NCLEX Saunders -NEURO
NCLEX Saunders -NEURO
Study online at https://quizlet.com/_15rj91
1. A client with amyotrophic lateral sclerosis (ALS) tells Powerlessness
the nurse, "Sometimes I feel so frustrated. I can't do
anything without help!" This comment best supports
which nursing diagnosis?
2. When caring for a client with a head injury, the nurse Rising blood pressure and
must stay alert for signs and symptoms of increased bradycardia
intracranial pressure (ICP). Which cardiovascular find-
ings are late indicators of increased ICP?
3. The nurse receives a physician's order to administer 31
1,000 ml of normal saline solution I.V. over 8 hours to a
client who recently had a stroke. What should the drip
rate be if the drop factor of the tubing is 15 gtt/ml?
4. When caring for a client with head trauma, the nurse Test the nasal drainage for
notes a small amount of clear, watery fluid oozing glucose.
from the client's nose. What should the nurse do?
5. The physician orders measurement of the serum ac- 4 hours
etaminophen level of a client admitted with a suspect-
ed overdose of this drug. To ensure an accurate result,
the nurse should wait how long after acetaminophen
(Tylenol) ingestion before drawing the blood sample?
6. A home health nurse visits a client who's taking pilo- Advise the client to discard
carpine, a miotic agent, to treat glaucoma. The nurse the drug because it may
notes that the client's pilocarpine solution is cloudy. have undergone chemical
What should the nurse do first? changes or become cont-
aminated.
7. Damage to which area of the brain results in receptive Temporal lobe
aphasia?
actualstudy Page 1
, NCLEX Saunders -NEURO
NCLEX Saunders -NEURO
Study online at https://quizlet.com/_15rj91
8. A client who sustained an L1 to L2 spinal cord injury "What has your physician
in a construction accident asks a nurse if he'll ever be told you about your ability
able to walk again. Which response by the nurse is to walk again?"
appropriate?
9. A client is admitted to an acute care facility for treat- Muscle contraction is pal-
ment of a brain tumor. When reviewing the chart, pable and visible.
the nurse notes that the client's extremity muscle
strength is rated 1/5. What does this mean?
10. A client with a spinal cord injury and subsequent urine increase the frequency of
retention receives intermittent catheterization every the catheterizations.
4 hours. The average catheterized urine volume has
been 550 ml. The nurse should plan to:
11. (SELECT ALL THAT APPLY) The nurse is planning care (1) Visual disturbances,
for a client with multiple sclerosis. Which problems (3) Balance problems, (5)
should the nurse expect the client to experience? Mood disorders
12. A client undergoes cerebral angiography to evaluate Hemiplegia, seizures, and
for neurologic deficits. Afterward, the nurse checks decreased level of con-
frequently for signs and symptoms of complications sciousness (LOC)
associated with this procedure. Which findings indi-
cate spasm or occlusion of a cerebral vessel by a clot?
13. The nurse is administering neostigmine to a client Schedule the medication
with myasthenia gravis. Which nursing intervention before meals.
should the nurse implement?
14. A 78-year-old Alzheimer's client is being treated for wander.
malnutrition and dehydration. The nurse decides to
actualstudy Page 2
, NCLEX Saunders -NEURO
NCLEX Saunders -NEURO
Study online at https://quizlet.com/_15rj91
place him closer to the nurses' station because of his
tendency to:
15. During the course of a busy shift, a nurse fails to doc- Notify the physician of the
ument that a client's ventricular drain had an output documentation omission.
of 150 ml. Assuming that the drain was no longer
draining cerebrospinal fluid, the physician removes
the drain. When the nurse arrives for work the next
morning, she learns that the client became agitated
during the night and his blood pressure became ele-
vated. What action should the nurse take?
16. How should the nurse position a client for a lumbar Laterally, with knees
puncture? drawn up to the abdomen
and chin touching the
chest
17. A client with Guillain-Barré syndrome has paralysis af- "The paralysis caused by
fecting the respiratory muscles and requires mechan- this disease is temporary."
ical ventilation. What should the nurse tell the client
about the paralysis?
18. What should the nurse do when administering pilo- Apply pressure on the in-
carpine (Pilocar)? ner canthus to prevent
systemic absorption.
19. (SELECT ALL THAT APPLY) A client is admitted to the (2) Turn the client on his
medical-surgical unit after undergoing intracranial right side., (5) Apply a soft
surgery to remove a tumor from the left cerebral collar to keep the client's
hemisphere. Which nursing interventions are appro- neck in a neutral position.
priate for the client's postoperative care?
20.
actualstudy Page 3
NCLEX Saunders -NEURO
Study online at https://quizlet.com/_15rj91
1. A client with amyotrophic lateral sclerosis (ALS) tells Powerlessness
the nurse, "Sometimes I feel so frustrated. I can't do
anything without help!" This comment best supports
which nursing diagnosis?
2. When caring for a client with a head injury, the nurse Rising blood pressure and
must stay alert for signs and symptoms of increased bradycardia
intracranial pressure (ICP). Which cardiovascular find-
ings are late indicators of increased ICP?
3. The nurse receives a physician's order to administer 31
1,000 ml of normal saline solution I.V. over 8 hours to a
client who recently had a stroke. What should the drip
rate be if the drop factor of the tubing is 15 gtt/ml?
4. When caring for a client with head trauma, the nurse Test the nasal drainage for
notes a small amount of clear, watery fluid oozing glucose.
from the client's nose. What should the nurse do?
5. The physician orders measurement of the serum ac- 4 hours
etaminophen level of a client admitted with a suspect-
ed overdose of this drug. To ensure an accurate result,
the nurse should wait how long after acetaminophen
(Tylenol) ingestion before drawing the blood sample?
6. A home health nurse visits a client who's taking pilo- Advise the client to discard
carpine, a miotic agent, to treat glaucoma. The nurse the drug because it may
notes that the client's pilocarpine solution is cloudy. have undergone chemical
What should the nurse do first? changes or become cont-
aminated.
7. Damage to which area of the brain results in receptive Temporal lobe
aphasia?
actualstudy Page 1
, NCLEX Saunders -NEURO
NCLEX Saunders -NEURO
Study online at https://quizlet.com/_15rj91
8. A client who sustained an L1 to L2 spinal cord injury "What has your physician
in a construction accident asks a nurse if he'll ever be told you about your ability
able to walk again. Which response by the nurse is to walk again?"
appropriate?
9. A client is admitted to an acute care facility for treat- Muscle contraction is pal-
ment of a brain tumor. When reviewing the chart, pable and visible.
the nurse notes that the client's extremity muscle
strength is rated 1/5. What does this mean?
10. A client with a spinal cord injury and subsequent urine increase the frequency of
retention receives intermittent catheterization every the catheterizations.
4 hours. The average catheterized urine volume has
been 550 ml. The nurse should plan to:
11. (SELECT ALL THAT APPLY) The nurse is planning care (1) Visual disturbances,
for a client with multiple sclerosis. Which problems (3) Balance problems, (5)
should the nurse expect the client to experience? Mood disorders
12. A client undergoes cerebral angiography to evaluate Hemiplegia, seizures, and
for neurologic deficits. Afterward, the nurse checks decreased level of con-
frequently for signs and symptoms of complications sciousness (LOC)
associated with this procedure. Which findings indi-
cate spasm or occlusion of a cerebral vessel by a clot?
13. The nurse is administering neostigmine to a client Schedule the medication
with myasthenia gravis. Which nursing intervention before meals.
should the nurse implement?
14. A 78-year-old Alzheimer's client is being treated for wander.
malnutrition and dehydration. The nurse decides to
actualstudy Page 2
, NCLEX Saunders -NEURO
NCLEX Saunders -NEURO
Study online at https://quizlet.com/_15rj91
place him closer to the nurses' station because of his
tendency to:
15. During the course of a busy shift, a nurse fails to doc- Notify the physician of the
ument that a client's ventricular drain had an output documentation omission.
of 150 ml. Assuming that the drain was no longer
draining cerebrospinal fluid, the physician removes
the drain. When the nurse arrives for work the next
morning, she learns that the client became agitated
during the night and his blood pressure became ele-
vated. What action should the nurse take?
16. How should the nurse position a client for a lumbar Laterally, with knees
puncture? drawn up to the abdomen
and chin touching the
chest
17. A client with Guillain-Barré syndrome has paralysis af- "The paralysis caused by
fecting the respiratory muscles and requires mechan- this disease is temporary."
ical ventilation. What should the nurse tell the client
about the paralysis?
18. What should the nurse do when administering pilo- Apply pressure on the in-
carpine (Pilocar)? ner canthus to prevent
systemic absorption.
19. (SELECT ALL THAT APPLY) A client is admitted to the (2) Turn the client on his
medical-surgical unit after undergoing intracranial right side., (5) Apply a soft
surgery to remove a tumor from the left cerebral collar to keep the client's
hemisphere. Which nursing interventions are appro- neck in a neutral position.
priate for the client's postoperative care?
20.
actualstudy Page 3
