NUR2214 MODULE 4 EAQS NEUROLOGIC DISORDERS &
SEIZURE MANAGEMENT — Q&A WITH RATIONALES
COMPLETE SOLUTION!!
1. During a neurologic exam, stroking the lateral sole causes dorsiflexion of the big
toe and fanning of the others. What should the nurse document?
Answer: “Positive Babinski sign.”
Rationale: A positive Babinski reflex indicates upper motor neuron dysfunction in
anyone older than infancy.
2. A client is admitted after a tonic-clonic seizure at work. What question is most
helpful for planning care?
Answer: “Did you notice anything unusual before the seizure began?”
Rationale: Asking about an aura or warning helps identify triggers and guides
preventive measures.
3. The day after ventriculoperitoneal shunt placement, an infant’s temperature rises
to 103°F (39.4°C). After notifying the provider, what should the nurse do next?
Answer: Remove excess clothing.
Rationale: Reducing external heat helps manage fever while further evaluation
occurs, and fever may indicate shunt infection.
4. A client is comatose after a stroke. What is the priority nursing action?
,Answer: Ensure the airway is open.
Rationale: Airway maintenance is the top priority to prevent hypoxia and
complications in an unconscious client.
5. A CVA patient has expressive aphasia; the spouse answers questions for him.
How should the nurse respond?
Answer: Acknowledge the spouse but direct questions and eye contact to the client.
Rationale: This encourages the client’s communication efforts and preserves
autonomy.
6. A child begins a tonic-clonic seizure while sitting in a chair. What is the nurse’s
first action?
Answer: Move the child to the floor safely.
Rationale: Lowering the child prevents injury from a fall during convulsions.
7. A client has inflammation of the facial nerve with one-sided facial paralysis.
What diagnosis is expected?
Answer: Bell palsy.
Rationale: Bell palsy results from cranial nerve VII inflammation, producing
unilateral facial weakness.
,8. Which antiepileptic drug is first-line for absence seizures?
Answer: Valproic acid.
Rationale: Valproic acid is commonly used to treat absence seizures when
ethosuximide is not chosen.
9. A client reports inability to smell coffee or most foods. Which cranial nerve
should be assessed?
Answer: Cranial nerve I (olfactory).
Rationale: CN I controls the sense of smell.
10. Which statement reflects accurate knowledge about cluster headaches
(trigeminal autonomic cephalalgia)?
Answer: They are associated with hypothalamic overactivity.
Rationale: Research shows cluster headaches involve abnormal hypothalamic
activation affecting circadian rhythms.
11. A client taking large amounts of aspirin complains of tinnitus and dizziness.
What complication does this suggest?
Answer: Salicylate toxicity.
Rationale: Early signs of aspirin toxicity include ringing in the ears, dizziness, and
nausea.
, 12. Damage to which cranial nerve causes reduced sense of smell?
Answer: Cranial nerve I.
Rationale: Injury to the olfactory nerve impairs detection of odors.
13. While using the Glasgow Coma Scale, the nurse applies nail-bed pressure.
Which response is most concerning?
Answer: Extension of the upper extremity.
Rationale: Decerebrate posturing (extension) indicates severe brainstem injury and
has a poor prognosis.
14. Which signs indicate increased intracranial pressure in a 3-year-old with
meningitis? (Select all that apply.)
Answer:
Vomiting
Headache
Irritability
SEIZURE MANAGEMENT — Q&A WITH RATIONALES
COMPLETE SOLUTION!!
1. During a neurologic exam, stroking the lateral sole causes dorsiflexion of the big
toe and fanning of the others. What should the nurse document?
Answer: “Positive Babinski sign.”
Rationale: A positive Babinski reflex indicates upper motor neuron dysfunction in
anyone older than infancy.
2. A client is admitted after a tonic-clonic seizure at work. What question is most
helpful for planning care?
Answer: “Did you notice anything unusual before the seizure began?”
Rationale: Asking about an aura or warning helps identify triggers and guides
preventive measures.
3. The day after ventriculoperitoneal shunt placement, an infant’s temperature rises
to 103°F (39.4°C). After notifying the provider, what should the nurse do next?
Answer: Remove excess clothing.
Rationale: Reducing external heat helps manage fever while further evaluation
occurs, and fever may indicate shunt infection.
4. A client is comatose after a stroke. What is the priority nursing action?
,Answer: Ensure the airway is open.
Rationale: Airway maintenance is the top priority to prevent hypoxia and
complications in an unconscious client.
5. A CVA patient has expressive aphasia; the spouse answers questions for him.
How should the nurse respond?
Answer: Acknowledge the spouse but direct questions and eye contact to the client.
Rationale: This encourages the client’s communication efforts and preserves
autonomy.
6. A child begins a tonic-clonic seizure while sitting in a chair. What is the nurse’s
first action?
Answer: Move the child to the floor safely.
Rationale: Lowering the child prevents injury from a fall during convulsions.
7. A client has inflammation of the facial nerve with one-sided facial paralysis.
What diagnosis is expected?
Answer: Bell palsy.
Rationale: Bell palsy results from cranial nerve VII inflammation, producing
unilateral facial weakness.
,8. Which antiepileptic drug is first-line for absence seizures?
Answer: Valproic acid.
Rationale: Valproic acid is commonly used to treat absence seizures when
ethosuximide is not chosen.
9. A client reports inability to smell coffee or most foods. Which cranial nerve
should be assessed?
Answer: Cranial nerve I (olfactory).
Rationale: CN I controls the sense of smell.
10. Which statement reflects accurate knowledge about cluster headaches
(trigeminal autonomic cephalalgia)?
Answer: They are associated with hypothalamic overactivity.
Rationale: Research shows cluster headaches involve abnormal hypothalamic
activation affecting circadian rhythms.
11. A client taking large amounts of aspirin complains of tinnitus and dizziness.
What complication does this suggest?
Answer: Salicylate toxicity.
Rationale: Early signs of aspirin toxicity include ringing in the ears, dizziness, and
nausea.
, 12. Damage to which cranial nerve causes reduced sense of smell?
Answer: Cranial nerve I.
Rationale: Injury to the olfactory nerve impairs detection of odors.
13. While using the Glasgow Coma Scale, the nurse applies nail-bed pressure.
Which response is most concerning?
Answer: Extension of the upper extremity.
Rationale: Decerebrate posturing (extension) indicates severe brainstem injury and
has a poor prognosis.
14. Which signs indicate increased intracranial pressure in a 3-year-old with
meningitis? (Select all that apply.)
Answer:
Vomiting
Headache
Irritability
