1) The nurse is assisting with caring for a client after a

craniotomy. Which is the best position for the client to be

placed?

Semi-Fowler's position

2) The nurse is caring for a client following a supratentorial

craniotomy, in which a large tumor was removed from the
left side. In which position can the nurse safely place the
client? Refer to Figures.

3) A client with a seizure disorder is being admitted to the

hospital. Which should the nurse plan to implement for this
client? Select all that apply

Pad the bed's side rails.

Place an airway at the bedside.
Place oxygen equipment at the bedside.
Place suction equipment at the bedside.

4) The nurse is caring for a client with increased intracranial

pressure (ICP). Which change in vital signs would occur if
ICP is rising?

Increasing temperature, decreasing pulse, decreasing

respirations, increasing BP

5) The nurse observes the unlicensed assistive personnel

(UAP) positioning the client with increased intracranial
pressure (ICP). Which position would require intervention
by the nurse?

Head turned to the side

6) The client recovering from a head injury is arousable and

participating in care. The nurse determines that the client
understands measures to prevent elevations in intracranial
pressure (ICP) if the nurse observes the client doing which
activity?
 Exhaling during repositioning

7) The client has clear fluid leaking from the nose after a
basilar skull fracture. The nurse determines that this is
cerebrospinal fluid (CSF) if the fluid meets which criteria?

Separates into concentric rings and tests positive for

glucose

8) The client is admitted to the hospital for observation with a

probable minor head injury after an automobile crash. The
nurse expects the cervical collar will remain in place until
which time?

The health care provider reviews the x-ray results.

9) The client was seen and treated in the emergency

department (ED) for a concussion. Before discharge, the
nurse explains the signs/symptoms of a worsening
condition. The nurse determines that the family needs
further teaching if they state they will return to the ED if
the client experiences which sign/symptom?

Minor Headache

10) The nurse is caring for a client who has undergone

craniotomy with a supratentorial incision. The nurse should
plan to place the client in which position postoperatively?

Head of bed elevated 30 to 45 degrees, head and

neck midline

11) The client with a cervical spine injury has Crutchfield tongs
applied in the emergency department. The nurse should
perform which essential action when caring for this client?

Comparing the amount of prescribed weights with the

amount in use

12) The nurse has provided discharge instructions to a client

with an application of a halo device. The nurse determines
 that the client needs further teaching if which statement
is made?

"I will drive only during the daytime."

13) The nurse is caring for the client who has suffered spinal
cord injury. The nurse further monitors the client for signs
of autonomic dysreflexia and suspects this complication if
which sign/symptom is noted?

Severe, throbbing headache

14) The client with spinal cord injury is prone to experiencing

autonomic dysreflexia. The least appropriate measure to
minimize the risk of autonomic dysreflexia is which action?

Limiting bladder catheterization to once every 12

hours

15) The client with spinal cord injury suddenly experiences an

episode of autonomic dysreflexia. After checking vital
signs, which immediate action should the nurse take?

Raise the head of the bed and remove the noxious

stimulus.

16) The nurse is assigned to care for an adult client who had a
stroke and is aphasic. Which interventions should the
nurse use for communicating with the client? Select all
that apply.

Face the client when talking.

Speak slowly and maintain eye contact.
Use gestures when talking to enhance words.
Give the client directions using short phrases and
simple terms.

17) The nurse is admitting a client with Guillain-Barr

syndrome to the nursing unit. The client has an ascending
paralysis to the level of the waist. Knowing the
 complications of the disorder, the nurse should bring which
items into the client's room?

Electrocardiographic monitoring electrodes and

intubation tray

18) The nurse is caring for a client with an intracranial

aneurysm who was previously alert. Which finding should
be an early indication that the level of consciousness
(LOC) is deteriorating?

Drowsiness

19) The nurse is planning to put aneurysm precautions in place

for the client with a cerebral aneurysm. Which item should
be included as part of the precautions?

Maintaining the head of the bed at 15 degrees

20) The nurse is caring for a client who begins to experience

seizure activity while in bed. Which action by the nurse
would be contraindicated?

Restrain the client's limbs.

21) The nurse is planning care for the client with hemiparesis
of the right arm and leg. Where should the nurse plan to
place objects needed by the client?

Within the client's reach, on the left side

22) The nurse is reinforcing instructions to the family of a

stroke client who has homonymous hemianopsia about
measures to help the client overcome the deficit. The nurse
determines that the family understands the measures to
use if they state that they will do which?

Remind the client to turn the head to scan the lost

visual field.
23) A client has experienced an episode of myasthenic crisis.
The nurse collects data to determine whether the client has
experienced which precipitating factor?

Omitted doses of medication

24) A client with Parkinson's disease is embarrassed about the

symptoms of the disorder and is bored and lonely. The
nurse should plan which approach as therapeutic in
assisting the client to cope with the disease?

Encourage and praise perseverance in exercising and

performing ADL.

25) The nurse has given suggestions to the client with

trigeminal neuralgia about strategies to minimize episodes
of pain. The nurse determines that the client needs
further teaching if the client made which statement?

"I will try to eat my food either very warm or very

cold."

26) A client has an impairment of cranial nerve II. Specific to

this impairment, the nurse plans to do which to ensure
client safety?

Provide a clear path for ambulation without obstacles.

27) The nurse is monitoring a client with a blunt head injury

sustained from a motor vehicle crash. Which would indicate
a basal skull fracture as a result of the injury?

Bloody or clear drainage from the auditory canal

28) A client has a cerebellar lesion. The nurse determines that

the client is adapting successfully to this problem if the
client demonstrates proper use of which item?

Walker
29) The nurse is planning care for a client who displays
confusion secondary to a neurological problem. Which
approach by the nurse would be least helpful in assisting
this client?

Encouraging multiple visitors at one time

30) A client with a neurological impairment experiences urinary

incontinence. Which nursing action should help the client
adapt to this alteration?

Establishing a toileting schedule

31) The nurse has obtained a personal and family history from
a client with a neurological disorder. Which finding in the
client's history is least likely associated with a risk for
neurological problems?

Allergy to pollen

32) A client with right leg hemiplegia is experiencing difficulty

with mobility. The nurse determines that the family needs
reinforcement of teaching if the nurse observes which
action by the family?

Encouraging the client to stand unassisted on the leg

33) The nurse is preparing a client who is scheduled to have

cerebral angiography performed. Which should the nurse
check before the procedure?

Allergy to iodine or shellfish

34) A client admitted to the hospital with a neurological

problem indicates to the nurse that magnetic resonance
imaging (MRI) may be done. Which finding noted in the
client history indicates that the client may be ineligible for
this diagnostic procedure?

Prosthetic valve replacement

35) A client is somewhat nervous about having magnetic
resonance imaging (MRI). Which statement by the nurse
should provide reassurance to the client about the
procedure?

"Even though you are alone in the scanner, you will

be in voice communication with the technologist
during the procedure."

36) The nurse is trying to help the family of an unconscious

client cope with the situation. Which intervention should
the nurse plan to incorporate into the care routine for the
client?

Explaining equipment and procedures on an ongoing

basis

37) The nurse is suctioning an unconscious client who has a

tracheostomy. The nurse should avoid which action during
this procedure?

Making sure not to suction for longer than 30 seconds

38) The nurse has applied a hypothermia blanket to a client

with a fever. The nurse should inspect the skin frequently
to detect which complication of hypothermia blanket use?

Skin breakdown

39) The nurse is caring for an unconscious client who is

experiencing persistent hyperthermia with no signs and
symptoms of infection. The nurse understands that there
may be damage to the client's thermoregulatory center
which is located in which part of the brain?

Hypothalamus

40) A client seeking treatment for an episode of hyperthermia

is being discharged to home. The nurse determines that
the client needs clarification of discharge instructions
if the client makes which statement?
 "I can resume a full activity level immediately."

41) The family of an unconscious client with increased

intracranial pressure is talking at the client's bedside. They
are discussing the gravity of the client's condition and
wondering if the client will ever recover. How should the
nurse interpret the client's situation?

It is possible the client can hear the family.

42) The nurse is providing care to a client with increased

intracranial pressure (ICP). Which approaches would be
beneficial in controlling the client's ICP from an
environmental viewpoint? Select all that apply.

Reducing environmental noise

Maintaining a calm atmosphere
Allowing the client uninterrupted time for sleep

43) The nurse is preparing to give the postcraniotomy client

medication for incisional pain. The family asks the nurse
why the client is receiving codeine sulfate and not
"something stronger." The nurse should formulate a
response based on which understanding of codeine?

Codeine does not alter respirations or mask

neurological signs as do other opioids.

44) The nurse reinforces home care instructions to the

postcraniotomy client. Which statement by the client
indicates the need for further teaching?

"I will not hear sounds clearly unless they are loud."

45) The nurse notes documentation that a postcraniotomy

client is having difficulty with body image. The nurse
determines that the client is still working on the
postoperative outcome criteria when the client indicates
which altered personal appearance?
 Indicates that facial puffiness will be a permanent
problem

46) A client with spinal cord injury becomes angry and

belligerent whenever the nurse tries to administer care.
Which is the best response by the nurse?

Acknowledge the client's anger and continue to

encourage participation in care.

47) A client with a spinal cord injury expresses little interest in

food and is very particular about the choice of meals that
are actually eaten. How should the nurse interpret this?

Meal choices represent an area of client control and

should be encouraged as much as is nutritionally
reasonable.

48) A client who is paraplegic after spinal cord injury has been
taught muscle-strengthening exercises for the upper body.
The nurse determines that the client will derive the least
muscle-strengthening benefit from which activity?

Doing active range of motion to finger joints

49) A client with diplopia has been taught to use an eye patch
to promote better vision and prevent injury. The nurse
determines that the client understands how to use the
patch if the client states that he or she will do which?

Wear the patch continuously, alternating eyes each

day.

50) The nurse is planning care for a client in spinal shock.

Which action would be least helpful in minimizing the
effects of vasodilation below the level of the injury?

Moving the client quickly as one unit

51) The nursing instructor asks a nursing student about the
points to document if the client has had a seizure. The
instructor determines that the student needs to research
seizures and related documentation points if the student
states which assessment is important?

Client's diet in the 2 hours preceding seizure activity

52) The nurse is planning to institute seizure precautions for a

client who is being admitted from the emergency
department. Which measure should the nurse avoid in
planning for the client's safety?

Putting a padded tongue blade at the head of the bed

53) The nurse has given medication instructions to the client

receiving phenytoin (Dilantin). The nurse determines that
the client understands the instructions if the client makes
which comment?

"Good oral hygiene is needed, including brushing and

flossing."

54) A client with a stroke (brain attack) has residual

dysphagia. When a diet prescription is initiated, the should
nurse avoid which action?

Giving the client thin liquids

55) The nurse is trying to communicate with a stroke (brain

attack) client with aphasia. Which action by the nurse
would be least helpful to the client?

Completing the sentences that the client cannot finish

56) A client receives a dose of edrophonium (Enlon). The client

shows improvement in muscle strength for a period of time
following the injection. The nurse should interpret this
finding as indicative of which disease process?

Myasthenia gravis
57) A client with myasthenia gravis is having difficulty
speaking. The client's speech is dysarthric and has a nasal
tone. The nurse should use which communication
strategies when working with this client? Select all that
apply.

Listening attentively
Asking yes and no questions when able
Using a communication board when necessary
Repeating what the client said to verify the message

58) The nurse is teaching the client with myasthenia gravis

about prevention of myasthenic and cholinergic crises. The
nurse tells the client that this is most effectively done by
which activity?

Taking medications on time to maintain therapeutic

blood levels

59) The nurse has instructed the client with myasthenia gravis
about ways to manage his or her own health at home. The
nurse determines that the client needs further teaching
if the client makes which statements?

"Going to the beach will be a nice, relaxing form of

activity."

60) A client with Parkinson's disease is experiencing a

parkinsonian crisis. The nurse should immediately place
the client where?

In a quiet, dim room with respiratory and cardiac

support available

61) The nurse has given instructions to the client with

Parkinson's disease about maintaining mobility. The nurse
determines that the client understands the directions if the
client states that he or she will perform which activity?

Rock back and forth to start movement with

bradykinesia.
62) An adult client had a cerebrospinal fluid (CSF) analysis
after lumbar puncture. The nurse interprets that a negative
value of which is consistent with normal findings?

Red blood cells

63) The nurse is collecting data on a client with a diagnosis of

meningitis and notes that the client is assuming this
posture. (Refer to figure.) The nurse contacts the health
care provider and reports that the client is exhibiting
which?

Opisthotonos

64) An older gentleman is brought to the emergency

department by a neighbor who heard him talking and
wandering in the street at 3 am. The nurse should first
determine which about the client?

Whether this is a change in his usual level of

orientation

65) An 84-year-old client in an acute state of disorientation

was brought to the emergency department by the client's
daughter. The daughter states that this is the first time
that the client experienced confusion. The nurse
determines from this piece of information that which is
unlikely to be the cause of the client's disorientation?

Alzheimer's disease

66) A resident in a long-term care facility prepares to walk out

into a rainstorm after saying, "My father is waiting to take
me for a ride." An appropriate response by the nurse is
which?

"I'm glad you told me that. Let's have a cup of coffee

and you can tell me about your father."
67) The nurse observes that a client with Parkinson's disease
has very little facial expression. The nurse attributes this
piece of data to which information?

Masklike facies is a component of Parkinson's

disease.

68) The nurse overhears the term sundowning used to describe

the behavior of a client newly admitted to the nursing unit
during the previous evening shift. Of which diagnosis is
sundowning a symptom?

Alzheimer's disease

69) A client in the emergency department is diagnosed with

Bell's palsy. The nurse collecting data on this client expects
to note which observation?

A lag in closing the bottom eyelid

70) An adult client with suspected meningitis has undergone

lumbar puncture to obtain cerebrospinal fluid (CSF) for
analysis of a bacterial infection. The nurse checks for which
value indicating a bacterial infection of the CSF?

Decreased glucose level

71) The nurse is monitoring a client with a head injury and

notes that the client is assuming the posture shown in the
figure. What is the client exhibiting that would require the
nurse to notify the registered nurse immediately? Refer to
the figure.

Decorticate posturing

72) The nurse is assisting in caring for a client who sustained a

traumatic head injury following a motor vehicle crash. The
nurse documents that the client is exhibiting decerebrate
posturing. The nurse bases this documentation on which
observation?
 Extension of the extremities and pronation of the
arms

73) The nurse is caring for a client diagnosed with Bell's palsy
1 week ago. Which data would indicate a potential
complication associated with Bell's palsy?

Excessive tearing

74) The nurse is collecting data on a client suspected of

having Alzheimer's disease. The priority data should focus
on which characteristic of this disease?

Recent memory loss

75) The nurse is monitoring a client with a C5 spinal cord

injury for spinal shock. Which findings would be associated
with spinal shock in this client? Select all that apply.

Bowel sounds are absent.

The client's abdomen is distended.
Respiratory excursion is diminished.
Accessory muscles of respiration are areflexic.

76) The nurse is ambulating a client with a known seizure

disorder. The client says, "I'm seeing those flashing lights
again," then loses consciousness and develops a clonic-
tonic seizure. Which would be the nurse's initial action?

Assist the client to the floor.

77) The nurse is collecting data on a client with myasthenia

gravis. The nurse determines that the client may be
developing myasthenic crisis if the client makes which
statement?
 "I can't swallow very well today."

78) Which information will the nurse reinforce to the client

scheduled for a lumbar puncture?

An informed consent will be required.

79) The nurse is reinforcing instructions to a client taking

divalproex sodium (Depakote). The nurse tells the client to
return to the clinic for follow-up laboratory studies related
to which test?

Liver function studies

80) Which data collection finding supports the possible

diagnosis of Bell's palsy?

Speech or chewing difficulties accompanied by facial

droop

81) The nurse reviews the health care provider's treatment

plan for a client with Guillain-Barr syndrome. Which
prescription noted in the client's record should the nurse
question?

Clear liquid diet

82) A client has a halo vest that was applied following a C6

spinal cord injury. The nurse performs which action to
determine whether the client is ready to begin sitting up?

Compares the client's pulse and blood pressure when

both flat and sitting
83) A client is admitted to the emergency department with a
C4 spinal cord injury. The nurse performs which
intervention first when collecting data on the client?

Monitoring the respiratory rate

84) A client with myasthenia gravis is experiencing prolonged

periods of weakness. The health care provider prescribes a
test dose of edrophonium (Enlon) and the client becomes
weaker. The nurse interprets this outcome as indicative of
which result?

Cholinergic crisis

85) The nurse is assisting in gathering data on cranial nerve

XII of a client who sustained a brain attack (stroke). The
nurse understands that the client should be asked to
perform which action?

Extend the tongue.

86) The nurse is reviewing the medical record of a client

diagnosed with amyotrophic lateral sclerosis (ALS). Which
initial sign/symptom of this disorder supports this
diagnosis?

Mild clumsiness

87) The nurse is assisting in caring for a client with a

supratentorial lesion. The nurse monitors which criterion as
the critical index of central nervous system (CNS)
dysfunction?

Level of consciousness

88) The nurse caring for a client following a craniotomy

monitors for signs of increased intracranial pressure (ICP).
Which indicates an early sign of increased ICP?
 Confusion

89) Acetazolamide is prescribed for a client with a diagnosis of

a supratentorial lesion. The nurse monitors the client for
effectiveness of this medication, knowing which is its
primary action?

Decrease cerebrospinal fluid production

90) Which sign/symptom is observed in the clonic phase of a

seizure?

Extension spasms of the body

91) The nurse is preparing for the admission of a client with a

prescription for seizure precautions. Which supplies will the
nurse make available to this client? Select all that apply.

Suction machine
Oxygen administration
Padding for the side rails
Prescribed diazepam (Valium)

92) The nurse is preparing for the admission of a client with a

diagnosis of early stage Alzheimer's disease. The nurse
assists in developing a plan of care, knowing that which is
a characteristic of early Alzheimer's disease?

Forgetfulness

93) The clinic nurse is reviewing the medical record of a client

scheduled to be seen in the clinic. The nurse notes that the
client is prescribed selegiline hydrochloride (Eldepryl). The
nurse understands that this medication is prescribed for
which diagnosis?

Parkinson's disease
94) The nurse is reviewing the record of a client with a
suspected diagnosis of Huntington's disease. Which
documented early symptom supports this diagnosis?

Vertigo

95) The nurse is assisting in caring for a client with a

suspected diagnosis of meningitis. The nurse reinforces to
the client information regarding which diagnostic test that
is commonly used to confirm this diagnosis?

Lumbar puncture

96) The nurse is preparing for the admission of a client with a

suspected diagnosis of herpes simplex encephalitis. Which
diagnostic test should be prescribed to confirm this
diagnosis?

Brain biopsy

97) The nurse is caring for a client with a diagnosis of multiple

sclerosis who has been prescribed oxybutynin (Ditropan).
The nurse evaluates the effectiveness of the medication
by asking the client which question?

"Are you getting up at night to urinate?"

98) The nurse is preparing for the admission of a client with a

suspected diagnosis of Guillain-Barr syndrome. Which
sign/symptom is considered a primary symptom of this
syndrome?

Development of muscle weakness

99) A thymectomy via a median sternotomy approach is
performed on a client with a diagnosis of myasthenia
gravis. The nurse has assisted in developing a plan of care
for the client and includes which nursing action in the plan?

Monitor the chest tube drainage.

100) The nurse is caring for a client with a diagnosis of

right (nondominant) hemispheric brain attack (stroke). The
nurse notes that the client is alert and oriented to time and
place. Based on these findings, the nurse makes which
determination?

The client may have perceptual and spatial

disabilities.

101) The nurse is preparing to care for a client with a

diagnosis of brain attack (stroke). The nurse notes in the
client's record that the client has anosognosia. The nurse
plans care, knowing which is a characteristic of
anosognosia?

The client neglects the affected side.

102) The nurse is preparing a plan of care for a client with

a brain attack (stroke) who has global aphasia. The nurse
incorporates communication strategies in the plan of care,
knowing that the client's speech should fit which
characterization?

Associated with poor comprehension

103) The nurse is caring for a client with a diagnosis of

brain attack (stroke) with anosognosia. To meet the needs
of the client with this deficit, which action does the nurse
plan?

Increase the client's awareness of the affected side.

104) The nurse is caring for a client who sustained a spinal
cord injury. While administering morning care, the client
developed signs and symptoms of autonomic dysreflexia.
Which is the initial nursing action?

Elevate the head of the bed.

105) A female client with myasthenia gravis comes to the

health care provider's office for a scheduled office visit. The
client is very concerned and tells the nurse that her
husband seems to be avoiding her because she is very
unattractive. Which is the appropriate nursing response?

"Have you thought about sharing your feelings with

your husband?"

106) A client is recovering at home after suffering a brain

attack (stroke) 2 weeks ago. A home caregiver tells the
home health nurse that the client has some difficulty
swallowing food and fluids. Which nursing action would be
appropriate?

Observe the client feeding himself or herself.

107) The nurse is collecting neurological data on a

poststroke adult client. Which technique should the nurse
perform to adequately check proprioception?

Hold the sides of the client's great toe, and while

moving it, ask what position it is in.

108) The nurse develops a plan of care for a client following

a lumbar puncture. Which interventions should be included
in the plan? Select all that apply.

Monitor the client's ability to void.

Maintain the client in a flat position.
 Monitor the client's ability to move the extremities.
Inspect the puncture site for swelling, redness, and
drainage.

109) A client with Parkinson's disease "freezes" while

ambulating, increasing the risk for falls. Which suggestion
should the nurse include in the client's plan of care to
alleviate this problem?

Consciously think about walking over imaginary lines

on the floor.

110) The nurse is assisting in checking for Tinel's sign in a

client suspected of having carpal tunnel syndrome (CTS).
Which technique should the nurse expect to be used to
elicit this sign?

Percuss the medial nerve at the wrist as it enters the

carpal tunnel, and monitor for tingling sensations.

111) The nurse is monitoring a client with a spinal cord

injury who is experiencing spinal shock. Which assessment
will provide the nurse with the best information about
recovery from the spinal shock?

Reflexes

112) The nurse is caring for a client with a cerebral

aneurysm who is on aneurysm precautions and is
monitoring the client for signs of aneurysm rupture. The
nurse understands that an early sign of rupture is which?

A decline in the level of consciousness

113) The nurse is caring for a client with a head injury and
is monitoring the client for signs of increased intracranial
 pressure (ICP). Which sign if noted in the client should the
nurse report immediately?

The client vomits.

114) The nurse is caring for a client with a spinal cord

injury. High-top sneakers on the client's feet will prevent
the occurrence of which?

Foot drop

115) A halo vest is applied to a client following a cervical

spine fracture. The nurse reinforces instructions to the
client regarding safety measures related to the vest. Which
statement by the client indicates a need for further
teaching?

"I will bend at the waist, keeping the halo vest

straight to pick up items."

116) The nurse is preparing a plan of care to monitor for

complications in a client who will be returning from the
operating room following transsphenoidal resection of a
pituitary adenoma. Which intervention does the nurse
document in the plan as the priority nursing intervention
for this client?

Monitor urine output.

117) The nurse is reinforcing discharge instructions to a

client who has undergone transsphenoidal surgery for a
pituitary adenoma. Which statement by the client indicates
the client understands the discharge instructions?

"I need to call the doctor if I develop frequent

swallowing or postnasal drip."
118) The nurse is collecting admission data on a client with
Parkinson's disease. The nurse asks the client to stand with
the feet together and the arms at the side and then to
close the eyes. The nurse notes that the client begins to
fall when the eyes are closed. Based on this finding, the
nurse documents which in the client's record?

Positive Romberg's test

119) A nursing student is collecting data on a client recently

diagnosed with meningitis. The student expects to note
which signs and symptoms? Select all that apply.

Tachycardia
Photophobia
Red, macular rash
Positive Kernig's sign

120) A client is suspected of having a diagnosis of Guillain-

Barr syndrome (GBS). Which findings would support a
diagnosis of Guillain-Barr syndrome? Select all that
apply.

Visual and hearing disturbances

Ascending symmetrical muscle weakness

121) The nurse is collecting data on a client diagnosed with

Parkinson's disease. Which finding indicates a serious
complication of this disorder?

Congested cough and coarse rhonchi heard during

auscultation

122) The nurse notices that a client with trigeminal

neuralgia has been withdrawn, is having frequent episodes
of crying, and is sleeping excessively. Which method is the
 best way for the nurse to explore issues with the client
regarding these behaviors?

Have the client express the feelings in writing.

123) A client with suspected Guillain-Barr syndrome has a

lumbar puncture performed. The cerebrospinal fluid (CSF)
protein is 750 mg/dL. The nurse analyzes these results as
which?

Higher than normal, supporting the diagnosis of

Guillain-Barr

124) A client with a T4 spinal cord injury is to be monitored

for autonomic dysreflexia (hyperreflexia). Which finding is
indicative of this complication?

The client complains of a headache, and the blood

pressure is elevated.

125) The nurse is monitoring a client with a spinal cord

injury for signs of spinal shock. Which sign is indicative of
this complication of a spinal cord injury?

Areflexia below the level of injury

126) A client with tetraplegia complains bitterly about the

nurse's slow response to the call light and the rigidity of
the therapy schedule. Which interpretation of this behavior
should serve as a basis for planning nursing care?

The client is reacting to loss of control.

127) A client with Parkinson's disease is developing

dementia. Which action should the nurse plan to assist the
client in maintaining self-care abilities?
 Break down activities into small steps.

128) The nurse is caring for a client that is comatose and

notes in the client's chart that the client is exhibiting
decerebrate posturing. The nurse understands that which
definition describes decerebrate posturing?

The extension of the extremities and pronation of the

arms

129) A client recovering from a craniotomy complains of a

"runny nose." Based on the interpretation of the client's
complaint, which action should the nurse take?

Notify the registered nurse.

130) The nurse is planning care for a client with Bell's

palsy. Which measure should be included in the plan?

Instill artificial tears and wear a patch over the

affected eye at night.

131) A client with Guillain-Barr syndrome has been asking

many questions about the condition, and the nursing staff
feels that the client is very discouraged about her
condition. It is important for the nurse to include which
information in discussions with the client?

Generally, a vast number of people recover from this

condition.

132) The nurse is monitoring a client who sustained a head

injury and suspects that the client has a skull fracture. This
conclusion is based on which findings? Select all that
apply.
 Drainage from ear
Bruising around the eyes
Pink-tinged drainage from the nose

133) A client experiences an episode of Bell's palsy and

complains about increasing clumsiness. The nurse should
prepare the client for which diagnostic study (studies) to
determine the cause of the complaints? Select all that
apply.

Cerebral angiography
Lumbar puncture (LP)
Computed tomography

134) When the nurse taps at the level of the client's facial
nerve, the following response is noted. How should the
nurse document this finding on the client record? Refer to
figure.

Positive Chvostek's sign

135) The nurse is collecting neurological data on an

unconscious client. On application of a central noxious
stimulus, the nurse observes this response. How should
the nurse document this response on the client's record?
Refer to figure.

Client demonstrated decerebrate posturing.

136) The nurse suspects neurogenic shock in a client with

complete transection of the spinal cord at the T3 (thoracic
3) level if which clinical symptoms are observed?

Hypotension and bradycardia

137) The nurse is told in report that a client has a positive
Chvostek's sign. Which other data should the nurse expect
to find on data collection? Select all that apply.

Tetany
Diarrhea
Possible seizure activity
Positive Trousseau's sign

138) The nurse determines that motor function of which

cranial nerve is intact if the client can perform this action?
Refer to figure.

Facial

139) A client complains of pain in the lower back and pain

and spasms in the hamstrings when the nurse attempts
to extend the client's leg. How should the nurse record this
finding on the client's medical record? Refer to figure.

Positive Kernig's sign

140) A client with a stroke (brain attack) is experiencing

residual dysphagia. The nurse should remove which food
items that arrived on the client's meal tray from the
dietary department?

Peas

141) The nurse is caring for a client following craniotomy

who has a supratentorial incision. The nurse reviews the
client's plan of care, expecting to note that the client
should be maintained in which position?

Semi-Fowler's position

142) A client is about to undergo a lumbar puncture (LP).

The nurse tells the client that which position will be used
during the procedure?

Side-lying with the legs pulled up and the head bent

down onto the chest