NUR2214 Module 4 Questions with Verified
Correct Answers
A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral
side of a client's foot is stroked with an applicator stick during a neurologic
examination. What should the nurse document in the client's medical record?
"Exhibits a positive Babinski sign"
A client has a tonic-clonic seizure at work and is admitted to the emergency
department. Which question is most useful when planning nursing care related to the
client's seizure?
"Were you aware of anything different or unusual just before your seizure began?"
On the day after surgery for insertion of a ventriculoperitoneal shunt to treat
hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse
immediately notifies the practitioner. What is the next nursing action?
Removing excess clothing from the infant
A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital
in a coma. What is the priority nursing care for this client?
Maintain an open airway.
A 50-year-old male client has difficulty communicating because of expressive aphasia
after a cerebrovascular accident (CVA, also known as a "brain attack"). When the
nurse asks the client how he is feeling, his wife answers for him. How should the nurse
address this behavior?
Acknowledge the wife but look at the client for a response.
,A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a
clenched jaw. What is the best initial action by the nurse?
Placing the child on the floor
A client has inflammation of the facial nerve, causing facial paralysis on one side.
Which diagnosis will the nurse most likely observe written in the medical record?
Bell palsy
Which antiepileptic drug is used as the first-line treatment for absence seizures?
valproic acid
During an annual physical assessment a client reports not being able to smell coffee and
most foods. Which cranial nerve function should the nurse assess?
I
Which statement indicates a nurse has a correct understanding about trigeminal
autonomic cephalalgia (cluster headaches)?
It is caused by an overactive hypothalamus.
A client who takes four 325-mg tablets of buffered aspirin four times a day for severe
arthritis complains of dizziness and ringing in the ears. Which complication does the
nurse conclude that the client probably is experiencing?
Salicylate toxicity
Which cranial nerve damage may lead to a decrease in the client's olfactory acuity?
Cranial nerve I
, A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury.
When the nurse applies pressure to the nail bed of a finger, which movement of the
client's upper arm should cause the most concern?
extending
The nurse caring for a 3-year-old child with meningitis should be alert for which signs
and symptoms of increased intracranial pressure? Select all that apply.
vomiting
headache
irritability
A nurse should plan to maintain a client who has experienced a subarachnoid
hemorrhage in what position?
In bed with the head of the bed elevated
During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds
followed by confusion. Which statement about this type of seizures is true? Select all
that apply.
These seizures increase the risk of injuries due to fall.
These seizures are most resistant to drug therapy.
A client has a tonic-clonic seizure that involves all extremities. The nurse anticipates
that the healthcare provider will prescribe the intravenous administration of which
drug?
Diazepam
Correct Answers
A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral
side of a client's foot is stroked with an applicator stick during a neurologic
examination. What should the nurse document in the client's medical record?
"Exhibits a positive Babinski sign"
A client has a tonic-clonic seizure at work and is admitted to the emergency
department. Which question is most useful when planning nursing care related to the
client's seizure?
"Were you aware of anything different or unusual just before your seizure began?"
On the day after surgery for insertion of a ventriculoperitoneal shunt to treat
hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse
immediately notifies the practitioner. What is the next nursing action?
Removing excess clothing from the infant
A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital
in a coma. What is the priority nursing care for this client?
Maintain an open airway.
A 50-year-old male client has difficulty communicating because of expressive aphasia
after a cerebrovascular accident (CVA, also known as a "brain attack"). When the
nurse asks the client how he is feeling, his wife answers for him. How should the nurse
address this behavior?
Acknowledge the wife but look at the client for a response.
,A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a
clenched jaw. What is the best initial action by the nurse?
Placing the child on the floor
A client has inflammation of the facial nerve, causing facial paralysis on one side.
Which diagnosis will the nurse most likely observe written in the medical record?
Bell palsy
Which antiepileptic drug is used as the first-line treatment for absence seizures?
valproic acid
During an annual physical assessment a client reports not being able to smell coffee and
most foods. Which cranial nerve function should the nurse assess?
I
Which statement indicates a nurse has a correct understanding about trigeminal
autonomic cephalalgia (cluster headaches)?
It is caused by an overactive hypothalamus.
A client who takes four 325-mg tablets of buffered aspirin four times a day for severe
arthritis complains of dizziness and ringing in the ears. Which complication does the
nurse conclude that the client probably is experiencing?
Salicylate toxicity
Which cranial nerve damage may lead to a decrease in the client's olfactory acuity?
Cranial nerve I
, A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury.
When the nurse applies pressure to the nail bed of a finger, which movement of the
client's upper arm should cause the most concern?
extending
The nurse caring for a 3-year-old child with meningitis should be alert for which signs
and symptoms of increased intracranial pressure? Select all that apply.
vomiting
headache
irritability
A nurse should plan to maintain a client who has experienced a subarachnoid
hemorrhage in what position?
In bed with the head of the bed elevated
During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds
followed by confusion. Which statement about this type of seizures is true? Select all
that apply.
These seizures increase the risk of injuries due to fall.
These seizures are most resistant to drug therapy.
A client has a tonic-clonic seizure that involves all extremities. The nurse anticipates
that the healthcare provider will prescribe the intravenous administration of which
drug?
Diazepam
