NUR 146 Neuro Exam With Complete Solutin
The nurse is providing care for an unconscious client. Which nursing priority is highest?
A. Accurately record intake and output
B. The client maintain a patent airway
C. Inserts NG tube as ordered
D. Appropriately administer pain management - ANSWER B. The client maintain a patent
airway
A seizure disorder client experiences a generalized seizure. Which nursing response is
most appropriate?
A. Restrain the client to prevent injury.
B. Open the client's jaws to insert an oral airway.
C. Place client in high Fowler position.
D. Loosen the client's restrictive clothing - ANSWER D. Loosen the client's restrictive
clothing
A client is admitted to the unit who has been receiving long-term therapy with the
medication phenytoin. Based on the side effects of this medication, which of the
following would be most important for the nurse to address in the plan of care for this
client?
A. Pulse oximetry
B. Low-protein diet
C. Providing thorough oral hygiene
D. Fluid restriction as ordered - ANSWER C. Providing thorough oral hygiene
A client is admitted to the ED with a blunt head injury and an altered state of
consciousness. What test results will provide the initial guidance for the nurse in
evaluating the client's LOC?
,A. Monro-Kellie hypothesis
B. Glasgow Coma scale
C. Cranial nerve function
D. Mental status examination - ANSWER B. Glasgow Coma scale
A client is admitted with increased intracranial pressure and has a ventriculostomy for
ICP monitoring. The nurse's latest assessment reveals that the client now exhibits
nuchal rigidity and photophobia. The nurse would be correct in suspecting which
complication?
A. Encephalitis
B. Cerebral spinal fluid leak
C. Meningitis
D. Catheter occlusion ANSWER C. Meningitis
The client is in status epilepticus and receiving care from the nurse. The nurse should
expect to administer which of the following medications to immediately stop the
seizure?
A. Intravenous phenobarbital
B. Intravenous diazepam
C. Oral lorazepam
D. Oral phenytoin - ANSWER B. Intravenous diazepam
A clinic nurse is caring for a client diagnosed with migraine headaches. During the
client teaching session the client asks the nurse about alcohol consumption. For what
does the nurse correctly inform the client about alcohol's effects?
A. Alcohol causes hormone fluctuations.
B. Alcohol causes vasodilation of the blood vessels.
C. Alcohol has an excitatory effect on the CNS.
D. Alcohol decreases endorphins in the brain - ANSWER B. Alcohol causes vasodilation
of the blood vessels.
, A client has been admitted with diabetes insipidus following increased ICP due to head
trauma. What nursing assessment best reflects this complication?
A. Close monitoring of fluid balance
B. Continuous BP monitoring
C. Serial arterial blood gases (ABGs)
D. Monitoring the client's airway for patency - ANSWER A. Close monitoring of fluid
balance
What should the nurse suspect when hourly assessment of urine output on a client post
craniotomy reveals a urine output from a catheter of 1,500 mL for two consecutive
hours?
A. Cushing syndrome
B. Syndrome of inappropriate antidiuretic hormone (SIADH)
C. Adrenal crisis
D. Diabetes insipidus - ANSWER D. Diabetes insipidus
A nurse is providing care for a client who is experiencing withdrawal from heavy use of
alcohol. The nurse and other members of the care team are at the bedside when the
client seizes. While preparing to document this clinical event, the nurse should note
which of the following?
A. The ability of the client to follow instructions during the seizure.
B. Success or failure of the care team in physically restraining the client
C. Ability of the client to explain his seizure during the postictal period
D. Activities of the client immediately before the seizure - ANSWER D. Activities of the
client immediately before the seizure.
A client has seized, stiffening and then following a pattern of relaxation and contraction
of muscles. The nurse recognizes this as what type of seizure?
A. Unidentified seizure
B. Absence seizure
The nurse is providing care for an unconscious client. Which nursing priority is highest?
A. Accurately record intake and output
B. The client maintain a patent airway
C. Inserts NG tube as ordered
D. Appropriately administer pain management - ANSWER B. The client maintain a patent
airway
A seizure disorder client experiences a generalized seizure. Which nursing response is
most appropriate?
A. Restrain the client to prevent injury.
B. Open the client's jaws to insert an oral airway.
C. Place client in high Fowler position.
D. Loosen the client's restrictive clothing - ANSWER D. Loosen the client's restrictive
clothing
A client is admitted to the unit who has been receiving long-term therapy with the
medication phenytoin. Based on the side effects of this medication, which of the
following would be most important for the nurse to address in the plan of care for this
client?
A. Pulse oximetry
B. Low-protein diet
C. Providing thorough oral hygiene
D. Fluid restriction as ordered - ANSWER C. Providing thorough oral hygiene
A client is admitted to the ED with a blunt head injury and an altered state of
consciousness. What test results will provide the initial guidance for the nurse in
evaluating the client's LOC?
,A. Monro-Kellie hypothesis
B. Glasgow Coma scale
C. Cranial nerve function
D. Mental status examination - ANSWER B. Glasgow Coma scale
A client is admitted with increased intracranial pressure and has a ventriculostomy for
ICP monitoring. The nurse's latest assessment reveals that the client now exhibits
nuchal rigidity and photophobia. The nurse would be correct in suspecting which
complication?
A. Encephalitis
B. Cerebral spinal fluid leak
C. Meningitis
D. Catheter occlusion ANSWER C. Meningitis
The client is in status epilepticus and receiving care from the nurse. The nurse should
expect to administer which of the following medications to immediately stop the
seizure?
A. Intravenous phenobarbital
B. Intravenous diazepam
C. Oral lorazepam
D. Oral phenytoin - ANSWER B. Intravenous diazepam
A clinic nurse is caring for a client diagnosed with migraine headaches. During the
client teaching session the client asks the nurse about alcohol consumption. For what
does the nurse correctly inform the client about alcohol's effects?
A. Alcohol causes hormone fluctuations.
B. Alcohol causes vasodilation of the blood vessels.
C. Alcohol has an excitatory effect on the CNS.
D. Alcohol decreases endorphins in the brain - ANSWER B. Alcohol causes vasodilation
of the blood vessels.
, A client has been admitted with diabetes insipidus following increased ICP due to head
trauma. What nursing assessment best reflects this complication?
A. Close monitoring of fluid balance
B. Continuous BP monitoring
C. Serial arterial blood gases (ABGs)
D. Monitoring the client's airway for patency - ANSWER A. Close monitoring of fluid
balance
What should the nurse suspect when hourly assessment of urine output on a client post
craniotomy reveals a urine output from a catheter of 1,500 mL for two consecutive
hours?
A. Cushing syndrome
B. Syndrome of inappropriate antidiuretic hormone (SIADH)
C. Adrenal crisis
D. Diabetes insipidus - ANSWER D. Diabetes insipidus
A nurse is providing care for a client who is experiencing withdrawal from heavy use of
alcohol. The nurse and other members of the care team are at the bedside when the
client seizes. While preparing to document this clinical event, the nurse should note
which of the following?
A. The ability of the client to follow instructions during the seizure.
B. Success or failure of the care team in physically restraining the client
C. Ability of the client to explain his seizure during the postictal period
D. Activities of the client immediately before the seizure - ANSWER D. Activities of the
client immediately before the seizure.
A client has seized, stiffening and then following a pattern of relaxation and contraction
of muscles. The nurse recognizes this as what type of seizure?
A. Unidentified seizure
B. Absence seizure
