Neuro Saunders Nclex questions
Neuro Saunders Nclex questions
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1. The nurse is assess- Nail bed pressure
ing the motor func- Motor testing in the unconscious client can be done only by testing
tion of an unconscious response to painful stimuli. Nail bed pressure tests a basic peripheral
client. The nurse should response. Cerebral responses to pain are tested using a sternal rub,
plan to use which tech- placing upward pressure on the orbital rim, or squeezing the clavicle or
nique to test the client's sternocleidomastoid muscle.
peripheral response to
pain?
2. The nurse is caring Increasing temperature, decreasing pulse, decreasing respirations, in-
for the client with creasing blood pressure
increased intracranial A change in vital signs may be a late sign of increased intracranial
pressure. The nurse pressure. Trends include increasing temperature and blood pressure
would note which trend and decreasing pulse and respirations. Respiratory irregularities also
in vital signs if the in- may occur.
tracranial pressure is
rising?
3. A client recovering from Exhaling during repositioning
a head injury is par- Activities that increase intrathoracic and intraabdominal pressures cause
ticipating in care. The an indirect elevation of the intracranial pressure. Some of these activities
nurse determines that include isometric exercises, Valsalva's maneuver, coughing, sneezing,
the client understands and blowing the nose. Exhaling during activities such as repositioning
measures to prevent el- or pulling up in bed, opens the glottis, which prevents intrathoracic
evations in intracranial pressure from rising.
pressure if the nurse
observes the client do-
ing which activity?
4. A client has clear fluid Fluid separates into concentric rings and tests positive for glucose.
leaking from the nose Leakage of cerebrospinal fluid (CSF) from the ears or nose may ac-
following a basilar skull company basilar skull fracture. CSF can be distinguished from other
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fracture. Which finding body fluids because the drainage will separate into bloody and yellow
would alert the nurse concentric rings on dressing material, called a halo sign. The fluid also
that cerebrospinal fluid tests positive for glucose.
is present?
5. A client with a spinal Limiting bladder catheterization to once every 12 hours
cord injury is prone to The most frequent cause of autonomic dysreflexia is a distended
experiencing autonom- bladder. Straight catheterization should be done every 4 to 6 hours
ic dysreflexia. The nurse (catheterization every 12 hours is too infrequent), and Foley catheters
should avoid which should be checked frequently to prevent kinks in the tubing. Consti-
measure to minimize pation and fecal impaction are other causes, so maintaining bowel
the risk of occurrence? regularity is important. Other causes include stimulation of the skin
from tactile, thermal, or painful stimuli. The nurse administers care to
minimize risk in these areas.
6. The nurse is evaluating Flaccid paralysis
the neurological signs Resolution of spinal shock is occurring when there is return of reflexes
of a client in spinal (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia
shock following spinal rather than flaccidity, and reflex emptying of the bladder.
cord injury. Which ob-
servation indicates that
spinal shock persists?
7. The nurse is caring for a Restraining the client's limbs
client who begins to ex- Nursing actions during a seizure include providing for privacy, loosen-
perience seizure activity ing restrictive clothing, removing the pillow and raising padded side
while in bed. Which ac- rails in the bed, and placing the client on one side with the head flexed
tion by the nurse is con- forward, if possible, to allow the tongue to fall forward and facilitate
traindicated? drainage. The limbs are never restrained because the strong muscle
contractions could cause the client harm. If the client is not in bed when
seizure activity begins, the nurse lowers the client to the floor, if possible,
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protects the head from injury, and moves furniture that may injure the
client.
8. The nurse is as- The client is aphasic.
signed to care for a The client has weakness in the face and tongue.
client with complete The client has weakness on the right side of the body.
right-sided hemipare- Hemiparesis is a weakness of one side of the body that may occur after
sis. Which characteris- a stroke. It involves weakness of the face and tongue, arm, and leg on
tics are associated with one side. These clients are also aphasic: unable to discriminate words
this condition? and letters. They are generally very cautious and get anxious when
attempting a new task. Complete bilateral paralysis does not occur in
this hemiparesis. The client with right-sided hemiparesis has weakness
of the right arm and leg and needs assistance with feeding, bathing,
and ambulating.
9. The nurse has in- "We need to remind him to turn his head to scan the lost visual field."
structed the family of Homonymous hemianopsia is loss of half of the visual field. The client
a client with stroke with homonymous hemianopsia should have objects placed in the intact
(brain attack) who has field of vision, and the nurse also should approach the client from
homonymous hemi- the intact side. The nurse instructs the client to scan the environment
anopsia about mea- to overcome the visual deficit and does client teaching from within
sures to help the client the intact field of vision. The nurse encourages the use of personal
overcome the deficit. eyeglasses, if they are available.
Which statement sug-
gests that the family
understands the mea-
sures to use when car-
ing for the client?
10. The nurse is assess- Consistently uses adaptive equipment in dressing self
ing the adaptation of Clients are evaluated as coping successfully with lifestyle changes after
a client to changes in
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functional status after a brain attack (stroke) if they make appropriate lifestyle alterations, use
a stroke (brain attack). the assistance of others, and have appropriate social interactions.
Which observation indi-
cates to the nurse that
the client is adapting
most successfully?
11. The nurse is teaching Taking medications on time to maintain therapeutic blood levels
a client with myasthe- Clients with myasthenia gravis are taught to space out activities over the
nia gravis about the pre- day to conserve energy and restore muscle strength. Taking medications
vention of myasthenic correctly to maintain blood levels that are not too low or too high
and cholinergic crises. is important. Muscle-strengthening exercises are not helpful and can
Which client activity fatigue the client. Overeating is a cause of exacerbation of symptoms, as
suggests that teaching is exposure to heat, crowds, erratic sleep habits, and emotional stress.
is most effective?
12. The nurse has given in- Rocks back and forth to start movement with bradykinesia.
structions to a client The client with Parkinson's disease should exercise in the morning when
with Parkinson's dis- energy levels are highest. The client should avoid sitting in soft deep
ease about maintaining chairs because they are difficult to get up from. The client can rock back
mobility. Which action and forth to initiate movement. The client should buy clothes with Velcro
demonstrates that the fasteners and slide-locking buckles to support the ability to dress self.
client understands the
directions?
13. The nurse has given "I'll try to eat my food either very warm or very cold."
suggestions to a client Facial pain can be minimized by using cotton pads to wash the face
with trigeminal neural- and using room temperature water. The client should chew on the
gia about strategies to unaffected side of the mouth, eat a soft diet, and take in foods and
minimize episodes of beverages at room temperature. If toothbrushing triggers pain, an oral
pain. The nurse deter- rinse after meals may be helpful instead.
mines that the client
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Neuro Saunders Nclex questions
Study online at https://quizlet.com/_bdk1yk
1. The nurse is assess- Nail bed pressure
ing the motor func- Motor testing in the unconscious client can be done only by testing
tion of an unconscious response to painful stimuli. Nail bed pressure tests a basic peripheral
client. The nurse should response. Cerebral responses to pain are tested using a sternal rub,
plan to use which tech- placing upward pressure on the orbital rim, or squeezing the clavicle or
nique to test the client's sternocleidomastoid muscle.
peripheral response to
pain?
2. The nurse is caring Increasing temperature, decreasing pulse, decreasing respirations, in-
for the client with creasing blood pressure
increased intracranial A change in vital signs may be a late sign of increased intracranial
pressure. The nurse pressure. Trends include increasing temperature and blood pressure
would note which trend and decreasing pulse and respirations. Respiratory irregularities also
in vital signs if the in- may occur.
tracranial pressure is
rising?
3. A client recovering from Exhaling during repositioning
a head injury is par- Activities that increase intrathoracic and intraabdominal pressures cause
ticipating in care. The an indirect elevation of the intracranial pressure. Some of these activities
nurse determines that include isometric exercises, Valsalva's maneuver, coughing, sneezing,
the client understands and blowing the nose. Exhaling during activities such as repositioning
measures to prevent el- or pulling up in bed, opens the glottis, which prevents intrathoracic
evations in intracranial pressure from rising.
pressure if the nurse
observes the client do-
ing which activity?
4. A client has clear fluid Fluid separates into concentric rings and tests positive for glucose.
leaking from the nose Leakage of cerebrospinal fluid (CSF) from the ears or nose may ac-
following a basilar skull company basilar skull fracture. CSF can be distinguished from other
https://www.stuvia.com/user/actualstudy 1
, Neuro Saunders Nclex questions
Neuro Saunders Nclex questions
Study online at https://quizlet.com/_bdk1yk
fracture. Which finding body fluids because the drainage will separate into bloody and yellow
would alert the nurse concentric rings on dressing material, called a halo sign. The fluid also
that cerebrospinal fluid tests positive for glucose.
is present?
5. A client with a spinal Limiting bladder catheterization to once every 12 hours
cord injury is prone to The most frequent cause of autonomic dysreflexia is a distended
experiencing autonom- bladder. Straight catheterization should be done every 4 to 6 hours
ic dysreflexia. The nurse (catheterization every 12 hours is too infrequent), and Foley catheters
should avoid which should be checked frequently to prevent kinks in the tubing. Consti-
measure to minimize pation and fecal impaction are other causes, so maintaining bowel
the risk of occurrence? regularity is important. Other causes include stimulation of the skin
from tactile, thermal, or painful stimuli. The nurse administers care to
minimize risk in these areas.
6. The nurse is evaluating Flaccid paralysis
the neurological signs Resolution of spinal shock is occurring when there is return of reflexes
of a client in spinal (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia
shock following spinal rather than flaccidity, and reflex emptying of the bladder.
cord injury. Which ob-
servation indicates that
spinal shock persists?
7. The nurse is caring for a Restraining the client's limbs
client who begins to ex- Nursing actions during a seizure include providing for privacy, loosen-
perience seizure activity ing restrictive clothing, removing the pillow and raising padded side
while in bed. Which ac- rails in the bed, and placing the client on one side with the head flexed
tion by the nurse is con- forward, if possible, to allow the tongue to fall forward and facilitate
traindicated? drainage. The limbs are never restrained because the strong muscle
contractions could cause the client harm. If the client is not in bed when
seizure activity begins, the nurse lowers the client to the floor, if possible,
https://www.stuvia.com/user/actualstudy 2
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Neuro Saunders Nclex questions
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protects the head from injury, and moves furniture that may injure the
client.
8. The nurse is as- The client is aphasic.
signed to care for a The client has weakness in the face and tongue.
client with complete The client has weakness on the right side of the body.
right-sided hemipare- Hemiparesis is a weakness of one side of the body that may occur after
sis. Which characteris- a stroke. It involves weakness of the face and tongue, arm, and leg on
tics are associated with one side. These clients are also aphasic: unable to discriminate words
this condition? and letters. They are generally very cautious and get anxious when
attempting a new task. Complete bilateral paralysis does not occur in
this hemiparesis. The client with right-sided hemiparesis has weakness
of the right arm and leg and needs assistance with feeding, bathing,
and ambulating.
9. The nurse has in- "We need to remind him to turn his head to scan the lost visual field."
structed the family of Homonymous hemianopsia is loss of half of the visual field. The client
a client with stroke with homonymous hemianopsia should have objects placed in the intact
(brain attack) who has field of vision, and the nurse also should approach the client from
homonymous hemi- the intact side. The nurse instructs the client to scan the environment
anopsia about mea- to overcome the visual deficit and does client teaching from within
sures to help the client the intact field of vision. The nurse encourages the use of personal
overcome the deficit. eyeglasses, if they are available.
Which statement sug-
gests that the family
understands the mea-
sures to use when car-
ing for the client?
10. The nurse is assess- Consistently uses adaptive equipment in dressing self
ing the adaptation of Clients are evaluated as coping successfully with lifestyle changes after
a client to changes in
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Neuro Saunders Nclex questions
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functional status after a brain attack (stroke) if they make appropriate lifestyle alterations, use
a stroke (brain attack). the assistance of others, and have appropriate social interactions.
Which observation indi-
cates to the nurse that
the client is adapting
most successfully?
11. The nurse is teaching Taking medications on time to maintain therapeutic blood levels
a client with myasthe- Clients with myasthenia gravis are taught to space out activities over the
nia gravis about the pre- day to conserve energy and restore muscle strength. Taking medications
vention of myasthenic correctly to maintain blood levels that are not too low or too high
and cholinergic crises. is important. Muscle-strengthening exercises are not helpful and can
Which client activity fatigue the client. Overeating is a cause of exacerbation of symptoms, as
suggests that teaching is exposure to heat, crowds, erratic sleep habits, and emotional stress.
is most effective?
12. The nurse has given in- Rocks back and forth to start movement with bradykinesia.
structions to a client The client with Parkinson's disease should exercise in the morning when
with Parkinson's dis- energy levels are highest. The client should avoid sitting in soft deep
ease about maintaining chairs because they are difficult to get up from. The client can rock back
mobility. Which action and forth to initiate movement. The client should buy clothes with Velcro
demonstrates that the fasteners and slide-locking buckles to support the ability to dress self.
client understands the
directions?
13. The nurse has given "I'll try to eat my food either very warm or very cold."
suggestions to a client Facial pain can be minimized by using cotton pads to wash the face
with trigeminal neural- and using room temperature water. The client should chew on the
gia about strategies to unaffected side of the mouth, eat a soft diet, and take in foods and
minimize episodes of beverages at room temperature. If toothbrushing triggers pain, an oral
pain. The nurse deter- rinse after meals may be helpful instead.
mines that the client
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