Neurological Problem
The nurse is caring for the client with increased intracranial pressure. The nurse would note
which trend in vital signs if the intracranial pressure 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
2.
Rationale:A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and blood pressure and decreasing pulse and respirations.
Respiratory irregularities also may occur.
The nurse is caring for a client who begins to experience seizure activity while in bed. Which
actions should the nurse take? Select all that apply.
1. Loosening restrictive clothing
2. Restraining the client's limbs
3. Removing the pillow and raising padded side rails 4.Positioning the client to the side,
if possible, with the head flexed forward
5.Keeping the curtain around the client and the room door open so when help arrives they can
quickly enter to assist
1,3,4
Rationale:Nursing actions during a seizure include providing for privacy, loosening restrictive
clothing, removing the pillow and raising padded side rails in the bed, and placing the client on
one side with the head flexed forward, if possible, to allow the tongue to fall forward and
facilitate drainage. 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.
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,The nurse is instructing a client with Parkinson's disease about preventing falls. Which client
statement reflects a need for further teaching?
1. "I can sit down to put on my pants and shoes."
2. "I try to exercise every day and rest when I'm tired." 3."My son removed all loose rugs
from my bedroom." 4."I don't need to use my walker to get to the bathroom."
4
Rationale:The client with Parkinson's disease should be instructed regarding safety measures in
the home. The client should use his or her walker as support to get to the bathroom because of
bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client
should exercise every day in the morning when energy levels are highest. The client should have
all loose rugs in the home removed to prevent falling.
The nurse is instituting seizure precautions for a client who is being admitted from the
emergency department. Which measures should the nurse include in planning for the client's
safety? Select all that apply.
1.Padding the side rails of the bed
2.Placing an airway at the bedside
3.Placing the bed in the high position
P a g e 2 | 428
,4. Putting a padded tongue blade at the head of the bed
5. Placing oxygen and suction equipment at the bedside 6.Flushing the intravenous catheter
to ensure that the site is patent
1,2,5,6
Rationale:Seizure precautions may vary from agency to agency, but they generally have some
common features. Usually, an airway, oxygen, and suctioning equipment are kept available at
the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The
client has an intravenous access in place to have a readily accessible route if antiseizure
medications must be administered, and as part of the routine assessment the nurse should be
checking patency of the catheter. The use of padded tongue blades is highly controversial, and
they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure
more likely will harm the client who bites down during seizure activity. Risks include blocking
the airway from improper placement, chipping the client's teeth, and subsequent risk of
aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse
enough time to place an oral airway before seizure activity begins.
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which
assessment finding would indicate that the client is developing meningitis as a complication of
surgery?
1.A negative Kernig's sign
2.Absence of nuchal rigidity
3.A positive Brudzinski's sign
4.A Glasgow Coma Scale score of
15 3
Rationale:Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a
positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff
neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is
positive when the client feels pain and spasm of the hamstring muscles when the leg is fully
flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees
in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale
score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological
deficits.
The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place
the client in which best position following the procedure?
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, 1. Prone in semi Fowler's position
2. Supine in semi Fowler's position
3. Prone with a small pillow under the abdomen 4.Lateral with the head slightly lower than
the rest of the body
3
Rationale:After the procedure, the client assumes a flat position. If the client is able, a prone
position with a pillow under the abdomen is the best position. This position helps reduce
cerebrospinal fluid leakage and decreases the likelihood of post–lumbar puncture headache. The
remaining options are incorrect.
The student nurse develops a plan of care for a client after a lumbar puncture. The nursing
instructor corrects the student if the student documents which incorrect intervention in the plan?
1.Maintain the client in a flat position.
2. Restrict fluid intake for a period of 2 hours.
P a g e 4 | 428
The nurse is caring for the client with increased intracranial pressure. The nurse would note
which trend in vital signs if the intracranial pressure 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
2.
Rationale:A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and blood pressure and decreasing pulse and respirations.
Respiratory irregularities also may occur.
The nurse is caring for a client who begins to experience seizure activity while in bed. Which
actions should the nurse take? Select all that apply.
1. Loosening restrictive clothing
2. Restraining the client's limbs
3. Removing the pillow and raising padded side rails 4.Positioning the client to the side,
if possible, with the head flexed forward
5.Keeping the curtain around the client and the room door open so when help arrives they can
quickly enter to assist
1,3,4
Rationale:Nursing actions during a seizure include providing for privacy, loosening restrictive
clothing, removing the pillow and raising padded side rails in the bed, and placing the client on
one side with the head flexed forward, if possible, to allow the tongue to fall forward and
facilitate drainage. 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.
P a g e 1 | 428
,The nurse is instructing a client with Parkinson's disease about preventing falls. Which client
statement reflects a need for further teaching?
1. "I can sit down to put on my pants and shoes."
2. "I try to exercise every day and rest when I'm tired." 3."My son removed all loose rugs
from my bedroom." 4."I don't need to use my walker to get to the bathroom."
4
Rationale:The client with Parkinson's disease should be instructed regarding safety measures in
the home. The client should use his or her walker as support to get to the bathroom because of
bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client
should exercise every day in the morning when energy levels are highest. The client should have
all loose rugs in the home removed to prevent falling.
The nurse is instituting seizure precautions for a client who is being admitted from the
emergency department. Which measures should the nurse include in planning for the client's
safety? Select all that apply.
1.Padding the side rails of the bed
2.Placing an airway at the bedside
3.Placing the bed in the high position
P a g e 2 | 428
,4. Putting a padded tongue blade at the head of the bed
5. Placing oxygen and suction equipment at the bedside 6.Flushing the intravenous catheter
to ensure that the site is patent
1,2,5,6
Rationale:Seizure precautions may vary from agency to agency, but they generally have some
common features. Usually, an airway, oxygen, and suctioning equipment are kept available at
the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The
client has an intravenous access in place to have a readily accessible route if antiseizure
medications must be administered, and as part of the routine assessment the nurse should be
checking patency of the catheter. The use of padded tongue blades is highly controversial, and
they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure
more likely will harm the client who bites down during seizure activity. Risks include blocking
the airway from improper placement, chipping the client's teeth, and subsequent risk of
aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse
enough time to place an oral airway before seizure activity begins.
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which
assessment finding would indicate that the client is developing meningitis as a complication of
surgery?
1.A negative Kernig's sign
2.Absence of nuchal rigidity
3.A positive Brudzinski's sign
4.A Glasgow Coma Scale score of
15 3
Rationale:Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a
positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff
neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is
positive when the client feels pain and spasm of the hamstring muscles when the leg is fully
flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees
in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale
score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological
deficits.
The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place
the client in which best position following the procedure?
P a g e 3 | 428
, 1. Prone in semi Fowler's position
2. Supine in semi Fowler's position
3. Prone with a small pillow under the abdomen 4.Lateral with the head slightly lower than
the rest of the body
3
Rationale:After the procedure, the client assumes a flat position. If the client is able, a prone
position with a pillow under the abdomen is the best position. This position helps reduce
cerebrospinal fluid leakage and decreases the likelihood of post–lumbar puncture headache. The
remaining options are incorrect.
The student nurse develops a plan of care for a client after a lumbar puncture. The nursing
instructor corrects the student if the student documents which incorrect intervention in the plan?
1.Maintain the client in a flat position.
2. Restrict fluid intake for a period of 2 hours.
P a g e 4 | 428
