Nervous System | Neurological Disorders NCLEX Quiz 52

1. Which of the following assessment data indicated nuchal rigidity?

Positive Kernig’s sign

Negative Brudzinski’s sign

Positive homan’s sign

Negative Kernig’s sign

A positive Kernig’s sign indicated nuchal rigidity. caused by an irritative lesion of the subarachnoid space. Brudzinski’s sign is also indicative of the condition.

Explanation

A positive Kernig’s sign indicated nuchal rigidity. caused by an irritative lesion of the subarachnoid space. Brudzinski’s sign is also indicative of the condition.

2. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus. the nurse would anticipate that the client has problems with:

Body temperature control.

Balance and equilibrium.

Visual acuity.

Thinking and reasoning.

The body’s thermostat is located in the hypothalamus; therefore. injury to that area can cause problems of body temperature control.Option B: Balance and equilibrium problems are related to cerebellar damage.Option C: Visual acuity problems would occur following occipital or optic nerve injury.Option D: Thinking and reasoning problems are the result of injury to the cerebrum.

Explanation

The body’s thermostat is located in the hypothalamus; therefore. injury to that area can cause problems of body temperature control.Option B: Balance and equilibrium problems are related to cerebellar damage.Option C: Visual acuity problems would occur following occipital or optic nerve injury.Option D: Thinking and reasoning problems are the result of injury to the cerebrum.

3. When obtaining the health history from a male client with retinal detachment. the nurse expects the client to report:

Light flashes and floaters in front of the eye.

A recent driving accident while changing lanes.

Headaches. nausea. and redness of the eyes.

Frequent episodes of double vision.

The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment.Option B: Difficulty seeing cars in another driving lane suggests a gradual loss of peripheral vision. which may indicate glaucoma.Option C: Headache. nausea. and redness of the eyes are signs of acute (angle-closure) glaucoma.Option D: Double vision is common in clients with cataracts.

Explanation

The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment.Option B: Difficulty seeing cars in another driving lane suggests a gradual loss of peripheral vision. which may indicate glaucoma.Option C: Headache. nausea. and redness of the eyes are signs of acute (angle-closure) glaucoma.Option D: Double vision is common in clients with cataracts.

4. A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child. the nurse would expect to note which of the following if this type of posturing was present?

Abnormal flexion of the upper extremities and extension of the lower extremities

Rigid extension and pronation of the arms and legs

Rigid pronation of all extremities

Flaccid paralysis of all extremities

Decerebrate posturing is characterized by the rigid extension and pronation of the arms and legs.

Explanation

Decerebrate posturing is characterized by the rigid extension and pronation of the arms and legs.

5. Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions?

Congenital anatomic abnormality of the meninges

Lack of acquired resistance to the various etiologic organisms

Occlusion or narrowing of the CSF pathway

Natural affinity of the CNS to certain pathogens

Extension of a variety of bacterial infections is a major causative factor of meningitis and occurs as a result of a lack of acquired resistance to the etiologic organisms. Preexisting CNS anomalies are factors that contribute to susceptibility.

Explanation

Extension of a variety of bacterial infections is a major causative factor of meningitis and occurs as a result of a lack of acquired resistance to the etiologic organisms. Preexisting CNS anomalies are factors that contribute to susceptibility.

6. You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN?

Complete admission assessment.

Set up oxygen and suction equipment.

Place a padded tongue blade at bedside.

Pad the side rails before patient arrives.

The LPN/LVN can set up the equipment for oxygen and suctioning. Focus: Delegation/supervision.Option A: The RN should perform the complete initial assessment.Option C: Tongue blades should not be at the bedside and should never be inserted into the patient’s mouth after a seizure begins.Option D: Padded side rails are controversial in terms of whether they actually provide safety and ay embarrass the patient and family.

Explanation

The LPN/LVN can set up the equipment for oxygen and suctioning. Focus: Delegation/supervision.Option A: The RN should perform the complete initial assessment.Option C: Tongue blades should not be at the bedside and should never be inserted into the patient’s mouth after a seizure begins.Option D: Padded side rails are controversial in terms of whether they actually provide safety and ay embarrass the patient and family.

7. After striking his head on a tree while falling from a ladder. a young man age 18 is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?

Give him a barbiturate.

Place him on mechanical ventilation.

Perform a lumbar puncture.

Elevate the head of his bed.

The client’s history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case. lumbar puncture shouldn’t be done because it can quickly decompress the central nervous system and. thereby. cause additional damage.Option A: After a head injury. barbiturates may be given to prevent seizures.Option B: Mechanical ventilation may be required if breathing deteriorates.Option D: Elevating the head of the bed may be used to reduce ICP.

Explanation

The client’s history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case. lumbar puncture shouldn’t be done because it can quickly decompress the central nervous system and. thereby. cause additional damage.Option A: After a head injury. barbiturates may be given to prevent seizures.Option B: Mechanical ventilation may be required if breathing deteriorates.Option D: Elevating the head of the bed may be used to reduce ICP.

8. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning. the nurse anticipates administering which drug endotracheally before suctioning?

Phenytoin (Dilantin)

Mannitol (Osmitrol)

Lidocaine (Xylocaine)

Furosemide (Lasix)

Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning.Option A: Phenytoin doesn’t reduce ICP directly but may be used to abolish seizures. which can increase ICP. However. phenytoin isn’t administered endotracheally.Option B and D: Although mannitol and furosemide may be given to reduce ICP. they’re administered parenterally. not endotracheally.

Explanation

Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning.Option A: Phenytoin doesn’t reduce ICP directly but may be used to abolish seizures. which can increase ICP. However. phenytoin isn’t administered endotracheally.Option B and D: Although mannitol and furosemide may be given to reduce ICP. they’re administered parenterally. not endotracheally.

9. Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?

Imbalanced nutrition: Less than body requirements

Ineffective airway clearance

Impaired urinary elimination

Risk for injury

In Parkinson’s crisis. dopamine-related symptoms are severely exacerbated. virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also. excessive drooling increases the risk of airway obstruction. Because of these concerns. the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate. they aren’t immediately life-threatening.

Explanation

In Parkinson’s crisis. dopamine-related symptoms are severely exacerbated. virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also. excessive drooling increases the risk of airway obstruction. Because of these concerns. the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate. they aren’t immediately life-threatening.

10. Which of the following pathologic processes is often associated with aseptic meningitis?

Ischemic infarction of cerebral tissue

Childhood diseases of viral causation such as mumps

Brain abscesses caused by a variety of pyogenic organisms

Cerebral ventricular irritation from a traumatic brain injury

Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles. mumps. herpes. and leukemia.Options A and C: Incidences of brain abscess are high in bacterial meningitis. and ischemic infarction of cerebral tissue can occur with tubercular meningitis.Option D: Traumatic brain injury could lead to bacterial (not viral) meningitis.

Explanation

Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles. mumps. herpes. and leukemia.Options A and C: Incidences of brain abscess are high in bacterial meningitis. and ischemic infarction of cerebral tissue can occur with tubercular meningitis.Option D: Traumatic brain injury could lead to bacterial (not viral) meningitis.