Neuro nclex review
Neuro nclex review
Study online at https://quizlet.com/_fpcvih
1. The nurse is assisting with caring for a client after a 3. Semi-Fowler's position
craniotomy. Which are the positions that can be used 5.With the foot of the bed
for the client? Select all that apply. flat
2. The nurse is caring for a client following a craniotomy A. Clients who have under-
in which a large tumor was removed from the left side. gone craniotomy should
In which position can the nurse safely place the client? have the head of the bed
Refer to the Figure. elevated 30 degrees to
promote venous drainage
from the head. The client
is positioned to avoid ex-
treme hip or neck flex-
ion and the head is
maintained in a mid-
line, neutral position. If a
large tumor has been re-
moved, the client should
be placed on the nonop-
erative side to prevent dis-
placement of the cranial
contents. A flat position
or Trendelenburg's posi-
tion would increase in-
tracranial pressure. A re-
verse Trendelenburg's po-
sition would not be help-
ful and may be uncom-
fortable for the client.
3. A client with a seizure disorder is being admitted to 1.Pad the bed's side rails.
the hospital. Which should the nurse plan to imple- 2.Place an airway at the
ment for this client? Select all that apply. bedside. 3.Place oxygen
https://www.stuvia.com/user/actualstudy Page 1 of 26
, Neuro nclex review
Neuro nclex review
Study online at https://quizlet.com/_fpcvih
equipment at the bedside.
4.Place suction equipment
at the bedside.
4. The nurse is caring for a client with increased intracra- Increasing temperature,
nial pressure (ICP). Which change in vital signs would decreasing pulse, de-
occur if ICP is rising? creasing respirations, in-
creasing BP
5. The nurse observes the unlicensed assistive person- Head turned to the side
nel (UAP) positioning the client with increased in-
tracranial pressure (ICP). Which position would re-
quire intervention by the nurse?
6. The client recovering from a head injury is arousable Exhaling during reposi-
and participating in care. The nurse determines that tioning
the client understands measures to prevent eleva-
tions in intracranial pressure (ICP) if the nurse ob-
serves the client doing which activity?
7. The client has clear fluid leaking from the nose after a Separates into concentric
basilar skull fracture. The nurse determines that this rings and tests positive for
is cerebrospinal fluid (CSF) if the fluid meets which glucose
criteria?
8. The client is admitted to the hospital for observation The primary health care
with a probable minor head injury after an automobile provider (PHCP) reviews
crash. The nurse expects the cervical collar will remain the x-ray results.
in place until which time?
9. The client was seen and treated in the emergency de- Minor headache
partment (ED) for a concussion. Before discharge, the
nurse explains the signs/symptoms of a worsening
https://www.stuvia.com/user/actualstudy Page 2 of 26
, Neuro nclex review
Neuro nclex review
Study online at https://quizlet.com/_fpcvih
condition. The nurse determines that the family needs
further teaching if they state they will return to the ED
if the client experiences which sign/symptom?
10. The nurse is caring for a client who has undergone Head of bed elevated 30
craniotomy with a supratentorial incision. The nurse to 45 degrees, head and
should plan to place the client in which position post- neck midline
operatively?
11. The client with a cervical spine injury has Crutch- Comparing the amount of
field tongs applied in the emergency department. The prescribed weights with
nurse should perform which essential action when the amount in use
caring for this client?
12. The nurse has provided discharge instructions to a "I will drive only during the
client with an application of a halo device. The nurse daytime."
determines that the client needs further teaching if
which statement is made?
13. The nurse is caring for the client who has suffered Severe, throbbing
spinal cord injury. The nurse further monitors the headache
client for signs of autonomic dysreflexia and suspects
this complication if which sign/symptom is noted?
14. The client with spinal cord injury is prone to experi- Limiting bladder catheter-
encing autonomic dysreflexia. The least appropriate ization to once every 12
measure to minimize the risk of autonomic dysreflexia hours
is which action?
15. The client with spinal cord injury suddenly expe- Raise the head of the bed
riences an episode of autonomic dysreflexia. After and remove the noxious
checking vital signs, which immediate action should stimulus.
the nurse take?
https://www.stuvia.com/user/actualstudy Page 3 of 26
Neuro nclex review
Study online at https://quizlet.com/_fpcvih
1. The nurse is assisting with caring for a client after a 3. Semi-Fowler's position
craniotomy. Which are the positions that can be used 5.With the foot of the bed
for the client? Select all that apply. flat
2. The nurse is caring for a client following a craniotomy A. Clients who have under-
in which a large tumor was removed from the left side. gone craniotomy should
In which position can the nurse safely place the client? have the head of the bed
Refer to the Figure. elevated 30 degrees to
promote venous drainage
from the head. The client
is positioned to avoid ex-
treme hip or neck flex-
ion and the head is
maintained in a mid-
line, neutral position. If a
large tumor has been re-
moved, the client should
be placed on the nonop-
erative side to prevent dis-
placement of the cranial
contents. A flat position
or Trendelenburg's posi-
tion would increase in-
tracranial pressure. A re-
verse Trendelenburg's po-
sition would not be help-
ful and may be uncom-
fortable for the client.
3. A client with a seizure disorder is being admitted to 1.Pad the bed's side rails.
the hospital. Which should the nurse plan to imple- 2.Place an airway at the
ment for this client? Select all that apply. bedside. 3.Place oxygen
https://www.stuvia.com/user/actualstudy Page 1 of 26
, Neuro nclex review
Neuro nclex review
Study online at https://quizlet.com/_fpcvih
equipment at the bedside.
4.Place suction equipment
at the bedside.
4. The nurse is caring for a client with increased intracra- Increasing temperature,
nial pressure (ICP). Which change in vital signs would decreasing pulse, de-
occur if ICP is rising? creasing respirations, in-
creasing BP
5. The nurse observes the unlicensed assistive person- Head turned to the side
nel (UAP) positioning the client with increased in-
tracranial pressure (ICP). Which position would re-
quire intervention by the nurse?
6. The client recovering from a head injury is arousable Exhaling during reposi-
and participating in care. The nurse determines that tioning
the client understands measures to prevent eleva-
tions in intracranial pressure (ICP) if the nurse ob-
serves the client doing which activity?
7. The client has clear fluid leaking from the nose after a Separates into concentric
basilar skull fracture. The nurse determines that this rings and tests positive for
is cerebrospinal fluid (CSF) if the fluid meets which glucose
criteria?
8. The client is admitted to the hospital for observation The primary health care
with a probable minor head injury after an automobile provider (PHCP) reviews
crash. The nurse expects the cervical collar will remain the x-ray results.
in place until which time?
9. The client was seen and treated in the emergency de- Minor headache
partment (ED) for a concussion. Before discharge, the
nurse explains the signs/symptoms of a worsening
https://www.stuvia.com/user/actualstudy Page 2 of 26
, Neuro nclex review
Neuro nclex review
Study online at https://quizlet.com/_fpcvih
condition. The nurse determines that the family needs
further teaching if they state they will return to the ED
if the client experiences which sign/symptom?
10. The nurse is caring for a client who has undergone Head of bed elevated 30
craniotomy with a supratentorial incision. The nurse to 45 degrees, head and
should plan to place the client in which position post- neck midline
operatively?
11. The client with a cervical spine injury has Crutch- Comparing the amount of
field tongs applied in the emergency department. The prescribed weights with
nurse should perform which essential action when the amount in use
caring for this client?
12. The nurse has provided discharge instructions to a "I will drive only during the
client with an application of a halo device. The nurse daytime."
determines that the client needs further teaching if
which statement is made?
13. The nurse is caring for the client who has suffered Severe, throbbing
spinal cord injury. The nurse further monitors the headache
client for signs of autonomic dysreflexia and suspects
this complication if which sign/symptom is noted?
14. The client with spinal cord injury is prone to experi- Limiting bladder catheter-
encing autonomic dysreflexia. The least appropriate ization to once every 12
measure to minimize the risk of autonomic dysreflexia hours
is which action?
15. The client with spinal cord injury suddenly expe- Raise the head of the bed
riences an episode of autonomic dysreflexia. After and remove the noxious
checking vital signs, which immediate action should stimulus.
the nurse take?
https://www.stuvia.com/user/actualstudy Page 3 of 26
