NERVOUS SYSTEM
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,Nervous System NCLEX | codersimon
8. A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the
patient's illness, the most essential assessment for the nurse to carry out is
a. monitoring the cardiac rhythm continuously.
b. determining the level of consciousness q2hr.
c. evaluating sensation and strength of the extremities.
d. performing constant evaluation of respiratory function.
Correct Answer: D
Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse
should monitor respiratory function continuously. The other assessments will also be included in nursing
care, but they are not as important as respiratory assessment.
Cognitive Level: Comprehension Text Reference: p. 1586
Nursing Process: Assessment NCLEX: Physiological Integrity
13. A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial
treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence
of spinal shock on finding
a. hypotension, bradycardia, and warm extremities.
b. involuntary, spastic movements of the arms and legs.
c. the presence of hyperactive reflex activity below the level of the injury.
d. flaccid paralysis and lack of sensation below the level of the injury.
Correct Answer: D
Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid
paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of
neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this
stage of spinal cord injury.
Cognitive Level: Comprehension Text Reference: p. 1590
Nursing Process: Assessment NCLEX: Physiological Integrity
15. As a result of a gunshot wound, a patient has an incomplete right spinal cord lesion at the level of T7,
resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?
a. Assessment of the patient for left leg pain
b. Assessment of the patient for left arm weakness
c. Positioning the patient's right leg when turning the patient
d. Teaching the patient to look at the left leg to verify its position
,Correct Answer: C
Rationale: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and
will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm
weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the
left leg.
Cognitive Level: Application Text Reference: pp. 1591-1592
Nursing Process: Implementation NCLEX: Physiological Integrity
D. Propranolol is associated with a higher incidence of foot ulcers.
18. A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When
the nurse develops a plan of care for this problem, which nursing action will be most appropriate?
a. Teaching the patient how to self-catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the bladder
d. Catheterization for residual urine after voiding
Correct Answer: A
Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder
wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals
through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder
will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a
reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.
Cognitive Level: Application Text Reference: p. 1605
Nursing Process: Planning NCLEX: Physiological Integrity
27. When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which
nursing action has the highest priority?
a. Continuous cardiac monitoring for bradycardia
b. Administration of methylprednisolone (Solu-Medrol) infusion
c. Assessment of respiratory rate and depth
d. Application of pneumatic compression devices to both legs
Correct Answer: C
Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is
assessment of the patient's respiratory function. The other actions are also appropriate but are not as
important as assessment of respiratory effort.
Cognitive Level: Application Text Reference: p. 1602
Nursing Process: Assessment NCLEX: Physiological Integrity
23. A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury.
The home care nurse visits and notices that the patient's spouse and parents are performing many of the
, activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most
appropriate action by the nurse at this time is to
a. tell the family members that the patient can perform ADLs independently.
b. remind the patient about the importance of independence in daily activities.
c. recognize that it is important for the patient's family to be involved in the patient's care and support their
activities.
d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and
parents.
Correct Answer: D
Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care.
Because family members who will be assisting with the patient's ongoing care need to feel that their input is
important, telling the family that the patient can perform ADLs independently is not the best choice.
Reminding the patient about the importance of independence may not change the behaviors of the family
members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient.
Cognitive Level: Application Text Reference: p. 1609
Nursing Process: Implementation NCLEX: Psychosocial Integrity
2. During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should
a. examine the mouth and teeth thoroughly.
b. have the patient clench and relax the jaw and eyes.
c. identify trigger zones by lightly touching the affected side.
d. gently palpate the face to compare skin temperature bilaterally.
Correct Answer: A
Rationale: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient
clench the facial muscles will not be useful because the sensory branches of the nerve are affected by
trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
Cognitive Level: Application Text Reference: p. 1583
Nursing Process: Assessment NCLEX: Physiological Integrity
4. When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of
trigeminal neuralgia, an appropriate action to include is
a. teach facial and jaw relaxation techniques.
b. assess intake and output and dietary intake.
c. apply ice packs for no more than 20 minutes.
d. spend time at the bedside talking with the patient.
Correct Answer: B
Rationale: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so
assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating
factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to
precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.
7 LATEST VERSIONS/ STUDY SETS/TESTs /Exams)
OVER 300 VERIFIED QUESTIONS AND ANSWERS
BEST DOCUMENT FOR EXAM PREPARATION
100 % SUCCESS GUARANTEED
COMPLETE AND LATEST GUIDE
FOR
Nervous system
UP TO DATE
,Nervous System NCLEX | codersimon
8. A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the
patient's illness, the most essential assessment for the nurse to carry out is
a. monitoring the cardiac rhythm continuously.
b. determining the level of consciousness q2hr.
c. evaluating sensation and strength of the extremities.
d. performing constant evaluation of respiratory function.
Correct Answer: D
Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse
should monitor respiratory function continuously. The other assessments will also be included in nursing
care, but they are not as important as respiratory assessment.
Cognitive Level: Comprehension Text Reference: p. 1586
Nursing Process: Assessment NCLEX: Physiological Integrity
13. A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial
treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence
of spinal shock on finding
a. hypotension, bradycardia, and warm extremities.
b. involuntary, spastic movements of the arms and legs.
c. the presence of hyperactive reflex activity below the level of the injury.
d. flaccid paralysis and lack of sensation below the level of the injury.
Correct Answer: D
Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid
paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of
neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this
stage of spinal cord injury.
Cognitive Level: Comprehension Text Reference: p. 1590
Nursing Process: Assessment NCLEX: Physiological Integrity
15. As a result of a gunshot wound, a patient has an incomplete right spinal cord lesion at the level of T7,
resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?
a. Assessment of the patient for left leg pain
b. Assessment of the patient for left arm weakness
c. Positioning the patient's right leg when turning the patient
d. Teaching the patient to look at the left leg to verify its position
,Correct Answer: C
Rationale: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and
will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm
weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the
left leg.
Cognitive Level: Application Text Reference: pp. 1591-1592
Nursing Process: Implementation NCLEX: Physiological Integrity
D. Propranolol is associated with a higher incidence of foot ulcers.
18. A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When
the nurse develops a plan of care for this problem, which nursing action will be most appropriate?
a. Teaching the patient how to self-catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the bladder
d. Catheterization for residual urine after voiding
Correct Answer: A
Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder
wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals
through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder
will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a
reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.
Cognitive Level: Application Text Reference: p. 1605
Nursing Process: Planning NCLEX: Physiological Integrity
27. When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which
nursing action has the highest priority?
a. Continuous cardiac monitoring for bradycardia
b. Administration of methylprednisolone (Solu-Medrol) infusion
c. Assessment of respiratory rate and depth
d. Application of pneumatic compression devices to both legs
Correct Answer: C
Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is
assessment of the patient's respiratory function. The other actions are also appropriate but are not as
important as assessment of respiratory effort.
Cognitive Level: Application Text Reference: p. 1602
Nursing Process: Assessment NCLEX: Physiological Integrity
23. A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury.
The home care nurse visits and notices that the patient's spouse and parents are performing many of the
, activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most
appropriate action by the nurse at this time is to
a. tell the family members that the patient can perform ADLs independently.
b. remind the patient about the importance of independence in daily activities.
c. recognize that it is important for the patient's family to be involved in the patient's care and support their
activities.
d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and
parents.
Correct Answer: D
Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care.
Because family members who will be assisting with the patient's ongoing care need to feel that their input is
important, telling the family that the patient can perform ADLs independently is not the best choice.
Reminding the patient about the importance of independence may not change the behaviors of the family
members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient.
Cognitive Level: Application Text Reference: p. 1609
Nursing Process: Implementation NCLEX: Psychosocial Integrity
2. During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should
a. examine the mouth and teeth thoroughly.
b. have the patient clench and relax the jaw and eyes.
c. identify trigger zones by lightly touching the affected side.
d. gently palpate the face to compare skin temperature bilaterally.
Correct Answer: A
Rationale: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient
clench the facial muscles will not be useful because the sensory branches of the nerve are affected by
trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
Cognitive Level: Application Text Reference: p. 1583
Nursing Process: Assessment NCLEX: Physiological Integrity
4. When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of
trigeminal neuralgia, an appropriate action to include is
a. teach facial and jaw relaxation techniques.
b. assess intake and output and dietary intake.
c. apply ice packs for no more than 20 minutes.
d. spend time at the bedside talking with the patient.
Correct Answer: B
Rationale: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so
assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating
factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to
precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.
