Module 4: NUR 2214 Module 4 :EA Questions & Answers
A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's
foot is stroked with an applicator stick during a neurologic examination. What should the nurse
document in the client's medical record? - ANSWER:"Exhibits a positive Babinski sign"
A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question
is most useful when planning nursing care related to the client's seizure? - ANSWER:"Were you aware of
anything different or unusual just before your seizure began?"
On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's
temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the
next nursing action? - ANSWER:Removing excess clothing from the infant
A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is
the priority nursing care for this client? - ANSWER:Maintain an open airway.
A 50-year-old male client has difficulty communicating because of expressive aphasia after a
cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse asks the client how he is
feeling, his wife answers for him. How should the nurse address this behavior? - ANSWER:Acknowledge
the wife but look at the client for a response.
A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is
the best initial action by the nurse? - ANSWER:Placing the child on the floor
A client has inflammation of the facial nerve, causing facial paralysis on one side. Which diagnosis will
the nurse most likely observe written in the medical record? - ANSWER:Bell palsy
Which antiepileptic drug is used as the first-line treatment for absence seizures? - ANSWER:valproic acid
During an annual physical assessment a client reports not being able to smell coffee and most foods.
Which cranial nerve function should the nurse assess? - ANSWER:I
Which statement indicates a nurse has a correct understanding about trigeminal autonomic cephalalgia
(cluster headaches)? - ANSWER:It is caused by an overactive hypothalamus.
A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains
of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably
is experiencing? - ANSWER:Salicylate toxicity
Which cranial nerve damage may lead to a decrease in the client's olfactory acuity? - ANSWER:Cranial
nerve I
A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse
applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the
most concern? - ANSWER:extending
The nurse caring for a 3-year-old child with meningitis should be alert for which signs and symptoms of
increased intracranial pressure? Select all that apply. - ANSWER:vomiting
, headache
irritability
A nurse should plan to maintain a client who has experienced a subarachnoid hemorrhage in what
position? - ANSWER:In bed with the head of the bed elevated
During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by
confusion. Which statement about this type of seizures is true? Select all that apply. - ANSWER:These
seizures increase the risk of injuries due to fall.
These seizures are most resistant to drug therapy.
A client has a tonic-clonic seizure that involves all extremities. The nurse anticipates that the healthcare
provider will prescribe the intravenous administration of which drug? - ANSWER:Diazepam
A primary healthcare provider diagnoses late-stage (tertiary) syphilis in a client. Which statement made
by the client supports this diagnosis? - ANSWER:"I'm having trouble keeping my balance."
A client is taking phenytoin to treat clonic-tonic seizures. The client's phenytoin level is 16 mg/L. Which
action should the nurse take? - ANSWER:Administer the next dose of the medication as prescribed.
The nurse is teaching a client with multiple sclerosis methods to reduce fatigue. Which statement
indicates an understanding of the education? - ANSWER:Rest in an air-conditioned room.
While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which
condition should the nurse record in the assessment findings? - ANSWER:Decerebration
During the first month in a nursing home, an older client with dementia demonstrates numerous
disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into
consideration when planning care? - ANSWER:Stressors that appear to precipitate the client's disruptive
behavior
During a follow-up visit, the nurse finds increased intracranial pressure in a client who has undergone
nasal hypophysectomy for hyperpituitarism. Which action taken by the client is responsible for this
condition? - ANSWER:Blowing the nose and sneezing
While assessing the airway patency of a client after a bomb blast, the nurse suspects severe brain injury
and gives a score of 7 using the Glasgow Coma Scale (GCS). Which intervention is most appropriate for
the client? - ANSWER:Preparing for endotracheal intubation and mechanical ventilation
What is the most common type of pituitary tumor? - ANSWER:Adenoma
Which symptoms can be present with a transient ischemic attack (TIA)? Select all that apply. -
ANSWER:vertigo
aphasia
blurred vision
An injury that is caused by an external force contacting the head, placing the head in sudden motion, is
known as what? - ANSWER:acceleration injury
A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's
foot is stroked with an applicator stick during a neurologic examination. What should the nurse
document in the client's medical record? - ANSWER:"Exhibits a positive Babinski sign"
A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question
is most useful when planning nursing care related to the client's seizure? - ANSWER:"Were you aware of
anything different or unusual just before your seizure began?"
On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's
temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the
next nursing action? - ANSWER:Removing excess clothing from the infant
A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is
the priority nursing care for this client? - ANSWER:Maintain an open airway.
A 50-year-old male client has difficulty communicating because of expressive aphasia after a
cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse asks the client how he is
feeling, his wife answers for him. How should the nurse address this behavior? - ANSWER:Acknowledge
the wife but look at the client for a response.
A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is
the best initial action by the nurse? - ANSWER:Placing the child on the floor
A client has inflammation of the facial nerve, causing facial paralysis on one side. Which diagnosis will
the nurse most likely observe written in the medical record? - ANSWER:Bell palsy
Which antiepileptic drug is used as the first-line treatment for absence seizures? - ANSWER:valproic acid
During an annual physical assessment a client reports not being able to smell coffee and most foods.
Which cranial nerve function should the nurse assess? - ANSWER:I
Which statement indicates a nurse has a correct understanding about trigeminal autonomic cephalalgia
(cluster headaches)? - ANSWER:It is caused by an overactive hypothalamus.
A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains
of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably
is experiencing? - ANSWER:Salicylate toxicity
Which cranial nerve damage may lead to a decrease in the client's olfactory acuity? - ANSWER:Cranial
nerve I
A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse
applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the
most concern? - ANSWER:extending
The nurse caring for a 3-year-old child with meningitis should be alert for which signs and symptoms of
increased intracranial pressure? Select all that apply. - ANSWER:vomiting
, headache
irritability
A nurse should plan to maintain a client who has experienced a subarachnoid hemorrhage in what
position? - ANSWER:In bed with the head of the bed elevated
During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by
confusion. Which statement about this type of seizures is true? Select all that apply. - ANSWER:These
seizures increase the risk of injuries due to fall.
These seizures are most resistant to drug therapy.
A client has a tonic-clonic seizure that involves all extremities. The nurse anticipates that the healthcare
provider will prescribe the intravenous administration of which drug? - ANSWER:Diazepam
A primary healthcare provider diagnoses late-stage (tertiary) syphilis in a client. Which statement made
by the client supports this diagnosis? - ANSWER:"I'm having trouble keeping my balance."
A client is taking phenytoin to treat clonic-tonic seizures. The client's phenytoin level is 16 mg/L. Which
action should the nurse take? - ANSWER:Administer the next dose of the medication as prescribed.
The nurse is teaching a client with multiple sclerosis methods to reduce fatigue. Which statement
indicates an understanding of the education? - ANSWER:Rest in an air-conditioned room.
While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which
condition should the nurse record in the assessment findings? - ANSWER:Decerebration
During the first month in a nursing home, an older client with dementia demonstrates numerous
disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into
consideration when planning care? - ANSWER:Stressors that appear to precipitate the client's disruptive
behavior
During a follow-up visit, the nurse finds increased intracranial pressure in a client who has undergone
nasal hypophysectomy for hyperpituitarism. Which action taken by the client is responsible for this
condition? - ANSWER:Blowing the nose and sneezing
While assessing the airway patency of a client after a bomb blast, the nurse suspects severe brain injury
and gives a score of 7 using the Glasgow Coma Scale (GCS). Which intervention is most appropriate for
the client? - ANSWER:Preparing for endotracheal intubation and mechanical ventilation
What is the most common type of pituitary tumor? - ANSWER:Adenoma
Which symptoms can be present with a transient ischemic attack (TIA)? Select all that apply. -
ANSWER:vertigo
aphasia
blurred vision
An injury that is caused by an external force contacting the head, placing the head in sudden motion, is
known as what? - ANSWER:acceleration injury
