A. Systolic blood pressure.
B. Urine output.
C. Breath sounds.
D. Cerebral perfusion pressure.
E. Level of pain.
02. A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor?
A. Unequal pupil size.
B. Decreasing systolic blood pressure.
C. Tachycardia.
D. Decreasing body temperature.
03. Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem?
A. Slow, irregular respirations.
B. Rapid, shallow respirations.
C. Asymmetric chest excursion.
D. Nasal fl aring.
04. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the I.V. line. Which nursing intervention protects the client without increasing her increased intracranial pressure (ICP)?
A. Place her in a jacket restraint.
B. Wrap her hands in soft “mitten” restraints.
C. Tuck her arms and hands under the drawsheet.
D. Apply a wrist restraint to each arm.
05. The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring?
A. Muscle relaxation.
B. Intake and output.
C. Widening of the pulse pressure.
D. Pupil dilation.
06. Which of the following is contraindicated for a client with seizure precautions?
A. Encouraging him to perform his own personal hygiene.
B. Allowing him to wear his own clothing.
C. Assessing oral temperature with a glass thermometer.
D. Encouraging him to be out of bed.
07. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should:
A. Count the rate to be sure that ventilations are deep enough to be suffi cient.
B. Notify the physician of the client’s breathing pattern.
C. Increase the rate of ventilations.
D. Increase the tidal volume on the ventilator.
08. The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has?
A. Drowsiness.
B. Inability to move.
C. Paresthesia.
D. Hypotension.
09. What is the priority nursing intervention in the postictal phase of a seizure?
A. Reorient the client to time, person, and place.
B. Determine the client’s level of sleepiness.
C. Assess the client’s breathing pattern.
D. Position the client comfortably.
10. During the fi rst 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client’s:
A. Pulse.
B. Respirations.
C. Blood pressure.
D. Temperature.
11. Which of the following techniques does the nurse avoid when changing a client’s position in bed if the client has hemiparalysis?
A. Rolling the client onto the side.
B. Sliding the client to move up in bed.
C. Lifting the client when moving the client up in bed.
D. Having the client help lift off the bed using a trapeze.
12. For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?
A. Speaking loudly.
B. Using a picture board.
C. Writing directions so client can read them.
D. Speaking in short sentences.
13. Which of the following is an initial sign of Parkinson’s disease?
A. Rigidity.
B. Tremor.
C. Bradykinesia.
D. Akinesia.
14. A client with Parkinson’s disease is prescribed levodopa (L-dopa) therapy. Improvement in which of the following indicates effective therapy?
A. Mood.
B. Muscle rigidity.
C. Appetite.
D. Alertness.
15. Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)?
A. Double vision.
B. Sudden bursts of energy.
C. Weakness in the extremities.
D. Muscle tremors.
16. The nurse observes that the right eye of an unconscious client does not close completely.Which nursing intervention is most appropriate?
A. Have the client wear eyeglasses at all times.
B. Lightly tape the eyelid shut.
C. Instill artifi cial tears once every shift.
D. Clean the eyelid with a washcloth every shift.
17. Which sign is an early indicator of hypoxia in the unconscious client?
A. Cyanosis.
B. Decreased respirations.
C. Restlessness.
D. Hypotension.
18. Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system should include:
A. Reassuring the client that pain will be relieved.
B. Documenting the client’s response to pain medication on a routine basis.
C. Instructing the client to continue pressing the system’s button whenever pain occurs.
D. Titrating the client’s pain medication until the client is free from pain.
19. The nurse notices that a client with Parkinson’s disease is coughing frequently when eating.Which one of the following interventions should the nurse consider?
A. Have the client hyperextend the neck when swallowing.
B. Tell the client to place the chin fi rmly against the chest when eating.
C. Thicken all liquids before offering to the client.
D. Place the client on a clear liquid diet.
Neurological Disorder Answer and Rational
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