2020 NURS618 Saunders Medical Surgical Revised Question With Answers-111 Solved Questions

NURS 618 Saunders Med Surg Neuro Revised 2020
Saunders Med Surg Neuro
1. 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?
A. Sternal rub
B. Nail bed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle
Answer: B. Nail bed pressure
Rationale:
Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral responses to
pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing
the clavicle or sternocleidomastoid muscle.
2. 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?
A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood
pressure
B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood
pressure
C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood
pressure
D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood
pressure
Answer: B. Increasing temperature, decreasing pulse, decreasing respirations, increasing
blood pressure
Rationale:
A change in vital signs may be a late sign of increased intracranial pressure. Trends include
increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory
irregularities also may occur.

3. 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?
A. Blowing the nose
B. Isometric exercises
C. Coughing vigorously
D. Exhaling during repositioning
Answer: D. Exhaling during repositioning
Rationale:
Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation
of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's
maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as
repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure
from rising.
4. 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?
A. Fluid is clear and tests negative for glucose.
B. Fluid is grossly bloody in appearance and has a pH of 6.
C. Fluid clumps together on the dressing and has a pH of 7.
D. Fluid separates into concentric rings and tests positive for glucose.
Answer: D. Fluid separates into concentric rings and tests positive for glucose.
Rationale:
Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull
fracture. CSF can be distinguished from other body fluids because the drainage will separate
into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid
also tests positive for glucose.
5. 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.
A. Keeping the linens wrinkle-free under the client
B. Preventing unnecessary pressure on the lower limbs
C. Limiting bladder catheterization to once every 12 hours

D. Turning and repositioning the client at least every 2 hours
E. Ensuring that the client has a bowel movement at least once a week
Answer: A. Keeping the linens wrinkle-free under the client
B. Preventing unnecessary pressure on the lower limbs
D. Turning and repositioning the client at least every 2 hours
Rationale:
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too
infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing.
Constipation and fecal impaction are other causes, so maintaining bowel regularity is
important. Ensuring a bowel movement once a week is much too infrequent. Other causes
include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers
care to minimize risk in these areas.
6. The nurse is evaluating the neurological signs of a client in spinal shock following spinal
cord injury. Which observation indicates that spinal shock persists?
A. Hyperreflexia
B. Positive reflexes
C. Flaccid paralysis
D. Reflex emptying of the bladder
Answer: C. Flaccid paralysis
Rationale:
Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to
noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying
of the bladder.
7. 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.
A. The client is aphasic.
B. The client has weakness on the right side of the body.
C. The client has complete bilateral paralysis of the arms and legs.
D. The client has weakness on the right side of the face and tongue.

E. The client has lost the ability to move the right arm but is able to walk independently. 6.
The client has lost the ability to ambulate independently but is able to feed and bathe himself
or herself without assistance.
Answer: A. The client is aphasic.
B. The client has weakness on the right side of the body.
D. The client has weakness on the right side of the face and tongue.
Rationale:
Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves
weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic:
unable to discriminate words and letters. They are generally very cautious and get anxious
when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The
client with right-sided hemiparesis has weakness of the right arm and leg and needs
assistance with feeding, bathing, and ambulating.
8. The nurse has instructed the family of a client with stroke (brain attack) who has
homonymous hemianopsia about measures to help the client overcome the deficit. Which
statement suggests that the family understands the measures to use when caring
for the client?
A. "We need to discourage him from wearing eyeglasses."
B. "We need to place objects in his impaired field of vision."
C. "We need to approach him from the impaired field of vision."
D. "We need to remind him to turn his head to scan the lost visual field."
Answer: D. "We need to remind him to turn his head to scan the lost visual field."
Rationale:
Homonymous hemianopsia is loss of half of the visual field. The client with homonymous
hemianopsia should have objects placed in the intact field of vision, and the nurse also should
approach the client from the intact side. The nurse instructs the client to scan the environment
to overcome the visual deficit and does client teaching from within the intact field of vision.
The nurse encourages the use of personal eyeglasses, if they are available.
9. The nurse is assessing the adaptation of a client to changes in functional status after a
stroke (brain attack). Which observation indicates to the nurse that the client is adapting most
successfully?
A. Gets angry with family if they interrupt a task

B. Experiences bouts of depression and irritability
C. Has difficulty with using modified feeding utensils
D. Consistently uses adaptive equipment in dressing self
Answer: D. Consistently uses adaptive equipment in dressing self
Rationale:
Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make
appropriate lifestyle alterations, use the assistance of others, and have appropriate social
interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet
successful attempt to adapt.
10. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic
and cholinergic crises. Which client activity suggests that teaching is most effective?
A. Taking medications as scheduled
B. Eating large, well-balanced meals
C. Doing muscle-strengthening exercises
D. Doing all chores early in the day while less fatigued
Answer: A. Taking medications as scheduled
Rationale:
Clients with myasthenia gravis are taught to space out activities over the day to conserve
energy and restore muscle strength. Taking medications correctly to maintain blood levels
that are not too low or too high is important. Muscle-strengthening exercises are not helpful
and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure
to heat, crowds, erratic sleep habits, and emotional stress.
11. The nurse has completed discharge instructions for a client with application of a halo
device. Which statement indicates that the client needs further clarification of the
instructions?
A. "I will use a straw for drinking."
B. "I will drive only during the daytime."
C. "I will be careful because the device alters balance."
D. "I will wash the skin daily under the lamb's wool liner of the vest."
Answer: B. "I will drive only during the daytime."
Rationale:

The halo device alters balance and can cause fatigue because of its weight. The client should
cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the
use of powder or lotions. The liner should be changed if odor becomes a problem. The client
should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin
care is done as instructed. The client cannot drive at all because the device impairs the range
of vision.
12. The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is
at risk for increased intracranial pressure. Pending specific health care provider prescriptions,
the nurse should safely place the client in which positions? Select all that apply.
A. Head midline
B. Neck in neutral position
C. Head of bed elevated 30 to 45 degrees
D. Head turned to the side when flat in bed
E. Neck and jaw flexed forward when opening the mouth
Answer: A. Head midline
B. Neck in neutral position
C. Head of bed elevated 30 to 45 degrees
Rationale:
Use of proper positions promotes venous drainage from the cranium to keep intracranial
pressure from elevating. The head of the client at risk for or with increased intracranial
pressure should be positioned so that it is in a neutral, midline position. The head of the bed
should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's
neck or turning the client's head from side to side.
13. The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection
of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is
surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate?
A. Document the findings.
B. Reinforce the dressing.
C. Notify the health care provider (HCP).
D. Mark the area of drainage with a pen and monitor for further drainage.
Answer: C. Notify the health care provider (HCP).
Rationale:

Cerebrospinal fluid (CSF) leakage after cranial surgery may be detected by noting drainage
that is serosanguineous surrounded by an area of straw-coloured or pale drainage. The
physical appearance of CSF drainage is that of a halo. If the nurse notes the presence of this
type of drainage, the HCP needs to be notified. The remaining options are inappropriate
nursing actions.
14. The nurse in the neurological unit is caring for a client who was in a motor vehicle crash
and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of
bloody drainage from the nose. Which nursing action is most appropriate?
A. Insert nasal packing.
B. Document the findings.
C. Contact the health care provider (HCP).
D. Monitor the client's blood pressure and check for signs of increased intracranial pressure.
Answer: C. Contact the health care provider (HCP).
Rationale:
Bloody or clear drainage from either the nasal or the auditory canal after head trauma could
indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP,
because this finding requires immediate intervention. The remaining options are
inappropriate nursing actions in this situation.
15. The nurse is planning care for a client who displays confusion secondary to a neurological
problem. Which approaches by the nurse would be helpful in assisting this
client? Select all that apply.
A. Providing sensory cues
B. Giving simple, clear directions
C. Providing a stable environment
D. Keeping family pictures at the bedside
E. Encouraging family members to visit at the same time
Answer: A. Providing sensory cues
B. Giving simple, clear directions
C. Providing a stable environment
D. Keeping family pictures at the bedside
Rationale:

Clients with cognitive impairment from neurological dysfunction respond best to a stable
environment that is limited in amount and type of sensory input. The nurse can provide
sensory cues and give clear, simple directions in a positive manner. Confusion can be
minimized by reducing environmental stimuli (such as television or multiple visitors) and by
keeping familiar personal articles (such as family pictures) at the bedside.
16. The nurse has determined that a client with a neurological disorder also has difficulty
breathing. Which activities would be appropriate components of the care plan for this client?
Select all that apply.
A. Keep suction equipment at the bedside.
B. Elevate the head of the bed 30 degrees.
C. Keep the client lying in a supine position.
D. Keep the head and neck in good alignment.
E. Administer prescribed respiratory treatments as needed.
Answer: A. Keep suction equipment at the bedside.
B. Elevate the head of the bed 30 degrees.
D. Keep the head and neck in good alignment.
E. Administer prescribed respiratory treatments as needed.
Rationale:
The nurse maintains a patent airway for the client with difficulty breathing by keeping the
head and neck in good alignment and elevating the head of the bed 30 degrees unless
contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The
client should be kept in a side-lying position whenever possible to minimize the risk of
aspiration.
17. The nurse is trying to help the family of an unconscious client cope with the situation.
Which intervention should the nurse plan to incorporate into the care routine for the client
and family?
A. Discouraging the family from touching the client
B. Explaining equipment and procedures on an ongoing basis
C. Ensuring adherence to visiting hours to ensure the client's rest
D. Encouraging the family not to "give in" to their feelings of grief
Answer: B. Explaining equipment and procedures on an ongoing basis
Rationale:

Families often need assistance to cope with the illness of a loved one. The nurse should
explain all equipment, treatments, and procedures and should supplement or reinforce
information given by the health care provider. Family members should be encouraged to
touch and speak to the client and to become involved in the client's care to the extent they are
comfortable. The nurse should allow the family to stay with the client to the extent possible
and should encourage them to eat and sleep adequately to maintain strength. The nurse can
help family members of an unconscious client by assisting them to work through their
feelings of grief.
18. Members of the family of an unconscious client with increased intracranial pressure are
talking at the client's bedside. They are discussing the client's condition and wondering
whether the client will ever recover. The nurse intervenes on the basis of which
interpretation?
A. It is possible the client can hear the family.
B. The family needs immediate crisis intervention.
C. The client might have wanted a visit from the hospital chaplain.
D. The family could benefit from a conference with the health care provider.
Answer: A. It is possible the client can hear the family.
Rationale:
Some clients who have awakened from an unconscious state have remembered hearing
specific voices and conversations. Family and staff should assume that the client's sense of
hearing is intact and act accordingly. {The last sense a person loses is the hearing}. In
addition, positive outcomes are associated with coma stimulation–that is, speaking to and
touching the client. The remaining options are incorrect interpretations.
19. The nurse is conducting home visits with a head-injured client with residual cognitive
deficits. The client has problems with memory, has a shortened attention span, is easily
distracted, and processes information slowly. The nurse plans to talk with the primary health
care provider about referring the client to which professional?
A. A psychologist
B. A social worker
C. A neuropsychologist
D. A vocational rehabilitation specialist
Answer: C. A neuropsychologist

Rationale:
Clients with cognitive deficits after head injury may benefit from referral to a
neuropsychologist, who specializes in evaluating and treating cognitive problems. The
neuropsychologist plans an individual program of therapy and initiates counseling to help the
client reach maximal potential. The neuropsychologist works in collaboration with other
disciplines that are involved in the client's care and rehabilitation. The remaining options are
incorrect because these health care workers do not specialize in evaluating and treating
cognitive problems.
20. The nurse is caring for a client who has undergone a craniotomy and has a supratentorial
incision. The nurse should place the client in which position postoperatively?

A. Head of bed flat, head and neck midline
B. Head of bed flat, head turned to the nonoperative side
C. Head of bed elevated 30 to 45 degrees, head and neck midline
D. Head of bed elevated 30 to 45 degrees, head turned to the operative side
Answer: C. Head of bed elevated 30 to 45 degrees, head and neck midline
Rationale:
After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck
should not be angled either anteriorly or laterally but rather should be kept in a neutral

(midline) position. This promotes venous return through the jugular veins, which will help
prevent a rise in intracranial pressure. (The supratentorial region of the brain is the area
located above the tentorium cerebelli. The area of the brain below the tentorium cerebelli is
the infratentorial region. The supratentorial region contains the cerebrum, while the
infratentorial region contains the cerebellum).
21. The nurse is assessing fluid balance in a client who has undergone a craniotomy. The
nurse should assess for which finding as a sign of overhydration, which would aggravate
cerebral edema?
A. Unchanged weight
B. Shift intake 950 mL, output 900 mL
C. Blood urea nitrogen (BUN) 10 mg/dL (3.6 mmol/L)
D. Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)
Answer: D. Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)
Rationale:
After craniotomy the goal is to keep the serum osmolality on the high side of normal to
minimize excess body water and control cerebral edema. The normal serum osmolality is 285
to 295 mOsm/kg H2O (285 to 295 mmol/kg). A higher value indicates dehydration; a lower
value indicates overhydration. Stable weight indicates that there is neither fluid excess nor
fluid deficit. A difference of 50 mL in intake and output for an 8hour shift is insignificant.
The BUN of 10 mg/dL (3.6 mmol/L) is within normal range and does not indicate
overhydration or underhydration.
22. The nurse is reviewing a discharge teaching plan for a post-craniotomy client that was
prepared by a nursing student. The nurse would intervene and provide teaching to the student
if the student included which home care instruction?
A. Sounds will not be heard clearly unless they are loud.
B. Obtain assistance with ambulation if the client is lightheaded.
C. Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed.
D. Use a check-off system for administering anticonvulsant medications to avoid missing
doses.
Answer: A. Sounds will not be heard clearly unless they are loud.
Rationale:

The post-craniotomy client typically is sensitive to loud noises and can find them excessively
irritating. Control of environmental noise by others will be helpful for this client. Seizures are
a potential complication that may occur for up to 1 year after surgery. For this reason, the
client must diligently take anticonvulsant medications. The client and family are encouraged
to keep track of the doses administered. The family should learn seizure precautions and
should accompany the client during ambulation if dizziness or seizures tend to occur. The
suture line is kept dry until sutures are removed to prevent infection.
23. The nurse has made a judgment that a client who had a craniotomy is experiencing a
problem with body image. The nurse develops goals for the client but determines that the
client has not met the outcome criteria by discharge if the client performs which action?
A. Wears a turban to cover the incision
B. Indicates that facial puffiness will be a permanent problem
C. Verbalizes that periorbital bruising will disappear over time
D. States an intention to purchase a hairpiece until hair has grown back
Answer: B. Indicates that facial puffiness will be a permanent problem
Rationale:
After craniotomy, clients may experience difficulty with altered personal appearance.
The nurse can help by listening to the client's concerns and by clarifying any misconceptions
about facial edema, periorbital bruising, and hair loss (all of which are temporary). The nurse
can encourage the client to participate in self-grooming and use personal articles of clothing.
Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client
adapt to the temporary change in appearance.
24. A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and
ineffective cough and is using accessory neck muscles in breathing. The nurse carefully
monitors the client and suspects the presence of which problem?
A. Altered breathing pattern
B. Increased likelihood of injury
C. Ineffective oxygen consumption
D. Increased susceptibility to aspiration
Answer: A. Altered breathing pattern
Rationale:

Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest
wall movements are insufficient for optimal ventilation of the client. This is a risk for clients
with spinal cord injury in the lower cervical area. Ineffective oxygen consumption occurs
when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary
membrane. Increased susceptibility to aspiration and increased likelihood of injury are
unrelated to the subject of the question.
25. A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries
to administer care. The nurse should perform which action?
A. Ask the family to deliver the care.
B. Leave the client alone until ready to participate.
C. Advise the client that rehabilitation progresses more quickly with cooperation.
D. Acknowledge the client's anger and continue to encourage participation in care.
Answer: D. Acknowledge the client's anger and continue to encourage participation in care.
Rationale:
Adjusting to paralysis is physically and psychosocially difficult for the client and family. The
nurse recognizes that the client goes through the grieving process in adjusting to the loss and
may move back and forth among the stages of grief. The nurse acknowledges the client's
feelings while continuing to meet the client's physical needs and encouraging independence.
The family also is in crisis and needs the nurse's support and should not be relied on to
provide care. The nurse cannot simply neglect the client until the client is ready to participate.
Option 3 represents a factual but noncaring approach to the client and is not therapeutic.
26. A client has a difficulty with the ability to flex the hips. The nurse determines that the
client is adapting successfully to this problem if the client demonstrates proper use of which
item?
A. Walker
B. Slider board
C. Raised toilet seat
D. Adaptive eating utensils
Answer: C. Raised toilet seat
Rationale:
A raised toilet seat is useful if the client does not have the mobility or ability to flex the hips.
The cerebellum is responsible for balance and coordination. A walker would provide stability

for the client during ambulation. A slider board is used in transferring a client from a bed to a
stretcher or wheelchair. Adaptive eating utensils may be beneficial if the client has partial
paralysis of the hand.
27. The nurse is assessing the client's gait and notes it is unsteady and staggering. Which
description should the nurse use when documenting the assessment finding?
A. Spastic
B. Ataxic
C. Festinating
D. Dystrophic or broad-based
Answer: B. Ataxic
Rationale:
An ataxic gait is characterized by unsteadiness and staggering. A spastic gait is characterized
by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and
drag. A festinating gait is best described as walking on the toes with an accelerating pace. A
dystrophic or broad-based gait is seen as waddling, with the weight shifting from side to side
and the legs far apart.
28. A client with a neurological impairment experiences urinary incontinence. Which nursing
action would be most helpful in assisting the client to adapt to this alteration?
A. Using adult diapers
B. Inserting a Foley catheter
C. Establishing a toileting schedule
D. Padding the bed with an absorbent cotton pad
Answer: C. Establishing a toileting schedule
Rationale:
A bladder retraining program, such as use of a toileting schedule, may be helpful to clients
experiencing urinary incontinence. A Foley catheter should be used only when necessary
because of the associated risk of infection. Use of diapers or pads is the least acceptable
alternative because of the risk of skin breakdown.
29. A client with a neurological problem is experiencing hyperthermia. Which measures
would be appropriate for the nurse to use in trying to lower the client's body temperature?
Select all that apply.

A. Giving tepid sponge baths
B. Applying a hypothermia blanket
C. Covering the client with blankets
D. Administering acetaminophen per protocol
E. Placing ice packs over the client's abdomen and in the axilla and groin
Answer: A. Giving tepid sponge baths
B. Applying a hypothermia blanket
D. Administering acetaminophen per protocol
Rationale:
Standard measures to lower body temperature include removing bed covers, providing cool
sponge baths, using an electric fan in the room, administering acetaminophen, and placing a
hypothermia blanket under the client. Ice packs are not used because they could cause
shivering, which increases cellular oxygen demands, with the potential for increased
intracranial pressure.
30. A client is somewhat nervous about undergoing magnetic resonance imaging (MRI).
Which statement by the nurse would provide the most reassurance to the client about the
procedure?
A. "The MRI machine is a long, narrow, hollow tube and may make you feel somewhat
claustrophobic."
B. "You will be able to eat before the procedure unless you get nauseated easily. If so, you
should eat lightly."
C. "Even though you are alone in the scanner, you will be in voice communication with the
technologist at all times during the procedure."
D. "It is necessary to remove any metal or metal-containing objects before having the MRI
done to avoid the metal being drawn into the magnetic field."
Answer: C. "Even though you are alone in the scanner, you will be in voice communication
with the technologist at all times during the procedure."
Rationale:
The MRI scanner is a hollow tube that gives some clients a feeling of claustrophobia. Metal
objects must be removed before the procedure so that they are not drawn into the magnetic
field. The client may eat and may take all prescribed medications before the procedure. If a
contrast medium is used, the client may wish to eat lightly if he or she has a tendency to
become nauseated easily. The client lies supine on a padded table that moves into the imager.

The client must lie still during the procedure. The imager makes tapping noises during the
scanning. The client is alone in the imager, but the nurse can reassure the client that the
technologist will be in voice communication with the client at all times during the procedure.
31. The nurse is administering mouth care to an unconscious client. The nurse should perform
which actions in the care of this person? Select all that apply.
A. Use products that contain alcohol.
B. Position the client on his or her side.
C. Brush the teeth with a small, soft toothbrush.
D. Cleanse the mucous membranes with soft sponges.
E. Use lemon glycerine swabs when performing mouth care.
Answer: B. Position the client on his or her side.
C. Brush the teeth with a small, soft toothbrush.
D. Cleanse the mucous membranes with soft sponges.
Rationale:
The unconscious client is positioned on the side during mouth care to prevent aspiration. The
teeth are brushed at least twice daily with a small toothbrush. The gums, tongue, roof of the
mouth, and oral mucous membranes are cleansed with soft sponges to avoid encrustation and
infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and
encrustation. The use of products with alcohol and lemon glycerine swabs should be avoided
because they have a drying effect.
32. The nurse assigned to the care of an unconscious client is making initial daily rounds. On
entering the client's room, the nurse observes that the client is lying supine in bed, with the
head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at
70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath
sounds. Which judgment should the nurse formulate for
the client?
A. Impaired nutritional intake
B. Increased risk for aspiration
C. Increased likelihood for injury
D. Susceptibility to fluid volume deficit
Answer: B. Increased risk for aspiration
Rationale:

Increased risk for aspiration is a condition in which an individual is at risk for entry of
gastrointestinal (GI) secretions, oropharyngeal secretions, or solids or fluids into
tracheobronchial passages. Conditions that place the client at risk for aspiration include
reduced level of consciousness, depressed cough and gag reflexes, and feeding via a GI tube.
There is no information in the question indicating that the remaining options are a concern.
33. The nurse is caring for a client with a head injury. The client's intracranial pressure
reading is 8 mm Hg. Which condition should the nurse document?
A. The intracranial pressure reading is normal.
B. The intracranial pressure reading is elevated.
C. he intracranial pressure reading is borderline.
D. An intracranial pressure reading of 8 mm Hg is low.
Answer: A. The intracranial pressure reading is normal.
Rationale:
The normal intracranial pressure is 5 to 15 mm Hg. A pressure of 8 mm Hg is within normal
range.
34. The nurse in the neurological unit is monitoring a client for signs of increased intracranial
pressure (ICP). The nurse reviews the assessment findings for the client and notes
documentation of the presence of Cushing's reflex. The nurse determines that the presence of
this reflex is obtained by assessing which item?
A. Blood pressure
B. Motor response
C. Pupillary response
D. Level of consciousness
Answer: A. Blood pressure
Rationale:
Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure
(systolic pressure rises faster than diastolic pressure) and bradycardia. The remaining options
are unrelated to monitoring for Cushing's reflex.
35. The nurse is performing a neurological assessment on a client and is assessing the
function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield
the best information about these cranial nerves?

A. Eye movements
B. Response to verbal stimuli
C. Affect, feelings, or emotions
D. Insight, judgment, and planning
Answer: A. Eye movements
Rationale:
Eye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness
(response to verbal stimuli) is controlled by the reticular activating system and both cerebral
hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres.
Insight, judgment, and planning are part of the function of the frontal lobe in conjunction
with association fibers that connect to other areas of the cerebrum.
36. The nurse is reviewing the medical records of a client admitted to the nursing unit with a
diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is
documented in the assessment data section of the record?
A. Sudden loss of consciousness occurred.
B. Signs and symptoms occurred suddenly.
C. The client experienced paresthesias a few days before admission to the hospital.
D. The client complained of a severe headache, which was followed by sudden onset of
paralysis.
Answer: C. The client experienced paresthesias a few days before admission to the hospital.
Rationale:
Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a
thrombotic brain attack (stroke), the client may experience a transient loss of speech,
hemiplegia, or paresthesias on 1 side of the body. Signs and symptoms of thrombotic brain
attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is
rare, but some clients with stroke (brain attack) experience signs and symptoms similar to
those of cerebral embolism or intracranial hemorrhage.
37. The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment,
the client is unable to understand the nurse's commands. Which condition should the nurse
document?
A. Occipital lobe impairment
B. Damage to the auditory association areas

C. Frontal lobe and optic nerve tracts damage
D. Difficulty with concept formation and abstraction areas
Answer: B. Damage to the auditory association areas
Rationale:
Auditory association and storage areas are located in the temporal lobe and relate to
understanding spoken language. {Wernicke's Aphasia (receptive- temporoparietal damage)}
The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle
activity, including speech, and an impairment can result in expressive aphasia. The parietal
lobe contains association areas for concept formation, abstraction, spatial orientation, body
and object size and shape, and tactile sensation.
38. The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke
(brain attack). Which assessment question would elicit data specific to this type of stroke?
A. "Have you had any headaches in the past few days?"
B. "Have you recently been having difficulty with seeing at nighttime?"
C. "Have you had any sudden episodes of passing out in the past few days?"
D. "Have you had any numbness or tingling or paralysis-type feelings in any of your
extremities recently?"
Answer: D. "Have you had any numbness or tingling or paralysis-type feelings in any of
your extremities recently?"
Rationale:
Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours
preceding the thrombotic stroke, the client may experience a transient loss of speech,
hemiparesis, or paresthesias on 1 side of the body. Signs and symptoms of this type of stroke
vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but
some clients with stroke experience signs and symptoms similar to those of cerebral
embolism or intracranial hemorrhage. The client does not complain of difficulty with night
vision as part of this clinical problem. In addition, most clients do not have repeated episodes
of loss of consciousness.
39. The nurse is creating a plan of care for a client with dysphagia following a stroke
(brain attack). Which should the nurse include in the plan? Select all that apply.
A. Thicken liquids.
B. Assist the client with eating.

C. Assess for the presence of a swallow reflex.
D. Place the food on the affected side of the mouth.
E. Provide ample time for the client to chew and swallow.
Answer: A. Thicken liquids.
B. Assist the client with eating.
C. Assess for the presence of a swallow reflex.
E. Provide ample time for the client to chew and swallow.
Rationale:
Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and
place food on the unaffected side of the mouth. The nurse should assess for gag and
swallowing reflexes before the client with dysphagia is started on a diet. The client should be
allowed ample time to chew and swallow to prevent choking.
40. The nurse is creating a plan of care for a client with a stroke (brain attack) who has right
homonymous hemianopsia. Which should the nurse include in the plan of care for
the client?
A. Place an eye patch on the left eye.
B. Place personal articles on the client's right side.
C. Approach the client from the right field of vision.
D. Instruct the client to turn the head to scan the right visual field.
Answer: D. Instruct the client to turn the head to scan the right visual field.
Rationale:
Homonymous hemianopsia is a loss of half of the visual field {Right homonymous
hemianopsia means that the pt is losing the right field of vision on both eyes}. The nurse
instructs the client to scan the environment and stands within the client's intact field of vision.
The nurse should not patch the eye because the client does not have double vision. The client
should have objects placed in the intact fields of vision, and the nurse should approach the
client from the intact side.
41. The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral
sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which
intervention should be included in the care plan for this client? Select all that apply.
A. Provide oral hygiene after each meal.
B. Assess swallowing ability frequently.

C. Allow the client sufficient time to eat.
D. Maintain a suction machine at the bedside.
E. Provide a full liquid diet for ease in swallowing.
Answer: A. Provide oral hygiene after each meal.
B. Assess swallowing ability frequently.
C. Allow the client sufficient time to eat.
D. Maintain a suction machine at the bedside.
Rationale:
A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently.
The client should be given a sufficient amount of time to eat. Semisoft foods are easiest to
swallow and require less chewing. Oral hygiene is necessary after each meal. Suctioning
should be available for clients who experience dysphagia and are at risk for aspiration.
42. The nurse is reviewing the record for a client seen in the health care clinic and notes that
the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS).
Which initial clinical manifestation of this disorder should the nurse expect to see
documented in the record?
A. Muscle wasting
B. Mild clumsiness
C. Altered mentation
D. Diminished gag reflex
Answer: B. Mild clumsiness
Rationale:
The initial symptom of ALS is a mild clumsiness, usually noted in the distal portion of one
extremity. The client may complain of tripping and drag one leg when the lower extremities
are involved. Mentation and intellectual function usually are normal.
Diminished gag reflex and muscle wasting are not initial clinical manifestations.
43. The nurse in the neurological unit is caring for a client with a supratentorial lesion. The
nurse assesses which measurement as the most critical index of central nervous system (CNS)
dysfunction?
A. Temperature
B. Blood pressure
C. Ability to speak

D. Level of consciousness
Answer: D. Level of consciousness
Rationale:
Level of consciousness is the most critical index of CNS dysfunction. Changes in level of
consciousness can indicate clinical improvement or deterioration. Although blood pressure,
temperature, and ability to speak may be components of the assessment, the client's level of
consciousness is the most critical index of CNS dysfunction.
44. The nurse is caring for a client after a craniotomy and monitors the client for signs of
increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an
early sign of increased ICP?
A. Confusion
B. Bradycardia
C. Sluggish pupils
D. A widened pulse pressure
Answer: A. Confusion
Rationale:
Early manifestations of increased ICP are subtle and often may be transient, lasting for only a
few minutes in some cases. These early clinical manifestations include episodes of confusion,
drowsiness, and slight pupillary and breathing changes. Later manifestations include a further
decrease in the level of consciousness, a widened pulse pressure, and bradycardia. CheyneStokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary
sluggishness and dilatation appear in the late stages.
45. The nurse is planning discharge teaching for a client started on acetazolamide for a
supratentorial lesion. Which information about the primary action of the medication should
be included in the client's education?
A. It will prevent hypertension.
B. It will prevent hyperthermia.
C. It decreases cerebrospinal fluid production.
D. It maintains adequate blood pressure for cerebral perfusion.
Answer: C. It decreases cerebrospinal fluid production.
Rationale:

Acetazolamide is a carbonic anhydrase inhibitor and a diuretic. It is used in the client with or
at risk for increased intracranial pressure to decrease cerebrospinal fluid production. The
remaining options are not actions of this medication.
46. A thymectomy accomplished via a median sternotomy approach is performed in a client
with a diagnosis of myasthenia gravis. The nurse creates a postoperative plan of care for the
client that should include which intervention?
A. Monitor the chest tube drainage.
B. Restrict visitors for 24 hours postoperatively.
C. Maintain intravenous infusion of lactated Ringer's solution.
D. Avoid administering pain medication to prevent respiratory depression.
Answer: A. Monitor the chest tube drainage.
Rationale:
The thymus has played a role in the development of myasthenia gravis. A thymectomy is the
surgical removal of the thymus gland and may be used for management of clients with
myasthenia gravis to improve weakness. The procedure is performed through a median
sternotomy or a transcervical approach. Postoperatively the client will have a chest tube in
the mediastinum. Lactated intravenous solutions usually are avoided because they can
increase weakness. Pain medication is administered as needed, but the client is monitored
closely for respiratory depression. There is no reason to restrict
visitors.
47. The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack).
On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The
nursing care plan should address which manifestation related to this finding?
A. The client will be easily fatigued.
B. The client will have difficulty speaking.
C. The client will have difficulty swallowing.
D. The client will exhibit neglect of the affected side.
Answer: D. The client will exhibit neglect of the affected side.
Rationale:
In anosognosia, the client neglects the affected side of the body. The client either may ignore
the presence of the affected side (often creating a safety hazard as a result of potential
injuries) or may state that the involved arm or leg belongs to someone else.

The remaining options are not associated with anosognosia.
48. The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack)
with anosognosia. To meet the needs of the client with this deficit, the nurse should include
activities that will achieve which outcome?
A. Encourage communication.
B. Provide a consistent daily routine.
C. Promote adequate bowel elimination.
D. Increase the client's awareness of the affected side.
Answer: D. Increase the client's awareness of the affected side.
Rationale:
In anosognosia, the client exhibits neglect of the affected side of the body. The nurse will
plan care activities that remind the client to perform actions that require looking at the
affected arm or leg, as well as activities that will increase the client's awareness of the
affected side. The remaining options are not associated with this deficit.
49. The nurse is caring for a client who sustained a spinal cord injury. During administration
of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia.
Which initial nursing action should the nurse take?
A. Elevate the head of the bed.
B. Examine the rectum digitally.
C. Assess the client's blood pressure.
D. Place the client in the prone position.
Answer: A. Elevate the head of the bed.
Rationale:
Autonomic dysreflexia is a serious complication that can occur in the spinal cord– injured
client. Once the syndrome is identified, the nurse elevates the head of the client's bed and
then examines the client for the source of noxious stimuli. The nurse also assesses the client's
blood pressure, but the initial action would be to elevate the head of the bed. The client would
not be placed in the prone position; lying flat will increase the client's blood pressure.
{Nursing interventions in this serious emergency are 1st elevate HOB 45 degrees or sit pt
upright to decrease the elevated BP (priority if BP is high) then loosen any tight clothing &
assess to determine the cause (e.g. bladder distention, kinks in the tubing of Foley, etc.)}

50. The home care nurse is making a visit to a client who requires use of a wheelchair after a
spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures
that which intervention has been done to prevent an episode of autonomic dysreflexia
(hyperreflexia)?
A. Updating the home safety sheet
B. Leaving the client in an un-chilled area of the room
C. Noting a bowel movement on the client progress note
D. Recording the amount of urine obtained with catheterization
Answer: B. Leaving the client in an un-chilled area of the room
Rationale:
The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage
of urinary drainage or with constipation. Barring these, other causes include noxious
mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the
nurse ensures that the client is positioned with no pinching or pressure on paralyzed body
parts and that the client will be sufficiently warm.
51. At 8:00 a.m., A client who has had a stroke (brain attack) was awake and alert with vital
signs of temperature 98°F (37.2°C) orally, pulse 80 beats/min, respirations 18 breaths/min,
and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to
tactile stimuli, and vital signs are temperature 99°F (36.7°C) orally, pulse 62 beats/min,
respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which
action?
A. Reorient the client.
B. Retake the vital signs.
C. Call the health care provider (HCP).
D. Administer an antihypertensive PRN (as needed).
Answer: C. Call the health care provider (HCP).
Rationale:
The important nursing action is to call the HCP. The deterioration in neurological status,
decreasing pulse, and increasing blood pressure with a widening pulse pressure all indicate
that the client is experiencing increased intracranial pressure, which requires immediate
treatment to prevent further complications and possible death. The nurse should retake the
vital signs and reorient the client to surroundings. If the client's blood pressure falls within

parameters for PRN antihypertensive medication, the medication also should be administered.
However, options 1, 2, and 4 are secondary nursing actions.
52. A client had a transsphenoidal resection of the pituitary gland. The nurse notes drainage
on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse should look for
drainage that is of which characteristic?
A. Serosanguineous only
B. Bloody with very small clots
C. Sanguineous only with no clot formation
D. Serosanguineous, surrounded by clear to straw-coloured fluid
Answer: D. Serosanguineous, surrounded by clear to straw-coloured fluid
Rationale:
CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous
(from the surgery) and surrounded by an area of clear or straw-coloured drainage. The typical
appearance of CSF drainage is that of a "halo." The nurse also would further verify actual
CSF drainage by testing the drainage for glucose, which would be positive.
53. A client arrives in the hospital emergency department with a closed head injury to the
right side of the head caused by an assault with a baseball bat. The nurse assesses the client
neurologically, looking primarily for motor response deficits that involve which area?
A. The left side of the body
B. The right side of the body
C. Both sides of the body equally
D. Cranial nerves only, such as speech and pupillary response
Answer: A. The left side of the body
Rationale:
Motor responses such as weakness and decreased movement will be seen on the side of the
body that is opposite an area of head injury. Contralateral deficits result from compression of
the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the
client may have a variety of neurological deficits.
54. The nurse has a prescription to begin aneurysm precautions for a client with a
subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to
incorporate which intervention in controlling the environment for this client?

A. Keep the window blinds open.
B. Turn on a small spotlight above the client's head.
C. Make sure the door to the room is open at all times.
D. Prohibit or limit the use of a radio or television and reading.
Answer: D. Prohibit or limit the use of a radio or television and reading.
Rationale:
Environmental stimuli are kept to a minimum with subarachnoid precautions to prevent or
minimize increases in intracranial pressure. For this reason, lighting is reduced by closing
window blinds and keeping the door to the client's room shut. Overhead lighting also is
avoided for the same reason. The nurse prohibits television, radio, and reading unless this is
so stressful for the client that it would be counterproductive. In that instance, minimal
amounts of stimuli by these means are allowed with approval of the health care provider.
55. The nurse is caring for a client who is on bed rest as part of aneurysm precautions. The
nurse should avoid doing which action when giving respiratory care to this client?
A. Encouraging hourly coughing
B. Assisting with incentive spirometer
C. Encouraging hourly deep breathing
D. Repositioning gently side to side every 2 hours
Answer: A. Encouraging hourly coughing
Rationale:
With aneurysm precautions, any activity that could raise the client's intracranial pressure
(ICP) is avoided. For this reason, activities such as straining, coughing, blowing the nose, and
even sneezing are avoided whenever possible. The other interventions (repositioning, deep
breathing, and incentive spirometry) do not provide added risk of increasing ICP and are
beneficial in reducing the respiratory complications of bed rest.
56. At the end of the work shift, the nurse is reviewing the respiratory status of a client
admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's
airway is patent if which data are identified?
A. Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear
B. Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear
C. Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally

D. Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath sounds in lung
bases
Answer: B. Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear
Rationale:
The client's airway is most protected if all of the respiratory parameters measured fall within
normal limits. Therefore, the respiratory rate should ideally be 16 to 20 breaths/min, the
oxygen saturation should be greater than 95%, and the breath sounds should be clear. The
correct option is the only one that meets all 3 criteria.
57. At the beginning of the work shift, the nurse assesses the status of the client wearing a
halo device. The nurse determines that which assessment finding requires intervention?
A. Tightened screws
B. Red skin areas under the jacket
C. Clean and dry lamb's wool jacket lining
D. Finger-width space between the jacket and the skin
Answer: B. Red skin areas under the jacket
Rationale:
Red skin areas under the jacket indicate that the jacket is too tight. The resulting pressure
could lead to altered skin integrity and needs to be relieved by loosening the jacket. The
screws all should be properly tightened. A clean, dry lamb's wool lining should be in place
underneath the jacket, and there should be a finger-width space between the jacket and the
skin. In addition, the client should wear a clean white cotton T-shirt next to the skin to help
prevent itching.
58. A client who has a spinal cord injury that resulted in paraplegia experiences a sudden
onset of severe headache and nausea. The client is diaphoretic with piloerection and has
flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the
nurse immediately suspect?
A. Return of spinal shock
B. Malignant hypertension
C. Impending brain attack (stroke)
D. Autonomic dysreflexia (hyperreflexia)
Answer: D. Autonomic dysreflexia (hyperreflexia)
Rationale:

Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the
sympathetic nervous system in response to a noxious stimulus. Signs and symptoms include
pounding headache, nausea, nasal stuffiness, flushed skin, piloerection {Piloerection means
involuntary erection or bristling of body hairs due to a sympathetic reflex}, and diaphoresis.
Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It
often is triggered by thermal or mechanical events such as a kinking of catheter tubing,
constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must
recognize this situation immediately and take corrective action to remove the stimulus. If
untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.
59. A client who had a stroke (brain attack) has right-sided hemianopsia. What should the
nurse plan to do to help the client adapt to this problem?
A. Teach the client to scan the environment.
B. Place all objects within the left visual field.
C. Place all objects within the right visual field.
D. Ensure that the family brings the client's eyeglasses to hospital.
Answer: A. Teach the client to scan the environment.
Rationale:
Hemianopsia is blindness in half of the visual field. The client with hemianopsia is taught to
scan the environment. This allows the client to take in the entirety of the visual field, which is
necessary for proper functioning within the environment and helps to prevent injury to the
client. Options 2 and 3 will not help the client adapt to this visual impairment. Eyeglasses are
useful if the client already wears them, but they will not correct this visual field deficit.
60. The nurse is caring for a client who is brought to the hospital emergency department with
a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing
which action?
A. Keeping the client on a stretcher
B. Logrolling the client onto a soft mattress
C. Logrolling the client onto a firm mattress
D. Placing the client on a bed that provides spinal immobilization
Answer: D. Placing the client on a bed that provides spinal immobilization
Rationale:

Spinal immobilization is necessary after spinal cord injury to prevent further damage and
insult to the spinal cord. Whenever possible, the client is placed on a special bed, such as a
Stryker frame, which allows the nurse to turn the client to prevent complications of
immobility while maintaining alignment of the spine. If a Stryker frame is not available, a
firm mattress with a bed board under it should be used. The remaining options are incorrect
and potentially harmful interventions.
61. A client with myasthenia gravis is having difficulty with airway clearance and difficulty
with maintaining an effective breathing pattern. The nurse should keep which most important
items available at the client's bedside?
A. Oxygen and metered-dose inhaler
B. Ambu bag and suction equipment
C. Pulse oximeter and cardiac monitor
D. Incentive spirometer and cough pillow
Answer: B. Ambu bag and suction equipment
Rationale:
The client with myasthenia gravis may experience episodes of respiratory distress if
excessively fatigued or with development of myasthenic or cholinergic crisis. For this reason,
an Ambu bag, intubation tray, and suction equipment should be available at the bedside.
62. The home health nurse is visiting a client with myasthenia gravis and is discussing
methods to minimize the risk of aspiration during meals related to decreased muscle strength.
Which suggestions should the nurse give to the client? Select all that apply.
A. Chew food thoroughly.
B. Cut food into very small pieces.
C. Sit straight up in the chair while eating.
D. Lift the head while swallowing liquids.
E. Swallow when the chin is tipped slightly downward to the chest.
Answer: A. Chew food thoroughly.
B. Cut food into very small pieces.
C. Sit straight up in the chair while eating.
E. Swallow when the chin is tipped slightly downward to the chest.
Rationale:

The client avoids swallowing any type of food or drink with the head lifted upward, which
could actually cause aspiration by opening the glottis. The client should be advised to sit
upright while eating, not to talk with food in the mouth (talking requires opening the glottis),
cut food into very small pieces, chew thoroughly, and tip the chin downward to swallow.
63. The nurse has instructed a client with myasthenia gravis about strategies for self
management at home. The nurse determines a need for further teaching if the client makes
which statement?
A. "Here's the Medic-Alert bracelet I obtained."
B. "I should take my medications an hour before mealtime."
C. "Going to the beach will be a nice, relaxing form of activity."
D. "I've made arrangements to get a portable resuscitation bag and home suction equipment."
Answer: C. "Going to the beach will be a nice, relaxing form of activity."
Rationale:
Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client
must be aware of the lifestyle changes needed to maintain independence. The client should
carry medical identification about the presence of the condition. Taking medications an hour
before mealtime gives greater muscle strength for chewing and is indicated. The client should
have portable suction equipment and a portable resuscitation bag available in case of
respiratory distress. The client should avoid situations and other factors, including stress,
infection, heat, surgery, and alcohol, that could worsen the symptoms.
64. Which assessment finding should the nurse expect to note in the client hospitalized with a
diagnosis of stroke who has difficulty chewing food?
A. Dysfunction of vagus nerve (cranial nerve X)
B. Dysfunction of trigeminal nerve (cranial nerve V)
C. Dysfunction of hypoglossal nerve (cranial nerve XII)
D. Dysfunction of spinal accessory nerve (cranial nerve XI)
Answer: B. Dysfunction of trigeminal nerve (cranial nerve V)
Rationale:
The motor branch of cranial nerve V is responsible for the ability to chew food. The vagus
nerve is active in parasympathetic functions of the autonomic nervous system. The
hypoglossal nerve aids in swallowing. The spinal accessory nerve is responsible for shoulder
movement, among other things.

65. The nurse has applied a hypothermia blanket to a client with a fever. The nurse should
inspect the skin frequently to detect which condition that is a complication of hypothermia
blanket use?
A. Frostbite
B. Skin breakdown
C. Arterial insufficiency
D. Venous insufficiency
Answer: B. Skin breakdown
Rationale:
When a hypothermia blanket is used, the skin is inspected frequently for pressure points,
which over time could lead to skin breakdown. The hypothermia blanket decreases the blood
flow to pressure areas and can cause numbness, making it so that the client is not aware of
damage to the skin. The temperature of the blanket is not cold enough to cause frostbite.
Arterial insufficiency and venous insufficiency are not complications of hypothermia blanket
use.
66. The nurse is caring for an unconscious client who is experiencing persistent hyperthermia
with no signs of infection. On the basis of these findings the nurse suspects dysfunction in
which area of the brain?
A. Cerebrum
B. Cerebellum
C. Hippocampus
D. Hypothalamus
Answer: D. Hypothalamus
Rationale:
Hypothalamic damage causes persistent hyperthermia, which also may be called central
fever. It is characterized by a persistent high fever with no diurnal variation. Another
characteristic feature is absence of sweating. Hyperthermia would not result from damage to
the cerebrum, cerebellum, or hippocampus.
67. The nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The
nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity
of which finding?

A. 5 mm Hg
B. 8 mm Hg
C. 14 mm Hg
D. 22 mm Hg
Answer: D. 22 mm Hg
Rationale:
Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg
are considered to represent increased ICP, which seriously impairs cerebral perfusion.
68. The nurse is caring for a client with intracranial pressure (ICP) monitoring. Which
intervention is appropriate to include in the plan of care?
A. Place the client in Sims' position.
B. Change the drainage tubing every 48 hours.
C. Level the transducer at the lowest point of the ear.
D. Use strict aseptic technique when touching the monitoring system.
Answer: D. Use strict aseptic technique when touching the monitoring system.
Rationale:
Because there is a foreign body embedded in the client's brain, vigilant aseptic technique
should be implemented. Sims' is a side-lying, flat position. With a client who has increased
ICP, the head of the bed should be elevated at least 30 degrees to improve jugular outflow.
The drainage tubing should not be routinely changed. It should remain for the duration of the
monitoring. To obtain accurate ICP pressure readings, the transducer is zeroed at the level of
the foramen of Monro, which is approximated by placing the transducer 1 inch above the
level of the ear. Serial ICP readings should be done with the client's head in the same
position.
69. A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes
normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG)
results are within which ranges?
A. PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCO2 25 to 30 mm Hg (25 to 30 mm Hg)
B. PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCO2 30 to 35 mm Hg (30 to 35 mm Hg)
C. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCO2 25 to 30 mm Hg (25 to 30 mm Hg)
D. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCO2 35 to 38 mm Hg (35 to 38 mm Hg)

Answer: D. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCO2 35 to 38 mm Hg (35 to38
mm Hg)
Rationale:
The goal is to maintain the partial pressure of arterial carbon dioxide (PaCO2) at 35 to 38 mm
Hg (35 to 38 mm Hg). Carbon dioxide is a very potent vasodilator that can contribute to
increases in ICP. The PaO2 is not allowed to fall below 80 mm Hg (80 mm Hg), to prevent
cerebral vasodilation from hypoxemia, which can also result in an increase in ICP. Therefore,
the remaining options are incorrect.
70. The nurse is providing care to a client with increased intracranial pressure (ICP). Which
approach is beneficial in controlling the client's ICP from an environmental viewpoint?
A. Reduce environmental noise.
B. Allow visitors as desired by the client and family.
C. Awaken the client every 2 to 3 hours to monitor mental status.
D. Cluster nursing activities to reduce the number of interruptions.
Answer: A. Reduce environmental noise.
Rationale:
Nursing interventions to control ICP include maintaining a calm, quiet, and restful
environment. Environmental noise should be kept at a minimum. Visiting should be
monitored to avoid emotional stress and interruption of sleep. Interventions should be spaced
out over the shift to minimize the risk of a sustained rise in ICP.
71. The home care nurse is making extended follow-up visits to a client discharged from the
hospital after a moderately severe head injury. The family states that the client is behaving
differently than before the accident. The client is more fatigued and irritable and has some
memory problems. The client, who was previously very even tempered, is prone to outbursts
of temper now. The nurse determines that these behaviors are indicative of which problem?
A. Intracranial pressure changes
B. A long-term sequela of the injury
C. A worsening of the original injury
D. A short-term problem that will resolve in about 1 month
Answer: B. A long-term sequela of the injury
Rationale:

Clients with moderate to severe head injury usually have residual physical and cognitive
disabilities; these include personality changes, increased fatigue and irritability, mood
alterations, and memory changes. The client also may require frequent to constant
supervision. The nurse assesses the family's ability to cope and makes appropriate referrals to
respite services, support groups, and state or local chapters of the National
Head Injury Foundation.
72. A client was seen and treated in the hospital emergency department for a concussion. The
nurse determines that the family needs further teaching if they verbalize to call the health care
provider (HCP) for which client sign or symptom?
A. Vomiting
B. Minor headache
C. Difficulty speaking
D. Difficulty awakening
Answer: B. Minor headache
Rationale:
A concussion after head injury is a temporary loss of consciousness (from a few seconds to a
few minutes) without evidence of structural damage. After concussion, the family is taught to
monitor the client and call the HCP or return the client to the emergency department for signs
and symptoms such as confusion, difficulty awakening or speaking, one-sided weakness,
vomiting, and severe headache. Minor headache is
expected.
73. A client with a spinal cord injury expresses little interest in food and is very particular
about the choice of meals that are actually eaten. How should the nurse interpret this
information?
A. Anorexia is a sign of clinical depression, and a referral to a psychologist is needed.
B. The client has compulsive habits that should be ignored as long as they are not harmful.
C. The client probably has a naturally slow metabolism, and the decreased nutritional intake
will not matter.
D. Meal choices represent an area of client control and should be encouraged as much as is
nutritionally reasonable.
Answer: D. Meal choices represent an area of client control and should be encouraged as
much as is nutritionally reasonable.

Rationale:
Depression frequently may be seen in the client with spinal cord injury and may be exhibited
as a loss of appetite. However, the client should be allowed to choose the types of food eaten
and when they are eaten as much as is feasible because it is one of the few areas of control
that the client has left. There is no information in the question that would indicate that the
client is anorexic or obsessive-compulsive or has a slow metabolism.
74. The nurse is teaching a client with paraplegia measures to maintain skin integrity.
Which instruction will be most helpful to the client?
A. Shift weight every 2 hours while in a wheelchair.
B. Change bed sheets every other week to maintain cleanliness.
C. Place a pillow on the seat of the wheelchair to provide extra comfort.
D. Use a mirror to inspect for redness and skin breakdown twice a week.
Answer: A. Shift weight every 2 hours while in a wheelchair.
Rationale:
To maintain skin integrity, the client should shift weight in the wheelchair every 2 hours and
use a pressure relief pad. A pillow is not sufficient to relieve the pressure. While the client is
in bed, the bottom sheet should be free of wrinkles and wetness. Sheets should be changed as
needed and more frequently than every other week. The client should use a mirror to inspect
the skin twice daily (morning and evening) to assess for redness, edema, and breakdown.
General additional measures include a nutritious diet and meticulous skin care.
75. The nurse is caring for a client with an intracranial aneurysm who has been alert. Which
signs and symptoms are an early indication that the level of consciousness (LOC) is
deteriorating? Select all that apply.
A. Mild drowsiness
B. Drooping eyelids
C. Ptosis of the left eyelid
D. Slight slurring of speech
E. Less frequent spontaneous speech
Answer: A. Mild drowsiness
B. Slight slurring of speech
E. Less frequent spontaneous speech
Rationale:

Early changes in LOC relate to orientation, alertness, and verbal responsiveness. Mild
drowsiness, slight slurring of speech, and less frequent spontaneous speech are early signs of
decreasing LOC. Ptosis (drooping) of the eyelid is caused by pressure on and dysfunction of
cranial nerve III. Once ptosis occurs, it is ongoing; it does not relate to
LOC.
76. The nurse has provided instructions to a client with a diagnosis of myasthenia gravis
about home care measures. Which client statement indicates the need for further teaching?
A. "I will rest each afternoon after my walk."
B. "I should cough and deep breathe many times during the day."
C. "I can change the time of my medication on the mornings when I feel strong."
D. "If I get abdominal cramps and diarrhea, I should call my health care provider."
Answer: C. "I can change the time of my medication on the mornings when I feel strong."
Rationale:
The client with myasthenia gravis and the family should be taught information about the
disease and its treatment. They should be aware of the side and adverse effects of
anticholinesterase medications and corticosteroids and should be taught that timing of
anticholinesterase medication is critical. It is important to instruct the client to administer the
medication on time to maintain a chemical balance at the neuromuscular junction. If it is not
given on time, the client may become too weak to even swallow. Resting after a walk,
coughing and deep-breathing many times during the day, and calling the health care provider
when experiencing abdominal cramps and diarrhoea indicate a correct understanding of home
care instructions to maintain health with this neurological degenerative disease.
77. The nurse is performing an assessment on a client with a head injury and notes that the
client is assuming this posture. The nurse contacts the health care provider and reports that
the client is exhibiting which posture? Refer to Figure.
View Figure

A. Opisthotonos
B. Decorticate rigidity
C. Decerebrate rigidity
D. Flaccid quadriplegia
Answer: B. Decorticate rigidity
Rationale:
In decorticate rigidity, the upper extremities (arms, wrists, and fingers) are flexed with
adduction of the arms. The lower extremities are extended with internal rotation and plantar
flexion. Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex.
Opisthotonos is prolonged arching of the back with the head and heels bent backward.
Opisthotonos indicates meningeal irritation. In decerebrate rigidity, the upper extremities are
stiffly extended and adducted with internal rotation and pronation of the palms. The lower
extremities are stiffly extended with plantar flexion. The teeth are clenched, and the back is
hyperextended. Decerebrate rigidity indicates a lesion in the brainstem at the midbrain or
upper pons. Flaccid quadriplegia is complete loss of muscle tone and paralysis of all four
extremities, indicating a completely nonfunctional brainstem.
78. An older client is brought to the hospital emergency department by a neighbor who heard
the client talking and found him wandering in the street at 3 a.m. The nurse should first
determine which data about the client?
A. His insurance status
B. Blood toxicology levels
C. Whether he ate his evening meal
D. Whether this is a change in usual level of orientation
Answer: D. Whether this is a change in usual level of orientation
Rationale:

The nurse should first determine whether this behavior represents a change in the client's
neurological status. The next item to determine is when the client last ate. Blood toxicology
levels may or may not be needed, but the health care provider would likely prescribe these.
Insurance information must be obtained at some point but is not the priority from a clinical
care viewpoint.
79. The nurse is evaluating a function of the limbic system as a part of the neurological status
of a client. What should the nurse assess?
A. Experience of pain
B. Affect or emotions
C. Response to verbal stimuli
D. Insight, judgment, and planning
Answer: B. Affect or emotions
Rationale:
Affect and emotions are part of the role of the limbic system and involve both hemispheres of
the brain. Pain is a complex experience involving several areas of the central nervous system.
The response to verbal stimuli is part of the level of consciousness, which is under the control
of the reticular activating system and both cerebral hemispheres. Insight, judgment, and
planning are part of the functions of the frontal lobes of the brain in conjunction with
association fibers connecting to other areas of the cerebrum.
80. A client has sustained damage to Wernicke's area from a stroke (brain attack). On
assessment of the client, which sign or symptom would be noted?
A. Difficulty speaking
B. Problem with understanding language
C. Difficulty controlling voluntary motor activity
D. Problem with articulating events from the remote past
Answer: B. Problem with understanding language
Rationale:
Wernicke's area consists of a small group of cells in the temporal lobe whose function is the
understanding of language. Damage to Broca's area is responsible for aphasia. The motor
cortex in the precentral gyrus controls voluntary motor activity. The hippocampus is
responsible for the storage of memory. {Receptive aphasia is associated with the Wernicke's
area in the temporal lobe. Expressive aphasia is associated with Broca’s area in the frontal

lobe of the brain}. {Note: a term of similar pronunciation and that is commonly asked in
NCLEX is Wernich’s syndrome: Thiamine deficiency in pt with alcohol dependence and
causes confusion, ataxia, visual problems. Imp. Q. Wernich’s syndrome can be prevented by
giving the patient
Thiamin}.
81. A client has suffered a head injury affecting the occipital lobe of the brain. What is the
focus of the nurse's immediate assessment?
A. Taste
B. Smell
C. Vision
D. Hearing
Answer: C. Vision
Rationale:
The occipital lobe is responsible for reception of vision and contains visual association areas.
This area of the brain helps the individual to visually recognize and understand the
surroundings. The other senses listed are not a function of the occipital lobe.
82. A client has suffered damage to Broca's area of the brain. Which priority assessment
should the nurse perform?
A. Speech
B. Hearing
C. Balance
D. Level of consciousness
Answer: A. Speech
Rationale:
Broca's area in the brain is responsible for the motor aspects of speech, through coordination
of the muscular activity of the tongue, mouth, and larynx. The term assigned to damage in
this area is aphasia. The items listed in the other options are not the responsibility of Broca's
area.
83. The nurse notes that a client who has suffered a brain injury has an adequate heart rate,
blood pressure, fluid balance, and body temperature. Based on these clinical findings, the
nurse determines that which brain area is functioning properly?

A. Thalamus
B. Hypothalamus
C. Limbic system
D. Reticular activating system
Answer: B. Hypothalamus
Rationale:
The hypothalamus is responsible for autonomic nervous system functions, such as heart rate,
blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus
acts as a relay station for sensory and motor information. The limbic system is responsible for
emotions. The reticular activating system is responsible for the sleep wake cycle.
84. A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by
arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur
as a result of this elevated CO2?
A. It will cause arteriovenous shunting.
B. It will cause vasodilation of blood vessels in the brain.
C. It will cause blood vessels in the circle of Willis to collapse.
D. It will cause hyperresponsiveness of blood vessels in the brain.
Answer: B. It will cause vasodilation of blood vessels in the brain.
Rationale:
CO2 is one of the metabolic end products that can alter the tone of the blood vessels in the
brain. High CO2 levels cause vasodilation, which may cause headache, whereas low CO2
levels cause vasoconstriction, which may cause light headed ness. The statements included in
the other options are incorrect effects.
85. A client is anxious about an upcoming diagnostic procedure. The client's pupils are
dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline.
The nurse determines that the client's clinical manifestations are due to what type of
physiologic response?
A. Vagal
B. Peripheral nervous system
C. Sympathetic nervous system
D. Parasympathetic nervous system
Answer: C. Sympathetic nervous system

Rationale:
The sympathetic nervous system is responsible for the so-called fight or flight response,
which is characterized by dilated pupils, increases in heart rate and cardiac output, and
increases in respiratory rate and blood pressure. The sympathetic nervous system response
affects some type of change in most systems of the body. The responses stated in the other
options do not produce these effects.
86. A client who is experiencing an inferior wall myocardial infarction has had a drop in heart
rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. On the
basis of these findings, the nurse determines that the client is experiencing parasympathetic
stimulation of which cranial nerve?
A. Vagus (CN X)
B. Hypoglossal (CN XII)
C. Spinal accessory (CN XI)
D. Glossopharyngeal (CN IX)
Answer: A. Vagus (CN X)
Rationale:
The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It also is
responsible for the decrease in heart rate because approximately 75% of all parasympathetic
stimulation is carried by the vagus nerve. {Treatment of Bradycardia is Atropine, an
anticholinergic medication that blocks the vagus nerve “cranial nerve X}.
CN XII is responsible for tongue movement. CN XI is responsible for neck and shoulder
movement. CN IX is responsible for taste in the posterior two thirds of the tongue,
pharyngeal sensation, and swallowing.
87. A client with myasthenia gravis arrives at the hospital emergency department in suspected
crisis. The health care provider plans to administer edrophonium to differentiate between
myasthenic and cholinergic crises. The nurse ensures that which medication is available in
the event that the client is in cholinergic crisis?
A. Atropine sulfate
B. Morphine sulfate
C. Protamine sulfate
D. Pyridostigmine bromide
Answer: A. Atropine sulfate

Rationale:
Clients with cholinergic crisis have experienced overdosage of medication.
Edrophonium will exacerbate symptoms in cholinergic crisis to the point at which the client
may need intubation and mechanical ventilation. Intravenous atropine sulfate is used to
reverse the effects of these anticholinesterase medications. Morphine sulfate and
pyridostigmine bromide would worsen the symptoms of cholinergic crisis. Protamine sulfate
is the antidote for heparin.
88. A client admitted to the nursing unit from the hospital emergency department has a C4
spinal cord injury. In conducting the admission assessment, what is the nurse's priority
action?
A. Take the temperature.
B. Listen to breath sounds.
C. Observe for dyskinesias.
D. Assess extremity muscle strength.
Answer: B. Listen to breath sounds.
Rationale:
Because compromise of respiration is a leading cause of death in cervical cord injury,
respiratory assessment is the highest priority. Assessment of temperature and strength can be
done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar
disorders, this is not as important a concern as in cord-injured clients unless head injury is
suspected.
89. The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke.
To assess function of this nerve, which action should the nurse ask the client to perform?
A. Extend the arms.
B. Extend the tongue.
C. Turn the head toward the nurse's arm.
D. Focus the eyes on the object held by the nurse.
Answer: B. Extend the tongue.
Rationale:
Impairment of cranial nerve XII can occur with a stroke. To assess the function of cranial
nerve XII (the hypoglossal nerve), the nurse would assess the client's ability to extend the

tongue. The maneuvers noted in the remaining options do not test the function of cranial
nerve XII.
90. The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse
should plan to place the client in which position?
A. Prone
B. Supine
C. Side-lying
D. Semi Fowler's
Answer: D. Semi Fowler's
Rationale:
After supratentorial surgery (surgery above the tentorium of the brain), the head of the client's
bed usually is elevated 30 degrees to promote venous outflow through the jugular veins.
Prone, supine, and side-lying denote incorrect positions after this surgery, and these positions
could result in edema at the surgical site and increased intracranial pressure. The health care
provider's prescriptions are always followed with regard to positioning the client.
91. The nurse is admitting a client to the hospital emergency department from a nursing
home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of
epidural hematoma is suspected. Which question is of the highest priority for the emergency
department nurse to ask of the transferring nurse at the nursing
home?
A. "When did the injury occur?"
B. "Was the client awake and talking right after the injury?"
C. "What medications has the client received since the fall?"
D. "What was the client's level of consciousness before the injury?"
Answer: B. "Was the client awake and talking right after the injury?"
Rationale:
Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to
hours, during which the client is awake and talking. After this lucid interval, signs and
symptoms progress rapidly, with potentially catastrophic intracranial pressure increase.
Epidural hematomas are medical emergencies. It is important for the nurse to assist in the
differentiation between epidural hematoma and other types of head injuries.

92. The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is
at risk for increased intracranial pressure (ICP). Pending specific health care provider
prescriptions, the nurse should plan to place the client in which positions?
Select all that apply.
A. Head midline
B. Neck in neutral position
C. Flat, with head turned to the side
D. Head of bed elevated 30 to 45 degrees
E. Head of bed elevated with the neck extended
Answer: A. Head midline
B. Neck in neutral position
D. Head of bed elevated 30 to 45 degrees
Rationale:
The client who is at risk for or who has increased ICP should be positioned so that the head is
in a neutral, midline position. The nurse should avoid flexing or extending the client's neck or
turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees.
Use of proper positions promotes venous drainage from the cranium to keep ICP down.
93. The nurse is caring for a client who is at risk for increased intracranial pressure (ICP)
after a stroke. Which activities performed by the nurse will assist with preventing increases in
ICP? Select all that apply.
A. Clustering nursing activities
B. Hyper-oxygenating before suctioning
C. Maintaining 20-degree flexion of the knees
D. Maintaining the head and neck in midline position
E. Maintaining the head of the bed (HOB) at 30 degrees elevation
Answer: B. Hyper-oxygenating before suctioning
D. Maintaining the head and neck in midline position
E. Maintaining the head of the bed (HOB) at 30 degrees elevation
Rationale:
Measures aimed at preventing increased ICP in the poststroke client include hyperoxgenating
before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of
cerebral arteries; maintaining the head in a midline, neutral position to help promote venous
drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to

prevent a decreased blood flow to the brain. Clustering activities can be stressful for the client
and increase ICP. Maintaining 20-degree flexion of the knees increases intraabdominal
pressure and consequently ICP.
94. The nurse is trying to communicate with a client who had a stroke and has aphasia.
Which actions by the nurse would be most helpful to the client? Select all that apply.
A. Speaking to the client at a slower rate
B. Allowing plenty of time for the client to respond
C. Completing the sentences that the client cannot finish
D. Looking directly at the client during attempts at speech
E. Shouting words if it seems as though the client has difficulty understanding
Answer: A. Speaking to the client at a slower rate
B. Allowing plenty of time for the client to respond
D. Looking directly at the client during attempts at speech
Rationale:
Clients with aphasia after brain attack often fatigue easily and have a short attention span.
General guidelines when trying to communicate with the aphasic client include speaking
more slowly and allowing adequate response time, listening to and watching attempts to
communicate, and trying to put the client at ease with a caring and understanding manner.
The nurse would avoid shouting (because the client is not deaf), appearing rushed for a
response, and letting family members provide all responses for
the client.
95. The client with a cervical spine injury has cervical tongs applied in the emergency
department. What should the nurse include when planning care for this client? Select all that
apply.
A. Using a RotoRest bed
B. Ensuring that weights hang freely
C. Removing the weights to reposition the client
D. Assessing the integrity of the weights and pulleys
E. Comparing the amount of prescribed traction with the amount in use
Answer: A. Using a RotoRest bed
B. Ensuring that weights hang freely
D. Assessing the integrity of the weights and pulleys

E. Comparing the amount of prescribed traction with the amount in use
Rationale:
Cervical tongs are applied after drilling holes in the client's skull under local anesthesia.
Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the
cervical spine. Serial x-rays of the cervical spine are taken, with weights being added
gradually until the x-ray reveals that the vertebral column is realigned. After that, weights
may be reduced gradually to a point that maintains alignment. The client with cervical tongs
is placed on a Stryker frame or RotoRest bed. The nurse ensures that weights hang freely and
the amount of weight matches the current prescription. The nurse also inspects the integrity
and position of the ropes and pulleys. The nurse does not remove the weights to administer
care.
96. The nurse is caring for the client who suffered a spinal cord injury 48 hours ago.
What should the nurse assess for when monitoring for gastrointestinal complications?
A. A history of diarrhea
B. A flattened abdomen
C. Hyperactive bowel sounds
D. Hematest-positive nasogastric tube drainage
Answer: D. Hematest-positive nasogastric tube drainage
Rationale:
Development of a stress ulcer also can occur after spinal cord injury and can be detected by
Hematest-positive nasogastric tube aspirate or stool. The client is also at risk for paralytic
ileus, which is characterized by the absence of bowel sounds and abdominal distention. A
history of diarrhea is irrelevant.
97. The client has an impairment of cranial nerve II. Specific to this impairment, what should
the nurse plan to do to ensure client safety?
A. Speak loudly to the client.
B. Test the temperature of the shower water.
C. Check the temperature of the food on the dietary tray.
D. Provide a clear path for ambulation without obstacles.
Answer: D. Provide a clear path for ambulation without obstacles.
Rationale:

Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the
visually impaired client by clearing the path of obstacles when ambulating.
Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear).
Testing the shower water temperature would be useful if there was an impairment of
peripheral nerves. Cranial nerves VII (facial) and IX (glossopharyngeal) control taste from
the anterior two thirds and posterior third of the tongue, respectively.
98. Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain,
and the nurse instructs the client about the purpose of the TENS unit. Which statement by the
client indicates the need for further teaching?
A. "The unit relieves pain."
B. "Electrodes are attached to the skin."
C. "The unit will reduce the need for analgesics."
D. "Hospitalization is required because the unit is not portable."
Answer: D. "Hospitalization is required because the unit is not portable."
Rationale:
The TENS unit is portable and the client controls the system for relieving pain and reducing
the need for analgesics. It is attached to the skin of the body by electrodes.
Hospitalization is not required.
99. The client with a head injury opens eyes to sound, has no verbal response, and localizes to
painful stimuli when applied to each extremity. How should the nurse document the Glasgow
Coma Scale (GCS) score?
A. GCS = 3
B. GCS = 6
C. GCS = 9
D. GCS = 11
Answer: C. GCS = 9
Rationale:
The GCS is a method for assessing neurological status. The highest possible GCS score is 15.
A score lower than 8 indicates that coma is present. Motor response points are as follows:
Obeys a simple response = 6; Localizes painful stimuli = 5; Normal flexion
(withdrawal) = 4; Abnormal flexion (decorticate posturing) = 3; Extensor response
(decerebrate posturing) = 2; No motor response to pain = 1. Verbal response points are as

follows: Oriented = 5; Confused conversation = 4; Inappropriate words = 3; Responds with
incomprehensible sounds = 2; No verbal response = 1. Eye opening points are as follows:
Spontaneous = 4; In response to sound = 3; In response to pain = 2; No response, even to
painful stimuli = 1. Using the GCS, a score of 3 is given when the client opens the eyes to
sound. Localization to pain is scored as 5. When there is no verbal response the score is 1.
The total score is then equal to 9.
100. The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing
headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention?
A. Notify the health care provider (HCP).
B. Loosen tight clothing on the client.
C. Place the client in a sitting position.
D. Check the urinary catheter tubing for kinks or obstruction.
Answer: C. Place the client in a sitting position.
Rationale:
The client is demonstrating clinical manifestations of autonomic dysreflexia, which is a
neurological emergency. The first priority is to place the client in a sitting position to prevent
hypertensive stroke. Loosening tight clothing and checking the urinary catheter can then be
done, and the HCP can be notified once initial interventions are done.
101. The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and
has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which
is the appropriate nursing intervention?
A. Assist the client to eat with the left hand to build strength.
B. Provide a pureed diet that is easy for the client to swallow.
C. Inform the client that a feeding tube will be placed if progress is not made.
D. Provide a variety of foods on the meal tray to stimulate the client's appetite.
Answer: A. Assist the client to eat with the left hand to build strength.
Rationale:
Right-sided hemiparesis is weakness of the right arm and leg. The nurse should teach the
client to use both sides of the body to increase strength and build endurance. Providing a
pureed diet is incorrect. The question does not mention swallowing difficulty, so there is no
need to puree the food. Informing the client that a feeding tube may need to be placed is
incorrect. That information would come from the health care provider. Providing a variety of

foods is also incorrect because the problem is not the food selection but the client's ability to
eat the food independently.
102. A client is newly admitted to the hospital with a diagnosis of stroke (brain attack)
manifested by complete hemiplegia. Which item in the medical history of the client should
the nurse be most concerned about?
A. Glaucoma
B. Emphysema
C. Hypertension
D. Diabetes mellitus
Answer: B. Emphysema
Rationale:
The nurse should be most concerned about emphysema. The respiratory system is the priority
in the acute phase of a stroke. The client with a stroke is vulnerable to respiratory
complications such as atelectasis and pneumonia. Because the client has complete hemiplegia
(is unable to move) and has emphysema, these risks are very significant. Although the other
conditions of glaucoma, hypertension, and diabetes mellitus are important, they are not as
significant as emphysema.
103. A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and
is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which
precipitating factor?
A. Getting too little exercise
B. Taking excess medication
C. Omitting doses of medication
D. Increasing intake of fatty foods
Answer: C. Omitting doses of medication
Rationale:
Myasthenic crisis often is caused by undermedication and responds to the administration of
cholinergic medications. Cholinergic crisis (the opposite problem) is caused by excess
medication and responds to withholding of medications. Too little exercise and excessive
fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic
crisis.

104. The nurse is positioning a client who has increased intracranial pressure. Which position
should the nurse avoid?
A. Head midline
B. Head turned to the side
C. Neck in neutral position
D. Head of bed elevated 30 to 45 degrees
Answer: B. Head turned to the side
Rationale:
The head of a client with increased intracranial pressure should be kept in a neutral midline
position. The nurse should avoid flexing or extending the client's neck or turning the head
from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper
positions promotes venous drainage from the cranium to keep intracranial pressure down.
105. A client who has had a stroke (brain attack) has residual dysphagia. When a diet
prescription is initiated, the nurse should take which actions? Select all that apply.
A. Giving the client thin liquids
B. Thickening liquids to the consistency of oatmeal
C. Placing food on the unaffected side of the mouth
D. Allowing plenty of time for chewing and swallowing
E. Leave the client alone so that the client will gain independence by feeding self
Answer: B. Thickening liquids to the consistency of oatmeal
C. Placing food on the unaffected side of the mouth
D. Allowing plenty of time for chewing and swallowing
Rationale:
The client with dysphagia is started on a diet only after the gag and swallow reflexes have
returned. The client is assisted with meals as needed and is given ample time to chew and
swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid
aspiration. The client is not left alone because of the risk of aspiration.
106. A postoperative craniotomy client who sustained a severe head injury is admitted to the
neurological unit. What nursing intervention is necessary for this client?
A. Take and record vital signs every 4 to 8 hours.
B. Prophylactically hyperventilate during the first 24 hours.

C. Treat a central fever with the administration of antipyretic medications such as
acetaminophen.
D. Keep the head of the bed elevated at least 30 degrees, and position the client to avoid
extreme flexion or extension of the neck and head.
Answer: D. Keep the head of the bed elevated at least 30 degrees, and position the client to
avoid extreme flexion or extension of the neck and head.
Rationale:
Avoiding extreme flexion and extension of the neck can enhance venous drainage and help
prevent increased intracranial pressure. As a general rule, hyperventilation is avoided during
the first 24 hours postoperatively because it may produce ischemia caused by cerebral
vasoconstriction. Vital signs need to be taken and recorded at least every 1 to 2 hours. Central
fevers caused by hypothalamic damage respond better to cooling (hypothermia blankets,
sponge baths) than to the administration of antipyretic
medications.
107. A client has a cerebellar lesion. The nurse would plan to obtain which item for use by
this client?
A. Walker
B. Slider board
C. Raised toilet seat
D. Adaptive eating utensils
Answer: A. Walker
Rationale:
The cerebellum is responsible for balance and coordination. A walker provides stability for
the client during ambulation. A raised toilet seat is useful if the client has sufficient mobility
or ability to flex the hips. A slider board is used in transferring a client with weak or
paralyzed legs from a bed to stretcher or wheelchair. Adaptive eating utensils are beneficial if
the client has partial paralysis of the hand.
108. The nurse is caring for a client who was admitted for a stroke (brain attack) of the
temporal lobe. Which clinical manifestations should the nurse expect to note in the client?
A. The client will be unable to recall past events.
B. The client will have difficulty understanding language.
C. The client will demonstrate difficulty articulating words.

D. The client will have difficulty moving 1 side of the body.
Answer: B. The client will have difficulty understanding language.
Rationale:
Wernicke's area consists of a small group of cells in the temporal lobe, the function of which
is the understanding of language. {Receptive aphasia} The hippocampus is responsible for
the storage of memory (the client will be unable to recall past events). Damage to Broca's
area is responsible for aphasia (the client will demonstrate difficulty articulating words).
{Expressive aphasia}. The motor cortex in the precentral gyrus controls voluntary motor
activity (the client will have difficulty moving one side of the body).
109. A client who is experiencing an inferior wall myocardial infarction has had a drop in
heart rate into the 50 to 56 beats/minute range. The client is also complaining of nausea.
Which cranial nerve damage should the nurse expect that the client is experiencing?
A. Vagus (CN X)
B. Hypoglossal (CN XII)
C. Spinal accessory (CN XI)
D. Glossopharyngeal (CN IX)
Answer: A. Vagus (CN X)
Rationale:
The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It is also
responsible for the decrease in heart rate because approximately 75% of all parasympathetic
stimulation is carried by the vagus nerve. CN IX is responsible for taste in the posterior two
thirds of the tongue, pharyngeal sensation, and swallowing. CN XI is responsible for neck
and shoulder movement. CN XII is responsible for tongue movement.
110. The nurse caring for a client following craniotomy who has a supratentorial incision
understands that the client should most likely be maintained in which position?
A. Prone position
B. Supine position
C. Semi Fowler's position
D. Dorsal recumbent position
Answer: C. Semi Fowler's position
Rationale:

In supratentorial surgery (surgery above the brain's tentorium), the client's head is usually
elevated 30 degrees to promote venous outflow through the jugular veins. The client's head or
the head of the bed is not lowered in the acute phase of care after supratentorial surgery. An
exception to this is the client who has undergone evacuation of a chronic subdural hematoma,
but a health care provider's (HCP's) prescription is required for positions other than those
involving head elevation. In addition, the HCP's prescription regarding positioning is always
checked and agency procedures are always followed.
111. The nurse is planning to perform an assessment of the client's level of consciousness
using the Glasgow Coma Scale. Which assessments should the nurse include in order to
calculate the score? Select all that apply.
A. Eye opening
B. Reflex response
C. Best verbal response
D. Best motor response
E. Pupil size and reaction
Answer: A. Eye opening
C. Best verbal response
D. Best motor response
Rationale:
Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma
Scale. The 3 categories included are eye opening, best verbal response, and best motor
response. Pupil assessment and reflex response is a necessary part of a total assessment of the
neurological status of a client but is not part of this particular scale.