1.

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. 2. 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. lidocaine (Xylocaine) d. furosemide (Lasix) 3. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. Hes 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. 4. 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. 5. Which nursing diagnosis takes highest priority for a client with Parkinsons crisis? a. Imbalanced nutrition: Less than body requirements b. Ineffective airway clearance c. Impaired urinary elimination d. Risk for injury 6. To encourage adequate nutritional intake for a female client with Alzheimers 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. 7. The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses which of the following?

a. Cerebellar function b. Intellectual function c. Cerebral function d. Sensory function 8. Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed? a. In 30 to 45 seconds b. In 10 to 15 minutes c. In 30 to 45 minutes d. In 1 to 2 hours 9. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil a condition resulting from acute iris inflammation (iritis). As part of the clients therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? a. Parasympathomimetic agent b. Sympatholytic agent c. Adrenergic blocker d. Cholinergic blocker 10. Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and hes comatose. We intubated him and hes 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 Trendelenburgs position d. Assessing level of consciousness 11. 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 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.

12. Nurse April is caring for a client who underwent a lumbar laminectomy 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. Urine retention or incontinence d. Temperature of 99.2 F (37.3 C) 13. 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. 14. A female client whos 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. 15. 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 clients feet make a half circle. To document the clients gait, the nurse should use which term? a. Ataxic b. Dystrophic c. Helicopod d. Steppage 16. 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 semiprivate room with a 32-year-old client who has viral meningitis d. A two-bed room with a client who previously had bacterial meningitis 17. 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 clients history. Which preexisting condition would contraindicate the use of pyridostigmine? a. Ulcerative colitis b. Blood dyscrasia c. Intestinal obstruction d. Spinal cord injury

18. A female client is admitted to the facility for investigation of balance and coordination problems, including possible Mnires disease. When assessing this client, the nurse expects to note: a. vertigo, tinnitus, and hearing loss. b. vertigo, vomiting, and nystagmus c. vertigo, pain, and hearing impairment. d. vertigo, blurred vision, and fever. 19. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? a. Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours. b. Try to ambulate independently after about 24 hours. c. Shampoo your hair every day for 10 days to help prevent ear infection. d. Dont fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days. 20. Nurse Oliver is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? a. Excessive tearing b. Urine retention c. Muscle weakness d. Slurred speech 21. The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? a. Tachycardia b. Increased salivation c. Hypotension d. Apnea 22. A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this clients care, the nurse should assign highest priority to which nursing diagnosis? a. Impaired physical mobility b. Ineffective breathing pattern c. Disturbed sensory perception (tactile) d. Self-care deficient: Dressing/grooming 23. A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for: a. long-term treatment of epilepsy. b. postoperative pain management of laminectomy clients.

c. postoperative pain management of diskectomy clients d. treatment of spasticity associated with spinal cord lesions. 24. A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the clients oculocephalic (dolls eye) response by: a. introducing ice water into the external auditory canal. b. touching the cornea with a wisp of cotton. c. turning the clients head suddenly while holding the eyelids open. d. shining a bright light into the pupil. 25. While reviewing a clients 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 shouldnt be used; pancuronium may be used in a lower dosage. c. Pancuronium shouldnt be used; succinylcholine may be used in a lower dosage. d. Pancuronium and succinylcholine both require cautious administration. 26. 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. 27. 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 28. 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 29. 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. 30. 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 clients 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.

1. Answer A. The bodys thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum. 2. Answer C. Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Although mannitol and furosemide may be given to reduce ICP, theyre administered parenterally, not endotracheally. Phenytoin doesnt reduce ICP directly but may be used to abolish seizures, which can increase ICP. However, phenytoin isnt administered endotracheally. 3. Answer C. The clients history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldnt be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP. 4. Answer A. The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double vision is common in clients with cataracts. 5. Answer B. In Parkinsons crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they arent immediately lifethreatening. 6. Answer A. Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimers disease can forget how to eat. Allowing privacy during

meals, filling out the menu, or helping the client to complete the menu doesnt ensure adequate nutritional intake. 7. Answer C. The mental status examination assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning. Intellectual functioning isnt the only cerebral activity. Cerebellar function testing assesses coordination, equilibrium, and fine motor movement. Sensory function testing involves assessment of pain, light-touch sensation, and temperature discrimination. 8. Answer B. When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldnt exceed 100 mg in 24 hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose cant be repeated in 30 to 45 seconds because the first dose wouldnt have been administered completely by that time. Waiting longer than 15 minutes to repeat the dose would increase the clients risk of complications associated with status epilepticus. 9. Answer D. Atropine sulfate is a cholinergic blocker. It isnt a parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker. 10. Answer A. In the scenario, airway and breathing are established so the nurses next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site. Neurologic assessment is a secondary concern to airway, breathing, and circulation. The nurse doesnt have enough data to warrant putting the client in Trendelenburgs position. 11. Answer B. Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring. Dexamethasone and other anti-inflammatory agents dont inhibit the action of carbonic anhydrase or produce any type of miotic reaction. 12. Answer C. Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery. An increase in pain on the second postoperative day is common because the long-acting local anesthetic, which may have been injected during surgery, will wear off. While paresthesia is common after surgery, progressive weakness or paralysis may indicate spinal nerve compression. A mild fever is also common after surgery but is considered significant only if it reaches 101 F (38.3 C). 13. Answer B. The abbreviation "gtt" stands for drop, "i" is the apothecary symbol for the number 1, OU signifies both eyes, and "q.i.d." means four times a day. Therefore, one drop of pilocarpine 0.25% should be instilled into both eyes four times daily. 14. Answer B. Using a mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members. The client should keep the side rails up to help with repositioning and to prevent falls. The paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it, if needed. A client with left-side

paralysis may not realize that the left arm is hanging over the side of the wheelchair. However, the nurse should call this to the clients attention because the arm can get caught in the wheel spokes or develop impaired circulation from being in a dependent position for too long. 15. Answer C. A helicopod gait is an abnormal gait in which the clients feet make a half circle with each step. An ataxic gait is staggering and unsteady. In a dystrophic gait, the client waddles with the legs far apart. In a steppage gait, the feet and toes raise high off the floor and the heel comes down heavily with each step. 16. Answer B. A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the others disease. Immunity to bacterial meningitis cant be acquired; therefore, a client who previously had bacterial meningitis shouldnt be put at risk by rooming with a client who has just been diagnosed with this disease. 17. Answer C. Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. Ulcerative colitis, blood dyscrasia, and spinal cord injury dont contraindicate use of the drug. 18. Answer A. Mnires disease, an inner ear disease, is characterized by the symptom triad of vertigo, tinnitus, and hearing loss. The combination of vertigo, vomiting, and nystagmus suggests labyrinthitis. Mnires disease rarely causes pain, blurred vision, or fever. 19. Answer D. For 30 days after a stapedectomy, the client should avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes). Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. The clients first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. The client must avoid shampooing and swimming to keep the dressing and the ear dry. 20. Answer C. The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis. Muscle weakness is rarely severe enough to cause slurring of speech, drooling, and enuresis. Although excessive tearing and urine retention are adverse reactions associated with dantrolene use, they arent as common as muscle weakness 21. Answer A. Systemic absorption of atropine sulfate can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. The drug also may cause dry mouth. It isnt known to cause hypotension or apnea.

22. Answer B. Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. The other options may be appropriate for a client with a spinal cord injury particularly during the course of recovery but dont take precedence over a diagnosis of Ineffective breathing pattern. 23. Answer D. In addition to relieving painful muscle spasms, diazepam also is recommended for treatment of spasticity associated with spinal cord lesions. Diazepams use is limited by its central nervous system effects and the tolerance that develops with prolonged use. The parenteral form of diazepam can treat status epilepticus, but the drugs sedating properties make it an unsuitable choice for long-term management of epilepsy. Diazepam isnt an analgesic agent. 24. Answer C. To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the clients head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the clients eyes deviate to the side of ice water introduction. The nurse touches the clients cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the clients pupil helps evaluate brain stem and cranial nerve III functions; normally, the pupil responds by constricting. 25. Answer D. The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis. Such a client isnt less sensitive to the effects of a neuromuscular blocking agent. Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with myasthenia gravis. 26. Answer B. Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but cant discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isnt involved with color perception. 27. Answer C. Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity. 28. Answer A. Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive not absent. Babinskis sign may be positive. Tremors at rest arent characteristic of multiple sclerosis; however, intentional tremors, or those occurring with purposeful voluntary movement, are common in clients with multiple sclerosis. Affected muscles are spastic, rather than flaccid. 29. Answer D. The headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. Sitting with the client is appropriate but only after the physician has been notified of the change in the clients condition. The physician will decide

whether or not administration of an analgesic is indicated. Informing the nurse manager isnt necessary. 30. Answer D. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII dont possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

1. A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? a. Caucasian race b. Female sex c. Obesity d. Bronchial asthma 2. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: a. take a hot bath. b. rest in an air-conditioned room c. increase the dose of muscle relaxants. d. avoid naps during the day 3. A male client is having a tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the clients arms and legs. c. Place a tongue blade in the clients mouth. d. Take measures to prevent injury. 4. A female client with Guillain-Barr syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? a. You may have difficulty believing this, but the paralysis caused by this disease is temporary. b. Youll have to accept the fact that youre permanently paralyzed. However, you wont have any sensory loss. c. It must be hard to accept the permanency of your paralysis. d. Youll first regain use of your legs and then your arms.

5. The nurse is working on a surgical floor. The nurse must logroll a male client following a: a. laminectomy. b. thoracotomy. c. hemorrhoidectomy. d. cystectomy. 6. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? a. Immobilize the neck before the client is moved onto a stretcher. b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. c. Place a cap over the clients head. d. Administer a sedative as ordered. 7. During a routine physical examination to assess a male clients deep tendon reflexes, the nurse should make sure to: a. use the pointed end of the reflex hammer when striking the Achilles tendon. b. support the joint where the tendon is being tested. c. tap the tendon slowly and softly d. hold the reflex hammer tightly. 8. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this clients plan of care? a. Disturbed sensory perception (visual) b. Self-care deficient: Dressing/grooming c. Impaired verbal communication d. Risk for injury 9. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, Sometimes I feel so frustrated. I cant do anything without help! This comment best supports which nursing diagnosis? a. Anxiety b. Powerlessness c. Ineffective denial d. Risk for disuse syndrome 10. For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a. prevent respiratory alkalosis. b. lower arterial pH. c. promote carbon dioxide elimination. d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg 11. Nurse Maureen witnesses a neighbors husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to opens the airway in this victim by using which method? a. Flexed position

b. Head tilt-chin lift c. Jaw thrust maneuver d. Modified head tilt-chin lift 12. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the clients peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle 13. A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the clients history of: a. Hypertension b. Heart failure c. Prosthetic valve replacement d. Chronic obstructive pulmonary disorder 14. A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? a. Side-lying, with a pillow under the hip b. Prone, with a pillow under the abdomen c. Prone, in slight-Trendelenburgs position d. Side-lying, with the legs pulled up and head bent down onto chest. 15. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. Head mildline b. Head turned to the side c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees 16. A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: a. Is clear and tests negative for glucose b. Is grossly bloody in appearance and has a pH of 6 c. Clumps together on the dressing and has a pH of 7 d. Separates into concentric rings and test positive of glucose 17. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Keeping the linen wrinkle-free under the client

c. Preventing unnecessary pressure on the lower limbs d. Limiting bladder catheterization to once every 12 hours 18. The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a. Loosening restrictive clothing b. Restraining the clients limbs c. Removing the pillow and raising padded side rails d. Positioning the client to side, if possible, with the head flexed forward 19. The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: a. The client has complete bilateral paralysis of the arms and legs. b. The client has weakness on the right side of the body, including the face and tongue. c. The client has lost the ability to move the right arm but is able to walk independently. d. The client has lost the ability to move the right arm but is able to walk independently. 20. The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? a. Giving the client thin liquids b. Thickening liquids to the consistency of oatmeal c. Placing food on the unaffected side of the mouth d. Allowing plenty of time for chewing and swallowing 21. The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: a. Gets angry with family if they interrupt a task b. Experiences bouts of depression and irritability c. Has difficulty with using modified feeding utensils d. Consistently uses adaptive equipment in dressing self 22. Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? a. Speaking to the client at a slower rate b. Allowing plenty of time for the client to respond c. Completing the sentences that the client cannot finish d. Looking directly at the client during attempts at speech 23. A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: a. Getting too little exercise b. Taking excess medication c. Omitting doses of medication d. Increasing intake of fatty foods

24. The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: a. Eating large, well-balanced meals b. Doing muscle-strengthening exercises c. Doing all chores early in the day while less fatigued d. Taking medications on time to maintain therapeutic blood levels 25. A male client with Bells palsy asks the nurse what has caused this problem. The nurses response is based on an understanding that the cause is: a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem b. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia c. Primary genetic in origin, triggered by exposure to meningitis d. Primarily genetic in origin, triggered by exposure to neurotoxins 26. The nurse has given the male client with Bells palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: a. Exposure to cold and drafts b. Massage the face with a gentle upward motion c. Perform facial exercises d. Wrinkle the forehead, blow out the cheeks, and whistle 27. Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has history of: a. Seizures or trauma to the brain b. Meningitis during the last 5 years c. Back injury or trauma to the spinal cord d. Respiratory or gastrointestinal infection during the previous month. 28. A female client with Guillian-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? a. Giving client full control over care decisions and restricting visitors b. Providing positive feedback and encouraging active range of motion c. Providing information, giving positive feedback, and encouraging relaxation d. Providing intravaneously administered sedatives, reducing distractions and limiting visitors 29. A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client to ensure client safety? a. Speak loudly to the client b. Test the temperature of the shower water c. Check the temperature of the food on the delivery tray. d. Provide a clear path for ambulation without obstacles 30. A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the clients

behavior. a. Is disoriented to person, place, and time b. Affect is flat, with periods of emotional lability c. Cannot recall what was eaten for breakfast today d. Demonstrate inability to add and subtract; does not know who is president

1. Answer C. Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age. The clients race, sex, and bronchial asthma arent risk factors for CVA. 2. Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity. 3. Answer D. Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the clients condition or safety. Restraining the clients arms and legs could cause injury. Placing a tongue blade or other object in the clients mouth could damage the teeth. 4. Answer A. The nurse should inform the client that the paralysis that accompanies GuillainBarr syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs. 5. Answer A. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery. 6. Answer B. Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the clients head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client cant be expected to remain still during the CT scan. 7. Answer B. To prevent the attached muscle from contracting, the nurse should support the joint where the tendon is being tested. The nurse should use the flat, not pointed, end of the reflex

hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldnt provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc. 8. Answer D. Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Although the other options may be appropriate, theyre secondary because they dont immediately affect the clients health or safety. 9. Answer B. This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that cant perform even simple daily tasks. Although Anxiety and Risk for disuse syndrome may be diagnoses associated with ALS, the clients comment specifically refers to an inability to act autonomously. A diagnosis of Ineffective denial would be indicated if the client didnt seem to perceive the personal relevance of symptoms or danger. 10. Answer C. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isnt necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients. 11. Answer C. If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tiltchin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an inappropriate position for opening the airway. 12. Answer B. Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle. 13. Answer C. The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if significant risk exists. 14. Answer D. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae. 15. Answer B. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the clients neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees.

Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down. 16. Answer D. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose. 17. Answer D. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas. 18. Answer B. Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising 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. Other aspects of care are as described for the client who is in bed. 19. Answer B. Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating. 20. Answer A. Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration. 21. Answer D. Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options A, B, and C are not adaptive behaviors. 22. Answer C. Clients with aphasia after brain attack (stroke) often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all the responses for the client. 23. Answer C. Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and

responds to withholding of medications. Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis. 24. Answer D. Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress. 25. Answer A. Bells palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown, but may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors. 26. Answer A. Prevention of muscle atrophy with Bells palsy is accomplished with facial massage, facial exercises, and electrical stimulation of the nerves. Exposure to cold or drafts is avoided. Local application of heat to the face may improve blood flow and provide comfort. 27. Answer D. Guillain-Barr syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery. 28. Answer C. The client with Guillain-Barr syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the clients condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well. 29. Answer D. Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Testing the shower water temperature would be useful if there were an impairment of peripheral nerves. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively. 30. Answer B. The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relates to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.