ATI PN Learning System Medical-Surgical: Neurosensory
Practice Questions with Answers 2023-2024
1. A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis.
Which of the following supplies should the nurse place at the client's bedside?
Answer: Oral-nasal suction equipment
Rationale: The client who has myasthenia gravis is at risk for aspiration because of progressive
weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an
autoimmune disease that affects the acytylcholine receptors. The nurse should place oxygen and
oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.
2. A nurse in a rehabilitation center is collecting data from a client who is recovering from a lefthemisphere stroke. Which of the following findings should the nurse expect?
Answer: Difficulty with speech
Rationale: The left hemisphere of the brain is usually the dominant side and is responsible for
language. This is always true for right-handed clients and for the majority of left-handed clients.
Since this client is recovering from a left-hemisphere stroke, the nurse should anticipate that the
client will have aphasia and require speech therapy to establish communication.
3. A nurse is reinforcing teaching with a class of new parents about otitis media. Which of the
following manifestations should the nurse include in the teaching?
Answer: Feeling of fullness in the ear
Rationale: A client who has otitis media can develop a feeling of fullness in the ear. Other
manifestations can include ear pain, a crackling sound when yawning or swallowing, and mild
dizziness.
4. A nurse is caring for a client who has a closed head injury. The nurse should place the client in
which of the following positions?
Answer: Semi-Fowler's
Rationale: To prevent an increase in intracranial pressure, the nurse should position the client
with his head midline and the head of the bed elevated 30 degrees. This positioning permits
blood flow to the client's brain while allowing venous drainage, thereby decreasing the
postoperative risk of increased intracranial pressure.
5. A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate
posture in response to noxious stimuli. Which of the following reactions should the nurse
anticipate when drawing a blood sample?
Answer: A client who exhibits a decerebrate posture rigidly extends and pronates his four
extremities and externally rotates his wrists. Decerebrate posturing indicates severe brain stem
injury and late neurologic decline.
Rationale: Decerebrate posturing indicates severe brainstem injury, causing the limbs to be
rigid, extended, and pronated in response to stimuli. This posture suggests significant neurologic
dysfunction and can make drawing blood more challenging due to the abnormal positioning of
the limbs.
6. A nurse is collecting data from a client who is admitted to the facility for observation
following a closed head injury. Which of the following data is the priority for the nurse to collect
to detect a change in the client's neurologic status?
Answer: Level of consciousness
Rationale: The nurse should apply the urgent vs. nonurgent priority-setting framework. Using
this framework, the nurse should consider urgent needs the priority because they pose more of a
risk to the client. The nurse might also use Maslow's Hierarchy of Needs, the ABC prioritysetting framework, or nursing knowledge to identify the most urgent finding. Therefore, the
priority data collection is level of consciousness. A change in the client's level of consciousness
can be the first indication of a change in neurologic status.
7. A nurse is collecting data from a client who has a new diagnosis of acute angle-closure
glaucoma. The nurse should anticipate the client to report which of the following manifestations?
Answer: Severe eye pain
Rationale: Severe eye pain is a manifestation of acute angle-closure glaucoma. Other
manifestations can include report of halos around lights, blurred vision, headache, brow pain,
and nausea and vomiting.
8. A nurse is reinforcing discharge teaching with a client who is postoperative following scleral
buckling to repair a detached retina. Which of the following instructions should the nurse include
in the teaching?
Answer: "You should expect to see flashing lights in front of the affected eye after the
procedure."
Rationale: The client should expect to see flashing lights in front of the affected eye for several
weeks following the procedure.
9. A nurse is reinforcing teaching about auras with a client who has a new diagnosis of simple
partial seizures. Which of the following statements by the client indicates an understanding of
the teaching?
Answer: "An aura is a sensory warning that a seizure is imminent."
Rationale: An aura is a sensory warning that a seizure is imminent. The aura can be similar to a
hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or
smelling an odor.
10. A nurse is reviewing the medical history of a client who is schedules for a magnetic
resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the
provider to which of the following information in the client's history that is a contraindication to
the procedure?
Answer: The client has a pacemaker.
Rationale: An MRI uses strong magnets and radio waves that are evaluated using computer
technology to view three-dimensional images of the body. Since an MRI is magnetically
generated, it is not indicated for use in the presence of certain medical implants. Clients who
have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an
MRI because the strong magnetic force can interfere with these devices and obscure surrounding
anatomical structures.
11. A nurse is reinforcing teaching with the partner of a client who has a new diagnosis of
Parkinson's disease about degenerative complications. The nurse should include in the teaching
that which of the following manifestations is the priority?
Answer: Dysphagia
Rationale: The nurse should apply the ABC priority-setting framework. This framework
emphasizes the basic core of human functioning, which is having an open airway, being able to
breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the
blood. An alteration in any of these can indicate a threat to life and should be the nurse's priority
concern. When applying the ABC priority-setting framework, the airway is the priority because it
must be clear and open for oxygen exchange to occur. Breathing is the second priority in the
ABC priority-setting framework because adequate ventiatory effort is essential for oxygen
exchange to occur. Circulation is the third priority in the ABC priority-setting framework
because delivery of oxygen to critical organs only occurs if the heart and blood vessels are
capable of efficiently carrying oxygen to them. Dysphagia is the priority manifestation for this
client because it can lead to aspiration.
12. A nurse is collecting data from a client who is unconscious and has a rhythmical breathing
pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with
periods of apnea. The nurse should document that the client is experiencing which of the
following types of respirations?
Answer: Cheyne-Stokes
Rationale: Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths,
followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or
increased intracranial pressure and can precede death.
13. A nurse is collecting data from a client who has a recent head trauma and a urine output of
600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of
the following laboratory values should the nurse plan to obtain to monitor for DI?
Answer: Specific gravity
Rationale: Diabetes insipidus is caused by damage to the hypothalamus, or the pituitary gland,
as a result of cranial surgery, infection, or a tumor. It is a condition in which an inadequate
amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001
to 1.003) is a manifestation of diabetes insipidus.
14. A nurse is reinforcing teaching with a client who has a new diagnosis of Ménière's disease.
Which of the following instructions should the nurse include in the teaching?
Answer: Avoid sudden movements
Rationale: Ménière's disease is a disorder of the inner ear affecting balance and hearing,
characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid
sudden movements that can increase manifestations.
15. A nurse is collecting data from a client who has a new diagnosis of mastoiditis. Which of the
following manifestations should the nurse expect?
Answer: Swelling behind the affected ear
Rationale: Mastoiditis refers to an inflammation of the temporal bone behind the ear.
Manifestations of mastoiditis include swelling and pain behind the ear.
16. A nurse is reinforcing teaching with the family of a client who has stage II Alzheimer's
disease (AD). Which of the following information should the nurse include in the teaching?
Answer: Limit choices offered to the client.
Rationale: Choices should be limited for the client who has stage II AD to reduce confusion and
frustration.
17. A nurse is collecting data from a client who has a high-thoracic spinal cord injury. The nurse
should identify which of the following findings as a manifestation of autonomic dysreflexia?
Answer: Report of a headache
Rationale: Autonomic dysreflexia is a neurologic emergency that can occur in clients who have
a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be
triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing
headache; flushing of the face and neck; bradycardia; and extreme hypertension.
18. A nurse is collecting data from a client who has Guillain-Barre syndrome. Which of the
following findings should the nurse expect? Answer: Weakness of the lower extremities
Rationale: Guillain-Barré syndrome, also called acute inflammatory demyelinating
polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized by the
rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can
advance to the upper extremities.
19. A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has
manifestations of bacterial meningitis. The nurse should recognize which of the following
findings is consistent with this diagnosis?
Answer: Elevated protein
Rationale: An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination.
Manifestations of bacterial meningitis include an increase in protein in the cerebrospinal fluid.
20. A nurse is reinforcing teaching with a client who has a new diagnosis of primary open-angle
glaucoma (POAG). Which of the following information should the nurse include in the teaching?
(Select all that apply.)
Answer: Driving can be dangerous due to the loss of peripheral vision.
Rationale: Laser surgery can help reestablish the flow of aqueous humor.
Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a
decrease in peripheral vision and can cause complete vision loss if not treated.
Laser surgery can reopen the trabecular meshwork and widen the Canal of Schlemm.
21. A nurse is reinforcing teaching with a client who has a new diagnosis of migraine headaches
about interventions to reduce pain at the onset of a migraine. Which of the following instructions
should the nurse include in the teaching?
Answer: "Darken the lights."
Rationale: The nurse should instruct the client to lie down in a dark room to reduce migraine
pain.
22. A nurse is collecting data from a client who has a closed head injury and is receiving
mannitol for manifestations of increased intracranial pressure (ICP). Which of the following
findings indicates to the nurse that the medicaiton is having a therapeutic effect?
Answer: The client's urine output is 250 mL/hr
Rationale: Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out
of the brain tissue. An increase in urine output is desired. A decrease in cerebral edema should
result in a decrease in ICP.
23. A nurse is reinforcing teaching with an adolescent client who has recurrent external otitis.
Which of the following instructions should the nurse include in the teaching?
Answer: Instill a diluted alcohol solution into the ear after swimming.
Rationale: External otitis is an inflammation of the external auditory canal often due to the
retention of water in the ear from swimming. After the inflammation is gone, the client can
prevent recurrence of external otitis by instilling diluted alcohol drops to decrease bacteria and
dry the external ear canal.
24. A nurse is collecting data from a client who has a brain tumor. Which of the following
findings indicates cranial nerve involvement?
Answer: Dysphagia
Rationale: Dysphagia, or difficulty swallowing, can occur as a result of damage to cranial
nerves IX (glossopharyngeal) or X (vagus).
25. A nurse is reinforcing teaching with a group of clients about transient ischemic attacks
(TIAs). Which of the following information should the nurse include in the teaching?
Answer: A TIA can precede an ischemic stroke.
Rationale: TIAs are considered a manifestation of advanced atherosclerotic disease and often
precede an ischemic stroke. Manifestations of a TIA include loss of vision in one eye, inability to
speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness.
26. A nurse is reinforcing teaching with the family of a client who has a new diagnosis of
amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the
following findings is an early manifestation of ALS?
Answer: Weakness of the distal extremities
Rationale: ALS is a progressive neurogenerative disease that involves the motor nerve cells in
the brain and the spinal cord causing muscle wasting, spasticity, and eventually paralysis. Early
manifestations of ALS include increasing muscle weakness, especially involving the distal arms
and legs (hands and feet), speech, swallowing, and breathing.
27. A nurse is reinforcing discharge teaching with the family of a client who has a new diagnosis
of a seizure disorder. The nurse should instruct the client's family to take which of the following
actions first in the event of a seizure?
Answer: Protect the client's head.
Rationale: The nurse should apply the safety and risk reduction priority-setting framework. This
framework assigns priority to the factor or situation posing the greatest safety risk to the client.
When there are several risks to client safety, the one posing the greatest threat is the highest
priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting
framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
The client is at greatest risk for injury from hitting his head; therefore, the first action the nurse
should take is to protect the client's head from injury.
28. A nurse is reinforcing teaching with a client who is postoperative following cataract surgery
and has an intraocular lens implant. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: "I will avoid bending over."
Rationale: The nurse should instruct the client to avoid activities that can increase intraocular
pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in
intraocular pressure can result in intraocular hemorrhage.
29. A nurse is reinforcing teaching with a client who is preoperative for cataract surgery. The
nurse should include in the teaching that which of the following is an adverse effect of cataract
surgery?
Answer: Intraocular hemorrhage
Rationale: Intraocular hemorrhage is an adverse effect of cataract surgery. The client should
immediately report manifestations of intraocular hemorrhage, such as eye pain, brow pain, and
decreased vision, to the provider.
30. A nurse is collecting data from a client following a recent head injury. Which of the following
findings should the nurse recognize as a manifestation of increased intracranial pressure?
Answer: Widened pulse pressure
Rationale: A widening of the pulse pressure, the difference between the systolic and diastolic
pressure, is a manifestation of increased intracranial pressure. Other manifestations include pupil
changes, change in the level of consciousness, and nausea and vomiting.
