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MS2- |! Neurologic- |! NCLEX |! Exam |! with |!
precise |! detailed |! answers
The |! nurse |! is |! caring |! for |! the |! client |! with |! increased |! intracranial |! pressure. |! The |! nurse |! would |! note |! which |! trend |! in |! vital |! signs |! if |! the |! intracranial |! pressure |! 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 |! - |! Correct |! answer |! ✔ANS: |! 2 Increasing |! temperature, |! decreasing |! pulse, |! decreasing |! respirations, |! increasing |! blood |! pressure Rationale:
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. 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? |! Select |! all |! that |! apply. |!
- |! The |! client |! is |! aphasic
- |! The |! client |! has |! weakness |! on |! the |! right |! side |! of |! the |! body. |!
- |! The |! client |! has |! complete |! bilateral |! paralysis |! of |! the |! arms |! and |! legs. |!
- |! The |! client |! has |! weakness |! on |! the |! right |! side |! of |! the |! face |! and |! tongue. |!
- |! The |! client |! has |! lost |! the |! ability |! to |! move |! the |! right |! arm |! but |! is |! able |! to |! walk |! independently. |!
- |! The |! client |! has |! lost |! the |! ability |! to |! ambulate |! independently |! but |! is |! able |! to |! feed |! and |! bathe |! himself |! or |! herself |! without |! assistance. |! - |! Correct |! answer |! ✔ANS: |! 1, |! 2, |! 4
- |! The |! client |! is |! aphasic |!
- |! The |! client |! has |! weakness |! on |! the |! right |! side |! of |! the |! body. |!
"We |! need |! to |! remind |! him |! to |! turn |! his |! head |! to |! scan |! the |! lost |! visual |! field." Rationale: Homonymous |! hemianopsia |! is |! loss |! of |! half |! of |! the |! visual |! field. |! The |! client |! with |! homonymous |! hemianopsia |! should |! have |! objects |! placed |! in |! the |! intact |! field |! of |! vision, |! and |! the |! nurse |! also |! should |! approach |! the |! client |! from |! the |! intact |! side. |! The |! nurse |! instructs |! the |! client |! to |! scan |! the |! environment |! to |! overcome |! the |! visual |! deficit |! and |! does |! client |! teaching |! from |! within |! the |! intact |! field |! of |! vision. |! The |! nurse |! encourages |! the |! use |! of |! personal |! eyeglasses, |! if |! they |! are |! available. The |! nurse |! is |! assessing |! the |! adaptation |! of |! a |! client |! to |! changes |! in |! functional |! status |! after |! a |! stroke |! (brain |! attack). |! Which |! observation |! indicates |! to |! the |! nurse |! that |! the |! client |! is |! adapting |! most |! successfully?
- |! Gets |! angry |! with |! family |! if |! they |! interrupt |! a |! task
- |! Experiences |! bouts |! of |! depression |! and |! irritability |!
- |! Has |! difficulty |! with |! using |! modified |! feeding |! utensils |!
- |! Consistently |! uses |! adaptive |! equipment |! in |! dressing |! self |! - |! Correct |! answer |! ✔ANS: |! 4 Consistently |! uses |! adaptive |! equipment |! in |! dressing |! self |! Rationale:
Clients |! are |! evaluated |! as |! coping |! successfully |! with |! lifestyle |! changes |! after |! a |! stroke |! if |! they |! make |! appropriate |! lifestyle |! alterations, |! use |! the |! assistance |! of |! others, |! and |! have |! appropriate |! social |! interactions. |! Options |! 1 |! and |! 2 |! are |! not |! adaptive |! behaviors; |! option |! 3 |! indicates |! a |! not |! yet |! successful |! attempt |! to |! adapt. The |! nurse |! is |! teaching |! a |! client |! with |! myasthenia |! gravis |! about |! the |! prevention |! of |! myasthenic |! and |! cholinergic |! crises. |! Which |! client |! activity |! suggests |! that |! teaching |! is |! most |! effective?
- |! Taking |! medications |! as |! scheduled
- |! Eating |! large, |! well-balanced |! meals
- |! Doing |! muscle-strengthening |! exercises
- |! Doing |! all |! chores |! early |! in |! the |! day |! while |! less |! fatigued |! - |! Correct |! answer |! ✔ANS: |! 1 Taking |! medications |! as |! scheduled Rationale: Clients |! with |! myasthenia |! gravis |! are |! taught |! to |! space |! out |! activities |! over |! the |! day |! to |! conserve |! energy |! and |! restore |! muscle |! strength. |! Taking |! medications |! correctly |! to |! maintain |! blood |! levels |! that |! are |! not |! too |! low |! or |! too |! high |! is |! important. |! Muscle-strengthening |! exercises |! are |! not |! helpful |! and |! can |! fatigue |!
Members |! of |! the |! family |! of |! an |! unconscious |! client |! with |! increased |! intracranial |! pressure |! are |! talking |! at |! the |! client's |! bedside. |! They |! are |! discussing |! the |! client's |! condition |! and |! wondering |! whether |! the |! client |! will |! ever |! recover. |! The |! nurse |! intervenes |! on |! the |! basis |! of |! which |! interpretation?
- |! It |! is |! possible |! the |! client |! can |! hear |! the |! family. |!
- |! The |! family |! needs |! immediate |! crisis |! intervention. |!
- |! The |! client |! might |! have |! wanted |! a |! visit |! from |! the |! hospital |! chaplain. |!
- |! The |! family |! could |! benefit |! from |! a |! conference |! with |! the |! health |! care |! provider. |! - |! Correct |! answer |! ✔ANS: |! 1 It |! is |! possible |! the |! client |! can |! hear |! the |! family. |! Rationale: Some |! clients |! who |! have |! awakened |! from |! an |! unconscious |! state |! have |! remembered |! hearing |! specific |! voices |! and |! conversations. |! Family |! and |! staff |! should |! assume |! that |! the |! client's |! sense |! of |! hearing |! is |! intact |! and |! act |! accordingly. |! In |! addition, |! positive |! outcomes |! are |! associated |! with |! coma |! stimulation-that |! is, |! speaking |! to |! and |! touching |! the |! client. |! The |! remaining |! options |! are |! incorrect |! interpretations. A |! client |! has |! a |! difficulty |! with |! the |! ability |! to |! flex |! the |! hips. |! The |! nurse |! determines |! that |! the |! client |! is |! adapting |! successfully |! to |! this |! problem |! if |! the |! client |! demonstrates |! proper |! use |! of |! which |! item?
- |! Walker
- |! Slider |! board
- |! Raised |! toilet |! seat
- |! Adaptive |! eating |! utensils |! - |! Correct |! answer |! ✔ANS: |! 3 Raised |! toilet |! seat Rationale: A |! raised |! toilet |! seat |! is |! useful |! if |! the |! client |! does |! not |! have |! the |! mobility |! or |! ability |! to |! flex |! the |! hips. |! The |! cerebellum |! is |! responsible |! for |! balance |! and |! coordination. |! A |! walker |! would |! provide |! stability |! for |! the |! client |! during |! ambulation. |! A |! slider |! board |! is |! used |! in |! transferring |! a |! client |! from |! a |! bed |! to |! a |! stretcher |! or |! wheelchair. |! Adaptive |! eating |! utensils |! may |! be |! beneficial |! if |! the |! client |! has |! partial |! paralysis |! of |! the |! hand. The |! nurse |! is |! assessing |! the |! client's |! gait |! and |! notes |! it |! is |! unsteady |! and |! staggering. |! Which |! description |! should |! the |! nurse |! use |! when |! documenting |! the |! assessment |! finding?
- |! Spastic |!
- |! Ataxic |!
- |! Placing |! ice |! packs |! over |! the |! client's |! abdomen |! and |! in |! the |! axilla |! and |! groin |! - |! Correct |! answer |! ✔ANS: |! 1, |! 2, |! 4 Rationale: Standard |! measures |! to |! lower |! body |! temperature |! include |! removing |! bed |! covers, |! providing |! cool |! sponge |! baths, |! using |! an |! electric |! fan |! in |! the |! room, |! administering |! acetaminophen, |! and |! placing |! a |! hypothermia |! blanket |! under |! the |! client. |! Ice |! packs |! are |! not |! used |! because |! they |! could |! cause |! shivering, |! which |! increases |! cellular |! oxygen |! demands, |! with |! the |! potential |! for |! increased |! intracranial |! pressure. A |! client |! is |! somewhat |! nervous |! about |! undergoing |! magnetic |! resonance |! imaging |! (MRI). |! Which |! statement |! by |! the |! nurse |! would |! provide |! the |! most |! reassurance |! to |! the |! client |! about |! the |! procedure?
- |! "The |! MRI |! machine |! is |! a |! long, |! narrow, |! hollow |! tube |! and |! may |! make |! you |! feel |! somewhat |! claustrophobic."
- |! "You |! will |! be |! able |! to |! eat |! before |! the |! procedure |! unless |! you |! get |! nauseated |! easily. |! If |! so, |! you |! should |! eat |! lightly."
- |! "Even |! though |! you |! are |! alone |! in |! the |! scanner, |! you |! will |! be |! in |! voice |! communication |! with |! the |! technologist |! at |! all |! times |! during |! the |! procedure."
- |! "It |! is |! necessary |! to |! remove |! any |! metal |! or |! metal-containing |! objects |! before |! having |! the |! MRI |! done |! to |! avoid |! the |! metal |! being |! drawn |! into |! the |! magnetic |! field." |! - |! Correct |! answer |! ✔ANS: |! 3 "Even |! though |! you |! are |! alone |! in |! the |! scanner, |! you |! will |! be |! in |! voice |! communication |! with |! the |! technologist |! at |! all |! times |! during |! the |! procedure." Rationale: The |! MRI |! scanner |! is |! a |! hollow |! tube |! that |! gives |! some |! clients |! a |! feeling |! of |! claustrophobia. |! Metal |! objects |! must |! be |! removed |! before |! the |! procedure |! so |! that |! they |! are |! not |! drawn |! into |! the |! magnetic |! field. |! The |! client |! may |! eat |! and |! may |! take |! all |! prescribed |! medications |! before |! the |! procedure. |! If |! a |! contrast |! medium |! is |! used, |! the |! client |! may |! wish |! to |! eat |! lightly |! if |! he |! or |! she |! has |! a |! tendency |! to |! become |! nauseated |! easily. |! The |! client |! lies |! supine |! on |! a |! padded |! table |! that |! moves |! into |! the |! imager. |! The |! client |! must |! lie |! still |! during |! the |! procedure. |! The |! imager |! makes |! tapping |! noises |! during |! the |! scanning. |! The |! client |! is |! alone |! in |! the |! imager, |! but |! the |! nurse |! can |! reassure |! the |! client |! that |! the |! technologist |! will |! be |! in |! voice |! communication |! with |! the |! client |! at |! all |! times |! during |! the |! procedure. The |! nurse |! is |! administering |! mouth |! care |! to |! an |! unconscious |! client. |! The |! nurse |! should |! perform |! which |! actions |! in |! the |! care |! of |! this |! person? |! Select |! all |! that |! apply. |!
- |! Use |! products |! that |! contain |! alcohol.
- |! Position |! the |! client |! on |! his |! or |! her |! side. |!
- |! Insight, |! judgment, |! and |! planning |! - |! Correct |! answer |! ✔ANS: |! 1 Eye |! movements Rationale: Eye |! movements |! are |! under |! the |! control |! of |! cranial |! nerves |! III, |! IV, |! and |! VI. |! Level |! of |! consciousness |! (response |! to |! verbal |! stimuli) |! is |! controlled |! by |! the |! reticular |! activating |! system |! and |! both |! cerebral |! hemispheres. |! Feelings |! are |! part |! of |! the |! role |! of |! the |! limbic |! system |! and |! involve |! both |! hemispheres. |! Insight, |! judgment, |! and |! planning |! are |! part |! of |! the |! function |! of |! the |! frontal |! lobe |! in |! conjunction |! with |! association |! fibers |! that |! connect |! to |! other |! areas |! of |! the |! cerebrum. The |! nurse |! assesses |! a |! client |! who |! is |! diagnosed |! with |! a |! stroke |! (brain |! attack). |! On |! assessment, |! the |! client |! is |! unable |! to |! understand |! the |! nurse's |! commands. |! Which |! condition |! should |! the |! nurse |! document?
- |! Occipital |! lobe |! impairment
- |! Damage |! to |! the |! auditory |! association |! areas
- |! Frontal |! lobe |! and |! optic |! nerve |! tracts |! damage
- |! Difficulty |! with |! concept |! formation |! and |! abstraction |! areas |! - |! Correct |! answer |! ✔ANS: |! 2
Damage |! to |! the |! auditory |! association |! areas Rationale: Auditory |! association |! and |! storage |! areas |! are |! located |! in |! the |! temporal |! lobe |! and |! relate |! to |! understanding |! spoken |! language. |! The |! occipital |! lobe |! contains |! areas |! related |! to |! vision. |! The |! frontal |! lobe |! controls |! voluntary |! muscle |! activity, |! including |! speech, |! and |! an |! impairment |! can |! result |! in |! expressive |! aphasia. |! The |! parietal |! lobe |! contains |! association |! areas |! for |! concept |! formation, |! abstraction, |! spatial |! orientation, |! body |! and |! object |! size |! and |! shape, |! and |! tactile |! sensation. The |! nurse |! is |! performing |! an |! assessment |! on |! a |! client |! with |! a |! diagnosis |! of |! thrombotic |! stroke |! (brain |! attack). |! Which |! assessment |! question |! would |! elicit |! data |! specific |! to |! this |! type |! of |! stroke?
- |! "Have |! you |! had |! any |! headaches |! in |! the |! past |! few |! days?"
- |! "Have |! you |! recently |! been |! having |! difficulty |! with |! seeing |! at |! nighttime?"
- |! "Have |! you |! had |! any |! sudden |! episodes |! of |! passing |! out |! in |! the |! past |! few |! days?"
- |! "Have |! you |! had |! any |! numbness |! or |! tingling |! or |! paralysis-type |! feelings |! in |! any |! of |! your |! extremities |! recently?" |! - |! Correct |! answer |! ✔ANS: |! 4
- |! Provide |! ample |! time |! for |! the |! client |! to |! chew |! and |! swallow. |! - |! Correct |! answer |! ✔ANS: |! 1, |! 2, |! 3, |! 5 Rationale: Liquids |! are |! thickened |! to |! prevent |! aspiration. |! The |! nurse |! should |! assist |! the |! client |! with |! eating |! and |! place |! food |! on |! the |! unaffected |! side |! of |! the |! mouth. |! The |! nurse |! should |! assess |! for |! gag |! and |! swallowing |! reflexes |! before |! the |! client |! with |! dysphagia |! is |! started |! on |! a |! diet. |! The |! client |! should |! be |! allowed |! ample |! time |! to |! chew |! and |! swallow |! to |! prevent |! choking. The |! nurse |! is |! creating |! a |! plan |! of |! care |! for |! a |! client |! with |! a |! stroke |! (brain |! attack) |! who |! has |! right |! homonymous |! hemianopsia. |! Which |! should |! the |! nurse |! include |! in |! the |! plan |! of |! care |! for |! the |! client? |!
- |! Place |! an |! eye |! patch |! on |! the |! left |! eye. |!
- |! Place |! personal |! articles |! on |! the |! client's |! right |! side.
- |! Approach |! the |! client |! from |! the |! right |! field |! of |! vision.
- |! Instruct |! the |! client |! to |! turn |! the |! head |! to |! scan |! the |! right |! visual |! field. |! - |! Correct |! answer |! ✔ANS: |! 4 Instruct |! the |! client |! to |! turn |! the |! head |! to |! scan |! the |! right |! visual |! field. |! Rationale:
Homonymous |! hemianopsia |! is |! a |! loss |! of |! half |! of |! the |! visual |! field. |! The |! nurse |! instructs |! the |! client |! to |! scan |! the |! environment |! and |! stands |! within |! the |! client's |! intact |! field |! of |! vision. |! The |! nurse |! should |! not |! patch |! the |! eye |! because |! the |! client |! does |! not |! have |! double |! vision. |! The |! client |! should |! have |! objects |! placed |! in |! the |! intact |! fields |! of |! vision, |! and |! the |! nurse |! should |! approach |! the |! client |! from |! the |! intact |! side. The |! nurse |! is |! preparing |! a |! plan |! of |! care |! for |! a |! client |! with |! a |! diagnosis |! of |! amyotrophic |! lateral |! sclerosis |! (ALS). |! On |! assessment, |! the |! nurse |! notes |! that |! the |! client |! is |! severely |! dysphagic. |! Which |! intervention |! should |! be |! included |! in |! the |! care |! plan |! for |! this |! client? |! Select |! all |! that |! apply.
- |! Provide |! oral |! hygiene |! after |! each |! meal.
- |! Assess |! swallowing |! ability |! frequently. |!
- |! Allow |! the |! client |! sufficient |! time |! to |! eat.
- |! Maintain |! a |! suction |! machine |! at |! the |! bedside.
- |! - |! Correct |! answer |! ✔ANS: |! 1, |! 2, |! 3, |! 4 Rationale: A |! client |! who |! is |! severely |! dysphagic |! is |! at |! risk |! for |! aspiration. |! Swallowing |! is |! assessed |! frequently. |! The |! client |! should |! be |! given |! a |! sufficient |! amount |! of |! time |! to |! eat. |! Semisoft |! foods |! are |! easiest |! to |! swallow |! and |! require |! less |! chewing. |! Oral |!
The |! nurse |! is |! caring |! for |! a |! client |! after |! a |! craniotomy |! and |! monitors |! the |! client |! for |! signs |! of |! increased |! intracranial |! pressure |! (ICP). |! Which |! finding, |! if |! noted |! in |! the |! client, |! would |! indicate |! an |! early |! sign |! of |! increased |! ICP?
- |! Confusion
- |! Bradycardia
- |! Sluggish |! pupils
- |! A |! widened |! pulse |! pressure |! - |! Correct |! answer |! ✔ANS: |! 1 Confusion Rationale: Early |! manifestations |! of |! increased |! ICP |! are |! subtle |! and |! often |! may |! be |! transient, |! lasting |! for |! only |! a |! few |! minutes |! in |! some |! cases. |! These |! early |! clinical |! manifestations |! include |! episodes |! of |! confusion, |! drowsiness, |! and |! slight |! pupillary |! and |! breathing |! changes. |! Later |! manifestations |! include |! a |! further |! decrease |! in |! the |! level |! of |! consciousness, |! a |! widened |! pulse |! pressure, |! and |! bradycardia. |! Cheyne-Stokes |! respiratory |! pattern, |! or |! a |! hyperventilation |! respiratory |! pattern, |! and |! pupillary |! sluggishness |! and |! dilatation |! appear |! in |! the |! late |! stages. The |! nurse |! is |! reviewing |! the |! record |! of |! a |! client |! with |! a |! suspected |! diagnosis |! of |! Huntington's |! disease. |! The |! nurse |! should |! expect |! to |! note |! documentation |! of |! which |! early |! symptom |! of |! this |! disease?
- |! Aphasia
- |! Agnosia |!
- |! Difficulty |! with |! swallowing
- |! Balance |! and |! coordination |! problems |! - |! Correct |! answer |! ✔ANS: |! 4 Balance |! and |! coordination |! problems Rationale: Early |! symptoms |! of |! Huntington's |! disease |! include |! restlessness, |! forgetfulness, |! clumsiness, |! falls, |! balance |! and |! coordination |! problems, |! altered |! speech, |! and |! altered |! handwriting. |! Difficulty |! with |! swallowing |! occurs |! in |! the |! later |! stages. |! Aphasia |! and |! agnosia |! do |! not |! occur. The |! nurse |! is |! caring |! for |! a |! client |! with |! a |! diagnosis |! of |! right |! (nondominant) |! hemispheric |! stroke. |! The |! nurse |! notes |! that |! the |! client |! is |! alert |! and |! oriented |! to |! time |! and |! place. |! On |! the |! basis |! of |! these |! assessment |! findings, |! the |! nurse |! should |! make |! which |! interpretation?
- |! Had |! a |! very |! mild |! stroke
- |! Most |! likely |! suffered |! a |! transient |! ischemic |! attack
