Neurological NCLEX Review Saunders
Exam Questions & Answers (Grade
A+)
The nurse is caring for the client with increased intracranial
pressure. The nurse would note which trend in vital signs if the
intracranial pressure is rising?
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, increasing respirations,
decreasing blood pressure
4.
Decreasing temperature, increasing pulse, decreasing respirations,
increasing blood pressure -
correct answer ✅2.
,Neurological NCLEX Review Saunders
Exam Questions & Answers (Grade
A+)
Increasing temperature, decreasing pulse, decreasing respirations,
increasing blood pressure
Rationale:
A change in vital signs may be a late sign of increased intracranial
pressure. Trends include increasing temperature and blood
pressure and decreasing pulse and respirations. Respiratory
irregularities also may occur.
The nurse is assessing the motor function of an unconscious client.
The nurse should plan to use which technique to test the client's
peripheral response to pain?
1.
Sternal rub
2.
Nail bed pressure
3.
,Neurological NCLEX Review Saunders
Exam Questions & Answers (Grade
A+)
Pressure on the orbital rim
4.
Squeezing of the sternocleidomastoid muscle -
correct answer ✅2.
Nail bed pressure
Rationale:
Motor testing in the unconscious client can be done only by testing
response to painful stimuli. Nail bed pressure tests a basic
peripheral response. Cerebral responses to pain are tested using a
sternal rub, placing upward pressure on the orbital rim, or
squeezing the clavicle or sternocleidomastoid muscle.
A client recovering from a head injury is participating in care. The
nurse determines that the client understands measures to prevent
elevations in intracranial pressure if the nurse observes the client
doing which activity?
1.
, Neurological NCLEX Review Saunders
Exam Questions & Answers (Grade
A+)
Blowing the nose
2.
Isometric exercises
3.
Coughing vigorously
4.
Exhaling during repositioning -
correct answer ✅4.
Exhaling during repositioning
Rationale:
Activities that increase intrathoracic and intraabdominal pressures
cause an indirect elevation of the intracranial pressure. Some of
these activities include isometric exercises, Valsalva's maneuver,
coughing, sneezing, and blowing the nose. Exhaling during activities
such as repositioning or pulling up in bed, opens the glottis, which
prevents intrathoracic pressure from rising.
Exam Questions & Answers (Grade
A+)
The nurse is caring for the client with increased intracranial
pressure. The nurse would note which trend in vital signs if the
intracranial pressure is rising?
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, increasing respirations,
decreasing blood pressure
4.
Decreasing temperature, increasing pulse, decreasing respirations,
increasing blood pressure -
correct answer ✅2.
,Neurological NCLEX Review Saunders
Exam Questions & Answers (Grade
A+)
Increasing temperature, decreasing pulse, decreasing respirations,
increasing blood pressure
Rationale:
A change in vital signs may be a late sign of increased intracranial
pressure. Trends include increasing temperature and blood
pressure and decreasing pulse and respirations. Respiratory
irregularities also may occur.
The nurse is assessing the motor function of an unconscious client.
The nurse should plan to use which technique to test the client's
peripheral response to pain?
1.
Sternal rub
2.
Nail bed pressure
3.
,Neurological NCLEX Review Saunders
Exam Questions & Answers (Grade
A+)
Pressure on the orbital rim
4.
Squeezing of the sternocleidomastoid muscle -
correct answer ✅2.
Nail bed pressure
Rationale:
Motor testing in the unconscious client can be done only by testing
response to painful stimuli. Nail bed pressure tests a basic
peripheral response. Cerebral responses to pain are tested using a
sternal rub, placing upward pressure on the orbital rim, or
squeezing the clavicle or sternocleidomastoid muscle.
A client recovering from a head injury is participating in care. The
nurse determines that the client understands measures to prevent
elevations in intracranial pressure if the nurse observes the client
doing which activity?
1.
, Neurological NCLEX Review Saunders
Exam Questions & Answers (Grade
A+)
Blowing the nose
2.
Isometric exercises
3.
Coughing vigorously
4.
Exhaling during repositioning -
correct answer ✅4.
Exhaling during repositioning
Rationale:
Activities that increase intrathoracic and intraabdominal pressures
cause an indirect elevation of the intracranial pressure. Some of
these activities include isometric exercises, Valsalva's maneuver,
coughing, sneezing, and blowing the nose. Exhaling during activities
such as repositioning or pulling up in bed, opens the glottis, which
prevents intrathoracic pressure from rising.
