. Do not leave
the patient during and after a seizure to promote safety measures. Maintain in lying
position, flat surface; turn head to side during seizure activity. Helps in the drainage of
secretions; prevents the tongue from obstructing the airway. Loosen clothing from neck
or chest and abdominal areas to aid in breathing or chest expansion.
Option A: Elevating the head of the bed would have no effect on the client’s
condition or safety. Support the head, place on soft areas or assist to the floor if
out of bed. Supporting the extremities lessens the risk of physical injury when the
patient lacks voluntary muscle control.
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Option B: Restraining the client’s arms and legs could cause injury. Do not
attempt to restrain. If the attempt is made to restrain the patient during a seizure,
erratic movements may increase, and the patient may injure himself or others.
Option C: Placing a tongue blade or other object in the client’s mouth could
damage the teeth. Turn head to side and suction airway as indicated. Insert plastic
bite blocks only if the jaw relaxed. Helps maintain airway patency and reduces the
risk of oral trauma but should not be “forced” or inserted when teeth are clenched
because dental and soft-tissue damage may result. Note: Wooden tongue blades
should not be used because they may splinter and break in the patient’s mouth.
29. Question
A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and
requires mechanical ventilation. When the client asks the nurse about the paralysis, how should
the nurse respond?
A. “You may have difficulty believing this, but the paralysis caused by this disease is
temporary.”
B. “You’ll have to accept the fact that you’re permanently paralyzed. However, you
won’t have any sensory loss.”
C. “It must be hard to accept the permanency of your paralysis.”
D. “You’ll first regain use of your legs and then your arms.”
Incorrect
Correct Answer: A. “You may have difficulty believing this, but the paralysis caused
by this disease is temporary.”
The nurse should inform the client that the paralysis that accompanies Guillain-Barré
syndrome is only temporary. Return of motor function begins proximally and extends
distally in the legs. Guillain-Barre syndrome (GBS) patients describe a fulminant course of
symptoms that usually include ascending weakness and non-length dependent sensory
symptoms. By definition, the nadir is usually reached within 4 weeks. Symmetric
involvement is a key feature of GBS.
Option B: GBS is usually considered monophasic; therefore, a relapsing or
remitting course at presentation would be considered atypical. Additionally, a
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prior GBS event (recurrent GBS) is also unusual, occurring in < 10% of all patients.
If the patient reports progression beyond 8 weeks, other diagnoses should be
considered.
Option C: After the acute phase of illness, Guillain-Barre syndrome (GBS) patients
tend to do well. More than 80% achieve independent ambulation after 6 months.
Mortality during the acute phase of the illness is less than 5%.
Option D: Classically, patients with GBS will have a pattern of proximal and distal
weakness, which is flaccid and often profound if hospitalized. Significant neck
flexion weakness may be present and can portend the need for intubation.
Areflexia or hyporeflexia is usually present.
30. Question
The nurse is working on a surgical floor. The nurse must log roll a male client following a:
A. Laminectomy.
B. Thoracotomy.
C. Hemorrhoidectomy.
D. Cystectomy.
Incorrect
Correct Answer: A. Laminectomy.
The client who has had spinal surgery, such as laminectomy, must be logrolled to keep
the spinal column straight when turning. Laminectomy is among the most common
procedures performed by spinal surgeons to decompress the spinal canal in various
conditions. Preoperative and postoperative patient care is crucial to improve outcomes
of laminectomy.
Option B: Recovery for thoracotomy patients can be improved and hastened with
attention to detail postoperatively. Key interventions that seem simple and may
be easy to neglect will greatly benefit them. These include appropriate and timely
use of pain medication, frequent and proper use of incentive spirometry,
ambulation in hallways, regular work with physical therapy and occupational
therapy if necessary, and attention to detail while caring for patient incision sites.
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Option C: Under normal circumstances, hemorrhoidectomy is an outpatient
procedure, and the client may resume normal activities immediately after surgery.
Success rates of removal are excellent, with low rates of recurrence. When
comparing open and closed techniques, they both have similar rates of
postoperative pain, need for analgesics, and complications.
Option D: The client who has had a cystectomy may turn himself or may be
assisted into a comfortable position. While it may be tough, patients are strongly
encouraged to begin walking early as this is one of the most important things
they can do to improve recovery and prevent complications after surgery.
31. Question
A female client with a suspected brain tumor is scheduled for computed tomography (CT). What
should the nurse do when preparing the client for this test?
A. Immobilize the neck before the client is moved onto a stretcher.
B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
C. Place a cap on the client’s head.
D. Administer a sedative as ordered.
Incorrect
Correct Answer: B. Determine whether the client is allergic to iodine, contrast dyes,
or shellfish.
Because CT commonly involves the use of a contrast agent, the nurse should determine
whether the client is allergic to iodine, contrast dyes, or shellfish. In some patients,
contrast agents may cause allergic reactions, or in rare cases, temporary kidney failure. IV
contrast agents should not be administered to patients with abnormal kidney function
since they may induce a further reduction of kidney function, which may sometimes
become permanent.
Option A: Neck immobilization is necessary only if the client has a suspected
spinal cord injury. Unlike a conventional x-ray—which uses a fixed x-ray tube—a
CT scanner uses a motorized x-ray source that rotates around the circular opening
of a donut-shaped structure called a gantry. During a CT scan, the patient lies on
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a bed that slowly moves through the gantry while the x-ray tube rotates around
the patient, shooting narrow beams of x-ray through the body.
Option C: Placing a cap over the client’s head may lead to misinterpretation of
test results; instead, the hair should be combed smoothly. Metal objects, including
jewelry, eyeglasses, dentures, and hairpins, may affect the CT images. Leave them
at home or remove them prior to the exam. The client may also be asked to
remove hearing aids and removable dental work. Women will be asked to remove
bras containing metal underwire. The client may be asked to remove any
piercings, if possible.
Option D: The physician orders a sedative only if the client can’t be expected to
remain still during the CT scan. Though the scanning itself causes no pain, there
may be some discomfort from having to remain still for several minutes. If the
client has a hard time staying still, is claustrophobic, or has chronic pain, they may
find a CT exam to be stressful. The technologist or nurse, under the direction of a
physician, may offer some medication to help tolerate the CT scanning procedure.
32. Question
During a routine physical examination to assess a male client’s deep tendon reflexes, the nurse
should make sure to:
A. Use the pointed end of the reflex hammer when striking the Achilles' tendon.
B. Support the joint where the tendon is being tested.
C. Tap the tendon slowly and softly.
D. Hold the reflex hammer tightly.
Incorrect
Correct Answer: B. Support the joint where the tendon is being tested.
To prevent the attached muscle from contracting, the nurse should support the joint
where the tendon is being tested. With clean hands on a fully relaxed joint, the
tendon/target is struck with sufficient force to elicit the reflex while the clinician’s eyes
are focused on the proximal muscle group, looking for contraction, rather than the distal
appendage, looking for movement.
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Option A: The nurse should use the flat, not pointed, end of the reflex hammer
when striking the Achilles’ tendon. (The pointed end is used to strike over small
areas, such as the thumb placed over the biceps tendon). A variety of tools are
used to elicit a reflex which ranges from specialized to improvised, with
specialized hammers being generally preferable. The most commonly used
specialized reflex hammers are grouped into 3 types by the shape of the head:
triangular/tomahawk shaped (Taylor), T-shaped (Tromner, Buck), or circular
(Queen Square, Babinski).
Option C: Tapping the tendon slowly and softly wouldn’t provoke a deep tendon
reflex response. The technique may vary slightly depending on what type of tool
is used or what reflex is being tested, for instance, circular hammers can be
“dropped” passively through an arc using gravity to strike the patellar tendon, but
when striking the biceps tendon are generally swung like a drumstick.
Option D: The nurse should hold the reflex hammer loosely, not tightly, between
the thumb and fingers so it can swing in an arc. If a patient is hyperreflexic, a
clinician’s finger may be all that is needed because the forces needed are so
slight. With any tool, a finger can be placed on the tendon to help guide the
clinician’s blow to the correct location, to help feel the contraction, and to reduce
discomfort for the patient by cushioning the blow. This is most commonly done
when eliciting the biceps reflex.
33. Question
A female client is admitted in a disoriented and restless state after sustaining a concussion
during a car accident. Which nursing diagnosis takes highest priority for this client’s plan of
care?
A. Disturbed sensory perception (visual)
B. Self-care deficit: Dressing/grooming
C. Impaired verbal communication
D. Risk for injury
Incorrect
Correct Answer: D. Risk for injury
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Because the client is disoriented and restless, the most important nursing diagnosis is
risk for injury. Provide for safety needs (e.g., supervision, side rails, seizure precautions,
placing call bell within reach, positioning needed items within reach/clearing traffic
paths, ambulating with devices). This is to prevent untoward incidents and to promote
safety.
Option A: Avoid challenging illogical thinking. Challenges to the patient’s
thinking can be perceived as threatening and result in a defensive reaction. Orient
the patient to surroundings, staff, necessary activities as needed. Present reality
concisely and briefly. Avoid challenging illogical thinking—defensive reactions
may result. Increased orientation ensures greater degree of safety for the patient.
Option B: Modulate sensory exposure. Provide a calm environment; eliminate
extraneous noise and stimuli. Increased levels of visual and auditory stimulation
can be misinterpreted by the confused patient. Assist the family and significant
others in developing coping strategies. The family needs to let the patient do all
that he or she is able to do to maximize the patient’s level of functioning and
quality of life.
Option C: Give simple directions. Allow sufficient time for the patient to respond,
to communicate, to make decisions. This communication method can reduce
anxiety experienced in a strange environment.
34. Question
A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so
frustrated. I can’t do anything without help!” This comment best supports which nursing
diagnosis?
A. Anxiety
B. Powerlessness
C. Ineffective denial
D. Risk for disuse syndrome
Incorrect
Correct Answer: B. Powerlessness
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This comment best supports a nursing diagnosis of Powerlessness because ALS may lead
to locked-in syndrome, characterized by an active and functioning mind locked in a
body that can’t perform even simple daily tasks. Discuss with the patient concerning his
or her care (e.g., treatment options, convenience of visits, or time of ADLs). Allowing the
patient to participate in discussions will increase his or her sense of independence or
autonomy.
Option A: Depression has a significant effect on the quality of life in patients with
ALS, and studies have shown that treatment can improve quality of life. While no
controlled trials have evaluated the treatment of depression in patients with ALS,
Amitriptyline is commonly used as it can also treat other symptoms such as
insomnia, sialorrhea, and pseudobulbar affect.
Option D: Although Risk for disuse syndrome may be the nursing diagnosis
associated with ALS, the client’s comment specifically refers to an inability to act
autonomously. Limb onset ALS (LO) is the predominant type, presenting in 70% of
patients. LO ALS can be further classified as flail arm syndrome or brachial
amyotrophic diplegia, which is characterized by LMN weakness and wasting. It
usually starts proximally and often symmetrically, then progresses distally to a
point where upper extremity function is severely impaired.
Option C: A diagnosis of Ineffective denial would be indicated if the client didn’t
seem to perceive the personal relevance of symptoms or danger. Patients need to
know that this disease causes the muscles to weaken, eventually to the point of
paralysis. Patients should also be aware that the disease will get worse and
ultimately lead to death. Unfortunately, there is no cure; however, numerous
medications can help lessen the associated symptoms. Patients may begin to
notice difficulty with fine motor skills, from speaking to writing, as well as with
walking, and eventually breathing.
35. Question
For a male client with suspected increased intracranial pressure (ICP), a most appropriate
respiratory goal is to:
A. Prevent respiratory alkalosis.
B. Lower arterial pH.
C. Promote carbon dioxide elimination.
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D. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.
Incorrect
Correct Answer: C. Promote carbon dioxide elimination.
The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is
because an acid environment in the brain causes cerebral vessels to dilate and therefore
increases ICP. Hypercarbia lowers serum pH and can increase cerebral blood flow
contributing to rising ICP, hence hyperventilation to lower pCO2 to around 30 mm Hg
can be transiently used.
Option A: Cushing triad is a clinical syndrome consisting of hypertension,
bradycardia and irregular respiration and is a sign of impending brain herniation.
This occurs when the ICP is too high the elevation of blood pressure is a reflex
mechanism to maintain CPP. High blood pressure causes reflex bradycardia and
brain stem compromise affecting respiration.
Option B: Preventing respiratory alkalosis and lowering arterial pH may bring
about acidosis, an undesirable condition in this case. Clinical suspicion for
intracranial hypertension should be raised if a patient presents with the following
signs and symptoms: headaches, vomiting, and altered mental status varying from
drowsiness to coma.
Option D: It isn’t necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg
will adequately oxygenate most clients. Cerebral autoregulation is the process by
which cerebral blood flow varies to maintain adequate cerebral perfusion. When
the MAP is elevated, vasoconstriction occurs to limit blood flow and maintain
cerebral perfusion. However, if a patient is hypotensive, cerebral vasculature can
dilate to increase blood flow and maintain CPP.
36. Question
Nurse Mary witnesses a neighbor’s husband sustain a fall from the roof of his house. The nurse
rushes to the victim and determines the need to open the airway in this victim by using which
method?
A. Flexed position
B. Head tilt-chin lift
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C. Jaw-thrust maneuver
D. Modified head tilt-chin lift
Incorrect
Correct Answer: C. Jaw-thrust maneuver
If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The jaw
thrust maneuver more directly lifts the hyoid bone and tongue away from the posterior
pharyngeal wall by subluxating the mandible forward onto the sliding part of the
temporomandibular joint (mandibular advancement).
Option A: A flexed position is an inappropriate position for opening the airway.
Direct laryngoscopy and tracheal intubation is one of the basic and the most
important skills in anesthetic practice. This requires proper positioning of head
and neck to adequately visualize the glottis and easily negotiate the tracheal tube
through the glottic opening. The position traditionally recommended and taught
to all learners of airway management is the “sniffing position” (SP). This involves
neck flexion (head elevation) by putting a pillow under the head and then
extending the head at the atlanto-occipital joint.
Option B: The head tilt–chin lift maneuver produces hyperextension of the neck
and could cause complications if a neck injury is present. To relieve upper airway
obstruction, the clinician uses two hands to extend the patient’s neck. While one
hand applies downward pressure to the patient’s forehead, the tips of the index
and middle fingers of the second hand lift the mandible at the chin, which lifts the
tongue from the posterior pharynx. The head-tilt/chin-lift maneuver may be used
in any patient in whom cervical spine injury is NOT a concern.
Option D: To perform the head-tilt maneuver, approach the patient from the side
and place the palm of one hand on the patient’s forehead and push down gently,
rolling the patient’s head towards the top. Then, using the fingers of your free
hand, lightly lift the chin even further up.
37. Question
The nurse is assessing the motor function of an unconscious male client. The nurse would plan
to use which of the following to test the client’s peripheral response to pain?
A. Sternal rub
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B. Nail bed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle
Incorrect
Correct Answer: B. Nail bed pressure
Motor testing in the unconscious client can be done only by testing response to painful
stimuli. Nail bed pressure tests a basic peripheral response. Motor responses can be
purposeful, such as the patient pulling on an airway adjunct, or reflexive, including
withdrawal, flexion, or extension responses.
Option A: Response to these painful stimuli should be graded bilaterally, in case
of a focal spinal cord lesion. If these measures do not produce a response,
vigorously pressing the examiner’s knuckles up and down the sternum should
arouse any patient who is not deeply comatose.
Option C: The initial step is to evaluate for reactivity, using objective measures.
Address the patient verbally, and then progress to light shaking, then progress to
more intense mechanical stimulation. Sufficient stimulus to the supraorbital ridge,
nail beds, or temporomandibular joint can be painful without risk of tissue injury.
Option D: If no spontaneous movement is noted, provide central pain
stimulation. Central pain can be tested by rubbing the sternum, squeezing the
tissue in the axilla, squeezing the trapezius muscle at the angle of the neck and
shoulder, or by applying supraorbital pressure (avoid if facial fractures present).
38. Question
A female client admitted to the hospital with a neurological problem asks the nurse whether
magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible
for this diagnostic procedure based on the client’s history of:
A. Hypertension
B. Heart failure
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C. Prosthetic valve replacement
D. Chronic obstructive pulmonary disorder
Incorrect
Correct Answer: C. Prosthetic valve replacement
The client having a magnetic resonance imaging scan has all metallic objects removed
because of the magnetic field generated by the device. A careful history is obtained to
determine whether any metal objects are inside the client, such as orthopedic hardware,
pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may
heat up, become dislodged, or malfunction during this procedure. The client may be
ineligible if a significant risk exists.
Option A: MRI contrast agents are gadolinium chelates with different stability,
viscosity, and osmolality. Gadolinium is a relatively very safe contrast; however, it
rarely might cause allergic reactions in patients. Evaluate carefully patients with
diabetes mellitus or hypertension who are receiving treatment with medications;
calculate these patients’ estimated glomerular filtration rate, and if less than 35
mL/min/1.73 m2, there is a need to consult a radiologist for further instructions.
Option B: Patients with impaired renal function are at risk of NSF associated with
gadolinium chelate. Patients with known or at risk of renal impairment need to
require evaluation regarding their renal function before an MRI scan.
Option D: Patients who are unable to be still or obey breathing instructions in the
scanner need special attention. Some patients in pain might move during the
procedure, which degrades the quality of the images, restrict the interpretation,
and decrease the accuracy of the report. Some MRI sequences need to be
obtained while patients hold their breath and lie motionless.
39. Question
A male client is having a lumbar puncture performed. The nurse would plan to place the client
in which position?
A. Side-lying, with a pillow under the hip.
B. Prone, with a pillow under the abdomen.
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C. Prone, in slight-Trendelenburg’s position.
D. Side-lying, with the legs, pulled up and head bent down onto the chest.
Incorrect
Correct Answer: D. Side-lying, with the legs, pulled up and head bent down onto
the chest.
The client undergoing lumbar puncture is positioned lying on the side, with the legs
pulled up to the abdomen and the head bent down onto the chest. This position helps
open the spaces between the vertebrae.
Option A: The positioning of the patient in either a lateral recumbent position or
sitting position may be used. The lateral recumbent position is preferred as it will
allow an accurate measurement of opening pressure, and it also reduces the risk
of post-lumbar puncture headache.
Option B: To help keep the needle at the midline during insertion, the lumbar
spine should be perpendicular to the table in the sitting position and parallel to
the table if in the recumbent position.
Option C: The patient should be instructed to assume the fetal position, which
involves the flexion of the spine. It may be helpful to instruct the patient to flex
their back “like a cat.” By doing so, the space between the spinous processes
increases, allowing for easier needle insertion.
40. Question
The nurse is positioning the female client with increased intracranial pressure. Which of the
following positions would the nurse avoid?
A. Head midline
B. Head turned to the side
C. Neck in neutral position
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D. Head of bed elevated 30 to 45 degrees
Incorrect
Correct Answer: B. Head turned to the side
The head of the client with increased intracranial pressure should be positioned so the
head is in a neutral midline position. The nurse should avoid flexing or extending the
client’s neck or turning the head side to side. The head of the bed should be raised to 30
to 45 degrees. Use of proper positions promotes venous drainage from the cranium to
keep intracranial pressure down.
Option A: Elevate the head of the bed to greater than 30 degrees. Keep the neck
midline to facilitate venous drainage from the head. Communication regarding
indications/risks/contraindications for ICP monitoring or craniotomy needs to be
ongoing, particularly with respect to goals of care. Nursing care must pay close
attention to changes in neurologic status, any change in vitals such as an
increasingly erratic heart rate, development of bradycardia, accurate and equal
intake and output when having diuresis, and maintenance of proper blood
pressure.
Option C: In patients with raised ICP, it is a common practice to position the
patient in bed with the head elevated above the level of the heart. Kenning, et
al.,4 reported that elevating the head to 45° or 90° significantly reduced ICP.
However, some studies suggest that head elevation may also lower the CPP.
Option D: If a patient is suspected of having an increased ICP, methods to reduce
pressure from increasing further include elevating the patient’s head to 30
degrees, keeping their neck in a neutral position, avoiding overhydration,
maintaining normal body temperature, and maintaining normal oxygen and
carbon dioxide levels.
41. Question
A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse
assesses that this is cerebrospinal fluid if the fluid:
A. Is clear and tests negative for glucose.
B. Is grossly bloody in appearance and has a pH of 6.
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C. Clumps together on the dressing and has a pH of 7.
D. Separates into concentric rings and tests positive for glucose.
Incorrect
Correct Answer: D. Separates into concentric rings and tests positive for glucose.
Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull
fracture. CSF can be distinguished from other body fluids because the drainage will
separate into bloody and yellow concentric rings on dressing material, called a halo sign.
The fluid also tests positive for glucose.
Option A: Cerebrospinal fluid (CSF) is a clear liquid that is around and within the
organs of the central nervous system. When compared to plasma, CSF has a
higher concentration of sodium, chloride, and magnesium but a lower
concentration of potassium and calcium. Unlike plasma, CSF has only trace
amounts of cells, protein, and immunoglobulins.
Option B: Several analyses are possible on the contents of CSF obtained from a
lumbar puncture. Since CSF should be transparent, the color is worth noting. A
cloudy appearance can suggest an infectious cause, and red color can suggest the
presence of blood.
Option C: The CSF helps reduce the potential damage in such an event by acting
as a cushion and a shock absorber. Since there are continuous production and
production of CSF, it also appears to help clear waste products from around the
brain and regulate intracranial pressures.
42. Question
A male client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse
would avoid which of the following measures to minimize the risk of recurrence?
A. Strict adherence to a bowel retraining program.
B. Keeping the linen wrinkle-free under the client.
C. Preventing unnecessary pressure on the lower limbs.
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D. Limiting bladder catheterization to once every 12 hours.
Incorrect
Correct Answer: D. Limiting bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every four (4) to six (6) hours, and foley catheters should
be checked frequently to prevent kinks in the tubing. Other causes include stimulation of
the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize
risk in these areas.
Option A: Constipation and fecal impaction are other causes, so maintaining
bowel regularity is important. Establish a regular daily bowel program (digital
stimulation, prune juice, warm beverage, and use of stool softeners and
suppositories at set intervals. Determine usual time and routine of postinjury
evacuations.
Option B: Massage and lubricate skin with bland lotion or oil. Protect pressure
points by use of heel or elbow pads, lamb’s wool, foam padding, egg-crate
mattress. Use skin hardening agents (tincture of benzoin, karaya, Sween cream).
Enhances circulation and protects skin surfaces, reducing risk of ulceration.
Tetraplegic and paraplegic patients require lifelong protection from decubitus
formation, which can cause extensive tissue necrosis and sepsis. Keep bed clothes
dry and free of wrinkles, crumbs. Reduces or prevents skin irritation.
Option C: Elevate lower extremities at intervals when in chair, or raise foot of bed
when permitted in individual situations. Assess for edema of feet and ankles. Loss
of vascular tone and “muscle action” results in pooling of blood and venous stasis
in the lower abdomen and lower extremities, with increased risk of hypotension
and thrombus formation.
43. Question
The nurse is caring for the male client who begins to experience seizure activity while in bed.
Which of the following actions by the nurse would be contraindicated?
A. Loosening restrictive clothing.
B. Restraining the client’s limbs.
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C. Removing the pillow and raising padded side rails.
D. Positioning the client to the side, if possible, with the head flexed forward.
Incorrect
Correct Answer: B. Restraining the client’s limbs.
The limbs are never restrained because the strong muscle contractions could cause the
client harm. If the client is not in bed when seizure activity begins, the nurse lowers the
client to the floor, if possible, protects the head from injury, and moves furniture that
may injure the client. Other aspects of care are as described for the client who is in bed.
Option A: Nursing actions during a seizure include providing for privacy and
loosening restrictive clothing. Loosen clothing from neck or chest and abdominal
areas. Aids in breathing or chest expansion. Maintain in lying position, flat surface;
turn head to side during seizure activity. Helps in the drainage of secretions;
prevents the tongue from obstructing the airway.
Option C: Use and pad side rails with the bed in lowest position, or place the bed
up against the wall and pad floor if rails are not available or appropriate. Prevents
or minimizes injury when seizures (frequent or generalized) occur while the
patient is in bed. Note: Most individuals seize in place and if, in the middle of the
bed, the individual is unlikely to fall out of bed.
Option D: Turn head to side and suction airway as indicated. Insert plastic bite
blocks only if the jaw relaxed. Helps maintain airway patency and reduces the risk
of oral trauma but should not be “forced” or inserted when teeth are clenched
because dental and soft-tissue damage may result. Note: Wooden tongue blades
should not be used because they may splinter and break in the patient’s mouth.
44. Question
The nurse is assigned to care for a female client with complete right-sided hemiparesis. The
nurse plans care knowing that this condition:
A. The client has complete bilateral paralysis of the arms and legs.
B. The client has weakness on the right side of the body, including the face and
tongue.
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Neurological Disorders NCLEX Practice | Quiz #2: 50 Questions - Nurseslabs
C. The client has lost the ability to move the right arm but can walk independently.
D. The client has lost the ability to move the right arm but can walk independently.
Incorrect
Correct Answer: B. The client has weakness on the right side of the body, including
the face and tongue.
Hemiparesis is a weakness of one side of the body that may occur after a stroke.
Complete hemiparesis is a weakness of the face and tongue, arm, and leg on one side.
Complete bilateral paralysis does not occur in this condition.
Option A: Hemiparesis is weakness or the inability to move on one side of the
body, making it hard to perform everyday activities like eating or dressing. Braces,
canes, walkers, and wheelchairs can increase strength and movement. An anklefoot orthosis brace can help control your ankle and foot. A physical therapist can
recommend the appropriate device.
Option C: Left-sided weakness results from injury to the right side of the brain,
which controls nonverbal communication and certain behaviors. Repeated
practice and regular activity will help increase control and flexibility and reestablish nerve circuitry.
Option D: The client with right-sided hemiparesis has weakness of the right arm
and leg and needs assistance with feeding, bathing, and ambulating. Where the
stroke occurred in the brain will determine the location of your weakness. Injury
to the left side of the brain, which controls language and speaking, can result in
right-sided weakness.
45. Question
The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the
nurse avoids doing which of the following?
A. Giving the client thin liquids.
B. Thickening liquids to the consistency of oatmeal.
C. Placing food on the unaffected side of the mouth.
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Neurological Disorders NCLEX Practice | Quiz #2: 50 Questions - Nurseslabs
D. Allowing plenty of time for chewing and swallowing.
Incorrect
Correct Answer: A. Giving the client thin liquids.
Before the client with dysphagia is started on a diet, the gag and swallow reflexes must
have returned. Review individual pathology and ability to swallow, noting extent of the
paralysis: clarity of speech, tongue involvement, ability to protect airway, episodes of
coughing, presence of adventitious breath sounds. Weigh periodically as indicated.
Nutritional interventions and choices of feeding route are determined by these factors.
Option B: Liquids are thickened to avoid aspiration. Food consistency is
determined by individual deficit. For example: Patients with decreased range of
tongue motion require thick liquids initially, progressing to thin liquids, whereas
patients with delayed pharyngeal swallow will handle thick liquids and thicker
foods better.
Option C: Food is placed on the unaffected side of the mouth. Place food of
appropriate consistency on the unaffected side of the mouth. Provides sensory
stimulation (including taste), which may increase salivation and trigger swallowing
efforts, enhancing intake.
Option D: The client is assisted with meals as needed and is given ample time to
chew and swallow. Provide a pleasant and unhurried environment free of
distractions. Promotes relaxation and allows the patient to focus on the task of
eating. Promote effective swallowing: Schedule activities and medications to
provide a minimum of 30 min rest before eating. Promotes optimal muscle
function, helps to limit fatigue.
46. Question
The nurse is assessing the adaptation of the female client to changes in functional status after a
brain attack (stroke). The nurse assesses that the client is adapting most successfully if the
client:
A. Gets angry with family if they interrupt a task.
B. Experiences bouts of depression and irritability.
C. Has difficulty with using modified feeding utensils.
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Neurological Disorders NCLEX Practice | Quiz #2: 50 Questions - Nurseslabs
D. Consistently uses adaptive equipment in dressing self.
Incorrect
Correct Answer: D. Consistently uses adaptive equipment in dressing self
Clients are evaluated as coping successfully with lifestyle changes after a brain attack
(stroke) if they make appropriate lifestyle alterations, use the assistance of others, and
have appropriate social interactions.
Option A: Identify previous methods of dealing with life problems. Determine
presence of support systems. Provides opportunity to use behaviors previously
effective, build on past successes, and mobilize resources.
Option B: Encourage the patient to express feelings, including hostility or anger,
denial, depression, sense of disconnectedness. Demonstrates acceptance of the
patient in recognizing and beginning to deal with these feelings.
Option C: Emphasize small gains either in recovery of function or independence.
Consolidates gains, helps reduce feelings of anger and helplessness, and conveys
sense of progress. Support behaviors and efforts such as increased
interest/participation in rehabilitation activities. Suggest possible adaptation to
changes and understanding about your own role in future lifestyle.
47. Question
Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia.
Which of the following actions by the nurse would be least helpful to the client?
A. Speaking to the client at a slower rate.
B. Allowing plenty of time for the client to respond.
C. Completing the sentences that the client cannot finish.
D. Looking directly at the client during attempts at speech.
Incorrect
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Neurological Disorders NCLEX Practice | Quiz #2: 50 Questions - Nurseslabs
Correct Answer: C. Completing the sentences that the client cannot finish.
Clients with aphasia after brain attack (stroke) often fatigue easily and have a short
attention span. The nurse would avoid shouting (because the client is not deaf),
appearing rushed for a response, and letting family members provide all the responses
for the client.
Option A: Talk directly to the patient, speaking slowly and distinctly. Phrase
questions to be answered simply by yes or no. Progress in complexity as the
patient responds. Reduces confusion and allays anxiety at having to process and
respond to large amounts of information at one time. As retraining progresses,
advancing complexity of communication stimulates memory and further enhances
word and idea association.
Option B: Speak in normal tones and avoid talking too fast. Give the patient
ample time to respond. Avoid pressing for a response. Patient is not necessarily
hearing impaired, and raising their voice may irritate or anger the patient. Forcing
responses can result in frustration and may cause the patient to resort to
“automatic” speech (garbled speech, obscenities).
Option D: General guidelines when trying to communicate with the aphasic client
include speaking more slowly and allowing adequate response time, listening to
and watching attempts to communicate, and trying to put the client at ease with
a caring and understanding manner.
48. Question
A female client has experienced an episode of myasthenic crisis. The nurse would assess
whether the client has precipitating factors such as:
A. Getting too little exercise.
B. Taking excess medication.
C. Omitting doses of medication.
D. Increasing intake of fatty foods.
Incorrect
Correct Answer: C. Omitting doses of medication.
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Neurological Disorders NCLEX Practice | Quiz #2: 50 Questions - Nurseslabs
Myasthenic crisis often is caused by under medication and responds to the
administration of cholinergic medications, such as neostigmine (Prostigmin) and
pyridostigmine (Mestinon). Myasthenic crisis is a complication of myasthenia gravis
characterized by worsening of muscle weakness, resulting in respiratory failure that
requires intubation and mechanical ventilation.
Option A: The most common precipitant is infection. One series documented
infection in 38% of patients presenting with myasthenic crisis; most commonly,
the infection was bacterial pneumonia followed by a bacterial or viral upper
respiratory infection. Other antecedent factors include exposure to temperature
extremes, pain, sleep deprivation, and physical or emotional stress.
Option B: Cholinergic crisis (the opposite problem) is caused by excess
medication and responds to withholding of medications. Patients taking an excess
of acetylcholinesterase inhibitors may precipitate a cholinergic crisis characterized
by both muscarinic and nicotinic toxicity. Although cholinergic crisis is an
important consideration in the evaluation of the patient in myasthenic crisis, it is
uncommon.
Option D: Too little exercise and fatty food intake are incorrect. Overexertion and
overeating possibly could trigger a myasthenic crisis. Other precipitants include
aspiration pneumonitis, surgery, pregnancy, perimenstrual state, certain
medications (see below), and tapering of immune-modulating medications.
49. Question
The nurse is teaching the female client with myasthenia gravis about the prevention of
myasthenic and cholinergic crisis. The nurse tells the client that this is most effectively done by:
A. Eating large, well-balanced meals.
B. Doing muscle-strengthening exercises.
C. Doing all chores early in the day while less fatigued.
D. Taking medications on time to maintain therapeutic blood levels.
Incorrect
Correct Answer: D. Taking medications on time to maintain therapeutic blood
levels
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Neurological Disorders NCLEX Practice | Quiz #2: 50 Questions - Nurseslabs
Taking medications correctly to maintain blood levels that are not too low or too high is
important. The complication of myasthenia gravis includes myasthenic crisis, usually
secondary to infections, stress, or acute illnesses. Patients are advised to take their
medications as directed and to avoid taking new medicines without checking with the
medical provider.
Option A: Overeating is a cause of exacerbation of symptoms, as is exposure to
heat, crowds, erratic sleep habits, and emotional stress. It is important to stress
the value of avoiding precipitants like infections, excessive exertion, emotional
stress, worsening of chronic medical illnesses, and drugs (aminoglycosides,
fluoroquinolones, beta-blockers).
Option B: Muscle-strengthening exercises are not helpful and can fatigue the
client. Patients should also be educated about various complications and advised
to seek medical care as early as possible. Wearing a medical identification bracelet
that shows they have myasthenia gravis is also recommended. Health promotive
measures to prevent infections like handwashing and yearly flu vaccine should be
emphasized.
Option C: Clients with myasthenia gravis are taught to space out activities over
the day to conserve energy and restore muscle strength. The nurses encourage
the patients to follow preventive measures like handwashing, smoking cessation,
and age-appropriate vaccinations. These can prevent infections that could trigger
a myasthenic attack.
50. Question
A male client with Bell’s Palsy asks the nurse what has caused this problem. The nurse’s
response is based on an understanding that the cause is:
A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune
problem.
B. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia.
C. Primary genetic in origin, triggered by exposure to meningitis.
D. Primarily genetic in origin, triggered by exposure to neurotoxins.
Incorrect
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Neurological Disorders NCLEX Practice | Quiz #2: 50 Questions - Nurseslabs
Correct Answer: A. Unknown, but possibly includes ischemia, viral infection, or an
autoimmune problem
Bell’s palsy is a one-sided facial paralysis from compression of the facial nerve. The exact
cause is unknown but may include vascular ischemia, infection, exposure to viruses such
as herpes zoster or herpes simplex, autoimmune disease, or a combination of these
factors. BP is thought to result from compression of the seventh cranial nerve at the
geniculate ganglion. The first portion of the facial canal, the labyrinthine segment, is the
narrowest and it is here that most cases of compression occur. Due to the narrow
opening of the facial canal, inflammation causes compression and ischemia of the nerve.
Option B: BP is by definition idiopathic in nature. Increasing evidence in the
literature demonstrates multiple potential clinical conditions and pathologies
known to manifest, at least in part, with a period of unilateral facial paralysis. The
literature has highlighted several viral illnesses such as herpes simplex virus,
varicella-zoster virus, and Epstein-Barr virus.
Option C: Providers may ambiguously (and incorrectly) refer to a diagnosis of BP
in the setting of a potentially known etiologic mechanism. This can occur, for
example, in the setting of known associations (e.g. Ramsay-Hunt syndrome and
Lyme disease).
Option D: While there are many potential causes, including idiopathic, traumatic,
neoplastic, congenital, and autoimmune, about 70% of facial nerve palsies wind
up with a diagnosis of BP.
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