NEUROLOGICAL CONCEPTS AND PRACTICE
QUESTIONS WITH COMPLETE SOLUTION
The nurse is assessing the motor function of an unconscious client. The nurse
should plan to use which technique to test the client's peripheral response to
pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle - ANSWER - 2. Nail bed pressure
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 a sternal rub, placing upward pressure on the
orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
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 - ANSWER - 2. Increasing temperature, decreasing pulse,
decreasing respirations, increasing blood pressure
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.
A client recovering from a head injury is participating in care. The nurse
determines that the client understands measures to prevent elevations in
intracranial pressure if the nurse observes the client doing which activity?
1. Blowing the nose
2. Isometric exercises
3. Coughing vigorously
4. Exhaling during repositioning - ANSWER - 4. Exhaling during repositioning
Activities that increase intrathoracic and intraabdominal pressures cause an
indirect elevation of the intracranial pressure. Some of these activities include
isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the
nose. Exhaling during activities such as repositioning or pulling up in bed, opens
the glottis, which prevents intrathoracic pressure from rising.
A client has clear fluid leaking from the nose following a basilar skull fracture.
Which finding would alert the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
,3. Fluid clumps together on the dressing and has a pH of 7.
4. Fluid separates into concentric rings and tests positive for glucose. - ANSWER -
4. Fluid separates into concentric rings and tests positive for glucose.
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.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia.
The nurse should avoid which measure to minimize the risk of occurrence?
1. Strict adherence to a bowel retraining program
2. Keeping the linen wrinkle-free under the client
3. Preventing unnecessary pressure on the lower limbs
4. Limiting bladder catheterization to once every 12 hours - ANSWER - 4. Limiting
bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours (catheterization every 12 hours
is too infrequent), 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.
The nurse is evaluating the neurological signs of a client in spinal shock following
spinal cord injury. Which observation indicates that spinal shock persists?
, 1. Hyperreflexia
2. Positive reflexes
3. Flaccid paralysis
4. Reflex emptying of the bladder - ANSWER - 3. Flaccid paralysis
Resolution of spinal shock is occurring when there is return of reflexes (especially
flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than
flaccidity, and reflex emptying of the bladder.
The nurse is caring for a client who begins to experience seizure activity while in
bed. Which action by the nurse is contraindicated?
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 -
ANSWER - 2. Restraining the client's limbs
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.
QUESTIONS WITH COMPLETE SOLUTION
The nurse is assessing the motor function of an unconscious client. The nurse
should plan to use which technique to test the client's peripheral response to
pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle - ANSWER - 2. Nail bed pressure
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 a sternal rub, placing upward pressure on the
orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
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 - ANSWER - 2. Increasing temperature, decreasing pulse,
decreasing respirations, increasing blood pressure
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.
A client recovering from a head injury is participating in care. The nurse
determines that the client understands measures to prevent elevations in
intracranial pressure if the nurse observes the client doing which activity?
1. Blowing the nose
2. Isometric exercises
3. Coughing vigorously
4. Exhaling during repositioning - ANSWER - 4. Exhaling during repositioning
Activities that increase intrathoracic and intraabdominal pressures cause an
indirect elevation of the intracranial pressure. Some of these activities include
isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the
nose. Exhaling during activities such as repositioning or pulling up in bed, opens
the glottis, which prevents intrathoracic pressure from rising.
A client has clear fluid leaking from the nose following a basilar skull fracture.
Which finding would alert the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
,3. Fluid clumps together on the dressing and has a pH of 7.
4. Fluid separates into concentric rings and tests positive for glucose. - ANSWER -
4. Fluid separates into concentric rings and tests positive for glucose.
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.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia.
The nurse should avoid which measure to minimize the risk of occurrence?
1. Strict adherence to a bowel retraining program
2. Keeping the linen wrinkle-free under the client
3. Preventing unnecessary pressure on the lower limbs
4. Limiting bladder catheterization to once every 12 hours - ANSWER - 4. Limiting
bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours (catheterization every 12 hours
is too infrequent), 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.
The nurse is evaluating the neurological signs of a client in spinal shock following
spinal cord injury. Which observation indicates that spinal shock persists?
, 1. Hyperreflexia
2. Positive reflexes
3. Flaccid paralysis
4. Reflex emptying of the bladder - ANSWER - 3. Flaccid paralysis
Resolution of spinal shock is occurring when there is return of reflexes (especially
flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than
flaccidity, and reflex emptying of the bladder.
The nurse is caring for a client who begins to experience seizure activity while in
bed. Which action by the nurse is contraindicated?
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 -
ANSWER - 2. Restraining the client's limbs
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.
