Neurology NCLEX Questions and Answers Rated A

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Neurology NCLEX Questions and Answers Rated A Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial ... pressure monitoring. Which response by the nurse is best for this situation? A) "This type of monitoring system is complex, and it is managed by skilled staff." B) "The monitoring system helps show whether blood flow to the brain is adequate." C) "The ventriculostomy monitoring system helps check for changes in cerebral perfusion pressure." D) "This monitoring system has many benefits, including the ability to drain cerebrospinal fluid." ✔✔B) short, simple, and accurate explanations should be given initially to patients and family members; A & D do not answer the family's question; C uses terminology that is too complex for initial explanations Admission vitals for a patient who has a brain injury are BP 128/68, HR 110 bpm, and respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? A) BP 154/68, HR 56, respirations 12 breaths/min B) BP 134/72, HR, 90, respirations 32 breaths/min C) BP 148/78, HR 112, respirations 28 breaths/min D) BP 110/70, HR 120, respirations 30 breaths/min ✔✔A) systolic hypertension with widening pulse pressure, bradycardia, and abnormal respiratory rate are indicative of Cushing's triad. Indicates ICP has increased and brain herniation is imminent unless immediate action is taken; other VS indicate treatment is needed but are not as emergent as A When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as: A) flexion withdrawal B) localization of pain C) decorticate posturing D) decerebrate posturing ✔✔C) internal rotation, adduction and flexion of the arms is documented as decorticate posturing; decerebrate posturing is extension of the arms and legs; generalized flexion does not indicate localization of pain or flexion withdrawal The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? A) Blood pressure B) Oxygen saturation C) Intracranial pressure D) Hemoglobin and hematocrit ✔✔C) mannitol is an osmotic diuretic and will reduce cerebral edema and ICP; A & D are not the best parameters for measuring effectiveness; oxygen saturation will not directly improve due to mannitol administration An unconscious patient is admitted to the ED with a head injury. The patient's spouse and children stay at the bedside and ask many questions about the patient's treatments. What action is best for the nurse to take? A) Call the family's pastor to take them to the chapel B) Ask the family to remain in the waiting room until the assessment is completed C) Allow the family to stay with the patient and briefly explain all procedures to them D) Refer the family to the hospital's counseling services to help them deal with their anxiety ✔✔C) the nurse should allow family to observe care and explain procedures unless they interfere with emergent care needs A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? A) cough and deep breathe B) position patient with knees and hips flexed C) Keep head of the bed elevated to 30 degrees D) Cluster nursing interventions to provide rest periods ✔✔C) patients with increased ICP should be maintained in the head-up position to help reduce ICP; flexion of the hips and knees increases abdominal pressure, which further increases ICP; coughing increases ICP; stimuli from nursing interventions elevates ICP, so clustering them would progressively worsen ICP A 20 year-old male patient is admitted with a head injury from a collision while playing football. After noting the patient has developed clear nasal drainage, which action should the nurse take? A) have the patient gently blow his nose B) check the drainage for glucose content C) teach the patient that rhinorrhea is expected after a head injury D) obtain a specimen of the fluid to send for culture and sensitivity testing ✔✔B) clear nasal drainage in a patient with a head injury suggests a dural tear and CSF leakage - CSF will test positive for glucose; blowing the nose is avoided to prevent CSF leakage; C&S testing is unnecessary because the drainage will have normal nasal flora present Which action will the ED nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? A) coordinate the transfer of the patient to the OR B) provide discharge instructions about monitoring neurologic status C) arrange to admit the patient to a neuro unit for observation D) transport the patient to radiology for MRI testing ✔✔B) a patient with minor head trauma is usually discharged with instructions about neuro monitoring and the need to return if the condition deteriorates; other options are not indicated for a concussion A patient who has a suspected epidural hematoma is admitted to the ED. Which action can the nurse expect to take? A) administer IV furosemide (Lasix) B) prepare the patient for a craniotomy C) initiate high-dose barbiturate therapy D) type and crossmatch for a blood transfusion ✔✔B) the principal treatment for an epidural hematoma is rapid surgery to remove the hematoma and prevent herniation; IV lasix & barbiturate therapy may be needed after surgery to reduce ICP, but they will not be of benefit unless the hematoma is removed; minimal blood loss occurs with head injuries and transfusion is unnecessary The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear nasal drainage from the patient's nose. Which admission order should the nurse question? A) Keep the head of the bed elevated B) insert a NG tube with low suction C) turn patient side to side q 2h D) apply cold packs intermittently to face ✔✔B) clear nasal drainage may indicate CSF leakage - NG tube insertion will increase risk of infections like meningitis; all other options are appropriate orders A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing post-concussion syndrome? A) short-term memory B) muscle coordination C) Glasgow Coma Scale D) pupil reaction to light ✔✔A) decreased short-term memory is one indication of post-concussion syndrome; the other options may be assessed but are not indicative of post-concussion syndrome When assessing a patient who has a right frontal lobe tumor, which finding should the nurse expect? A) expressive aphasia B) impaired judgment C) right-sided weakness D) difficulty swallowing ✔✔B) the frontal lobe controls intellectual activities such as judgments; speech is controlled in the parietal lobe; weakness and hemiplegia occur on the contralateral side of the tumor; swallowing is controlled by the brainstem Which statement by a patient who is being discharged from the ED after a concussion indicates a need for intervention by the nurse? A) "I will return if I feel dizzy or nauseated" B) "I am going to drive right home and go to bed" C) "I can take Tylenol for my headache" D) "I don't remember even being in an accident today" ✔✔B) patients should not drive or operate machinery after a head injury; retrograde amnesia is common after a concussion; Tylenol may be taken for a headache and patient should return to ED if s/s of increased ICP occur After having a craniectomy and left anterior fossae incision, a 64-year-old patient has weakness, impaired physical mobility, and decreased LOC. Which nursing action will be included in the plan of care? A) cluster nursing activities to allow longer rest periods B) turn and reposition the patient side to side every 2 hours C) position the bed flat and log roll to reposition the patient D) perform range-of-motion (ROM) exercises every 4 hours ✔✔D) ROM exercises will help prevent complications of immobility; patients with anterior craniotomies are positioned with the head of the bed elevated; craniectomy patients should not be turned onto their operative side; if the patient is weak, clustering nursing care may further weaken the patient A public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective? A) emphasize the importance of hand hygiene before meals B) encourage immunization for adolescents and college freshman C) tell them to avoid crowds in the winter D) Select healthy nutritional options in the college cafeteria ✔✔B) the meningitis vaccine is recommended for children aged 11 - 12 years A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? A) the patient received a regular diet tray B) staff turned off the lights in the patient's room C) The bedrails at the foot and head of the bed are elevated D) Staff entered the patient's room without wearing a mask ✔✔D) Meningococcal meningitis is spread through respiratory secretions, so respiratory isolation and standard precautions must be maintained. The lights may be dimmed in the room to decrease pain caused by photophobia; bedrails at the foot and head of the bed may be elevated because a meningitis patient may be confused; nutrition is an important aspect of caring for a meningitis patient When assessing an adult who has bacterial meningitis, the nurse obtains the following data. Which of the following findings requires the most immediate intervention? A) the patient exhibits nuchal rigidity B) the patient has a positive Kernig's sign C) the patient's temperature is 101 F D) the patient's BP is 88/42 ✔✔D) Shock is a serious complication on meningitis, and the patient's low BP indicates a need for fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis; the nurse should intervene to lower the temperature, but it isn't as life-threatening as the hypotension The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture. Which assessment finding indicates a possible complication that should be reported immediately to the provider? A) report of a severe headache B) large contusion behind left ear C) bilateral periorbital ecchymosis D) Temperature of 101.4 F ✔✔D) Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the provider. The other options are expected findings with a basilar skull fracture The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? A) the staff nurse suctions the patient every 2 hours. B) the staff nurse assesses neurologic status every hour. C) the staff nurse elevates the head of the bed to 30 degrees. D) The staff nurse administers a mild analgesic before turning the patient. ✔✔A) Suctioning increases ICP, so it should only be done if the patient's respiratory status indicates it is needed. The other options are appropriate actions What topic should the nurse anticipate teaching the patient who had a brief episode of tinnitus, diplopia, and dysarthria with no residual effects? A) cerebral aneurysm clipping B) heparin IV infusion C) oral low-dose aspirin therapy D) tissue plasminogen activator (tPA) ✔✔C) the patient's symptoms are consistent with a transient ischemic attack (TIA) and drugs that inhibit platelet aggregation (aspirin) are prescribed after a TIA to prevent stroke A patient is being admitted with a possible stroke. What assessment information indicates that the nurse should consult the MD before administering a prescribed aspirin dose? A) the patient has dysphasia B) the patient has a-fib C) the patient reports that symptoms began with a severe headache D) the patient has a brief history of right-sided hemiplegia ✔✔C) sudden onset of a headache is typical of subarachnoid hemorrhage, and aspirin is contraindicated; aspirin may be used with the other options A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect? A) impulsive behavior B) right-sided neglect C) hyperactive left-sided tendon reflexes D) difficulty understanding instructions ✔✔D) right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and the use of language. Left-side reflexes should be intact; impulsive behavior and neglect are more likely with a right-brain stroke A nurse is told that a patient has an occluded left posterior cerebral artery. Which finding should the nurse anticipate? A) dysphasia B) confusion C) visual deficits D) poor judgment ✔✔C) visual disturbances are expected with posterior cerebral artery occlusion; aphasia occurs with middle cerebral arterial involvement; cognitive deficits and changes in judgment are more likely with anterior cerebral artery occlusion [Show More]

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