Prioritization_Chapter_7_Neurological_Revised_20_August_2022

KEY:
All un-highlighted questions are required for Medsurg 1
Red Text = Should Understand
Green Text = Absolutely Should Know
Yellow Highlight = Medsurg 2 Material (Skip in Medsurg 1)
Blue Highlight = Skip (In both Medsurg 1 & 2)


Chapter 7 Neurological

1. The charge nurse has received laboratory data for clients in the medical department. Which
client would require intervention by the charge nurse?

1. The client diagnosed with a stroke who has a platelet level of 250,000 μ/L.
2. The client with a seizure disorder who has a divalproex (Depakote) level of 75 μg/mL.
3. The client with multiple sclerosis on prednisone who has a glucose level of 208 mg/dL.
4. The client receiving the anticonvulsant phenytoin (Dilantin) who has serum levels of 24
mg/dL.

Correct answer: 4

1. The serum platelet level is within the normal range of 150,000 to 400,000 mL; therefore, this
laboratory does not warrant intervention by the charge nurse.
2. A therapeutic Depakote level is 50 to 100 ug/ mL; therefore, this laboratory result does not
warrant action by the nurse.
3. Steroids, such as prednisone, elevate a client’s blood glucose level; therefore, this does
not warrant intervention by the nurse.
4. The therapeutic range for Dilantin is 10–20 mg/dL. This client’s higher level
warrants intervention because the serum level is above therapeutic range.

MAKING NURSING DECISIONS: The nurse must be knowledgeable of normal laboratory
values. These values must be memorized and the nurse must be able to determine if the
laboratory value is normal for the client’s disease process or medications the client is taking.

2. The nurse is administering medications for clients on a neurological unit. Which
medication should the nurse administer first?

1. A pain medication to a client complaining of a headache rated an 8 on 1 to 10 pain scale.
2. A steroid to the client experiencing an acute exacerbation of multiple sclerosis.
3. An anticholinesterase medication to a client diagnosed with myasthenia gravis.
4. An antacid to a client with pyrosis who has called several times over the intercom.

Correct answer: 3

,1. A pain medication is important to administer in a timely manner, but its administration is not
priority over a medication that must be administered on time to prevent respiratory
complications.
2. A steroid medication is not priority over a client who may experience respiratory
difficulty. Steroids must be given to prevent adrenal sufficiency but it does not have to
be administered first.
3. Anticholinesterase medications administered for myasthenia gravis must be administered
on time to preserve muscle functioning, especially the functioning of the muscles of the upper
respiratory tract. {This is the priority medication.}
4. Clients who have called for medications should be attended to, but this client would not
receive an antacid for heartburn before the client diagnosed with myasthenia gravis or the client
in pain.

MAKING NURSING DECISIONS: The nurse must be aware of expected actions of
medications, and assess data indicating whether the medication is effective or the medication is
causing a side effect or an adverse effect.

3. The nurse has just received the shift report. Which client should the nurse assess first?

1. The client with Guillain-Barré syndrome who has ascending paralysis to the knees.
2. The client with a C-6 spinal cord injury who has autonomic dysreflexia.
3. The client with Parkinson’s disease who is experiencing “pill rolling.”
4. The client with Huntington’s disease who has writhing, twisting movements of the face.

Correct answer: 2

1. The nurse would expect the client with Guillain-Barr? syndrome to have ascending paralysis
and the problem has just reached the knees, so the nurse should not need to assess this client first.
2. The client with a C-6 SCI is expected to have autonomic dysreflexia but it is an
emergency situation; therefore, the nurse should assess this client first.
3. “Pill rolling,” a hand tremor wherein the thumb and forefinger appear to move in a rotary
fashion as if rolling a pill, is an expected clinical manifestation of Parkinson’s; therefore,
the nurse would not assess this client first.
4. The client with Huntington’s disease has chorea, which includes abnormal and
excessive involuntary movements; therefore, this client would not be assessed first.

MAKING NURSING DECISIONS: The nurse must determine which sign/symptom is not
expected for the disease process. If the sign/symptom is not expected or it is an emergency
situation, then the nurse should assess the client first. This type of question is determining if the
nurse is knowledgeable of signs/symptoms of a variety of disease processes.

4. The nurse and unlicensed assistive personnel (UAP) are caring for a client with
right-sided paralysis. Which action by the UAP requires the nurse to
intervene?

1. The UAP places the gait belt around the client’s waist prior to ambulating.
2. The UAP places the client on the abdomen with the client’s head to the side.

,3. The UAP places her hand under the client’s right axilla to help the client move up in bed.
4. The UAP praises the client for performing activities of daily living independently.

Correct answer: 3

1. Placing a gait belt prior to ambulating is an appropriate action for safety and would not
require the nurse to intervene.
2. Placing the client in a prone position helps promote hyperextension of the hip joints, which is
essential for normal gait and helps prevent knee and hip flexion contractures; therefore, this
would not require the nurse to intervene.
3. This action is inappropriate and would require intervention by the nurse because pulling on a
flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing
the arm underneath the client’s back or using a lift sheet.
4. The client should be encouraged and praised for attempting to perform any
activities independently, such as combing hair or brushing teeth.

MAKING NURSING DECISIONS: The nurse must ensure the UAP can perform any tasks
that are delegated. It is the nurse’s responsibility to demonstrate and/or teach the UAP how
to perform the task, and evaluate the task.

5. The charge nurse is making client assignments for a neuro-medical floor. Which
client should be assigned to the most experienced nurse?

1. The elderly client who is experiencing a stroke in evolution.
2. The client diagnosed with a transient ischemic attack 48 hours ago.
3. The client diagnosed with Guillain-Barré syndrome who complains of leg pain.
4. The client with Alzheimer’s disease who is wandering in the halls.

Correct answer: 1

1. Because the client is having an evolving stroke, the client is experiencing a worsening of
signs/symptoms over several minutes to hours; thus, the client is at risk for dying and should be
cared for by the most experienced nurse.
2. A transient ischemic attack by definition lasts less than 24 hours; thus, this client should be
stable at this time.
3. Pain is expected in clients with Guillain-Barr? syndrome, and symptoms typically occur on
the lower half of the body, which wouldn’t affect the airway. Therefore, a less experienced nurse
could care for this client.
4. The charge nurse could assign this client to an unlicensed assistive personnel (UAP).

MAKING NURSING DECISIONS: When the nurse is deciding which client should be
assigned to the most experienced nurse, the most critical and unstable client should be assigned
to the most experienced nurse.

, 6. The client diagnosed with a cerebrovascular accident (CVA) has residual right-sided
hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most
appropriate for the case manager to make at this time?

1. Inpatient rehabilitation unit.
2. Home healthcare agency.
3. Long-term care facility.
4. Outpatient therapy center.

Correct answer: 1

1. This client should be referred to an inpatient rehabilitation facility for intensive therapy before
deciding on long-term placement (home with home healthcare or a long-term care facility). The
initial rehabilitation a client receives can set the tone for all further recuperation. This is the
appropriate referral at this time.
2. A home healthcare agency may be needed when the client returns home, but the most
appropriate referral is to a rehabilitation center where intensive therapy can take place.
3. A long-term care facility may be needed at some point, but the client should be given the
opportunity to regain as much lost ability as possible at this time.
4. The outpatient center would be utilized when the client is ready for discharge from
the inpatient center.

MAKING NURSING DECISIONS: The nurse must be knowledgeable of the role of all
members of the multidisciplinary healthcare team, as well as HIPAA rules and regulations. These
will be tested on the NCLEX-RN® exam.

7. The nurse and LPN are caring for a client diagnosed with a stroke. Which intervention
should the nurse assign to the LPN?

1. Feed the client who is being allowed to eat for the first time.
2. Administer the client’s anticoagulant subcutaneously.
3. Check the client’s neurological signs and limb movement.
4. Teach the client to turn the head and tuck the chin to swallow.

Correct answer: 2

1. The nurse should be the first one to feed the client in order for the nurse to evaluate the
client’s ability to swallow and not aspirate.
2. The LPN could administer routine parenteral medications. This is the best task to assign to
the LPN.
3. This involves assessing the client; therefore, the nurse should not delegate this assignment to
the LPN.
4. Teaching is the responsibility of the RN.