RN NCLEX Neuro adult health questions
RN NCLEX Neuro adult health questions
Study online at https://quizlet.com/_9rplx8
1. A client is admitted to the hospital for severe Notify the health care
headaches. The client has a history of increased in- provider
tracranial pressure (ICP), which has required lumbar
punctures to relieve the pressure by draining cere- Unexpected and projectile
brospinal fluid. The client suddenly vomits and states, vomiting without nausea
"That's weird, I didn't even feel nauseated." Which can be a sign of increased
action by the nurse is the most appropriate? ICP, especially in the client
- Document the amount of emesis with a history. The unex-
- Lower the head of the bed pected vomiting is relat-
- Notify the health care provider (HCP) ed to pressure changes in
- Offer anti-nausea medication. the cranium. The vomit-
ing can be associated with
headache and gets worse
with lowered head position.
The most appropriate ac-
tion is to obtain a full set of
vital signs and contact the
HCP immediately
2. The nurse is caring for a client with an acute is- Monitor the blood pressure
chemic stroke who has a blood pressure of 178/95
mm Hg. The health care provider prescribes as-need-
ed anti-hypertensives to be given if the systolic pres-
sure is >200 mm Hg. Which action by the nurse is most
appropriate?
- Give the antihypertensive medication
- Monitor the blood pressure
- Notify the health care provider
- Question the prescription.
3. The nurse is assessing the cranial nerves and begins Raise your eyebrows, smile,
testing the facial nerve (cranial nerve VII). Which direc- and frown
actualstudy Page 1
, RN NCLEX Neuro adult health questions
RN NCLEX Neuro adult health questions
Study online at https://quizlet.com/_9rplx8
tion should the nurse give the client to test this cranial
nerve?
- Close your eyes and identify this smell
- Follow my finger with your eyes without moving your
head
- Look straight ahead and let me know when you can
see my finger
- Raise your eyebrows, smile, and frown.
4. The nurse is caring for a female client newly diag- - Avoid drinking alcoholic
nosed with epilepsy who has been prescribed pheny- beverages
toin. Which of the following should the nurse include - Do not abruptly stop tak-
in client teaching? Select all that apply ing your phenytoin
- Avoid drinking alcoholic beverages - Wear an epilepsy medical
- Do not abruptly stop taking your phenytoin alert bracelet
- Go to the emergency department every time a - You may need to start
seizure occurs using a nonhormonal birth
- Wear an epilepsy medical identification bracelet control method.
- You may need to start using nonhormonal birth con-
trol method.
5. The nurse is assessing a client with advanced amy- Difficulty breathing
otrophic lateral sclerosis. Which of the following as- Difficulty swallowing
sessment findings does the nurse expect? Select all Muscle weakness
that apply.
- Diarrhea
- Difficulty breathing
- Difficulty swallowing
- Muscle weakness
- Resting tremor.
6.
actualstudy Page 2
, RN NCLEX Neuro adult health questions
RN NCLEX Neuro adult health questions
Study online at https://quizlet.com/_9rplx8
A client with a T4 spinal cord injury has a severe throb- Determine if there is blad-
bing headache and appears flushed and diaphoretic. der distention
Which interventions should the nurse perform? Select Measure the client's blood
all that apply pressure
- Administer an analgesic as needed Remove constrictive cloth-
- Determine if there is bladder distention ing
- Measure the client's blood pressure
- Place the client in the Sim's position
- Remove constrictive clothing.
7. A client with a history of headaches is scheduled for I will need to lie on my
a lumbar puncture to assess the cerebrospinal fluid stomach during the proce-
pressure. The nurse is preparing the client for the dure.
procedure. Which statement by the client indicates a
need for further teaching by the nurse/
- I may feel a sharp pain that shoots to my leg, but it
should pass soon
- I will go to the bathroom and try to urinate before
the procedure
- I will need to lie on my stomach during the proce-
dure
- The physician will insert a needle between the bones
in my lower spine
8. The nurse reinforces education about safety modifica- - Arrange furniture to allow
tions in the home for the spouse of a client diagnosed for free movement
with Alzheimer's disease. What instructions should - Keep frequently used
the nurse include? Select all that apply items within easy reach
- Arrange furniture to allow for free movement - Lock doors leading to
- Keep frequently used items within easy reach stairwells and outside ar-
- Lock doors leading to stairwells and outside areas. eas
actualstudy Page 3
, RN NCLEX Neuro adult health questions
RN NCLEX Neuro adult health questions
Study online at https://quizlet.com/_9rplx8
- Place an identifying symbol on the bathroom door - Place an identifying sym-
- Provide a dark room free of shadows for sleeping bol on the bathroom door.
9. A client is brought to the emergency department by Maintain patent airway
emergency medical services with a flaccid right arm
and leg and lack of verbal response. The stroke team
is initiated. The nurse takes which priority action?
- Determine onset of symptoms
- Ensure that the client has 2 large-bore intravenous
IV lines
- Maintain patent airway
- Prepare for head CT scan
10. A nurse is evaluating an acutely ill client with sus- Place the client on droplet
pected meningitis. The nurse should take what action precautions
first/
- Check for Kernig's and Brudzinski's signs
- Establish IV access
- Place the client on droplet precautions
- Prepare the client for lumbar puncture
11. The emergency department nurse receives several Administer IV push nalox-
prescriptions for a client who was found unresponsive one once now.
after drinking beer and consuming unidentified pills.
Which prescription should the nurse implement first?
Exhibit: Vital signs
T: 96.4 F
BP: 90/62
HR: 53/min
RR: 6/min
O2 sat: 92%
- Administer IV push naloxone once now
actualstudy Page 4
RN NCLEX Neuro adult health questions
Study online at https://quizlet.com/_9rplx8
1. A client is admitted to the hospital for severe Notify the health care
headaches. The client has a history of increased in- provider
tracranial pressure (ICP), which has required lumbar
punctures to relieve the pressure by draining cere- Unexpected and projectile
brospinal fluid. The client suddenly vomits and states, vomiting without nausea
"That's weird, I didn't even feel nauseated." Which can be a sign of increased
action by the nurse is the most appropriate? ICP, especially in the client
- Document the amount of emesis with a history. The unex-
- Lower the head of the bed pected vomiting is relat-
- Notify the health care provider (HCP) ed to pressure changes in
- Offer anti-nausea medication. the cranium. The vomit-
ing can be associated with
headache and gets worse
with lowered head position.
The most appropriate ac-
tion is to obtain a full set of
vital signs and contact the
HCP immediately
2. The nurse is caring for a client with an acute is- Monitor the blood pressure
chemic stroke who has a blood pressure of 178/95
mm Hg. The health care provider prescribes as-need-
ed anti-hypertensives to be given if the systolic pres-
sure is >200 mm Hg. Which action by the nurse is most
appropriate?
- Give the antihypertensive medication
- Monitor the blood pressure
- Notify the health care provider
- Question the prescription.
3. The nurse is assessing the cranial nerves and begins Raise your eyebrows, smile,
testing the facial nerve (cranial nerve VII). Which direc- and frown
actualstudy Page 1
, RN NCLEX Neuro adult health questions
RN NCLEX Neuro adult health questions
Study online at https://quizlet.com/_9rplx8
tion should the nurse give the client to test this cranial
nerve?
- Close your eyes and identify this smell
- Follow my finger with your eyes without moving your
head
- Look straight ahead and let me know when you can
see my finger
- Raise your eyebrows, smile, and frown.
4. The nurse is caring for a female client newly diag- - Avoid drinking alcoholic
nosed with epilepsy who has been prescribed pheny- beverages
toin. Which of the following should the nurse include - Do not abruptly stop tak-
in client teaching? Select all that apply ing your phenytoin
- Avoid drinking alcoholic beverages - Wear an epilepsy medical
- Do not abruptly stop taking your phenytoin alert bracelet
- Go to the emergency department every time a - You may need to start
seizure occurs using a nonhormonal birth
- Wear an epilepsy medical identification bracelet control method.
- You may need to start using nonhormonal birth con-
trol method.
5. The nurse is assessing a client with advanced amy- Difficulty breathing
otrophic lateral sclerosis. Which of the following as- Difficulty swallowing
sessment findings does the nurse expect? Select all Muscle weakness
that apply.
- Diarrhea
- Difficulty breathing
- Difficulty swallowing
- Muscle weakness
- Resting tremor.
6.
actualstudy Page 2
, RN NCLEX Neuro adult health questions
RN NCLEX Neuro adult health questions
Study online at https://quizlet.com/_9rplx8
A client with a T4 spinal cord injury has a severe throb- Determine if there is blad-
bing headache and appears flushed and diaphoretic. der distention
Which interventions should the nurse perform? Select Measure the client's blood
all that apply pressure
- Administer an analgesic as needed Remove constrictive cloth-
- Determine if there is bladder distention ing
- Measure the client's blood pressure
- Place the client in the Sim's position
- Remove constrictive clothing.
7. A client with a history of headaches is scheduled for I will need to lie on my
a lumbar puncture to assess the cerebrospinal fluid stomach during the proce-
pressure. The nurse is preparing the client for the dure.
procedure. Which statement by the client indicates a
need for further teaching by the nurse/
- I may feel a sharp pain that shoots to my leg, but it
should pass soon
- I will go to the bathroom and try to urinate before
the procedure
- I will need to lie on my stomach during the proce-
dure
- The physician will insert a needle between the bones
in my lower spine
8. The nurse reinforces education about safety modifica- - Arrange furniture to allow
tions in the home for the spouse of a client diagnosed for free movement
with Alzheimer's disease. What instructions should - Keep frequently used
the nurse include? Select all that apply items within easy reach
- Arrange furniture to allow for free movement - Lock doors leading to
- Keep frequently used items within easy reach stairwells and outside ar-
- Lock doors leading to stairwells and outside areas. eas
actualstudy Page 3
, RN NCLEX Neuro adult health questions
RN NCLEX Neuro adult health questions
Study online at https://quizlet.com/_9rplx8
- Place an identifying symbol on the bathroom door - Place an identifying sym-
- Provide a dark room free of shadows for sleeping bol on the bathroom door.
9. A client is brought to the emergency department by Maintain patent airway
emergency medical services with a flaccid right arm
and leg and lack of verbal response. The stroke team
is initiated. The nurse takes which priority action?
- Determine onset of symptoms
- Ensure that the client has 2 large-bore intravenous
IV lines
- Maintain patent airway
- Prepare for head CT scan
10. A nurse is evaluating an acutely ill client with sus- Place the client on droplet
pected meningitis. The nurse should take what action precautions
first/
- Check for Kernig's and Brudzinski's signs
- Establish IV access
- Place the client on droplet precautions
- Prepare the client for lumbar puncture
11. The emergency department nurse receives several Administer IV push nalox-
prescriptions for a client who was found unresponsive one once now.
after drinking beer and consuming unidentified pills.
Which prescription should the nurse implement first?
Exhibit: Vital signs
T: 96.4 F
BP: 90/62
HR: 53/min
RR: 6/min
O2 sat: 92%
- Administer IV push naloxone once now
actualstudy Page 4
