Neurological NCLEX Questions with correct Answers

Neurological NCLEX Questions with correct Answers 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. Pressure on orbital rim 4. Squeezing of the sternocleidomastoid muscle - 2. Nail Bed Pressure The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in VS if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing BP 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing BP 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing BP 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing BP - 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing BP 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 the activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning - 4. Exhaling during repositioning A client has clear liquid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose. - 4. Fluid separates into concentric rings and tests positive for glucose. A client with a spinal chord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of occurrence? 1. Strict adherence to a bowel retraining program 2 Keeping the linen wrinkle-free under the client 3. Preventing unnecessary pressure on the lower limbs 4. Limiting bladder catheterization to once ever 12 hours - 4. Limiting bladder catheterization to once ever 12 hours The nurse is evaluating the neurological signs of a client in spinal shock following spinal chord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder - 3. Flaccid paralysis The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse is contraindicated? 1. Loosening restrictive clothing 2. Restraining the client's limbs 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward - 2. Restraining the client's limbs The nurse is assigned to care for a client with complete right-sided hemiparesis. Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic 2. The client has weakness in the face and tongue 3. The client has weakness on the right side of the body 4. The client has complete bilateral paralysis of the arms and legs 5. The client has lost the ability to move the right arm but is able to walk independently 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without - 1. The client is aphasic 2. The client has weakness in the face and tongue 3. The client has weakness on the right side of the body The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to help when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field." - 4. "We need to remind him to turn his head to scan the lost visual field." The nurse is assessing the adaption of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?