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Exam 4- Neurological Practice Questions & answers.
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Exam 4- Neurological PracticeQuestions & answers.
The nurse is assessing the motor and sensory function
of an unconscious client. The nurse should use
which technique to test the client's peripheral
response to pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle ANS -2. Nail bed pressure
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?
1. Increasing temperature, increasing pulse, increasing
respirations, decreasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing
respirations, increasing blood pressure
3. Decreasing temperature, decreasing pulse, increasing
respirations, decreasing blood pressure
4. Decreasing temperature, increasing pulse, decreasing
respirations, increasing blood pressure ANS -2. Increasing temperature, decreasing pulse, decreasing
respirations, increasing blood pressure
,A client recovering from a head injury is participating
in care. The nurse determines that the client
understands measures to prevent elevations in
intracranial pressure if the nurse observes the client
doing which activity?
1. Blowing the nose
2. Isometric exercises
3. Coughing vigorously
4. Exhaling during repositioning ANS -4. Exhaling during repositioning
A client has clear fluid leaking from the nose following
a basilar skull fracture. Which finding
would alert the nurse that cerebrospinal fluid is
present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a
pH of 6.
3. Fluid clumps together on the dressing and has a
pH of 7.
4. Fluid separates into concentric rings and tests
positive for glucose. ANS -4. Fluid separates into concentric rings and tests
positive for glucose.
A client with a spinal cord injury is prone to
experiencing autonomic dysreflexia. The nurse
should include which measures in the plan of care
to minimize the risk of occurrence? Select all that
,apply.
1. Keeping the linens wrinkle-free under the
client
2. Preventing unnecessary pressure on the
lower limbs
3. Limiting bladder catheterization to once
every 12 hours
4. Turning and repositioning the client at least
every 2 hours
5. Ensuring that the client has a bowel movement
at least once a week ANS -1. Keeping the linens wrinkle-free under the
client
2. Preventing unnecessary pressure on the
lower limbs
4. Turning and repositioning the client at least
every 2 hours
The nurse is evaluating the neurological signs of
a client in spinal shock following spinal cord injury. Which observation indicates that spinal
shock persists?
1. Hyperreflexia
2. Positive reflexes
3. Flaccid paralysis
4. Reflex emptying of the bladder ANS -3. Flaccid paralysis
The nurse is caring for a client who begins to
experience seizure activity while in bed. Which
, actions should the nurse take? Select all that apply.
1. Loosening restrictive clothing
2. Restraining the client's limbs
3. Removing the pillow and raising padded
side rails
4. Positioning the client to the side, if possible,
with the head flexed forward
5. Keeping the curtain around the client and the
room door open so when help arrives they
can quickly enter to assist ANS -1. Loosening restrictive clothing
3. Removing the pillow and raising padded
side rails
4. Positioning the client to the side, if possible,
with the head flexed forward
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.
1. The client is aphasic.
2. The client has weakness on the right side of
the body.
3. The client has complete bilateral paralysis of
the arms and legs.
4. The client has weakness on the right side of
the face and tongue.
5. The client has lost the abilityto move the right
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