100% CORRECT WELL DETAILED
The nurse is assessing the motor and sensory function of an unconscious client who
sustained a head injury. The nurse should use which technique to test the client's peripheral
response to pain?
A. Sternal rub
B. Nailbed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle - ANSWER B. Nailbed pressure
Nailbed pressure tests a basic motor and sensory peripheral response. Cerebral responses to
pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing
the clavicle or sternocleidomastoid muscle
The nurse is caring for the client with increased intracranial pressure as a result of a head
injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?
A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood
pressure
B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood
pressure
C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood
pressure
D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood
pressure - ANSWER B. Increasing temperature, decreasing pulse, decreasing
respirations, increasing blood pressure
1
,A change in vital signs may be a late sign of increased intracranial pressure. Trends include
increasing temperature and blood pressure and decreasing pulse and respirations.
Respiratory irregularities also may occur
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 which activity?
A. Blowing the nose
B. Isometric exercises
C. Coughing vigorously
D. Exhaling during repositioning - ANSWER D. Exhaling during repositioning
Activities that increase intrathoracic and intraabdominal pressures cause an indirect
elevation of the intracranial pressure. Some of these activities include isometric exercises,
Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities
such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic
pressure from rising
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord
injury. Which observation indicates that spinal shock persists?
A. Hyperreflexia
B. Positive reflexes
C. Flaccid paralysis
D. Reflex emptying of the bladder - ANSWER C. Flaccid paralysis
Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to
noxious cutaneous stimuli), a state of hyper-reflexia rather than flaccidity, and reflex
emptying of the bladder
2
,The nurse is caring for a client who begins to experience seizure activity while in bed. Which
actions should the nurse take? SATA
A. Loosening restrictive clothing
B. Restraining the client's limbs
C. Removing the pillow and raising padded side rails
D. Positioning the client to the side, if possible, with the head flexed forward
E. Keeping the curtain around the client and the room door open so when help arrives they
can quickly enter to assist - ANSWER A. Loosening restrictive clothing
C. Removing the pillow and raising padded side rails
D. Positioning the client to the side, if possible, with the head flexed forward
Nursing actions during a seizure include providing for privacy, loosening restrictive clothing,
removing the pillow and raising padded side rails in the bed, and placing the client on 1 side
with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate
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; protects the head from injury; and moves furniture that may
injure the client
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke
(brain attack). Which characteristics are associated with this condition? SATA
A. The client is aphasic
B. The client has weakness on the right side of the body
C. The client has complete bilateral paralysis of the arms and legs
D. The client has weakness on the right side of the face and tongue
E. The client has lost the ability to move the right arm but is able to walk independently
F. The client has lost the ability to ambulate independently but is able to feed and bathe
herself or himself without assistance - ANSWER A. The client is aphasic
B. The client has weakness on the right side of the body
3
, D. The client has weakness on the right side of the face and tongue
Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves
weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic,
unable to discriminate words and letters. They are generally very cautious and get anxious
when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The
client with right-sided hemiparesis has weakness of the right arm and leg and needs
assistance with feeding, bathing, and ambulating
The nurse is assessing the adaptation of a client to changes in functional status after a
stroke. Which observation indicates to the nurse that the client is adapting most
successfully?
A. Gents angry with family if the interrupt a task
B. Experiences bouts of depression and irritability
C. Has difficulty with using modified feeding utensils
D. Consistently uses adaptive equipment in dressing self - ANSWER D. Consistently
uses adaptive equipment in dressing self
Clients are evaluated as coping successfully with lifestyles changes after a stroke if they make
appropriate lifestyle alterations, use the assistance of others, and have appropriate social
interactions. Options A and B are not adaptive behaviors; option C indicates a not yet
successful attempt to adapt
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client
statement reflects a need for further teaching?
A. "I can sit down to put on my pants and shoes"
B. "I try to exercise every day and rest when I'm tired"
C. "My son removed all loose rugs from my bedroom"
D. "I don't need to use my walker to get to the bathroom" - ANSWER D. "I don't need
to use my walker to get to the bathroom
4
The nurse is assessing the motor and sensory function of an unconscious client who
sustained a head injury. The nurse should use which technique to test the client's peripheral
response to pain?
A. Sternal rub
B. Nailbed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle - ANSWER B. Nailbed pressure
Nailbed pressure tests a basic motor and sensory peripheral response. Cerebral responses to
pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing
the clavicle or sternocleidomastoid muscle
The nurse is caring for the client with increased intracranial pressure as a result of a head
injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?
A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood
pressure
B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood
pressure
C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood
pressure
D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood
pressure - ANSWER B. Increasing temperature, decreasing pulse, decreasing
respirations, increasing blood pressure
1
,A change in vital signs may be a late sign of increased intracranial pressure. Trends include
increasing temperature and blood pressure and decreasing pulse and respirations.
Respiratory irregularities also may occur
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 which activity?
A. Blowing the nose
B. Isometric exercises
C. Coughing vigorously
D. Exhaling during repositioning - ANSWER D. Exhaling during repositioning
Activities that increase intrathoracic and intraabdominal pressures cause an indirect
elevation of the intracranial pressure. Some of these activities include isometric exercises,
Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities
such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic
pressure from rising
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord
injury. Which observation indicates that spinal shock persists?
A. Hyperreflexia
B. Positive reflexes
C. Flaccid paralysis
D. Reflex emptying of the bladder - ANSWER C. Flaccid paralysis
Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to
noxious cutaneous stimuli), a state of hyper-reflexia rather than flaccidity, and reflex
emptying of the bladder
2
,The nurse is caring for a client who begins to experience seizure activity while in bed. Which
actions should the nurse take? SATA
A. Loosening restrictive clothing
B. Restraining the client's limbs
C. Removing the pillow and raising padded side rails
D. Positioning the client to the side, if possible, with the head flexed forward
E. Keeping the curtain around the client and the room door open so when help arrives they
can quickly enter to assist - ANSWER A. Loosening restrictive clothing
C. Removing the pillow and raising padded side rails
D. Positioning the client to the side, if possible, with the head flexed forward
Nursing actions during a seizure include providing for privacy, loosening restrictive clothing,
removing the pillow and raising padded side rails in the bed, and placing the client on 1 side
with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate
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; protects the head from injury; and moves furniture that may
injure the client
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke
(brain attack). Which characteristics are associated with this condition? SATA
A. The client is aphasic
B. The client has weakness on the right side of the body
C. The client has complete bilateral paralysis of the arms and legs
D. The client has weakness on the right side of the face and tongue
E. The client has lost the ability to move the right arm but is able to walk independently
F. The client has lost the ability to ambulate independently but is able to feed and bathe
herself or himself without assistance - ANSWER A. The client is aphasic
B. The client has weakness on the right side of the body
3
, D. The client has weakness on the right side of the face and tongue
Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves
weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic,
unable to discriminate words and letters. They are generally very cautious and get anxious
when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The
client with right-sided hemiparesis has weakness of the right arm and leg and needs
assistance with feeding, bathing, and ambulating
The nurse is assessing the adaptation of a client to changes in functional status after a
stroke. Which observation indicates to the nurse that the client is adapting most
successfully?
A. Gents angry with family if the interrupt a task
B. Experiences bouts of depression and irritability
C. Has difficulty with using modified feeding utensils
D. Consistently uses adaptive equipment in dressing self - ANSWER D. Consistently
uses adaptive equipment in dressing self
Clients are evaluated as coping successfully with lifestyles changes after a stroke if they make
appropriate lifestyle alterations, use the assistance of others, and have appropriate social
interactions. Options A and B are not adaptive behaviors; option C indicates a not yet
successful attempt to adapt
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client
statement reflects a need for further teaching?
A. "I can sit down to put on my pants and shoes"
B. "I try to exercise every day and rest when I'm tired"
C. "My son removed all loose rugs from my bedroom"
D. "I don't need to use my walker to get to the bathroom" - ANSWER D. "I don't need
to use my walker to get to the bathroom
4
