The Client with Neurologic Health problems. Best exam study Guide

The Client with Neurologic Health problems.
Best exam study Guide.

The Client with Neurologic Health
Problems
The Client with a Head Injury
The Client with Seizures
The Client with a Stroke
The Client with Parkinson’s Disease
The Client with Multiple Sclerosis
The Unconscious Client
The Client in Pain
Managing Care Quality and Safety
Answers, Rationales, and Test Taking Strategies

The Client with a Head Injury
1. Following a craniotomy, a client has been
admitted to the neurologic intensive care unit. The
nurse has established a goal to maintain intracranial
pressure (ICP) within the normal range. What
should the nurse do? Select all that apply.
1. Encourage the client to cough and take deep
breaths.
2. Elevate the head of the bed 15 to 30 degrees.
3. Contact the health care provider if ICP is
greater than 20 mm Hg.
4. Monitor neurologic status using the Glasgow
Coma Scale.
5. Stimulate the client with active range-of-motion
exercises.
2. The nurse is monitoring a client with
increased intracranial pressure (ICP). What indicators
are the most critical for the nurse to monitor?
Select all that apply.
1. Systolic blood pressure.
2. Urine output.
3. Breath sounds.
4. Cerebral perfusion pressure.
5. Level of pain.
3. A nurse is assessing a client with increasing
intracranial pressure. What is a client’s mean arterial
pressure (MAP) in mm Hg when blood pressure (BP)
is 120/60 mm Hg?
mm Hg.
4. A client with a contusion has been admitted
for observation following a motor vehicle accident
when he was driving his wife to the hospital to
deliver their child. The next morning, instead of
asking about his wife and baby, he asked to see the
football game on television that he thinks is starting
in 5 minutes. He is agitated that the nurse will not
turn on the television. What should the nurse do
next? Select all that apply.
1. Find a television so the client can view the

,The Client with Neurologic Health problems.
Best exam study Guide.
football game.
2. Determine if the client’s pupils are equal and
react to light.
3. Ask the client if he has a headache.
4. Arrange for the client to be with his wife and
baby.
5. Administer a sedative.
5. An unconscious client with multiple injuries
arrives in the emergency department. Which nursing
intervention receives the highest priority?
1. Establishing an airway.
2. Replacing blood loss.
3. Stopping bleeding from open wounds.
4. Checking for a neck fracture.
6. A client is at risk for increased intracranial
pressure (ICP). Which of the following would be the
priority for the nurse to monitor?
1. Unequal pupil size.
2. Decreasing systolic blood pressure.
3. Tachycardia.
4. Decreasing body temperature.

7. What should the nurse do fi rst when a client
with a head injury begins to have clear drainage
from his nose?
1. Compress the nares.
2. Tilt the head back.
3. Give the client tissues to collect the fl uid.
4. Administer an antihistamine for postnasal
drip.
8. Which of the following respiratory patterns
indicates increasing intracranial pressure in the
brain stem?
1. Slow, irregular respirations.
2. Rapid, shallow respirations.
3. Asymmetric chest excursion.
4. Nasal fl aring.
9. Which of the following nursing interventions
is appropriate for a client with an increased intracranial
pressure (ICP) of 20 mm Hg?
1. Give the client a warming blanket.
2. Administer low-dose barbiturates.
3. Encourage the client to hyperventilate.
4. Restrict fl uids.
10. The nurse is assessing a client with increasing
intracranial pressure (ICP). The nurse should
notify the health care provider about which of the
following changes in the client’s condition?
1. Widening pulse pressure.
2. Decrease in the pulse rate.
3. Dilated, fi xed pupils.
4. Decrease in level of consciousness (LOC).

,The Client with Neurologic Health problems.
Best exam study Guide.

11. The client has a sustained increased intracranial
pressure (ICP) of 20 mm Hg. Which client
position would be most appropriate?
1. The head of the bed elevated 30 to 45 degrees.
2. Trendelenburg’s position.
3. Left Sims position.
4. The head elevated on two pillows.
12. The nurse administers mannitol (Osmitrol)
to the client with increased intracranial pressure.
Which parameter requires close monitoring?
1. Muscle relaxation.
2. Intake and output.
3. Widening of the pulse pressure.
4. Pupil dilation.
13. A client is being admitted with a spinal cord
transection at C7. Which of the following assessments
take priority upon the client’s arrival? Select
all that apply.
1. Refl exes.
2. Bladder function.
3. Blood pressure.
4. Temperature.
5. Respirations.
14. The nurse is assessing a client for movement
after halo traction placement for a C8 fracture.
The nurse should document which of the
following?
1. The client’s shoulders shrug against downward
pressure of the examiner’s hands.
2. The client’s arm pulls up from a resting position
against resistance.
3. The client’s arm straightens out from a fl exed
position against resistance.
4. The client’s hand-grasp strength is equal.
15. Four days after surgery for internal fi xation of
a C3 to C4 fracture, a nurse is moving a client from
the bed to the wheelchair. The nurse is checking
the wheelchair for correct features for this client.
Which of the following features of the wheelchair
are appropriate for the needs of this client? Select
all that apply.
1. Back at the level of the client’s scapula.
2. Back and head that are high.
3. Seat that is lower than normal.
4. Seat with fi rm cushions.
5. Chair controlled by the client’s breath.
16. A male client with a head injury regains consciousness
after several days. Which of the following
nursing statements is most appropriate as the
client awakens?
1. “I’ll get your family.”
2. “Can you tell me your name and where you
live?”

, The Client with Neurologic Health problems.
Best exam study Guide.

3. “I’ll bet you’re a little confused right now.”
4. “You are in the hospital. You were in an accident
and unconscious.”
17. A client who is regaining consciousness
after a craniotomy becomes restless and attempts to
pull out the I.V. line. Which nursing intervention
protects the client without increasing her increased
intracranial pressure (ICP)?
1. Place her in a jacket restraint.
2. Wrap her hands in soft “mitten” restraints.
3. Tuck her arms and hands under the
drawsheet.
4. Apply a wrist restraint to each arm.
18. Which activity should the nurse encourage
the client to avoid when there is a risk for increased
intracranial pressure (ICP)?
1. Deep breathing.
2. Turning.
3. Coughing.
4. Passive range-of-motion (ROM) exercises.

19. Which of the following is most effective in
assessing the client suspected of developing diabetes
insipidus?
1. Taking vital signs every 2 hours.
2. Measuring urine output hourly.
3. Assessing arterial blood gas values every
other day.
4. Checking blood glucose levels.
20. A client who had a serious head injury with
increased intracranial pressure is to be discharged
to a rehabilitation facility. Which of the following
rehabilitation outcomes would be appropriate for
the client? The client will:
1. Exhibit no further episodes of short-term
memory loss.
2. Be able to return to his construction job in
3 weeks.
3. Actively participate in the rehabilitation
process as appropriate.
4. Be emotionally stable and display pre-injury
personality traits.
21. Which of the following describes decerebrate
posturing?
1. Internal rotation and adduction of arms with
fl exion of elbows, wrists, and fi ngers.
2. Back hunched over, rigid fl exion of all four
extremities with supination of arms and plantar
fl exion of feet.
3. Supination of arms, dorsifl exion of the feet.
4. Back arched, rigid extension of all four
extremities.
22. A client receiving vent-assisted mode ventilation