100 Neuro NCLEX Questions and Answers

100 Neuro NCLEX questions 1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? Reposition the client to avoid neck flexion Administer 1 g Mannitol IV as ordered Increase the ventilator’s respiratory rate to 20 breaths/minute Administer 100 mg of pentobarbital IV as ordered. 2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Rapid Dilantin administration can cause cardiac arrhythmias. Dilantin should be mixed in dextrose in water before administration. Dilantin should be administered through an IV catheter in the client’s hand. 3. A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? Evaluate urine specific gravity Anticipate treatment for renal failure Provide emollients to the skin to prevent breakdown Slow down the IV fluids and notify the physician 4. When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). Emergent; the client is poorly oxygenated. Normal Significant; the client has alveolar hypoventilation. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? 1. Bloody drainage from the ears 2. Frequent swallowing Guaiac-positive stools Hematuria 6. After a hypophysectomy, vasopressin is given IM for which of the following reasons? To treat growth failure To prevent syndrome of inappropriate antidiuretic hormone (SIADH) To reduce cerebral edema and lower intracranial pressure To replace antidiuretic hormone (ADH) normally secreted by the pituitary. 7. A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing interventions should be done first? Assess full ROM to determine extent of injuries Call for an immediate chest x-ray Immobilize the client’s head and neck Open the airway with the head-tilt-chin-lift maneuver 8. A client with a C6 spinal injury would most likely have which of the following symptoms? Aphasia Hemiparesis Paraplegia 4. Tetraplegia 9. A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? Bladder distension Neurological deficit 3. Pulse ox readings 4. The client’s feelings about the injury 10. While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? Autonomic dysreflexia Hemorrhagic shock 3. Neurogenic shock 4. Pulmonary embolism 11. A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? Acetazolamide (Diamox) Furosemide (Lasix) Methylprednisolone (Solu-Medrol) Sodium bicarbonate 12. A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? Place the client flat in bed Assess patency of the indwelling urinary catheter Give one SL nitroglycerin tablet Raise the head of the bed immediately to 90 degrees 13. A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? To hasten wound healing To immobilize the cervical spine To prevent autonomic dysreflexia To hold bony fragments of the skull together 14. Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? 1. Insert an indwelling urinary catheter to straight drainage 2. Schedule intermittent catheterization every 2 to 4 hours Perform a straight catheterization every 8 hours while awake Perform Crede’s maneuver to the lower abdomen before the client voids. 15. A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? Laceration of the middle meningeal artery Rupture of the carotid artery Thromboembolism from a carotid artery Venous bleeding from the arachnoid space 16. A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? Position the client flat in bed Check the fluid for dextrose with a dipstick Suction the nose to maintain airway patency Insert nasal and ear packing with sterile gauze 17. When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? An interval when the client’s speech is garbled An interval when the client is alert but can’t recall recent events An interval when the client is oriented but then becomes somnolent An interval when the client has a “warning” symptom, such as an odor or visual disturbance. 18. Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? A client with a brain injury A client with a herniated nucleus pulposus 3. A client with a high cervical spine injury 4. A client with a stroke 19. Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? 1. Absence of pain sensation in chest 2. Spasticity Spontaneous respirations Urinary continence 20. A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? Headache Lumbar spinal cord injury Neurogenic shock 4. Noxious stimuli 21. During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? Elevate the client’s legs Put the client flat in bed Put the client in the Trendelenburg’s position 4. Put the client in the high-Fowler’s position 22. A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? Autonomic dysreflexia Hypervolemia Neurogenic shock Sepsis 23. A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? Absent corneal reflex Decerebrate posturing Movement of only the right or left half of the body 4. The need for mechanical ventilation 24. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? 1. Decreased urine output or oliguria 2. Hypertension and bradycardia Respiratory depression Symptoms of shock 25. A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? “Clean the meatus from back to front.” “Measure the quantity of urine.” “Gently rotate the catheter during removal.” 4. “Clean the meatus with soap and water.” 26. An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? “Watch him for keyhole pupil the next 24 hours.” “Expect profuse vomiting for 24 hours after the injury.” “Wake him every hour and assess his orientation to person, time, and place.” “Notify the physician immediately if he has a headache.” 27. Which neurotransmitter is responsible for may of the functions of the frontal lobe? Dopamine GABA Histamine Norepinephrine 28. The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? Extent of intracranial bleeding Sites of brain injury 3. Activity of the brain 4. Percent of functional brain tissue 29. A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? Subdural hematoma Subarachnoid hemorrhage 3. Epidural hematoma 4. Contusion 30. After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? Quadriplegia with gross arm movement and diaphragmatic breathing Quadriplegia and loss of respiratory function Paraplegia with intercostal muscle loss Loss of bowel and bladder control 31. A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine injury is suspected. How should the first- responder open the client’s airway for rescue breathing? By inserting a nasopharyngeal airway By inserting a oropharyngeal airway 3. By performing a jaw-thrust maneuver 4. By performing the head-tilt, chin-lift maneuver 32. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. Elevate the HOB to 90 degrees Loosen constrictive clothing Use a fan to reduce diaphoresis Assess for bladder distention and bowel impaction Administer antihypertensive medication Place the client in a supine position with legs elevated 1,2,4,5 33. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client’s urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: Desmopressin (DDAVP, Stimate) Dexamethasone (Decadron) Ethacrynic acid (Edecrin) Mannitol (Osmitrol) 34. The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: Skull fracture Concussion Subdural hematoma 4. Epidural hematoma 35. The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: A flattened abdomen Hematest positive nasogastric tube drainage Hyperactive bowel sounds A history of diarrhea 36. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? Strict adherence to a bowel retraining program Limiting bladder catheterization to once every 12 hours Keeping the linen wrinkle-free under the client Preventing unnecessary pressure on the lower limbs 37. The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? Monitoring vital signs before and during position changes Using vasopressor medications as prescribed 3. Moving the client quickly as one unit 4. Applying Teds or compression stockings. 38. The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: Keeping the client on a stretcher Logrolling the client on a firm mattress Logrolling the client on a soft mattress 4. Placing the client on a Stryker frame 39. The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? Positive reflexes Hyperreflexia Inability to elicit a Babinski’s reflex Reflex emptying of the bladder 40. A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client’s vital signs, list in order of priority, the nurse’s actions (Number 1 being the first priority and number 5 being the last priority). Check for bladder distention Raise the head of the bed Contact the physician Loosen tight clothing on the client Administer an antihypertensive medication 2,4,1,3,5 41. A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? Unequal pupil size Decreasing systolic blood pressure Tachycardia Decreasing body temperature 42. Which of the following respiratory patterns indicate increasing ICP in the brain stem? Slow, irregular respirations Rapid, shallow respirations Asymmetric chest expansion Nasal flaring 43. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? Give the client a warming blanket Administer low-dose barbiturate Encourage the client to hyperventilate Restrict fluids 44. A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client’s condition? Widening pulse pressure Decrease in the pulse rate Dilated, fixed pupil 4. Decrease in LOC 45. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? Place her in a jacket restraint Wrap her hands in soft “mitten” restraints Tuck her arms and hands under the draw sheet Apply a wrist restraint to each arm 46. Which of the following describes decerebrate posturing? Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet Supination of arms, dorsiflexion of feet Back arched; rigid extension of all four extremities. 47. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? 1. Count the rate to be sure the ventilations are deep enough to be sufficient 2. Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score. Call the physician to adjust the ventilator settings. Check deep tendon reflexes to determine the best motor response 48. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? 1. Keeping the client flat on one side or the other 2. Elevating the head of the bed to 30 degrees Log rolling or turning as a unit when turning Keeping the head in neutral position 49. A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply. Decerebrate posturing Dilated nonreactive pupils Deep tendon reflexes Absent corneal reflex 2,3,4 50. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. Administer phenytoin (Dilantin) 200 mg PO daily. Teach patient about the need for good oral hygiene. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: Body temperature control. Balance and equilibrium. Visual acuity. Thinking and reasoning. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? Phenytoin (Dilantin) Mannitol (Osmitrol) C. Lidocaine (Xylocaine) D. Furosemide (Lasix) After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? Give him a barbiturate. Place him on mechanical ventilation. Perform a lumbar puncture. Elevate the head of his bed. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: Light flashes and floaters in front of the eye. A recent driving accident while changing lanes. Headaches, nausea, and redness of the eyes. Frequent episodes of double vision. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis? A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination D. Risk for injury To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the nurse should: Stay with the client and encourage him to eat. Help the client fill out his menu. Give the client privacy during meals. Fill out the menu for the client. The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? Cerebellar function Intellectual function C. Cerebral function D. Sensory function Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam, if needed and prescribed? A. In 30 to 45 seconds B. In 10 to 15 minutes C. In 30 to 45 minutes D. In 1 to 2 hours A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? Parasympathomimetic agent Sympatholytic agent Adrenergic blocker D. Cholinergic blocker Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, “He fell from a two- story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag.” Which intervention by the nurse has the highest priority? Assessing the left leg Assessing the pupils Placing the client in Trendelenburg’s position Assessing level of consciousness An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by: Increasing the exudative reaction of ocular tissue. Decreasing leukocyte infiltration at the site of ocular inflammation. Inhibiting the action of carbonic anhydrase. Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris. Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal? More back pain than the first postoperative day Paresthesia in the dermatomes near the wounds C. Urine retention or incontinence D. Temperature of 99.2° F (37.3° C) After an eye examination, a male client is diagnosed with open- angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: Instilling one drop of pilocarpine 0.25% into both eyes daily. Instilling one drop of pilocarpine 0.25% into both eyes four times daily. Instilling one drop of pilocarpine 0.25% into the right eye daily. Instilling one drop of pilocarpine 0.25% into the left eye four times daily. A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? The client leaves the side rails down. The client uses a mirror to inspect the skin. The client repositions only after being reminded to do so. The client hangs the left arm over the side of the wheelchair. A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client’s feet make a half circle. To document the client’s gait, the nurse should use which term? Ataxic Dystrophic C. Helicopod D. Steppage A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? A. A private room down the hall from the nurses’ station B. An isolation room three doors from the nurses’ station C. A semi private room with a 32-year-old client who has viral meningitis D. A two-bed room with a client who previously had bacterial meningitis A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client’s history. Which preexisting condition would contraindicate the use of pyridostigmine? Ulcerative colitis Blood dyscrasia Intestinal obstruction Spinal cord injury A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière’s disease. When assessing this client, the nurse expects to note: Vertigo, tinnitus, and hearing loss. Vertigo, vomiting, and nystagmus Vertigo, pain, and hearing impairment. Vertigo, blurred vision, and fever. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? “Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours.” “Try to ambulate independently after about 24 hours.” “Shampoo your hair every day for ten (10) days to help prevent ear infection.” “Don’t fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days.” Nurse Marty is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? Excessive tearing Urine retention C. Muscle weakness D. Slurred speech The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? Tachycardia Increased salivation Hypotension Apnea A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s care, the nurse should assign the highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Self-care deficit: Dressing/grooming A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), two (2) mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, Diazepam also is recommended for: long-term treatment of epilepsy. postoperative pain management of laminectomy clients. postoperative pain management of diskectomy clients treatment of spasticity associated with spinal cord lesions. A female client who was found unconscious at home is brought to the hospital by a rescue squaD. In the intensive care unit, the nurse checks the client’s oculocephalic (doll’s eye) response by: Introducing ice water into the external auditory canal. Touching the cornea with a wisp of cotton. Turning the client’s head suddenly while holding the eyelids open. Shining a bright light into the pupil. While reviewing a client’s chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? The client may be less sensitive to the effects of a neuromuscular blocking agent. Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage. Pancuronium shouldn’t be used; succinylcholine may be used in a lower dosage. Pancuronium and succinylcholine both require cautious administration. A male client is color blind. The nurse understands that this client has a problem with: Rods. Cones. Lens. Aqueous humor. A female client who was trapped inside a car for hours after a head- on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? Diencephalon Medulla C. Midbrain D. Cortex The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? Vision changes Absent deep tendon reflexes Tremors at rest Flaccid muscles The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? Sit with the client for a few minutes. Administer an analgesic. Inform the nurse manager. Call the physician immediately. During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing ability once each shift. This assessment evaluates: Cranial nerves I and II. Cranial nerves III and V. Cranial nerves VI and VIII. D. Cranial nerves IX and X. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? Vomiting continues Intracranial pressure (ICP) is increased The client needs mechanical ventilation Blood is anticipated in the cerebrospinal fluid (CSF) 82. A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? To reduce intraocular pressure To prevent acute tubular necrosis To promote osmotic diuresis to decrease ICP To draw water into the vascular system to increase blood pressure 83. A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? Urine output increases Pupils are 8 mm and nonreactive Systolic blood pressure remains at 150 mm Hg BUN and creatinine levels return to normal 84. Which of the following values is considered normal for ICP? 0 to 15 mm Hg 25 mm Hg 35 to 45 mm Hg 4. 120/80 mm Hg 85. Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? Ataxia and confusion Sodium depletion Tonic-clonic seizure Urinary incontinence 86. Which of the following signs and symptoms of increased ICP after head trauma would appear first? Bradycardia Large amounts of very dilute urine 3. Restlessness and confusion 4. Widened pulse pressure 87. Problems with memory and learning would relate to which of the following lobes? Frontal Occipital Parietal 4. Temporal 88. While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional? Frontal Occipital 3. Parietal 4. Temporal 89. The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain? Sternal rub Pressure on the orbital rim Squeezing the sternocleidomastoid muscle 4. Nail bed pressure 90. The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? Side-lying, with legs pulled up and head bent down onto the chest Side-lying, with a pillow under the hip Prone, in a slight Trendelenburg’s position Prone, with a pillow under the abdomen. 91. A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: A cerebral lesion A temporal lesion An intact brainstem Brain death 92. The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure. 93. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: A positive Brudzinski’s sign A negative Kernig’s sign Absence of nuchal rigidity A Glascow Coma Scale score of 15 94. A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: Tolerate the pain Decrease the perception of pain 3. Escape the source of pain 4. Divert attention from the source of pain. 95. During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? Limiting conversation with the child Keeping extraneous noise to a minimum Allowing the child to play in the bathtub Performing treatments quickly 96. Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? Hemorrhagic skin rash Edema Cyanosis Dyspnea on exertion 97. When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? 1. Bladder infection 2. Middle ear infection Fractured clavicle Septic arthritis 98. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. Head tilt Vomiting Polydipsia Lethargy Increased appetite Increased pulse 1,2,4 99. A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? 1. Cloudy CSF, decreased protein, and decreased glucose 2. Cloudy CSF, elevated protein, and decreased glucose Clear CSF, elevated protein, and decreased glucose Clear CSF, decreased pressure, and elevated protein 100. A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? No precautions are required as long as antibiotics have been started Maintain enteric precautions Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics Maintain neutropenic precautions