Neurological NCLEX Review saunders
Neurological NCLEX Review saunders
Study online at https://quizlet.com/_75nts8
1. The nurse is caring for 2.
the client with increased in- Increasing temperature, decreasing pulse, decreasing respira-
tracranial pressure. The nurse tions, increasing blood pressure
would note which trend in
vital signs if the intracranial Rationale:
pressure is rising? A change in vital signs may be a late sign of increased intracra-
nial pressure. Trends include increasing temperature and blood
1. pressure and decreasing pulse and respirations. Respiratory
Increasing temperature, in- irregularities also may occur.
creasing pulse, increasing res-
pirations, decreasing blood
pressure
2.
Increasing temperature, de-
creasing pulse, decreasing
respirations, increasing blood
pressure
3.
Decreasing temperature, de-
creasing pulse, increasing res-
pirations, decreasing blood
pressure
4.
Decreasing temperature, in-
creasing pulse, decreasing
respirations, increasing blood
pressure
2.
actualstudy Page 1
, Neurological NCLEX Review saunders
Neurological NCLEX Review saunders
Study online at https://quizlet.com/_75nts8
The nurse is assessing the mo- 2.
tor function of an unconscious Nail bed pressure
client. The nurse should plan
to use which technique to Rationale:
test the client's peripheral re- Motor testing in the unconscious client can be done only by
sponse to pain? testing response to painful stimuli. Nail bed pressure tests a ba-
sic peripheral response. Cerebral responses to pain are tested
1. using a sternal rub, placing upward pressure on the orbital rim,
Sternal rub or squeezing the clavicle or sternocleidomastoid muscle.
2.
Nail bed pressure
3.
Pressure on the orbital rim
4.
Squeezing of the sternoclei-
domastoid muscle
3. A client recovering from a 4.
head injury is participating in Exhaling during repositioning
care. The nurse determines
that the client understands Rationale:
measures to prevent eleva- Activities that increase intrathoracic and intraabdominal pres-
tions in intracranial pressure if sures cause an indirect elevation of the intracranial pressure.
the nurse observes the client Some of these activities include isometric exercises, Valsalva's
doing which activity? maneuver, coughing, sneezing, and blowing the nose. Exhaling
during activities such as repositioning or pulling up in bed,
1. opens the glottis, which prevents intrathoracic pressure from
Blowing the nose rising.
2.
actualstudy Page 2
, Neurological NCLEX Review saunders
Neurological NCLEX Review saunders
Study online at https://quizlet.com/_75nts8
Isometric exercises
3.
Coughing vigorously
4.
Exhaling during repositioning
4. A client has clear fluid leak- 4.
ing from the nose following Fluid separates into concentric rings and tests positive for glu-
a basilar skull fracture. Which cose.
finding would alert the nurse
Rationale:
that cerebrospinal fluid is pre-
sent? Leakage of cerebrospinal fluid (CSF) from the ears or nose
may accompany basilar skull fracture. CSF can be distinguished
1. from other body fluids because the drainage will separate into
Fluid is clear and tests nega- bloody and yellow concentric rings on dressing material, called
tive for glucose. a halo sign. The fluid also tests positive for glucose.
2.
Fluid is grossly bloody in ap-
pearance and has a pH of 6.
3.
Fluid clumps together on the
dressing and has a pH of 7.
4.
Fluid separates into concen-
tric rings and tests positive for
glucose.
5.
actualstudy Page 3
, Neurological NCLEX Review saunders
Neurological NCLEX Review saunders
Study online at https://quizlet.com/_75nts8
A client with a spinal cord 4.
injury is prone to experi- Limiting bladder catheterization to once every 12 hours
encing autonomic dysreflexia.
The nurse should avoid which Rationale:
measure to minimize the risk The most frequent cause of autonomic dysreflexia is a distended
of occurrence? bladder. Straight catheterization should be done every 4 to 6
hours (catheterization every 12 hours is too infrequent), and
1. Foley catheters should be checked frequently to prevent kinks
Strict adherence to a bowel re- in the tubing. Constipation and fecal impaction are other caus-
training program es, so maintaining bowel regularity is important. Other causes
include stimulation of the skin from tactile, thermal, or painful
2. stimuli. The nurse administers care to minimize risk in these
Keeping the linen wrinkle-free areas.
under the client
3.
Preventing unnecessary pres-
sure on the lower limbs
4.
Limiting bladder catheteriza-
tion to once every 12 hours
6. The nurse is evaluating the 3.
neurological signs of a client Flaccid paralysis
in spinal shock following
spinal cord injury. Which ob- Rationale:
servation indicates that spinal Resolution of spinal shock is occurring when there is return of
shock persists? reflexes (especially flexors to noxious cutaneous stimuli), a state
of hyperreflexia rather than flaccidity, and reflex emptying of the
1. bladder.
Hyperreflexia
actualstudy Page 4
Neurological NCLEX Review saunders
Study online at https://quizlet.com/_75nts8
1. The nurse is caring for 2.
the client with increased in- Increasing temperature, decreasing pulse, decreasing respira-
tracranial pressure. The nurse tions, increasing blood pressure
would note which trend in
vital signs if the intracranial Rationale:
pressure is rising? A change in vital signs may be a late sign of increased intracra-
nial pressure. Trends include increasing temperature and blood
1. pressure and decreasing pulse and respirations. Respiratory
Increasing temperature, in- irregularities also may occur.
creasing pulse, increasing res-
pirations, decreasing blood
pressure
2.
Increasing temperature, de-
creasing pulse, decreasing
respirations, increasing blood
pressure
3.
Decreasing temperature, de-
creasing pulse, increasing res-
pirations, decreasing blood
pressure
4.
Decreasing temperature, in-
creasing pulse, decreasing
respirations, increasing blood
pressure
2.
actualstudy Page 1
, Neurological NCLEX Review saunders
Neurological NCLEX Review saunders
Study online at https://quizlet.com/_75nts8
The nurse is assessing the mo- 2.
tor function of an unconscious Nail bed pressure
client. The nurse should plan
to use which technique to Rationale:
test the client's peripheral re- Motor testing in the unconscious client can be done only by
sponse to pain? testing response to painful stimuli. Nail bed pressure tests a ba-
sic peripheral response. Cerebral responses to pain are tested
1. using a sternal rub, placing upward pressure on the orbital rim,
Sternal rub or squeezing the clavicle or sternocleidomastoid muscle.
2.
Nail bed pressure
3.
Pressure on the orbital rim
4.
Squeezing of the sternoclei-
domastoid muscle
3. A client recovering from a 4.
head injury is participating in Exhaling during repositioning
care. The nurse determines
that the client understands Rationale:
measures to prevent eleva- Activities that increase intrathoracic and intraabdominal pres-
tions in intracranial pressure if sures cause an indirect elevation of the intracranial pressure.
the nurse observes the client Some of these activities include isometric exercises, Valsalva's
doing which activity? maneuver, coughing, sneezing, and blowing the nose. Exhaling
during activities such as repositioning or pulling up in bed,
1. opens the glottis, which prevents intrathoracic pressure from
Blowing the nose rising.
2.
actualstudy Page 2
, Neurological NCLEX Review saunders
Neurological NCLEX Review saunders
Study online at https://quizlet.com/_75nts8
Isometric exercises
3.
Coughing vigorously
4.
Exhaling during repositioning
4. A client has clear fluid leak- 4.
ing from the nose following Fluid separates into concentric rings and tests positive for glu-
a basilar skull fracture. Which cose.
finding would alert the nurse
Rationale:
that cerebrospinal fluid is pre-
sent? Leakage of cerebrospinal fluid (CSF) from the ears or nose
may accompany basilar skull fracture. CSF can be distinguished
1. from other body fluids because the drainage will separate into
Fluid is clear and tests nega- bloody and yellow concentric rings on dressing material, called
tive for glucose. a halo sign. The fluid also tests positive for glucose.
2.
Fluid is grossly bloody in ap-
pearance and has a pH of 6.
3.
Fluid clumps together on the
dressing and has a pH of 7.
4.
Fluid separates into concen-
tric rings and tests positive for
glucose.
5.
actualstudy Page 3
, Neurological NCLEX Review saunders
Neurological NCLEX Review saunders
Study online at https://quizlet.com/_75nts8
A client with a spinal cord 4.
injury is prone to experi- Limiting bladder catheterization to once every 12 hours
encing autonomic dysreflexia.
The nurse should avoid which Rationale:
measure to minimize the risk The most frequent cause of autonomic dysreflexia is a distended
of occurrence? bladder. Straight catheterization should be done every 4 to 6
hours (catheterization every 12 hours is too infrequent), and
1. Foley catheters should be checked frequently to prevent kinks
Strict adherence to a bowel re- in the tubing. Constipation and fecal impaction are other caus-
training program es, so maintaining bowel regularity is important. Other causes
include stimulation of the skin from tactile, thermal, or painful
2. stimuli. The nurse administers care to minimize risk in these
Keeping the linen wrinkle-free areas.
under the client
3.
Preventing unnecessary pres-
sure on the lower limbs
4.
Limiting bladder catheteriza-
tion to once every 12 hours
6. The nurse is evaluating the 3.
neurological signs of a client Flaccid paralysis
in spinal shock following
spinal cord injury. Which ob- Rationale:
servation indicates that spinal Resolution of spinal shock is occurring when there is return of
shock persists? reflexes (especially flexors to noxious cutaneous stimuli), a state
of hyperreflexia rather than flaccidity, and reflex emptying of the
1. bladder.
Hyperreflexia
actualstudy Page 4
