Saunders Neurological
Saunders Neurological
Study online at https://quizlet.com/_8dscpw
1. The nurse is assessing the motor and sensory function Nail bed pressure
of an unconscious client. The nurse should 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
2. The nurse is caring for the client with increased in- Increasing temperature,
tracranial pressure. The nurse would note which trend decreasing pulse, de-
in vital signs if the intracranial pressure is rising? creasing respirations, in-
creasing blood pressure
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, increas-
ing respirations, decreasing blood pressure
4.
Decreasing temperature, increasing pulse, decreas-
ing respirations, increasing blood pressure
actualstudy Page 1 of 94
, Saunders Neurological
Saunders Neurological
Study online at https://quizlet.com/_8dscpw
3. A client recovering from a head injury is participating Exhaling during reposi-
in care. The nurse determines that the client under- tioning
stands 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
4. A client has clear fluid leaking from the nose following Fluid separates into con-
a basilar skull fracture. Which finding would alert the centric rings and tests
nurse that cerebrospinal fluid is present? positive for glucose.
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.
5.
actualstudy Page 2 of 94
, Saunders Neurological
Saunders Neurological
Study online at https://quizlet.com/_8dscpw
1.
A client with a spinal cord injury is prone to experienc-
ing autonomic dysreflexia. The nurse should include Keeping the linens wrin-
which measures in the plan of care to minimize the kle-free under the client
risk of occurrence? Select all that apply. 2.
Preventing unnecessary
pressure on the lower
1.
limbs
Keeping the linens wrinkle-free under the client
4.
2.
Turning and repositioning
Preventing unnecessary pressure on the lower limbs
the client at least every 2
3.
hours
Limiting bladder catheterization to once every 12
hours
4.
Turning and repositioning the client at least every 2
hours
5.
Ensuring that the client has a bowel movement at
least once a week
6. The nurse is evaluating the neurological signs of a Flaccid paralysis
client in spinal shock following spinal cord injury.
Which observation indicates that spinal shock per-
sists?
1.
Hyperreflexia
2.
Positive reflexes
3.
Flaccid paralysis
actualstudy Page 3 of 94
, Saunders Neurological
Saunders Neurological
Study online at https://quizlet.com/_8dscpw
4.
Reflex emptying of the bladder
7. The nurse is caring for a client who begins to ex- 1.
perience seizure activity while in bed. Which actions Loosening restrictive
should the nurse take? Select all that apply. clothing
3.
Removing the pillow and
1.
raising padded side rails
Loosening restrictive clothing
4.
2.
Positioning the client to
Restraining the client's limbs
the side, if possible, with
3.
the head flexed forward
Removing the pillow and raising padded side rails
4.
Positioning the client to the side, if possible, with the
head flexed forward
5.
Keeping the curtain around the client and the room
door open so when help arrives they can quickly enter
to assist
8. The nurse is assigned to care for a client with complete1.
right-sided hemiparesis from a stroke (brain attack). The client is aphasic.
Which characteristics are associated with this condi- 2.
tion? Select all that apply. The client has weakness
on the right side of the
1. body.
The client is aphasic. 4.
2. The client has weakness
The client has weakness on the right side of the body. on the right side of the
3. face and tongue.
The client has complete bilateral paralysis of the arms
actualstudy Page 4 of 94
Saunders Neurological
Study online at https://quizlet.com/_8dscpw
1. The nurse is assessing the motor and sensory function Nail bed pressure
of an unconscious client. The nurse should 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
2. The nurse is caring for the client with increased in- Increasing temperature,
tracranial pressure. The nurse would note which trend decreasing pulse, de-
in vital signs if the intracranial pressure is rising? creasing respirations, in-
creasing blood pressure
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, increas-
ing respirations, decreasing blood pressure
4.
Decreasing temperature, increasing pulse, decreas-
ing respirations, increasing blood pressure
actualstudy Page 1 of 94
, Saunders Neurological
Saunders Neurological
Study online at https://quizlet.com/_8dscpw
3. A client recovering from a head injury is participating Exhaling during reposi-
in care. The nurse determines that the client under- tioning
stands 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
4. A client has clear fluid leaking from the nose following Fluid separates into con-
a basilar skull fracture. Which finding would alert the centric rings and tests
nurse that cerebrospinal fluid is present? positive for glucose.
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.
5.
actualstudy Page 2 of 94
, Saunders Neurological
Saunders Neurological
Study online at https://quizlet.com/_8dscpw
1.
A client with a spinal cord injury is prone to experienc-
ing autonomic dysreflexia. The nurse should include Keeping the linens wrin-
which measures in the plan of care to minimize the kle-free under the client
risk of occurrence? Select all that apply. 2.
Preventing unnecessary
pressure on the lower
1.
limbs
Keeping the linens wrinkle-free under the client
4.
2.
Turning and repositioning
Preventing unnecessary pressure on the lower limbs
the client at least every 2
3.
hours
Limiting bladder catheterization to once every 12
hours
4.
Turning and repositioning the client at least every 2
hours
5.
Ensuring that the client has a bowel movement at
least once a week
6. The nurse is evaluating the neurological signs of a Flaccid paralysis
client in spinal shock following spinal cord injury.
Which observation indicates that spinal shock per-
sists?
1.
Hyperreflexia
2.
Positive reflexes
3.
Flaccid paralysis
actualstudy Page 3 of 94
, Saunders Neurological
Saunders Neurological
Study online at https://quizlet.com/_8dscpw
4.
Reflex emptying of the bladder
7. The nurse is caring for a client who begins to ex- 1.
perience seizure activity while in bed. Which actions Loosening restrictive
should the nurse take? Select all that apply. clothing
3.
Removing the pillow and
1.
raising padded side rails
Loosening restrictive clothing
4.
2.
Positioning the client to
Restraining the client's limbs
the side, if possible, with
3.
the head flexed forward
Removing the pillow and raising padded side rails
4.
Positioning the client to the side, if possible, with the
head flexed forward
5.
Keeping the curtain around the client and the room
door open so when help arrives they can quickly enter
to assist
8. The nurse is assigned to care for a client with complete1.
right-sided hemiparesis from a stroke (brain attack). The client is aphasic.
Which characteristics are associated with this condi- 2.
tion? Select all that apply. The client has weakness
on the right side of the
1. body.
The client is aphasic. 4.
2. The client has weakness
The client has weakness on the right side of the body. on the right side of the
3. face and tongue.
The client has complete bilateral paralysis of the arms
actualstudy Page 4 of 94
