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RN Nursing School · Med-Surg · 428 questions

Neurological Disorders practice questions

Every question below is free to read with its full rationale. For timed sets, the rest of the bank and progress tracking on Neurological Disorders, practise in the app.

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  1. 1A nurse is caring for a patient with myasthenia gravis who becomes suddenly weak and has shallow respirations. Which action should the nurse AVOID?Answer →
  2. 2The charge nurse taught a group of new nursing students about assessing and managing patients with eye and vision disorders. The charge nurse knows the students understand the clinical manifestations of glaucoma when they: (Select all that apply)Answer →
  3. 3A nurse is caring for a client with a C5 spinal cord injury. Which of the following activity limitations should the nurse anticipate for this client?Answer →
  4. 4A 16-year-old patient is admitted to the emergency room with a complaint of neck discomfort after being hit from behind by another person at full force. He is complaining of neck discomfort, numbness in both of his upper extremities and tingling in his lower extremities. Vital signs: BP 100/64, HR 58, Resp 16, and Pulse ox 95%. He also states, "I have to urinate badly". Based on this assessment data, the nurse understands that the patient is experiencing:Answer →
  5. 5Which of the following actions should the nurse AVOID when administering pyridostigmine to a patient with myasthenia gravis?Answer →
  6. 6Which nursing action is LEAST appropriate when a patient with myasthenia gravis reports increasing difficulty swallowing?Answer →
  7. 7A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?Answer →
  8. 8When assisting a patient who is legally blind, which intervention would not be appropriate?Answer →
  9. 9A client has had a traumatic brain injury and is mechanically ventilated. Which technique would the nurse use to prevent increasing intracranial pressure (ICP)?Answer →
  10. 10The nurse in the pain management clinic plans to teach clients about pain management. What should the nurse include when speaking about acute versus chronic pain?Answer →
  11. 11For each client finding listed below, click to specify if the finding is consistent with symptoms identified by the F.A.S.T. stroke screening tool. Each finding may be associated with more than one part of the tool.Answer →
  12. 12A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?Answer →
  13. 13The nurse plans for the discharge of a patient with Parkinson's disease. Which outcomes should the nurse collaborate with the physical and occupational therapists to achieve? Select all that apply.Answer →
  14. 14A client presents to the health care clinic with reports of difficulty swallowing. Which cranial nerves will provide the nurse with information related to the problem? Select all that apply.Answer →
  15. 15Which of the following does NOT indicate a need to notify the provider regarding the GCS score?Answer →
  16. 16A patient is diagnosed with glaucoma. Which symptom should the nurse expect the patient to report?Answer →
  17. 17When evaluating a client with cognitive impairment, which tool is most appropriate for differentiating between delirium and dementia?Answer →
  18. 18A patient who was admitted with a new diagnosis of multiple sclerosis (MS) has been in her room sleeping all day and is ready for discharge to home. As a nurse you need to teach the patient with a new diagnosis of MS before they leave to:Answer →
  19. 19Which of the following is a primary action of entacapone when used with levodopa for clients with Parkinson's disease?Answer →
  20. 20Review the electronic health record. The nurse cares for the client in the intensive care unit. Which action(s) should the nurse implement? Select all that apply.Answer →
  21. 21For each of the symptoms listed below, indicate whether it is associated with Cataracts, Glaucoma, or Ménière's Disease. Each symptom may be associated with more than one condition.Answer →
  22. 22A nurse is assessing the client who was started on drug therapy with carbidopa/levodopa over two years ago. The nurse would observe for which of the following adverse effects of this drug?Answer →
  23. 23A nurse is planning the care for a client following a head injury in a motor vehicle accident. The nurse assesses the arterial blood gas findings. Which finding may lead to severe complications and needs to be reported to a healthcare provider?Answer →
  24. 24Which nonmodifiable and modifiable risk factors for stroke would be important to include when planning a community education program? Select all that apply.Answer →
  25. 25A nurse is preparing to transfer a client who has left-sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take?Answer →
  26. 26Which assessment findings would the nurse correlate or expect to find in a client with neurogenic shock? (Select all that apply.)Answer →
  27. 27A nurse is assessing a client who has ataxia. Which of the following actions should the nurse include in the plan of care?Answer →
  28. 28The nurse assesses a client admitted with an exacerbation of multiple sclerosis. Which assessment finding requires immediate follow-up by the nurse?Answer →
  29. 29The student nurse asks the clinical instructor, "what is the purpose of a hypnotic drug?" Hypnotic agents are specifically designed toAnswer →
  30. 30Drag from the choices below to specify which condition [blank1] the client is most likely experiencing, 2 actions [blank2] and [blank3] the nurse should take to address that condition, and 2 parameters [blank4] and [blank5] the nurse should monitor to assess the client's progress.Answer →
  31. 31A client with dementia is at risk for wandering. Which intervention best addresses this risk?Answer →
  32. 32A client in the critical care unit is exhibiting signs of Cushing's triad. Which assessment finding would be most consistent with this condition?Answer →
  33. 33Which of the following is NOT true about a total Glasgow Coma Scale score of 3?Answer →
  34. 34A nurse is monitoring a client with traumatic brain injury for signs of cerebral herniation. Which finding indicates a critical emergency?Answer →
  35. 35The nurse is caring for a patient with a new diagnosis of relapsing remitting primary multiple sclerosis (RRMS). The priority action by the nurse is to:Answer →
  36. 36A client presents with sudden onset of aphasia, decreased level of consciousness, and right-sided weakness. The client has a history of atrial fibrillation, heart failure, and transient ischemic attacks. Based on the history, the nurse suspects that the client has sustained which type of stroke?Answer →
  37. 37The nurse is performing an assessment of the motor system on a patient. The nurse observes ataxia and an abnormal arm swing while the patient is walking. What is the priority concern at this time?Answer →
  38. 38A nurse is unable to elicit a patient's patellar reflex. The nurse should initially:Answer →
  39. 39Based on the scenario of a client on a geriatric ward with balance issues and a history of falls, which of the following nursing actions are anticipated and contraindicated for fall prevention?Answer →
  40. 40A home health nurse who is taking care of an older adult client notices the client has been exhibiting fluctuating levels of orientation, disorganized thinking, and decreased ability to concentrate over the past two days. Which of the following is the client most likely experiencing?Answer →
  41. 41When observing decerebrate posturing in a client following a traumatic brain injury, which intervention should take priority?Answer →
  42. 42A nurse is caring for a client with Parkinson's disease who is taking benztropine. For which adverse effect should the nurse monitor?Answer →
  43. 43A nurse is providing teaching to a client newly diagnosed with amyotrophic lateral sclerosis (ALS). Which of the following statements should the nurse include? Select all that apply.Answer →
  44. 44A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? (Select all that apply.)Answer →
  45. 45What early clinical manifestation is most indicative of increased ICP?Answer →
  46. 46The nurse cares for a client with a head injury receiving a 3% sodium chloride intravenous infusion. For which complication of this therapy should the nurse monitor?Answer →
  47. 47A nurse is monitoring a patient for non-motor symptoms of Parkinson's Disease. Which of the following should the nurse document as an autonomic change?Answer →
  48. 48The nurse is planning care for a client in the first 24 hours after admission for a thrombotic stroke. Which assessment is a priority for the nurse to make during this time?Answer →
  49. 49The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will do what when eating?Answer →
  50. 50A patient has had a stroke affecting the posterior cerebral artery (PCA). Which deficit is most likely?Answer →
  51. 51Review the electronic health record. The nurse cares for a client in the emergency department. For each client finding, click to specify whether the finding is relevant to the reason for admission or not relevant.Answer →
  52. 52Which assessment finding is most strongly indicative of transient ischemic attack (TIA)?Answer →
  53. 53A nurse is caring for a client who is to receive liquid medications via a gastrostomy tube. The client is prescribed phenytoin 250 mg. The amount available is phenytoin oral solution 25 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  54. 54If a patient has dysphagia following a stroke, what is the initial nursing priority?Answer →
  55. 55A nurse is caring for a client with a traumatic brain injury (TBI). Which action(s) should the nurse plan to include to prevent increased intracranial pressure? Select all that apply.Answer →
  56. 56A 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor. Which topic would the nurse anticipate explaining to the patient?Answer →
  57. 57The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this client's care?Answer →
  58. 58Early manifestations of amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) are somewhat similar. Which clinical feature of ALS distinguishes it from MS?Answer →
  59. 59What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED?Answer →
  60. 60Which intervention is most appropriate for Parkinson's disease with drooling and mild dysphagia?Answer →
  61. 61A patient with a tremor is being evaluated for Parkinson's disease. What would the nurse explain to the patient to confirm the diagnosis of Parkinson's disease?Answer →
  62. 62A nurse is caring for a client with Obsessive-Compulsive Disorder (OCD) who spends several hours a day performing hand-washing rituals, resulting in red, excoriated skin. What is the priority nursing action during this time?Answer →
  63. 63When the nurse asks her 68-year-old client to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet further apart. The nurse would document this as aAnswer →
  64. 64When caring for a client newly diagnosed with Parkinson's disease, the nurse is correct in telling the client that which risk factor and neurotransmitter is associated with this condition?Answer →
  65. 65A client diagnosed with stroke is now experiencing left homonymous hemianopsia. How might the nurse help the client manage potential sensory and perceptional difficulties?Answer →
  66. 66A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following referrals should the nurse anticipate the provider to prescribe?Answer →
  67. 67A nurse is planning care for a client who has had a recent cerebrovascular accident (CVA). Which of the following actions should the nurse include in the plan of care to decrease the client's risk for footdrop?Answer →
  68. 68Drag the words from the choices below to fill in each blank in the following sentence. Common signs of increased intracranial pressure include [blank1], [blank2], and [blank3].Answer →
  69. 69What is the priority nursing intervention for a client who has developed left arm swelling after a thromboembolic right hemispheric stroke?Answer →
  70. 70A nurse is planning care for a client with a cervical spinal cord injury who requires a cervical collar. Which action should the nurse incorporate into the client's care plan?Answer →
  71. 71A nurse is caring for a client with antisocial personality disorder. Unit rules state that phone privileges end at 9:30 PM. At 10:00 PM, the client approaches the nurse and says, "My friend is going through a crisis; I need to make one quick call." Which response by the nurse is most therapeutic?Answer →
  72. 72Which of the following is the first step in assessing a patient's mental status?Answer →
  73. 73A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following?Answer →
  74. 74A patient with a GCS score of 8 is admitted to the ICU after a traumatic brain injury. Which of the following nursing interventions is the most appropriate?Answer →
  75. 75The client has hearing loss, and upon examination, a large amount of earwax is found in the client's ear. What type of hearing loss is the client likely experiencing?Answer →
  76. 76A client in the ICU presents with signs of increased ICP. Which of the following are indicative of increased ICP based on pathologic posturing clues? (Select all that apply.)Answer →
  77. 77A post-stroke patient presents with left-sided weakness and expressive (Broca's) aphasia. Damage is most likely in:Answer →
  78. 78The nurse is providing education to a client recently diagnosed with multiple sclerosis (MS). Which information should the nurse include in the teaching?Answer →
  79. 79A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following?Answer →
  80. 80A nurse is assessing a client with suspected brain herniation using the Glasgow Coma Scale (GCS). The client opens their eyes spontaneously, responds verbally with incomprehensible sounds, and withdraws from pain. What is the total GCS score for this patient?Answer →
  81. 81A nurse is caring for a client who has dysphagia following a stroke. Which of the following nursing interventions should the nurse prioritize to reduce the risk of aspiration?Answer →
  82. 82The registered nurse taking a shift report learns that an assigned client is blind. How should the nurse best communicate with this client?Answer →
  83. 83A nurse is visiting an older patient in their home in order to complete an assessment of the home environment. Which of the following would the nurse identify as a safety concern?Answer →
  84. 84The nurse cares for a client with traumatic brain injury (TBI). What ongoing nursing assessment is most important?Answer →
  85. 85A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?Answer →
  86. 86A client has just experienced a transient ischemic attack. Interprofessional collaborative care focuses on preventing another TIA or possible stroke and may include which of the following? Select all that apply.Answer →
  87. 87Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.Answer →
  88. 88What is the first priority for a patient presenting with a suspected ischemic stroke?Answer →
  89. 89The nurse is assisting a client with multiple sclerosis (MS) to set long-term goals. Which goal is realistic?Answer →
  90. 90The nurse is caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102 mm Hg. What should the nurse do first?Answer →
  91. 91A client has been diagnosed with glaucoma and the nurse is preparing health education regarding the client's medication regimen. The client states that he is eager to "beat this disease" and looks forward to the time that the client will no longer require medication. How should the nurse best respond?Answer →
  92. 92A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)Answer →
  93. 93The nurse observes that a client with Parkinson's disease (PD) has a mask-like face. Which follow-up assessment is most important for the nurse to implement?Answer →
  94. 94The nurse's initial action after assessing the client at 1400 is to [blank1]. The nurse suspects the client's new symptoms are related to [blank2].Answer →
  95. 95The nurse is planning care for a client with Guillain-Barré syndrome. Which activity can the nurse delegate to the unlicensed assistive personnel (UAP)?Answer →
  96. 96A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?Answer →
  97. 97A nurse is caring for a client in a long-term care facility who is in restraints. The nurse notes that the restrained extremity is cool to the touch, pale, and has decreased capillary refill. Based on the Omnibus Budget Reconciliation Act of 1987, which action should the nurse take first?Answer →
  98. 98A nurse is caring for a client who has dysphagia following a stroke. Which of the following nursing interventions should the nurse prioritize to reduce the risk of aspiration?Answer →
  99. 99A client with multiple sclerosis (MS) is receiving baclofen. The nurse determines that the drug is effective when it produces which outcome?Answer →
  100. 100Choose the actions that are appropriate for managing status epilepticus.Answer →
  101. 101Quetiapine complication in older adult with Alzheimer's?Answer →
  102. 102Which medication should be given as an antidote for atropine?Answer →
  103. 103A client with elevated ICP is being hyperventilated. What is the rationale for this intervention?Answer →
  104. 104A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?Answer →
  105. 105A nurse is providing teaching for a client who has age-related macular degeneration. Which of the following information should the nurse include in the teaching?Answer →
  106. 106A nurse is assessing a patient with neurologic deficits. Complete each statement by selecting the cranial nerve most likely affected.Answer →
  107. 107During bedside report, a client is alert to person, place, time, and situation. When the nurse reassesses the client later in the shift, they are only oriented to person and place. What should be the nurse's initial response to the client's change in behavior?Answer →
  108. 108A client with a spinal cord injury at the T1 to T5 level is experiencing limitations. Which of the following activities is MOST likely affected by this injury level?Answer →
  109. 109A nurse is caring for a client who just had a seizure and is now postictal. What action should the nurse take first?Answer →
  110. 110The nurse receives lab work for a client with seizure disorder who is on phenytoin. The results show a phenytoin level of 25 mcg/ml. Which action should the nurse take first?Answer →
  111. 111Why should shark, swordfish, tilefish, and king mackerel be avoided during pregnancy?Answer →
  112. 112A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?Answer →
  113. 113Delirium has been ruled out in a client with Alzheimer's disease consistently exhibiting agitation and aggressive. The client has been unresponsive to multiple traditional and conservative interventions, which medication may be appropriate?Answer →
  114. 114The nurse provides training to a group of unlicensed assistive personnel (UAPs) about seizure precautions and client safety. What statement by a UAP indicates a need for additional education?Answer →
  115. 115A client who has sustained a spinal cord injury above the level of T6 presents with bradycardia, hypotension, and warm, flushed skin. Which of the following findings is most indicative of neurogenic shock rather than spinal shock?Answer →
  116. 116A client in the ICU presents with signs of increased ICP. Which of the following are indicative of increased ICP based on pathologic posturing clues? (Select all that apply.)Answer →
  117. 117A client has problems maintaining balance and posture. Click to identify the part of the brain that is involved in the client's condition. Graphic description: Human brain with different lobes indicated by different colors. To the far left of the diagram is a royal blue section extending from the top of the brain to the base. This royal blue section surrounds a smaller grey section located near the base of the royal blue section. To the right of the royal blue section is an orange section that extends from the border of the blue section all the way to the far right of the diagram. From top to bottom, the orange section only goes halfway down toward the base. Below the orange section is a tan section, which starts just below the left side of the orange section. The tan section is about two-thirds of the width of the orange section above. The remaining third of the area below the orange section houses a much smaller green section. Located in the center of the junction of the orange/tan/green sections is a small yellow section. Lastly, there is a small brown section that only sits on the base of the far-right side of the diagram. This section sits just below the junction of the tan and green sections.Answer →
  118. 118A nurse is monitoring a patient that started escitalopram three weeks ago. What would be the most concerning assessment finding for the nurse?Answer →
  119. 119A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an early indication of increased intracranial pressure (ICP)?Answer →
  120. 120The Weber Test is a hearing test that is used to assess lateralization.Answer →
  121. 121A nurse is assessing cranial nerve function in a patient with a suspected neurologic disorder. Complete the table by selecting the correct cranial nerve and function for each assessment finding. 1. Patient unable to shrug shoulders against resistance - Cranial Nerve - Function 2. Patient has difficulty swallowing and absent gag reflex - Cranial Nerve - FunctionAnswer →
  122. 122The nurse is observing the unlicensed assistive personnel (UAP) give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which?Answer →
  123. 123A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?Answer →
  124. 124A nurse is providing teaching to a client about risk factors for developing glaucoma. Which of the following risk factors should the nurse include in the teaching?Answer →
  125. 125The nurse is caring for a 65-year-old patient with a head injury following a motor vehicle accident. Which assessment finding would need immediate intervention?Answer →
  126. 126A client received an influenza vaccination on January 1. Over the past week, the client reports 'not feeling well.' On January 10, the client presents to the emergency department with progressive difficulty walking. Within hours of admission, the client requires endotracheal intubation for airway protection. Which of the following does the nurse suspect is the most likely cause of the client's symptoms?Answer →
  127. 127The nurse provides prescribed treatments to a client with bacterial meningitis. What finding indicates to the nurse that the client's condition is improving?Answer →
  128. 128The nurse is planning care for a client who is experiencing expressive aphasia. Which nursing action is most helpful in promoting communication?Answer →
  129. 129A patient's temporomandibular joint course has a palpable crackling sensation and an audible click. He denies discomfort. No swelling or limited movements are present. The nurse would document the followingAnswer →
  130. 130A nurse is preparing to administer an ophthalmic medication to a client. Which of the following actions should the nurse plan take?Answer →
  131. 131The nurse is positioning a client who has hemiparalysis. Which technique is most effective when there is only one person to assist the client to move from the left side to the right side?Answer →
  132. 132A nurse is teaching a client who taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects?Answer →
  133. 133A client presents to the emergency department with right facial drooping and drooling. A diagnosis of Bell's palsy is confirmed. When instructing the spouse on the interventions needed to care for the client, which should be included? Select all that apply.Answer →
  134. 134A Parkinson's patient is getting ready to discharge home on a new medication, Benztropine (anti-cholinergic). The nurse will need to educate the patient on which of the following side effects?Answer →
  135. 135A nurse plans care for a client with a halo fixator. Which interventions would the nurse include in this client's plan of care? (Select all that apply)Answer →
  136. 136The nurse cares for a client newly diagnosed with a tumor in the parietal lobe. Which finding should the nurse anticipate?Answer →
  137. 137A nurse is providing care to a client diagnosed with meningitis and placed on seizure precautions. Classify the following interventions as indicated or contraindicated if the client experiences a seizure.Answer →
  138. 138A client presents with decerebrate posturing after a traumatic head injury. Which combination of findings would most likely indicate worsening intracranial pressure?Answer →
  139. 139A client diagnosed with major depressive disorder refuses to take prescribed venlafaxine ER. Which response by the nurse is most appropriate?Answer →
  140. 140A client was given intravenous lorazepam for short-term seizure control. The nurse should monitor for the medication side effect of: ___Answer →
  141. 141Ordered Prednisone 60mg po Daily Available liquid 5mg/mL How many mls would you give?Answer →
  142. 142Which actions by a nurse would demonstrate an aspect of nursing clinical judgment? (Select all that apply)Answer →
  143. 143A nurse is caring for a client with a spinal cord injury whose blood pressure is 250/130 mm Hg. The client is flushed, diaphoretic, and is complaining of a headache. What action should the nurse take first?Answer →
  144. 144The nurse is caring for a recently injured 18-year-old female client with a complete cervical spinal cord injury (C7) for acute rehabilitation and recognizes the need to help prevent and manage common complications. Indicate which nursing actions listed are appropriate for the potential complications associated with cervical spinal cord injuries.Answer →
  145. 145A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?Answer →
  146. 146A nurse is documenting the Glasgow Coma Scale (GCS) assessment findings for a client who has experienced a severe head injury. The client opens their eyes only in response to painful stimuli, makes incomprehensible sounds, and exhibits no motor response to pain. What is the correct GCS score for this client?Answer →
  147. 147A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?Answer →
  148. 148The nurse is testing stereognosis. The nurse would instruct the patient to close both eyes and then proceed byAnswer →
  149. 149A nurse is caring for a client who has just been admitted to the emergency department (ED). Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.Answer →
  150. 150When teaching the patient with newly diagnosed multiple sclerosis (MS) about the disease, which explanation would be most appropriate?Answer →
  151. 151The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious client. During the procedure the client reaches over with his left hand and tries to brush off the painful stimulus. How would the nurse document this motor response?Answer →
  152. 152A client with a suspected epidural hematoma has a brief loss of consciousness followed by a lucid interval. What diagnostic finding is most likely on CT scan?Answer →
  153. 153A patient diagnosed with open-angle glaucoma states during clinic follow-up, 'I stopped using my eye drops because my vision feels normal now.' What is the nurse's best response?Answer →
  154. 154The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?Answer →
  155. 155A patient is in a car accident and has a spinal cord injury at T12-L1. The physician has put the patient on high doses of corticosteroids to reduce the swelling in the spinal area. The primary goal for treatment of a spinal cord injury (SCI) is to:Answer →
  156. 156Critical care nurses managing a client in neurogenic shock should prioritize interventions to address [blank1] and [blank2].Answer →
  157. 157A 31-year-old client reports several episodes over the last few months in which they experienced leg weakness, blurry vision, and difficulty maintaining balance. The symptoms resolved on their own but have begun occurring more frequently. The client also reports profound fatigue after minimal activity. On examination, the nurse observes nystagmus, intention tremor, and spasticity in the lower extremities. An MRI of the brain reveals multiple areas of demyelination consistent with plaques. Instructions: Select one suspected neurological condition [blank1]. Two factors that increase risk for symptom exacerbation for this condition [blank2] and [blank3]. Two priority education points for this condition to reinforce with the client [blank4] and [blank5].Answer →
  158. 158A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?Answer →
  159. 159The nurse is assessing the neurological system of an adult patient. To test the patient's recent memory, the nurse should ask the patient which question?Answer →
  160. 160A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective?Answer →
  161. 161A patient with Parkinson's disease reports that their motor symptoms return an hour before their next dose of medication is scheduled. This is an example of which phenomenon?Answer →
  162. 162When obtaining a health history and physical assessment for a 39-year-old female client with possible multiple sclerosis (MS), the nurse should include which of the following assessment questions?Answer →
  163. 163A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?Answer →
  164. 164A client diagnosed with a brain trauma is receiving levetiracetam. The client's partner questions the use of the drug, since there is no history of a seizure disorder. What response will the nurse provide to be best address the partner's concern?Answer →
  165. 165Which nursing intervention is most helpful in meeting the needs of an older adult with moderate Alzheimer's disease?Answer →
  166. 166Which of the following would NOT be considered an abnormal response during a neurological examination?Answer →
  167. 167Which of the following core measures should the nurse implement for a client experiencing an acute stroke? Select four that apply.Answer →
  168. 168A patient with Myasthenia Gravis is eating lunch and the nurse observes the following: Pocketing of food Frequent coughing while swallowing Fatigue during the meal What is the priority nursing action?Answer →
  169. 169The nurse is teaching a client newly diagnosed with myasthenia gravis about the cause of this disease. The nurse determines that teaching has been effective when the client states:Answer →
  170. 170After a seizure, a patient is confused and wants to get out of bed. What is the priority nursing action?Answer →
  171. 171Which clinical finding is a key distinguishing factor between idiopathic Parkinson's disease and Parkinsonism?Answer →
  172. 172A nurse is assessing a client who is experiencing a change in vision. Which of the following statements indicates that the client might be developing cataracts?Answer →
  173. 173A 56-year-old nurse derives a sense of satisfaction from volunteering every Saturday at the free college campus clinic. Which Erikson stage does this reflect?Answer →
  174. 174A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?Answer →
  175. 175A client in the critical care unit is exhibiting signs of Cushing's triad. Which assessment finding would be most consistent with this condition?Answer →
  176. 176The nurse is assessing a client with multiple sclerosis (MS). Which clinical manifestations of multiple sclerosis would the nurse expect to observe in the client? Select all that apply.Answer →
  177. 177What patient should the nurse see first in the neurological intensive care unit?Answer →
  178. 178The nurse is developing a discharge teaching plan with a patient with multiple sclerosis. Which information should the nurse include in the discharge teaching plan? Select all that apply.Answer →
  179. 179A nurse is planning care for an alert and oriented client with newly diagnosed early-stage Alzheimer's disease. Which action(s) are appropriate when caring for this client? Select all that apply.Answer →
  180. 180Which of the following nursing actions is NOT appropriate at this time?Answer →
  181. 181A client has received a diagnosis of Guillan-Barre Syndrome. The nurse inquires during the nursing admission interview if the client has a history of:Answer →
  182. 182Match the following definitions with the appropriate eye disorder.Answer →
  183. 183The client with a history of alcohol use is admitted to the hospital. upon arrival anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis?Answer →
  184. 184The nurse uses the SBAR reporting technique and reports that, "The client is alert, oriented. They are able to make needs known. Dressing to right side of head is intact with scant amount of serosanguinous drainage. There are no signs of infection at the incision site and staples are intact. The client's vital signs are 126/82 mm Hg, heart rate 80, respirations 18, and O2 saturations are 96 percent on oxygen via nasal cannula." What aspect of SBAR is the nurse sharing?Answer →
  185. 185A client with increased ICP is receiving mannitol. What is an important nursing intervention to ensure its effectiveness?Answer →
  186. 186A nurse is assessing a client with a neurological disorder. Which finding is most consistent with multiple sclerosis?Answer →
  187. 187The nurse is developing a care plan to help a client with expressive aphasia communicate. Which actions would be helpful? Select all that apply.Answer →
  188. 188Patients with multiple sclerosis (MS) experience many different symptoms. Which of the following symptoms are atypical or unexpected of multiple sclerosis?Answer →
  189. 189A client has clinical manifestations of autonomic dysreflexia following a spinal cord injury above T6. What actions should the nurse take to manage this condition? (Select all that apply.)Answer →
  190. 190To test the motor function of the facial nerve (CN VII), the nurse should ask the patient to:Answer →
  191. 191Indicate which nursing action listed is appropriate for the potential complication. Note that not all actions will be used.Answer →
  192. 192After an episode of severe pain, a client says to the nurse, "The pain really frightened me. I thought I was going to die." Which statement is the most appropriate response from the nurse?Answer →
  193. 193Review is done of presenting data along with subjective and objective observations. Drag from the choices area to specify which condition the client is most likely experiencing [blank1], two actions the nurse should take to address that condition [blank2] and [blank3], and two parameters the nurse should monitor to assess the client's progress [blank4] and [blank5].Answer →
  194. 194When assessing decision-making capacity, what is primarily being evaluated?Answer →
  195. 195An unconscious client with a traumatic head injury has a blood pressure of 130/76 mm Hg, and an intracranial pressure (ICP) of 20 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ___ mm Hg.Answer →
  196. 196A nurse is admitting a client with a history of a spinal cord injury at T6 that occurred 5 years ago. Which finding should cause the nurse the greatest concern?Answer →
  197. 197A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select three that apply.)Answer →
  198. 198A nurse is caring for a client who has moderate Alzheimer's disease. During weekly home visits. the nurse notices that the client's caregiver is tired, irritable. and impatient with the client. Which of the following actions should the nurse recommend to the caregiver?Answer →
  199. 199A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an early increase in intracranial pressure (ICP)? Select all that apply.Answer →
  200. 200Parkinson's freezing gait: best interventionAnswer →
  201. 201The nurse is admitting a client to the emergency department (ED) who was in a motor vehicle collision and has multiple traumatic injuries. Which of the following assumptions is a priority guiding principle for the nurse in this situation?Answer →
  202. 202A nurse is reinforcing teaching with a newly licensed nurse about age-related changes to vision in older adult clients. Which of the following should the nurse include as an example of an expected age-related change?Answer →
  203. 203A client is assessed using the Glasgow Coma Scale (GCS) and demonstrates the following responses: eyes open to sound, incomprehensible sounds, and withdraws arm from pain. What is the total GCS score for this client?Answer →
  204. 204The nurse is caring for a client who is receiving alteplase tPA after developing a stroke. The nurse notes a heart rate of 128 beats per minute and a blood pressure of 90/60 mm Hg. The nurse will perform which priority action?Answer →
  205. 205Parkinson's disease assessment: identify expected vs not expected findingsAnswer →
  206. 206Which strategy can the nurse use to effectively approach the older adult patient during the health history?Answer →
  207. 207What intervention is most critical immediately after confirming an ischemic stroke on imaging?Answer →
  208. 208A nurse is reviewing the use of interferon beta medications for a client diagnosed with multiple sclerosis. Which of the following statements best reflects the nurse's understanding of the appropriate use of interferon beta medications?Answer →
  209. 209The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of this diagnosis?Answer →
  210. 210A patient who is going to drive 100 miles to enjoy a day of boating with friends this weekend plans to use diphenhydramine (Benadryl) to prevent sea sickness. The nurse should instruct the patient to do what?Answer →
  211. 211A client is prescribed 6 mg/kg/day of phenytoin in two divided doses. The client weighs 82 kg, and the available concentration is 125 mg in 5 mL. How many mL will the nurse administer per dose? (If needed, round to the nearest whole number.)Answer →
  212. 212Which of the following should the nurse AVOID when caring for a patient with myasthenia gravis?Answer →
  213. 213A nurse is providing care to a patient who is exhibiting the below picture. When documenting, how would the nurse describe this finding?Answer →
  214. 214During a sleep study, a nurse notes that a patient has reached the Rapid Eye Movement (REM) stage. Which physiological assessment finding is consistent with this stage of sleep?Answer →
  215. 215A patient with Bell's palsy affecting the right side presents with facial drooping. The nurse notes incomplete blinking and reports of eye dryness on the affected side. Which nursing intervention is the priority?Answer →
  216. 216Which finding will the nurse observe in the ictal phase of a generalized tonic-clonic seizure?Answer →
  217. 217Naloxone (Narcan) induces which one of the following responses?Answer →
  218. 218A nurse is caring for a client with a basilar skull fracture with a cerebrospinal fluid leak following a motor vehicle accident. Which finding should be reported to the healthcare provider immediately?Answer →
  219. 219The nurse interrupts unlicensed assistive personnel who is assisting a client with Parkinson's disease with breakfast. Which observation caused the nurse to immediately intervene?Answer →
  220. 220Which pharmacological treatment is most suitable for a client diagnosed with mild to moderate Alzheimer's disease?Answer →
  221. 221A client presents to the emergency department via ambulance with a suspected head injury after sustaining a 20-foot fall while at work. What assessment finding(s) require immediate follow-up by the nurse? Select all that apply.Answer →
  222. 222The client with Parkinson's disease is prescribed carbidopa/levodopa. What should the nurse include in the client's plan of care?Answer →
  223. 223A nurse is assessing a client who has meningitis. Which of the following findings is the priority for the nurse to report?Answer →
  224. 224A client who has migraine headaches wants to decrease the intake of foods high in tyramine to see if that will reduce the occurrence of headaches. Which food should the nurse recommend that the client eliminate?Answer →
  225. 225A nurse is monitoring a client receiving phenytoin for seizure control. The client reports dizziness, confusion, and unsteady gait. Which of the following assessments should the nurse prioritize to determine the underlying cause of these manifestations?Answer →
  226. 226A nurse suspects a client diagnosed with myasthenia gravis is experiencing a myasthenic crisis. What is the priority action for the nurse to perform?Answer →
  227. 227The nurse is directing the care team as they plan to move a person with a possible spinal cord injury. The nurse should direct the team to move the client using which procedure?Answer →
  228. 228When preparing to admit a patient who has been treated for status epilepticus in the emergency room, which equipment should the nurse have available in the room? Select all that apply.Answer →
  229. 229Review the electronic health record. What 2 potential complications should the nurse monitor for after alteplase administration? Select 2 complications.Answer →
  230. 230A nurse is administering IV mannitol to a client diagnosed with cerebral edema. Which of the following actions should the nurse perform prior to the administration of mannitol?Answer →
  231. 231A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?Answer →
  232. 232What manifestation is expected when a person with a spinal cord injury develops autonomic dysreflexia?Answer →
  233. 233Which of the following would indicate a potential neurological impairment when assessing a patient's response to stimuli?Answer →
  234. 234A home health nurse is planning to use nonpharmacological pain relief measures for a client who has severe chronic back pain. Which of the following pain management guidelines should the nurse use?Answer →
  235. 235A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?Answer →
  236. 236A patient receives a prescription for sumatriptan (Imitrex). Which information in the patient's history is a contraindication to the use of this drug?Answer →
  237. 237Which of the following best describes the mechanism of action of acetylcholinesterase inhibitors?Answer →
  238. 238A client diagnosed with bacterial meningitis exhibits agitation and confusion. Considering the psychosocial integrity domain, which nursing action best supports the client's emotional and psychological needs?Answer →
  239. 239A nurse is assessing the clinical manifestations for a patient diagnosed with Parkinson's disease. Which findings should the nurse assess for? (Select all that apply)Answer →
  240. 240A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?Answer →
  241. 241A nurse is assessing a client's cranial nerves (CN) as part of a neurological examination diagnosed with sensory deficit. The nurse is correct to identify which CN's to include (sensory only) in the examination? (Select All That Apply)Answer →
  242. 242The nurse assesses a client with suspected meningitis. What finding should cause the nurse to suspect the client of having increased intracranial pressure?Answer →
  243. 243The nurse is caring for a 65-year-old patient who had a stroke. The patient's wife is concerned because her husband has had a change in personality and mood. He cries easily. The cerebral lobe responsible for the change is:Answer →
  244. 244While attending to a pediatric client experiencing a tonic-clonic seizure, what is the most appropriate initial action for the nurse to prioritize to ensure patient safety?Answer →
  245. 245What effect does hypercapnia have on cerebral blood flow and intracranial pressure?Answer →
  246. 246First-line management of BPSD (dementia agitation)?Answer →
  247. 247What should you do when communicating with persons who are hearing impaired. Select all that apply.Answer →
  248. 248A patient diagnosed with Multiple Sclerosis (MS) is admitted to the hospital with worsening symptoms of visual changes, tremors, and bladder incontinence. What medication will the nurse anticipate giving this patient for this acute exacerbation?Answer →
  249. 249A patient presents with increasing weakness, decreased vital capacity, dysphagia, and ptosis. The provider orders a Tensilon test. Which of the following should the nurse anticipate?Answer →
  250. 250A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?Answer →
  251. 251Match each clinical description with the headache type it most accurately represents. Select one headache type per row.Answer →
  252. 252On admission to the emergency department, the client with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent in spinal shock. Which would be the nurse's best response?Answer →
  253. 253What assessment is completed with the Weber test?Answer →
  254. 254A nurse is caring for a client who has dysarthria following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?Answer →
  255. 255A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?Answer →
  256. 256A client has had a moderate to large hemispheric stroke and has facial weakness. What would an assessment of this client reveal?Answer →
  257. 257Ordered Morphine 6mg IM now Available Morphine 8mg/ml How many ml would you administer?Answer →
  258. 258A nurse is assessing a client who has a new onset of fever, confusion, and disorientation to time and place. Which of the following actions should the nurse take?Answer →
  259. 259A nurse is reviewing lab results and assessment findings for a client who is prescribed lithium carbonate for the past 3 months. Which finding requires the nurse to immediately contact the provider?Answer →
  260. 260Which of the following would the nurse document as a finding consistent with a neurological deficit? A. Lack of muscle strength B. Lack of coordination C. Negative Achilles reflex D. Positive Romberg's testAnswer →
  261. 261For each client finding below, click to specify if the finding is consistent with the following complications: Autonomic Dysreflexia or Neurogenic Shock. Each finding may support more than one complication.Answer →
  262. 262Which of the following actions should the nurse take first for a client with signs of increased intracranial pressure?Answer →
  263. 263The nurse is evaluating the need for the use of restraints when managing a patient with delirium. Which condition must be met before the nurse may use restraints? (Select all that apply)Answer →
  264. 264A nurse is caring for a client experiencing an acute migraine attack. The provider prescribes sumatriptan. Which of the following client findings should cause the nurse to question this prescription?Answer →
  265. 265A nurse is planning care for a client with Borderline Personality Disorder. Which client problem is the nurse most likely to add to the client's plan of care?Answer →
  266. 266Lead toxicity primarily damages which body system, leading to impaired thinking, reasoning, and perception?Answer →
  267. 267The nurse is planning the care of a client with hemiplegia to prevent joint deformities of the arm and hand. Which positions would be appropriate? Select all that apply.Answer →
  268. 268A patient diagnosed with open-angle glaucoma states during clinic follow-up, 'I stopped using my eye drops because my vision feels normal now.' What is the nurse's best response?Answer →
  269. 269A client has been admitted to the intensive care unit after an ischemic stroke, and a central venous pressure (CVP) monitoring line was placed. The nurse notes a low CVP. Which condition is the most likely reason for a low CVP?Answer →
  270. 270Which manifestation occurs after complete transection of the spinal cord?Answer →
  271. 271The client with a spinal cord injury (SCI) begins to have seizures, and the blood pressure (BP) rises rapidly to 210/160 mm Hg. Which is another indicator to suspect autonomic dysreflexia?Answer →
  272. 272The nurse is preparing a client who has multiple sclerosis (MS) for discharge home from a rehabilitation center. The client has been prescribed cyclophosphamide and methylprednisolone. Which instruction does the nurse include in the teaching plan for the client?Answer →
  273. 273A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?Answer →
  274. 2747-year-old only child begins bed wetting after the new baby is brought home. This type of reaction is consistent with which anxiety related defense mechanism?Answer →
  275. 275A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)?Answer →
  276. 276Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?Answer →
  277. 277Which finding will the nurse observe in the ictal phase of a generalized tonic-clonic seizure?Answer →
  278. 278A nurse is caring for a client who has experienced a traumatic brain injury (TBI) and is exhibiting signs of increased intracranial pressure. Which of the following interventions should the nurse implement first to address this critical condition?Answer →
  279. 279A nurse witnesses a patient having a generalized tonic-clonic seizure in bed. Which action should the nurse perform first?Answer →
  280. 280Mrs. Johnson arrived at her home, and her husband read the report from her eye doctor. It said that her eye exam revealed Emmetropia. What does this mean?Answer →
  281. 281A client with mania is currently taking lithium carbonate. Which assessment findings would indicate the client is experiencing toxicity?Answer →
  282. 282Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.Answer →
  283. 283During morning rounds, the nurse observes the following situations. Which client should the nurse assist first?Answer →
  284. 284A client with increased intracranial pressure presents with irregular respirations, bradycardia, and hypertension. What condition are these findings most indicative of?Answer →
  285. 285A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?Answer →
  286. 286A client has clinical manifestations of autonomic dysreflexia following a spinal cord injury above T6. What actions should the nurse take to manage this condition? (Select all that apply.)Answer →
  287. 287A client who experienced head trauma three hours ago now has clear fluid draining from the nose and mouth. What would the nurse suspect?Answer →
  288. 288The nurse is caring for a client with Parkinson's disease admitted for a Urinary Tract Infection (UTI). The client is currently receiving IV antibiotics. Which action by the nurse is the highest priority to ensure client safety?Answer →
  289. 289A patient experiencing numbness and tingling on one side of the body with a suspected autoimmune condition should have which initial diagnostic test?Answer →
  290. 290A nurse is monitoring a client receiving phenytoin for seizure control. The client reports dizziness, confusion, and unsteady gait. Which of the following assessments should the nurse prioritize to determine the underlying cause of these manifestations?Answer →
  291. 291The client is in the ictal phase of a seizure. What client behaviors might the nurse find in this stage of the seizure?Answer →
  292. 292Related to the pharmacodynamic of medications used for anxiety: identify the appropriate associations, between class, drug, and neurotransmitter (s). Select all that apply.Answer →
  293. 293A nurse is assisting in the care of a client who has right sided paralysis following a stroke. Click to highlight the information in the client's medical record that requires intervention by the nurse. To deselect a finding, click on the finding again.Answer →
  294. 294The nurse is planning education for a client with aphasia after an ischemic stroke. What action(s) should the nurse plan to include during client education to facilitate effective communication? Select all that apply.Answer →
  295. 295A nurse in an emergency department is assisting with the care of a client who is unconscious and has trauma to multiple systems following a motor vehicle crash. Which of the following actions should the nurse take first?Answer →
  296. 296Which of the following is NOT appropriate when performing a GCS assessment on an unconscious patient?Answer →
  297. 297A 7-year-old child is brought to the clinic by a parent who is concerned that the child has been "daydreaming" frequently at school. The teacher reports that the child seems to stare blankly for several seconds and does not respond when spoken to during these episodes. The child resumes normal activity immediately afterward, with no recollection of the event. Based on this information, which type of seizure is the child most likely experiencing?Answer →
  298. 298Review the electronic health record. Complete the following sentences by choosing from the lists of options. The client is most likely experiencing a [blank1] due to [blank2]. The most important treatment for this client is [blank3], and the nurse must ensure that [blank4] was completed before administration.Answer →
  299. 299The nurse is assessing a new adult client. What characteristic of this client's status should the nurse identify as increasing the client's risk for glaucoma?Answer →
  300. 300A patient with increased intracranial pressure (ICP) is ordered mannitol. Which assessment finding indicates the medication is effective?Answer →
  301. 301A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first?Answer →
  302. 302A client is receiving cyclobenzaprine (Flexeril) for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?Answer →
  303. 303Drag 1 condition and 1 client finding to fill in each blank in the following sentence: The client is at risk for developing [blank1] due to [blank2].Answer →
  304. 304A nurse is caring for a client who has Meniere's disease. Which of the following instructions should the nurse include?Answer →
  305. 305A client with a spinal cord injury at the C4 level is being prepared for discharge. Which patient teaching point should the nurse prioritize to prevent respiratory complications?Answer →
  306. 306The ICU nurse receives report on a new client being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his temp is 98.2, blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing?Answer →
  307. 307A client with a spinal cord injury at the C4 level is being prepared for discharge. Which patient teaching point should the nurse prioritize to prevent respiratory complications?Answer →
  308. 308Which organs are most affected by thiamine?Answer →
  309. 309A post-stroke patient has sudden vertigo (room-spinning), dysarthria (slurred speech), and dysmetria (poor coordination/overshoots on finger-to-nose). Which brain region is most likely affected?Answer →
  310. 310A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? (Select all that apply.)Answer →
  311. 311Which clinical finding would most strongly suggest a subarachnoid hemorrhage (SAH)?Answer →
  312. 312A client with newly diagnosed trigeminal neuralgia reports sudden, electric-shock-like facial pain triggered by light touch, chewing, and talking. Which nursing action is most appropriate to reduce the frequency of pain episodes?Answer →
  313. 313Which of the following actions should the nurse take to manage increased intracranial pressure (ICP) for a client with a closed-head injury? Select all that apply.Answer →
  314. 314A family member brings a 76-year-old client to the clinic, stating that the client has had two transient ischemic attacks (TIAs) in the past week. The health care provider orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option(s) does the nurse expect the health care provider to offer this client to increase blood flow to the brain? Select all that apply.Answer →
  315. 315The nurse assesses a client and notes signs of Tardive Dyskinesia. Which of the following best describes this assessment finding?Answer →
  316. 316A patient with hyponatremia becomes confused and lethargic. What is the nurse's priority concern?Answer →
  317. 317A patient newly diagnosed with Parkinson disease asks the nurse, "What does dopamine do in my brain and why do I need these medications?" The nurse's response will be that:Answer →
  318. 318A nurse is providing discharge teaching to a client recently diagnosed with dry age-related macular degeneration (AMD). Which instruction should the nurse prioritize to help slow the progression of the disease and manage the client's vision loss?Answer →
  319. 319What is the most common type of cerebral edema caused by disruption of the blood-brain barrier (BBB)?Answer →
  320. 320The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely?Answer →
  321. 321A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?Answer →
  322. 322A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)Answer →
  323. 323The nurse cares for a client in the emergency department with a suspected stroke. Radiology calls the nurse to report that the client has a cerebral hemorrhage. What healthcare provider order should the nurse anticipate?Answer →
  324. 324The nurse is evaluating the progress of a 15-year-old male client with a T6 spinal cord injury to determine whether or not he is ready for transfer to a facility for ongoing rehabilitation and preparation for self-management. For each assessment finding, click the radio button or option button to indicate whether the nursing and health care team interventions were Effective (helped to meet expected outcomes), Ineffective (did not help to meet expected outcomes), or Unrelated (not related to the expected outcomes).Answer →
  325. 325Drag from the choices below to specify: what condition [blank1] the client is most likely experiencing, 2 nursing actions [blank2] and [blank3] the nurse should take, and 2 parameters [blank4] and [blank5] the nurse should monitor to assess the client's progress.Answer →
  326. 326A client with Alzheimer's disease is experiencing increased confusion and agitation every evening. Which intervention should the nurse prioritize?Answer →
  327. 327A patient with a spinal cord injury asks the nurse why the dietitian has recommended decreasing the total daily intake of calcium. Which response by the nurse would provide the most accurate information?Answer →
  328. 328The nurse is developing a plan of care for a 17-year-old who was admitted to the hospital following a complete severing of the spinal cord at T10 resulting in paraplegia and necessitating mechanical ventilation for 24 hours; the client is now off the ventilator and breathing on his own. He was admitted to the neurosurgical unit after open reduction and internal fixation (ORIF) to stabilize his spine. Indicate whether the nursing actions below are Anticipated (appropriate or likely necessary), Contraindicated (could be harmful), or Non-Essential (make no difference or are not necessary) for the client's postoperative care at this time.Answer →
  329. 329A patient with a T4 spinal cord injury has blood pressure 76/40 mm Hg, heart rate 48/min, warm dry skin, and no active bleeding. Which assessment finding would best support neurogenic shock rather than hypovolemic shock?Answer →
  330. 330The nurse is caring for a client that is scheduled to receive electroconvulsive therapy (ECT). The family member asks, "What do we need to know about this procedure?" Which of the following is the best response by the nurse?Answer →
  331. 331A nurse is caring for a client with increased intracranial pressure (ICP) who is attempting to self-extubate. The healthcare provider has ordered wrist restraints. Which action(s) should the nurse incorporate into the client's plan of care? Select all that apply.Answer →
  332. 332A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should recognize the following triggers for autonomic dysreflexia? Select all that apply.Answer →
  333. 333A client with multiple sclerosis (MS) has a living will and a do not resuscitate (DNR) prescription in the medical record. Currently the client's oxygen saturation is 86% on room air and the client is anxious and requesting oxygen. Which intervention should the nurse implement first?Answer →
  334. 334A nurse is assessing a client presenting with sudden onset confusion and weakness in the emergency department. For each planned action, indicate whether it is Anticipated or Contraindicated.Answer →
  335. 335An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP indicates that the nurse should provide further instruction?Answer →
  336. 336In managing a client with Myasthenia Gravis, why is timing activities around peak medication effect important?Answer →
  337. 337A nurse is providing teaching to a group of clients about the changes that occur when clients experience cataracts. Which of the following statements should the nurse include in the teaching?Answer →
  338. 338A nurse in a substance abuse clinic is assessing a client who recently started taking disulfiram. The client reports having discontinued the medication after experiencing severe nausea and vomiting. Which of the following reasons should the nurse suspect to be a likely cause of the client's distress?Answer →
  339. 339A nurse is assessing a client admitted with a hemorrhagic stroke. The client opens their eyes upon painful stimulation, says inappropriate but identifiable words, and exhibits flexion posturing. What does the nurse determine is the client's Glasgow Coma Scale (GCS) score?Answer →
  340. 340A client who suffered a stroke had a NG tube inserted to facilitate feeding shortly after admission. The client has since become comatose and the client's family asks the nurse why the health care provider is recommending the removal of the client's NG tube and the insertion of a gastrostomy tube. What is the nurse's best response?Answer →
  341. 341A nurse is caring for a client who is experiencing insomnia. Which of the following recommendations should the nurse make?Answer →
  342. 342A nurse is assessing a client with complaints of anxiety. Which finding is most consistent with a specific phobia?Answer →
  343. 343What can cause autonomic dysreflexia in a person living with a spinal cord injury?Answer →
  344. 344A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?Answer →
  345. 345The client in the emergency department is diagnosed with an ischemic stroke and is being transferred to the intensive care unit. When the nurse explains this type of stroke to the family member, which statement by the family member leads the nurse to believe that the family member needs further explanation?Answer →
  346. 346The nurse is providing discharge education to a client newly diagnosed with Huntington's disease. Which client statement indicates a need for additional education?Answer →
  347. 347A 25-year-old client with a T6 spinal cord injury (SCI) is visiting his family from a long-term care facility for his birthday. He is in a permanent wheelchair and his home health nurse is with him. While visiting he develops diaphoresis and complains of a headache. Upon assessment the nurse takes his blood pressure and notes it is 210/90 mm/Hg. What is the priority intervention for the home health nurse?Answer →
  348. 348A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following?Answer →
  349. 349The condition the client is most likely experiencing is [blank1], two nursing actions to take are [blank2] and [blank3], two parameters the nurse should monitor are [blank4] and [blank5].Answer →
  350. 350Review the electronic health record. What healthcare provider order(s) should the nurse anticipate in the treatment of this client? Select all that apply.Answer →
  351. 351A patient with suspected myasthenia gravis is to undergo the Tensilon test with edrophonium. The patient asks if edrophonium can be used long term. What is the nurse's best response?Answer →
  352. 352The nurse provides care to a client in alcohol withdrawal who shows signs of restlessness and sweating. Which action should the nurse take?Answer →
  353. 353A nurse is caring for a client who has experienced a stroke. decreased weight. and a decreased prealbumin. Which of the following interdisciplinary team members should the nurse anticipate collaborating with about the client's condition?Answer →
  354. 354After assessing four clients, which will the triage nurse identify to be seen first in the ED?Answer →
  355. 355A 70-year-old man is brought to the emergency room after sustaining a stroke. He is not able to articulate words. The nurse would document that the patient hasAnswer →
  356. 356The nurse is developing a teaching plan for a client with open-angle glaucoma. Which instruction should the nurse include in the education?Answer →
  357. 357A nurse is using the NURSE mnemonic as part of therapeutic communication skills. Match each communication domain with the best nurse statement.Answer →
  358. 358A patient with Parkinson's disease reports that their morning dose of carbidopa-levodopa takes 60-90 minutes to begin working, causing significant difficulty with dressing and walking early in the day. Which action should the nurse take first?Answer →
  359. 359In managing a client experiencing an ischemic stroke, which of the following interventions should be prioritized based on the client's presentation and treatment plan? Select three that apply.Answer →
  360. 360A client presents with decerebrate posturing after a traumatic head injury. Which combination of findings would most likely indicate worsening intracranial pressure?Answer →
  361. 361A nurse caring for a client with a spinal cord injury and recognizes the risk for autonomic dysreflexia also called autonomic hyperreflexia, a life-threatening complication. In clients with a spinal cord injury, autonomic dysreflexia most commonly occurs with injuries at which spinal cord level?Answer →
  362. 362The nurse is caring for a client with Guillain-Barre syndrome (GBS). The client also has ascending paralysis. Knowing the potential complications of the disorder, what should the nurse always have ready at the bedside?Answer →
  363. 363Which outcomes would indicate effective management of a conscious client who is being treated with recombinant tissue plasminogen therapy during the initial phase of an ischemic cerebrovascular accident (CVA)? Select all that apply.Answer →
  364. 364An older adult client with a history of alcohol abuse is admitted to the hospital due to dehydration. The client is 20 lb (9.1 kg) under ideal weight and assessment findings include nystagmus, ataxia, and tremors. The nurse knows that these symptoms were most likely caused by which nutritional deficiency?Answer →
  365. 365Which of the following would NOT affect the accuracy of a GCS score?Answer →
  366. 366Which back pain finding is a red flag requiring immediate evaluation?Answer →
  367. 367A nurse is developing a care plan for the daughter of a patient with moderate Alzheimer's Disease. Which nursing intervention is a priority for addressing caregiver stress?Answer →
  368. 368The nurse assesses a newly admitted client who takes carbemazepine daily for epilepsy. What assessment finding requires immediate follow-up by the nurse?Answer →
  369. 369The nurse is monitoring a client admitted with a closed traumatic brain injury for indications of increasing intracranial pressure. Which assessment finding would the nurse report to the primary health care provider immediately?Answer →
  370. 370Which of the following is a priority when caring for a client with neurocognitive impairment (Alzheimer's Type)?Answer →
  371. 371A nurse is teaching a patient who had a stroke about ways to adapt to visual deficits and reduced vision. What does the nurse identify as the primary safety precaution to use?Answer →
  372. 372A patient taking pyridostigmine (Mestinon) for myasthenia gravis reports increased salivation, abdominal cramping, and diarrhea. The nurse recognizes these symptoms may indicate:Answer →
  373. 373The nurse is admitting a 55-year-old client diagnosed with a left eye retinal detachment. While assessing this client, what characteristic symptom would the nurse expect to find?Answer →
  374. 374Which of the following agents are used as adjuvants to opioid medications for greater analgesia in patients with neuropathic pain?Answer →
  375. 375A client admitted with possible ischemic stroke has been aphasic for 3 hours and has a blood pressure of 220/120 mm Hg. Which prescription by the health care provider should the nurse question?Answer →
  376. 376After teaching a client about myasthenia gravis, the nurse would judge that the client has formed a realistic concept of the disease and the treatment plan when the client makes which statement?Answer →
  377. 377Benztropine is prescribed for an older adult client with Parkinson's disease (PD). This medication must be avoided for this client for which side effects? Select all that apply.Answer →
  378. 378A nurse is caring for a client with a C4 spinal cord injury with an indwelling urinary catheter who exhibits signs of autonomic dysreflexia, including a severe headache and hypertension. What should the nurse do first?Answer →
  379. 379The nurse is planning education for the caregiver of a client with Alzheimer's disease about how to maintain safety in the home. What information should the nurse plan to include in the teaching?Answer →
  380. 380A client with Parkinsonism is experiencing visual hallucinations, which medication does the nurse anticipate administering?Answer →
  381. 381Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform first?Answer →
  382. 382A client with neurocognitive impairment is being treated for depression with escitalopram. Which electrolyte result would the nurse assess for related to this client's medication?Answer →
  383. 383A nurse is assessing a client in the early stages of Guillain-Barré syndrome. Which clinical manifestation should the nurse expect to observe?Answer →
  384. 384When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), which of following should the nurse assess for?Answer →
  385. 385The nurse is assessing a 28-year-old client who has been in 4-point restraints for two hours. The client is lying still but stating plans to destroy the day room. What is the best action by the nurse?Answer →
  386. 386A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?Answer →
  387. 387A patient with Guillain-Barré Syndrome reports numbness in the feet that has progressed to the thighs over several hours. Vital signs are: BP 138/84 mmHg, HR 88 bpm, RR 22/min, SpO: 94% on room air. Which action should the nurse take first?Answer →
  388. 388A nurse is evaluating a client with suspected increased intracranial pressure who opens their eyes only to painful stimuli, responds verbally with Inappropriate words, and localizes pain with their arm. What is the total Glasgow Coma Scale (GCS) score for this patient?Answer →
  389. 389Carbidopa-levodopa teaching: which instruction is correct?Answer →
  390. 390A patient has a serum sodium level of 126 mEq/L. What action should the nurse take to ensure for this patient's safety?Answer →
  391. 391A new nurse precepts on the brain injury rehab unit. The new nurse asks the preceptor to explain the mechanism by which impulses are transmitted across synapses in the brain. Which response should the nurse give?Answer →
  392. 392A nurse is preparing to administer IV fluids to a client with hyponatremia and signs of cerebral edema. Considering the properties and risks of IV solutions, which type of IV fluid is the most appropriate to administer?Answer →
  393. 393Which vision condition is noted when distant objects are usually seen more clearly than close ones?Answer →
  394. 394A 90-year-old client in the intensive care unit has a sudden change in mental status. Which of the following tools is the most appropriate to assess the condition?Answer →
  395. 395A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?Answer →
  396. 396Which of the following represents a normal response to testing the sensory tract of the Trigeminal nerve?Answer →
  397. 397The nurse is evaluating an arterial blood gas result from a client with a closed head injury and notes the PaCO₂ is 30 mmHg. How should the nurse interpret this result?Answer →
  398. 398The nurse is caring for a client diagnosed with delirium who is agitated and confused. What action(s) should the nurse take in the care of this client? Select all that apply.Answer →
  399. 399What is the safest method to help ambulate a client who has instability due to inner ear problems?Answer →
  400. 400Mr. Thompson, an 84-year-old widower, lives alone and was admitted after falling in his kitchen. He has a history of hypertension and mild dementia. He is scheduled for discharge tomorrow, and his daughter expresses concern about his ability to live independently. What is the nurse's priority intervention to promote Mr. Thompson's safety and well-being after discharge?Answer →
  401. 401The nurse is caring for a client admitted with new onset of slurred speech, facial droop, and left-sided weakness 6 hours ago. Diagnostic computed tomography scan confirms the presence of a hemorrhagic stroke. Which actions are most important to include in the client's plan of care? Select all that apply.Answer →
  402. 402A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP). The AP padded the wrist restraints and secured the straps to the bed frame with a double knot. Which of the following actions should the nurse take?Answer →
  403. 403A nurse is assessing a client who is experiencing a change in vision. Which of the following statements indicates that the client might be developing cataracts?Answer →
  404. 404Which intervention is appropriate to reduce cerebral edema in a patient with increased intracranial pressure?Answer →
  405. 405A patient is suspected of having a subarachnoid hemorrhage. Which diagnostic method should be prioritized initially and why?Answer →
  406. 406The nurse is caring for a group of clients. Which client should the nurse see first?Answer →
  407. 407A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and fatigue. Which of the following nursing statement are appropriate?Answer →
  408. 408A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take?Answer →
  409. 409A client with a history of major depression is brought to the ED by the client's parents. Which of the following nursing actions is most appropriate?Answer →
  410. 410Primary goal of GUIDE dementia model?Answer →
  411. 411When observing decerebrate posturing in a client following a traumatic brain injury, which intervention should take priority?Answer →
  412. 412A client with a spinal cord injury has been placed in a long-term nursing facility and has severe dysphagia. Which of the following would best assist this client in preventing further complications?Answer →
  413. 413A patient with a spinal cord injury is now considered a tetraplegia. The nurse understands that the patient will require assistance with:Answer →
  414. 414A nurse is reviewing documentation for clients with different types of seizures. Select one option per row.Answer →
  415. 415A nurse is educating a client with chronic migraines about dietary triggers. Which of the following foods should the nurse instruct the client to avoid due to their potential to provoke migraine headaches?Answer →
  416. 416A nurse is administering alteplase to a client. Which of the following are the nursing interventions before, during, and after IV administration of alteplase? Select all that apply.Answer →
  417. 417A client has been admitted to the intensive care unit after an ischemic stroke, and a central venous pressure (CVP) monitoring line was placed. The nurse notes a low CVP. Which condition is the most likely reason for a low CVP?Answer →
  418. 418A nurse is caring for a client who has Meniere's disease. Which of the following instructions should the nurse include?Answer →
  419. 419A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?Answer →
  420. 420The nurse is caring for a client who sustained a complete cervical spinal cord injury and is at risk for autonomic dysreflexia. Which assessment finding(s) would the nurse anticipate if this complication occurs? (Select all that apply.)Answer →
  421. 421A nurse witnessed a client displaying signs of lip-smacking during a seizure. The client had no recollection of this activity. How should the nurse describe this behavior when documenting?Answer →
  422. 422A nurse is reviewing the pathophysiology of Parkinson's disease. Which statement best describes the primary neurotransmitter imbalance associated with this condition?Answer →
  423. 423A nurse is assessing a client who has sustained a C4 spinal cord injury. Which assessment finding would indicate a potential need for ventilatory support?Answer →
  424. 424A nurse is conducting a mental health intake for a client who reports feelings of hopelessness and social isolation. Which action should the nurse take first to accurately assess the client's safety?Answer →
  425. 425A client diagnosed with Parkinson's disease is prescribed carbidopa-levodopa. What is the primary mechanism of action of this medication?Answer →
  426. 426A nurse in an emergency department (ED) is caring for a client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.Answer →
  427. 427Which of the following actions should be included in the core measures for stroke management as established by The Joint Commission? Select all that apply.Answer →
  428. 428After teaching the wife of a client who has Parkinson disease (PD), the nurse assesses the wife's understanding. Which statement by the client's wife indicates she correctly understands changes associated with this disease?Answer →