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Neuro exam1
test questions
| Question | Answer |
|---|---|
| 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? | The client’s history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn’t be done because it can quickly decompress the central nervous system and, thereby, cause additional damage |
| Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis? | The nursing diagnosis of Ineffective airway clearance is highest priority. |
| The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses which of the following? | The mental status examination assesses functions governed by the cerebrum. |
| A female pt. c/o periorbital aching, tearing, blurred vision, and photophobia in her right eye, examinations reveal a small, nonreactive pupil — a condition resulting from iris inflammation. The Dr. prescribes (Atropisol),it belongs to which drug class? | Atropine sulfate is a cholinergic blocker. |
| Emt's transport a 27-y/o to the ED. They report, “He fell from a building. He has a cut on his chest, a hematoma, a fracture of his femur, is in a coma, intubated and maintaining an o2 sat of 92 by pulse ox with ambu bag.” Which intervention is priority? | In the scenario, airway and breathing are established so the nurse’s next priority should be circulation. |
| A mechanic has battery acid in his eyes. He flush his eyes with water for 20 min. then goes to the ED he is treated for corneal injury. The Dr. prescribes Maxidex Ophthalmic, two drops to be placed in the conjunctival sacs q hr; Dexamethasone works by: | Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. |
| Nurse April is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal? | Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery. |
| After an eye examination, a pt is diagnosed with open-angle glaucoma. The Dr. prescribes (Pilocar), 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the pt or a family member to administer the drug by: | The abbreviation "gtt" stands for drop, "i" is the apothecary symbol for the number 1, OU signifies both eyes, and "q.i.d." means four times a day. Therefore, one drop of pilocarpine 0.25% should be instilled into both eyes four times daily. |
| A Dr. diagnoses a pt with myasthenia gravis, prescribing Mestinon, 60 mg P.O. q3 hours. Before giving this anticholinesterase agent, the nurse reviews the pt’s hx. Which preexisting condition would contraindicate the use of pyridostigmine? | Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. |
| Nurse Oliver is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? | The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis. |
| A male pt has a hx. of painful, continuous muscle spasms. He has taken several muscle relaxants without experiencing relief. His Dr. prescribes Valium, 2 mg P.O.bid. In addition to being used to relieve muscle spasms, diazepam also is recommended for: | Diazepam also is recommended for 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: | To elicit the oculocephalic response,the nurse turns the pt’s head suddenly while holding the eyes open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed |
| 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 nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a pt with myasthenia gravis. |
| A male client is color blind. The nurse understands that this client has a problem with: | Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs |
| A female pt was trapped in a car for hours after a head-on collision is rushed to the ED with multiple injuries. During the neuro exam, the pt responds to painful stimuli with decerebrate posturing. This indicates damage to which part of the brain? | Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain |
| 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, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis. |
| During a routine physical examination to assess a male client’s deep tendon reflexes, the nurse should make sure to: | To prevent the muscle from contracting, support the joint where the tendon is being tested. Use the flat end of the hammer when striking the tendon. Tapping softly won’t provoke a deep tendon reflex. Hold the hammer loosely,so it can swing in an arc. |
| The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client’s peripheral response to pain? | Motor testing in the unconscious pt can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. |
| The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: | Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is weakness of the face and tongue, arm, and leg on one side. |
| The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? | Before the pt with dysphagia is started on a diet, the gag and swallow reflexes must be present. The pt is assisted with meals and given time to chew and swallow. Food is placed on the unaffected side. Liquids are thickened to avoid aspiration. |
| The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: | Prevention of muscle atrophy with Bell’s palsy is accomplished with facial massage, facial exercises, and electrical stimulation of the nerves. Local application of heat to the face may improve blood flow and provide comfort. |
| Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has history of: | Guillain-Barré is a syndrome of unknown origin that involves cranial and peripheral nerves. Many pts report a hx. of respiratory or GI infection in the 1 to 4 wks before the onset of neuro deficits. The syndrome can be triggered by vaccination or surgery |
| A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client’s behavior. | The limbic system is responsible for feelings (affect) and emotions. |
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sevensmommy