NUR403>100 Neuro NCLEX Questions With Answers tested And Verified Exam Solutions, Exams of Nursing

Download NUR403>100 Neuro NCLEX Questions With Answers tested And Verified Exam Solutions and more Exams Nursing in PDF only on Docsity! NUR403>100 Neuro NCLEX Questions With Answers tested And Verified Exam Solutions 1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? 1.Reposition the client to avoid neck flexion 2.Administer 1 g Mannitol IV as ordered 3. Increase the ventilator’s respiratory rate to 20 breaths/minute 4.Administer 100 mg of pentobarbital IV as ordered. 2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Rapid Dilantin administration can cause cardiac arrhythmias. 3.Dilantin should be mixed in dextrose in water before administration. 4.Dilantin should be administered through an IV catheter in the client’s hand. 3. A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? 1.Evaluate urine specific gravity 2.Anticipate treatment for renal failure 3.Provide emollients to the skin to prevent breakdown 4.Slow down the IV fluids and notify the physician 4. When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? 1.Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). 2.Emergent; the client is poorly oxygenated. 3.Normal 4.Significant; the client has alveolar hypoventilation. 5. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? 1. Bloody drainage from the ears 2. Frequent swallowing 3.Guaiac-positive stools 4.Hematuria 6. After a hypophysectomy, vasopressin is given IM for which of the following reasons? 1.To treat growth failure 2.To prevent syndrome of inappropriate antidiuretic hormone (SIADH) 3.To reduce cerebral edema and lower intracranial pressure 4.To replace antidiuretic hormone (ADH) normally secreted by the pituitary. 7. A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing interventions should be done first? 3.Perform a straight catheterization every 8 hours while awake 4.Perform Crede’s maneuver to the lower abdomen before the client voids. 15. A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? 1.Laceration of the middle meningeal artery 2.Rupture of the carotid artery 3.Thromboembolism from a carotid artery 4.Venous bleeding from the arachnoid space 16. A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? 1.Position the client flat in bed 2.Check the fluid for dextrose with a dipstick 3.Suction the nose to maintain airway patency 4. Insert nasal and ear packing with sterile gauze 17. When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? 1.An interval when the client’s speech is garbled 2.An interval when the client is alert but can’t recall recent events 3.An interval when the client is oriented but then becomes somnolent 4.An interval when the client has a “warning” symptom, such as an odor or visual disturbance. 18. Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? 1.A client with a brain injury 2.A client with a herniated nucleus pulposus 3. A client with a high cervical spine injury 4. A client with a stroke 19. Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? 1. Absence of pain sensation in chest 2. Spasticity 3.Spontaneous respirations 4.Urinary continence 20. A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? 1.Headache 2.Lumbar spinal cord injury 3.Neurogenic shock 4. Noxious stimuli 21. During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? 1.Elevate the client’s legs 2.Put the client flat in bed 3.Put the client in the Trendelenburg’s position 4. Put the client in the high- Fowler’s position 22. A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? 1.Autonomic dysreflexia 2.Hypervolemia 3.Neurogenic shock 4.Sepsis 23. A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? 1.Absent corneal reflex 2.Decerebrate posturing 3.Movement of only the right or left half of the body 4. The need for mechanical ventilation 24. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? 1. Decreased urine output or oliguria 2. Hypertension and bradycardia 3.Respiratory depression 4.Symptoms of shock 1.By inserting a nasopharyngeal airway 2.By inserting a oropharyngeal airway 3. By performing a jaw- thrust maneuver 4. By performing the head-tilt, chin-lift maneuver 32. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. 1.Elevate the HOB to 90 degrees 2.Loosen constrictive clothing 3.Use a fan to reduce diaphoresis 4.Assess for bladder distention and bowel impaction 5.Administer antihypertensive medication 6.Place the client in a supine position with legs elevated 1,2,4,5 33. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client’s urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: 1.Desmopressin (DDAVP, Stimate) 2.Dexamethasone (Decadron) 3.Ethacrynic acid (Edecrin) 4.Mannitol (Osmitrol) 34. The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: 1.Skull fracture 2.Concussion 3.Subdural hematoma 4. Epidural hematoma 35. The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: 1.A flattened abdomen 2.Hematest positive nasogastric tube drainage 3.Hyperactive bowel sounds 4.A history of diarrhea 36. A 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? 1.Strict adherence to a bowel retraining program 2.Limiting bladder catheterization to once every 12 hours 3.Keeping the linen wrinkle-free under the client 4.Preventing unnecessary pressure on the lower limbs 37. The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? 1.Monitoring vital signs before and during position changes 2.Using vasopressor medications as prescribed 3. Moving the client quickly as one unit 4. Applying Teds or compression stockings. 38. The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: 1.Keeping the client on a stretcher 2.Logrolling the client on a firm mattress 3.Logrolling the client on a soft mattress 4. Placing the client on a Stryker frame 39. The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? 1.Positive reflexes 2.Hyperreflexia 3. Inability to elicit a Babinski’s reflex 4.Reflex emptying of the bladder 40. A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client’s vital signs, list in order of priority, the nurse’s actions (Number 1 being the first priority and number 5 being the last priority). 1.Check for bladder distention 2.Raise the head of the bed 3.Contact the physician 3.Call the physician to adjust the ventilator settings. 4.Check deep tendon reflexes to determine the best motor response 48. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? 1. Keeping the client flat on one side or the other 2. Elevating the head of the bed to 30 degrees 3.Log rolling or turning as a unit when turning 4.Keeping the head in neutral position 49. A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply. 1.Decerebrate posturing 2.Dilated nonreactive pupils 3.Deep tendon reflexes 4.Absent corneal reflex 2,3,4 50. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? 1.Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. 2.Administer phenytoin (Dilantin) 200 mg PO daily. 3.Teach patient about the need for good oral hygiene. 4.Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation. 51. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: A. Body temperature control. B. Balance and equilibrium. C.Visual acuity. D. Thinking and reasoning. 52. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? A. Phenytoin (Dilantin) B. Mannitol (Osmitrol) C. Lidocain e (Xylocaine) D. Furosemide (Lasix) 53. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? A. Give him a barbiturate. B. Place him on mechanical ventilation. C.Perform a lumbar puncture . D. Elevate the head of his bed. 54. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: A. Light flashes and floaters in front of the eye. B. A recent driving accident while changing lanes. C.Headaches, nausea, and redness of the eyes. D. Frequent episodes of double vision. 55. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis? A. Imbalanced nutrition : Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination D. Risk for injury 56. 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. 57. The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? 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 61. 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. 62. 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. Urin e retention or incontinence D. Temperature of 99.2° F (37.3° C) 63. 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. 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. 64. 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. 65. 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. Dystroph ic C. Helicopod D. Steppage 66. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? 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-bed room with a client who previously had bacterial meningitis 67. 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 68. 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 75. 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. 76. 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. 77. 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 78. 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 79. 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. 80. 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. 81. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? 1.Vomiting continues 2. Intracranial pressure (ICP) is increased 3.The client needs mechanical ventilation 4.Blood is anticipated in the cerebrospinal fluid (CSF) 82. A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? 1.To reduce intraocular pressure 2.To prevent acute tubular necrosis 3.To promote osmotic diuresis to decrease ICP 4.To draw water into the vascular system to increase blood pressure 83. A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? 1.Urin e output increases 2.Pupils are 8 mm and nonreactive 3.Systolic blood pressure remains at 150 mm Hg 4.BUN and creatinine levels return to normal 84. Which of the following values is considered normal for ICP? 1.0 to 15 mm Hg 2.25 mm Hg 3.An intact brainstem 4.Brain death 92. The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure. 93. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: 1.A positive Brudzinski’s sign 2.A negative Kernig’s sign 3.Absence of nuchal rigidity 4.A Glascow Coma Scale score of 15 94. A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: 1.Tolerate the pain 2.Decrease the perception of pain 3. Escape the source of pain 4. Divert attention from the source of pain. 95. During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? 1.Limiting conversation with the child 2.Keeping extraneous noise to a minimum 3.Allowing the child to play in the bathtub 4.Performing treatments quickly 96. Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? 1.Hemorrhagic skin rash 2.Edema 3.Cyanosis 4.Dyspnea on exertion 97. When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? 1. Bladde r infection 2. Middle ear infection 3.Fractured clavicle 4.Septic arthritis 98. The nurse is assessing a child diagnosed with a brain tumor . Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. 1.Head tilt 2.Vomiting 3.Polydipsia 4.Lethargy 5. Increased appetite 6. Increased pulse 1,2,4 99. A lumbar puncture is performed on a child suspected of having bacterial meningitis . CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? 1. Cloudy CSF, decreased protein, and decreased glucose 2. Cloudy CSF, elevated protein, and decreased glucose 3.Clear CSF, elevated protein, and decreased glucose 4.Clear CSF, decreased pressure, and elevated protein 100. A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? 1.No precautions are required as long as antibiotics have been started 2.Maintain enteric precautions 3.Maintain respiratory isolation precautions for at least 24 hours after the