NCLEX Neurology exam-with 100% verified answers-2024-2025 .docx, Exams of Nursing

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NCLEX Neurology exam-with 100%

verified answers-2024-

With 328 Q&A

1. The nurse is reinforcing home-care instructions to a client and family regarding care after cataract removal from the right eye. Which statement made by the client indicates an understanding of the instructions? Answer: "I should not sleep on my right side."
2. The nurse is assisting with caring for a client after a craniotomy. Which is the best position for the client to be placed? Answer: Semi-Fowler's position
3. The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to Figures. Answer: A
4. The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially? Answer: Stand in front of the client.
5. Which intervention should be implemented for the older client with presbycusis who has a hearing loss? Answer: Use low-pitched tones.
6. The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply. Answer: To avoid activities that require bending over To place an eye shield on the surgical eye at bedtime To contact the surgeon if a decrease in visual acuity occurs To take acetaminophen (Tylenol) for minor eye discomfort
7. The nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? Answer: Eye medications will need to be administered for the rest of your life.
8. The nurse is assigned to care for a client with a detached retina.

Which finding should the nurse expect to be documented in the client's record? Answer: A sense of a curtain falling across the field of vision

9. The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment? Answer: Complaints of a burst of black spots or floaters 10.A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position should the nurse prepare to position the client? Answer: On bed rest in a semi-Fowler's position

11.A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? Answer: Apply ice to the affected eye. 12.A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? Answer: Irrigating the eye with sterile normal saline 13.The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action? Answer: Report the finding to the registered nurse (RN). 14.The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique? Answer: Pulling the pinna up and back 15.The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication? Answer: Speak in a normal tone. 16.A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed? Answer: Instillation of mineral oil or diluted alcohol 17.The nurse notes that the health care provider has documented a diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as which? Answer: A sensorineural hearing loss that occurs with aging 18.A client with Ménière's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist in controlling the vertigo? Answer: Avoid sudden head movements. 19.The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client? Answer: Low-sodium diet 20.A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma? Answer: Cardiovascular disease 21.Betaxolol hydrochloride (Betoptic) eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of

this medication?

Answer: Monitoring blood pressure 22.The nurse assists to prepare the client for ear irrigation as prescribed by the health care provider. Which action should the nurse plan to take? Answer: Warm the irrigating solution to 98° F. 23.In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse administers the eyedrops knowing that the purpose of this medication is which? Answer: Dilate the pupil of the operative eye. 24.The nurse is providing instructions to a client who will be self- administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which? Answer: Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops. 25.The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take? Answer: Administer the eyedrop first, followed by the eye ointment. 26.The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question? Answer: Atropine sulfate (Isopto Atropine) 27.The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply. Answer: Wash hands. Put on gloves. Place the drop in the conjunctival sac. Pull the lower lid down against the cheekbone. 28.A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint? Answer: Acetylsalicylic acid (aspirin) 29.Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity? Answer: Atropine sulfate 30.A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which?

Answer: "The medication causes the pupil to constrict and will lower the pressure in the eye." 31.A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply. Answer: Pad the bed's side rails. Place an airway at the bedside. Place oxygen equipment at the bedside. Place suction equipment at the bedside. 32.The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising? Answer: Increasing temperature, decreasing pulse, decreasing respirations, increasing BP 33.The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse? Answer: Head turned to the side 34.The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity? Answer: Exhaling during repositioning 35.The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria? Answer: Separates into concentric rings and tests positive for glucose 36.The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? Answer: The health care provider reviews the x-ray results. 37.The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom? Answer: Minor headache 38.The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively? Answer: Head of bed elevated 30 to 45 degrees, head and neck midline

39.The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client? Answer: Comparing the amount of prescribed weights with the amount in use 40.The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? Answer: "I will drive only during the daytime." 41.The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted? Answer: Severe, throbbing headache 42.The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? Answer: Limiting bladder catheterization to once every 12 hours 43.The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take? Answer: Raise the head of the bed and remove the noxious stimulus. 44.The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply. Answer: Face the client when talking. Speak slowly and maintain eye contact. Use gestures when talking to enhance words. Give the client directions using short phrases and simple terms. 45.The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room? Answer: Electrocardiographic monitoring electrodes and intubation tray 46.The nurse is attempting to communicate with a hearing-impaired client. Which strategy by the nurse would be least helpful when talking to this client? Answer: Smiling continuously during conversation 47.The nurse is reviewing the record of a client with mastoiditis. The nurse should expect to note which documented characteristic regarding the results of the otoscopic examination?

Answer: Red, dull, thick, and immobile tympanic membrane 48.A client is diagnosed with a disorder involving the inner ear. The nurse caring for the client understands that which is the most common client complaint associated with a disorder involving the inner ear? Answer: Tinnitus 49.The nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. The nurse should expect to note documentation of which early symptom of this disorder? Answer: Ringing in the ears 50.The nurse provides discharge instructions to the client who was hospitalized for an acute attack of Ménière's disease. Which statement made by the client indicates a need for further teaching? Answer: "It is not necessary to restrict salt in my diet." 51.The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching? Answer: "I should turn the hearing aid off after removing it from my ear." 52.Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test and determines that the intraocular pressure is normal if which result is noted? Answer: 15 mm Hg 53.The nurse is assisting in developing a plan of care for the client scheduled for cataract surgery. The nurse makes suggestions regarding the plan, knowing that which problem is specifically associated with this type of surgery? Answer: Sensory perceptual alteration 54.The nurse is reviewing the health record of a client diagnosed with a cataract. The initial sign/symptom that the nurse should expect to note in the early stages of cataract formation is which? Answer: Blurred vision 55.The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position? Answer: On the nonoperative side 56.During the early postoperative stage, the cataract extraction client complains of nausea and severe eye pain over the operative site. Which action should the nurse implement? Answer: Report the client's complaints. 57.The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which finding should be an early indication that the level of consciousness (LOC) is deteriorating?

Answer: Drowsiness 58.The nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item should be included as part of the precautions? Answer: Maintaining the head of the bed at 15 degrees 59.The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated? Answer: Restrain the client's limbs. 60.The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client? Answer: Within the client's reach, on the left side 61.The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which? Answer: Remind the client to turn the head to scan the lost visual field. 62.A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor? Answer: Omitted doses of medication 63.A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse should plan which approach as therapeutic in assisting the client to cope with the disease? Answer: Encourage and praise perseverance in exercising and performing ADL. 64.The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement? Answer: "I will try to eat my food either very warm or very cold." 65.A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety? Answer: Provide a clear path for ambulation without obstacles. 66.The nurse reinforces home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further teaching? Answer: "I need to remove the eye dressing as soon as I get home and place a warm pack on my eye."

67.The nurse provides dietary instructions to a client with Ménière's disease. The nurse tells the client that which food or fluid item is acceptable to consume? Answer: Sugar-free Jell-O 68.The nurse is caring for a client who will be undergoing surgical treatment for Ménière's disease. The nurse plans care based on which expected outcome? Answer: The surgery relieves pressure from accumulation of inner ear fluid in the endolymphatic sac. 69.A clinic nurse notes that following several eye examinations the health care provider has documented a diagnosis of legal blindness in the client's chart. Which should the nurse expect to note documented as the result of the Snellen chart test? Answer: 20/200 vision 70.The nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops should the nurse expect to be prescribed? Answer: A mydriatic medication 71.A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions? Answer: "I will wear my eye shield at night and my glasses during the day." 72.A client with glaucoma asks the nurse if complete vision will return. The nurse should make which response to the client? Answer: "Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan." 73.A client with retinal detachment is admitted to the outpatient nursing unit in preparation for a scleral buckling procedure. Which prescription should the nurse anticipate? Answer: Placing an eye patch over the client's affected eye

74. The nurse should check for vision loss in a client with which condition? Answer: Diabetes mellitus 75.The nurse is assisting the health care provider with performing a Weber tuning fork test on a client. What does this test assess for? Answer: Hearing loss

76.The nurse is providing discharge instructions for a client who has had a fenestration procedure for the treatment of otosclerosis. Which statement by the client indicates an understanding of the instructions? Answer: "I will take stool softeners as prescribed by my doctor." 77.The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve should identify a complication specifically associated with this surgery? Answer: Cranial nerve VII, facial nerve 78.The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? Answer: Bloody or clear drainage from the auditory canal 79.The nurse is assigned to care for a client with a diagnosis of Ménière's disease. Which part of the ear is affected with Ménière's disease? Answer: Inner ear 80.Surgery has been recommended for the client with otosclerosis. The client tells the nurse that she would prefer not to have surgery and asks the nurse about alternative methods to improve hearing. The nurse should make which appropriate response to the client? Answer: "A hearing aid may improve your hearing." 81.The nurse is caring for a client hospitalized with an acute attack from Ménière's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which response should the nurse make to the client regarding the hearing loss? Answer: "The attack leaves a hearing loss in the involved ear." 82.The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of an acute attack of Ménière's disease. Which prescription noted on the client's chart should the nurse question? Answer: The administration of a vasoconstrictor 83.A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse reinforces instructions to the client regarding home care following the procedure. Which statement by the client indicates a need for further teaching? Answer: "I need to avoid air travel for at least 6 months." 84.The nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which should be included on the list of instructions prepared for the client? Answer: "You need to avoid air travel."

85.A myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the nurse that a small amount of brownish drainage has been coming from the ear. Which instruction should the nurse provide to the client? Answer: "Continue to monitor the drainage because this is normal and may occur for 24 to 48 hours following the surgery." 86.A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? Answer: Walker 87.The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? Answer: Encouraging multiple visitors at one time 88.A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration? Answer: Establishing a toileting schedule 89.The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems? Answer: Allergy to pollen 90.A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which action by the family? Answer: Encouraging the client to stand unassisted on the leg 91.The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which should the nurse check before the procedure? Answer: Allergy to iodine or shellfish 92.A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which finding noted in the client history indicates that the client may be ineligible for this diagnostic procedure? Answer: Prosthetic valve replacement 93.A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse should provide reassurance to the client about the procedure? Answer: "Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure."

94.The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client? Answer: Explaining equipment and procedures on an ongoing basis 95.The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure? Answer: Making sure not to suction for longer than 30 seconds 96.The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which complication of hypothermia blanket use? Answer: Skin breakdown 97.The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center which is located in which part of the brain? Answer: Hypothalamus 98.A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client makes which statement? Answer: "I can resume a full activity level immediately." 99.The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How should the nurse interpret the client's situation? Answer: It is possible the client can hear the family.

100. The nurse is providing care to a client with increased intracranial pressure (ICP). Which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply. Answer: Reducing environmental noise Maintaining a calm atmosphere Allowing the client uninterrupted time for sleep
101. The nurse is preparing to give the postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not "something stronger." The nurse should formulate a response based on which understanding of codeine? Answer: Codeine does not alter respirations or mask neurological signs as do other opioids.
102. The nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates

the need for further teaching? Answer: "I will not hear sounds clearly unless they are loud."

103. The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance? Answer: Indicates that facial puffiness will be a permanent problem
104. A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse? Answer: Acknowledge the client's anger and continue to encourage participation in care.
105. A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this? Answer: Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.
106. A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle- strengthening benefit from which activity? Answer: Doing active range of motion to finger joints
107. A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will do which? Answer: Wear the patch continuously, alternating eyes each day.
108. The nurse is planning care for a client in spinal shock. Which action would be least helpful in minimizing the effects of vasodilation below the level of the injury? Answer: Moving the client quickly as one unit
109. The nursing instructor asks a nursing student about the points to document if the client has had a seizure. The instructor determines that the student needs to research seizures and related documentation points if the student states which assessment is important? Answer: Client's diet in the 2 hours preceding seizure activity
110. The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measure should the nurse avoid in planning for the client's safety? Answer: Putting a padded tongue blade at the head of the bed
111. The nurse has given medication instructions to the client receiving phenytoin (Dilantin). The nurse determines that the client understands the instructions if the client makes which comment?

Answer: "Good oral hygiene is needed, including brushing and flossing."

112. A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the should nurse avoid which action? Answer: Giving the client thin liquids
113. The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client? Answer: Completing the sentences that the client cannot finish
114. A client receives a dose of edrophonium (Enlon). The client shows improvement in muscle strength for a period of time following the injection. The nurse should interpret this finding as indicative of which disease process? Answer: Myasthenia gravis
115. A client with myasthenia gravis is having difficulty speaking. The client's speech is dysarthric and has a nasal tone. The nurse should use which communication strategies when working with this client? Select all that apply. Answer: Listening attentively Asking yes and no questions when able Using a communication board when necessary Repeating what the client said to verify the message
116. The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by which activity? Answer: Taking medications on time to maintain therapeutic blood levels
117. The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statements? Answer: "Going to the beach will be a nice, relaxing form of activity."
118. A client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse should immediately place the client where? Answer: In a quiet, dim room with respiratory and cardiac support available
119. The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will perform which activity? Answer: Rock back and forth to start movement with bradykinesia.

120. An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which is consistent with normal findings? Answer: Red blood cells
121. The nurse is collecting data on a client with a diagnosis of meningitis and notes that the client is assuming this posture. (Refer to figure.) The nurse contacts the health care provider and reports that the client is exhibiting which? Answer: Opisthotonos
122. An older gentleman is brought to the emergency department by a neighbor who heard him talking and wandering in the street at 3 am. The nurse should first determine which about the client? Answer: Whether this is a change in his usual level of orientation
123. An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client's daughter. The daughter states that this is the first time that the client experienced confusion. The nurse determines from this piece of information that which is unlikely to be the cause of the client's disorientation? Answer: Alzheimer's disease
124. A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." An appropriate response by the nurse is which? Answer: "I'm glad you told me that. Let's have a cup of coffee and you can tell me about your father."
125. The nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which information? Answer: Masklike facies is a component of Parkinson's disease.
126. The nurse is communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse should perform which? Answer: Lower the voice pitch and face the client when speaking.
127. The nurse overhears the term sundowning used to describe the behavior of a client newly admitted to the nursing unit during the previous evening shift. Of which diagnosis is sundowning a symptom? Answer: Alzheimer's disease
128. The nurse has reinforced discharge instructions to the client who has had ocular surgery of the right eye. The nurse determines that the client needs further teaching if the client states which? Answer: "I will call the health care provider if a temperature of 99° F is present."

129. A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client makes which statement? Answer: "There is no difficulty driving at dusk."
130. A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which observation? Answer: A lag in closing the bottom eyelid
131. An adult client with suspected meningitis has undergone lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis of a bacterial infection. The nurse checks for which value indicating a bacterial infection of the CSF? Answer: Decreased glucose level
132. A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder? Answer: "Have you had difficulty with peripheral vision?"
133. The nurse is preparing to reinforce instructions to a client with glaucoma regarding the prescribed treatment measures for the disorder. The nurse prepares the instructions based on which treatment goal? Answer: Maintaining intraocular pressure at a reduced level
134. The nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which instructions should the nurse reinforce to the client? Answer: "You may return to work 1 or 2 days following the procedure."
135. The nurse reinforces instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure in the eyes. Which statement by the client indicates a need for further teaching? Answer: "I can tie my shoelaces by bending over slowly."
136. A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestation associated with this disorder should the nurse expect to be documented in the client's record? Answer: Painless, progressive loss of vision
137. Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse reinforces instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further teaching? Answer: "The prescriptive glasses will correct my visual

field of sight."

138. A client is brought to the ambulatory care department by the spouse one day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse reinforces instructions to the client and spouse regarding the treatment for the complication and makes which statement? Answer: "Maintain bed rest and patching of both eyes."
139. The nurse is reinforcing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for further teaching? Answer: "I can drink any liquids that I want to on the morning of the surgery."
140. The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse should expect the client to report which symptom? Answer: Blurred central vision
141. The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction should the nurse include in the teaching plan for the client? Answer: Apply a warm compress for 15 minutes four times daily.
142. The nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse should take which action? Answer: Notify the registered nurse.
143. A client arrives at the emergency department after experiencing a traumatic blow to the eye and a hyphema is diagnosed. In which position should the nurse place the client? Answer: In semi-Fowler's position
144. A client who was hit in the eye with a baseball bat sustains a contusion of the eyeball. The emergency department nurse implements which immediate action? Answer: Applies ice to the affected eye
145. A client arrives in the emergency department with an eye injury caused by metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse plan to assist with first? Answer: Irrigate the eye with sterile saline.
146. A client arrives in the emergency department with a chemical eye injury. The nurse immediately performs which action?

Answer: Irrigates the eye with copious amounts of sterile normal saline

147. The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan? Answer: Administering medications that will dilate the pupil
148. The nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for further teaching? Answer: "Sutures are removed in 2 weeks."
149. The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse should take which action? Answer: Notify the registered nurse.
150. The nurse is monitoring a client with a head injury and notes that the client is assuming the posture shown in the figure. What is the client exhibiting that would require the nurse to notify the registered nurse immediately? Refer to the figure. Answer: Decorticate posturing
151. The nurse is inserting soft contact lenses into the eyes of a client. Which direction does the nurse tell the client to look? Answer: Straight ahead
152. The nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs further teaching regarding the eye drop application of pilocarpine hydrochloride (Isopto Carpine)? Select all that apply. Answer: "I should apply the eye drops directly over my family member's pupil." "I have to contact the prescriber if my family member develops a small pupil." "I need to wipe off the tip of the eye drop bottle with a tissue between administrations."
153. The nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle crash. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation? Answer: Extension of the extremities and pronation of the arms
154. The nurse is caring for a client diagnosed with Bell's palsy 1 week ago. Which data would indicate a potential complication associated with Bell's palsy? Answer: Excessive tearing

155. The nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data should focus on which characteristic of this disease? Answer: Recent memory loss
156. The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply. Answer: Bowel sounds are absent. The client's abdomen is distended. Respiratory excursion is diminished. Accessory muscles of respiration are areflexic.
157. The nurse is ambulating a client with a known seizure disorder. The client says, "I'm seeing those flashing lights again," then loses consciousness and develops a clonic-tonic seizure. Which would be the nurse's initial action? Answer: Assist the client to the floor.
158. The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement? Answer: "I can't swallow very well today."
159. The nurse is providing client teaching regarding glaucoma. Which instructions are important to include in the teaching plan? Select all that apply. Answer: Follow a low-sodium, minimal-caffeine diet with plenty of fiber. Be sure to report halos of light or increased eye pain to your health care provider.
160. A client arrives at the emergency department following a blow to the eye from a softball. Which intervention should be implemented by the nurse initially? Answer: Apply ice to the affected eye.
161. While at home, the nurse receives a telephone call from a neighbor, who reports that while accidentally breaking a mirror, a piece of glass flew into her eye. Which is the appropriate initial nursing action after observing that the large glass shard is protruding from the neighbor's eye? Answer: Secure a paper cup over the affected eye.
162. A client arrives at the emergency department following an eye injury in which an acid used to clean the brick on the fireplace splashed into the eye. Which question should the nurse ask initially? Answer: "Did you flush the eye following the injury?"

163. The nurse is caring for a client following enucleation. Which postsurgical observation requires immediate attention by the nurse? Answer: Bright red drainage on the dressing
164. Which instruction is appropriate for the nurse to provide to a client who reports via telephone that he is certain an insect has flown into his ear because he can hear it "buzzing"? Answer: Use a flashlight to coax the insect out of the ear.
165. Which statement by the nurse indicates an understanding of the diagnosis of presbycusis? Answer: "It is a sensorineural type of hearing loss that occurs with aging."
166. The nurse determines that the client diagnosed with Ménière's disease understands the reinforced dietary instructions when the client states that which food will be avoided in the diet? Answer: Hot dogs
167. The nurse is assisting in developing a plan of care for a client following the surgical removal of an acoustic neuroma. Which assessment will be included in the plan of care for this specific intervention? Answer: Assessment of cranial nerve VII (facial)
168. A client is being discharged from the ambulatory care unit following cataract removal. Which instruction from the discharge teaching plan should the nurse reinforce? Answer: Take acetaminophen (Tylenol) if any discomfort occurs.
169. The nurse is reinforcing instructions to a client following a cataract extraction on the right eye. Which statement by the client indicates a need for further teaching? Answer: "I need to wear an eye shield all the time."
170. When the nurse documents the results of a Snellen vision test as 20/80 vision, the client asks the nurse to describe what these numbers mean. Which statement is the appropriate response? Answer: "You can read at a distance of 20 feet what a client with normal vision can read at 80 feet."
171. Which information will the nurse reinforce to the client scheduled for a lumbar puncture? Answer: An informed consent will be required.
172. The nurse is reinforcing instructions to a client taking divalproex sodium (Depakote). The nurse tells the client to return to the clinic for follow-up laboratory studies related to which test? Answer: Liver function studies

173. Which data collection finding supports the possible diagnosis of Bell's palsy? Answer: Speech or chewing difficulties accompanied by facial droop
174. The nurse reviews the health care provider's treatment plan for a client with Guillain-Barré syndrome. Which prescription noted in the client's record should the nurse question? Answer: Clear liquid diet
175. A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which action to determine whether the client is ready to begin sitting up? Answer: Compares the client's pulse and blood pressure when both flat and sitting
176. A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client? Answer: Monitoring the respiratory rate
177. A client with myasthenia gravis is experiencing prolonged periods of weakness. The health care provider prescribes a test dose of edrophonium (Enlon) and the client becomes weaker. The nurse interprets this outcome as indicative of which result? Answer: Cholinergic crisis
178. The nurse is assisting in gathering data on cranial nerve XII of a client who sustained a brain attack (stroke). The nurse understands that the client should be asked to perform which action? Answer: Extend the tongue.
179. The nurse is assisting to perform a Romberg test on a client being seen in the clinic. The nurse performs this test to make which determination? Answer: The ability of the vestibular apparatus in the inner ear
180. A perforated eardrum is suspected in a client who was hit in the ear with a basketball. Which documented observation concerning an otoscopic examination supports this suspicion? Answer: A round or oval darkened area on the eardrum
181. The nurse is assisting in performing a confrontation test on a client seen in the clinic. The nurse understands that this test is performed to check which client ability? Answer: The ability to demonstrate effective peripheral vision
182. The nurse in a health care clinic is assisting to test the client for accommodation. The nurse should ask the client to perform which initial action? Answer: Focus on a distant object.

183. The nurse is reviewing the medical record of a client diagnosed with amyotrophic lateral sclerosis (ALS). Which initial sign/symptom of this disorder supports this diagnosis? Answer: Mild clumsiness
184. The nurse is assisting in caring for a client with a supratentorial lesion. The nurse monitors which criterion as the critical index of central nervous system (CNS) dysfunction? Answer: Level of consciousness
185. The nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure (ICP). Which indicates an early sign of increased ICP? Answer: Confusion
186. Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. The nurse monitors the client for effectiveness of this medication, knowing which is its primary action? Answer: Decrease cerebrospinal fluid production
187. Which sign/symptom is observed in the clonic phase of a seizure? Answer: Extension spasms of the body
188. The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply. Answer: Suction machine Oxygen administration Padding for the side rails Prescribed diazepam (Valium)
189. The nurse is preparing for the admission of a client with a diagnosis of early stage Alzheimer's disease. The nurse assists in developing a plan of care, knowing that which is a characteristic of early Alzheimer's disease? Answer: Forgetfulness
190. The clinic nurse is reviewing the medical record of a client scheduled to be seen in the clinic. The nurse notes that the client is prescribed selegiline hydrochloride (Eldepryl). The nurse understands that this medication is prescribed for which diagnosis? Answer: Parkinson's disease
191. The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. Which documented early symptom supports this diagnosis? Answer: Vertigo