Nervous System | Neurological Disorders NCLEX Quiz 55

1. A male client is having tonic-clonic seizures. What should the nurse do first?

Elevate the head of the bed.

Restrain the client’s arms and legs.

Place a tongue blade in the client’s mouth.

Take measures to prevent injury.

Protecting the client from injury is the immediate priority during a seizure.Option A: Elevating the head of the bed would have no effect on the client’s condition or safety.Option B: Restraining the client’s arms and legs could cause injury.Option C: Placing a tongue blade or other object in the client’s mouth could damage the teeth.

Explanation

Protecting the client from injury is the immediate priority during a seizure.Option A: Elevating the head of the bed would have no effect on the client’s condition or safety.Option B: Restraining the client’s arms and legs could cause injury.Option C: Placing a tongue blade or other object in the client’s mouth could damage the teeth.

2. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

Sit with the client for a few minutes.

Administer an analgesic.

Inform the nurse manager.

Call the physician immediately.

A headache may be an indication that an aneurysm is leaking. The nurse should notify the physician immediately.Option A: Sitting with the client is appropriate but only after the physician has been notified of the change in the client’s condition.Option B: The physician will decide whether or not an administration of an analgesic is indicated.Option C: Informing the nurse manager isn’t necessary.

Explanation

A headache may be an indication that an aneurysm is leaking. The nurse should notify the physician immediately.Option A: Sitting with the client is appropriate but only after the physician has been notified of the change in the client’s condition.Option B: The physician will decide whether or not an administration of an analgesic is indicated.Option C: Informing the nurse manager isn’t necessary.

3. A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma. exogenous obesity. and iron deficiency anemia. Which history finding is a risk factor for CVA?

Caucasian race

Female sex

Obesity

Bronchial asthma

Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes. cardiovascular disease. diabetes mellitus. atherosclerosis of the cranial vessels. hypertension. polycythemia. smoking. hypercholesterolemia. oral contraceptive use. emotional stress. family history of CVA. and advancing age.Options A. B. and D: The client’s race. sex. and bronchial asthma aren’t a risk factors for CVA.

Explanation

Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes. cardiovascular disease. diabetes mellitus. atherosclerosis of the cranial vessels. hypertension. polycythemia. smoking. hypercholesterolemia. oral contraceptive use. emotional stress. family history of CVA. and advancing age.Options A. B. and D: The client’s race. sex. and bronchial asthma aren’t a risk factors for CVA.

4. The nurse is working on a surgical floor. The nurse must log roll a male client following a:

Laminectomy.

Thoracotomy.

Hemorrhoidectomy.

Cystectomy.

The client who has had spinal surgery. such as laminectomy. must be logrolled to keep the spinal column straight when turning.Options B and D: The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position.Option C: Under normal circumstances. hemorrhoidectomy is an outpatient procedure. and the client may resume normal activities immediately after surgery.

Explanation

The client who has had spinal surgery. such as laminectomy. must be logrolled to keep the spinal column straight when turning.Options B and D: The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position.Option C: Under normal circumstances. hemorrhoidectomy is an outpatient procedure. and the client may resume normal activities immediately after surgery.

5. A male client is color blind. The nurse understands that this client has a problem with:

Rods.

Cones.

Lens.

Aqueous humor.

Cones provide daylight color vision. and their stimulation is interpreted as color. If one or more types of cones are absent or defective. color blindness occurs.Option A: Rods are sensitive to low levels of illumination but can’t discriminate color.Option C: The lens is responsible for focusing images.Option D: Aqueous humor is a clear watery fluid and isn’t involved in color perception.

Explanation

Cones provide daylight color vision. and their stimulation is interpreted as color. If one or more types of cones are absent or defective. color blindness occurs.Option A: Rods are sensitive to low levels of illumination but can’t discriminate color.Option C: The lens is responsible for focusing images.Option D: Aqueous humor is a clear watery fluid and isn’t involved in color perception.

6. During recovery from a cerebrovascular accident (CVA). a female client is given nothing by mouth. to help prevent aspiration. To determine when the client is ready for a liquid diet. the nurse assesses the client's swallowing ability once each shift. This assessment evaluates:

Cranial nerves I and II.

Cranial nerves III and V.

Cranial nerves VI and VIII.

Cranial nerves IX and X.

Swallowing is a motor function of cranial nerves IX and X.Options A. B. and C: Cranial nerves I. II. and VIII don’t possess motor functions. The motor functions of cranial nerve III include extraocular eye movement. eyelid elevation. and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

Explanation

Swallowing is a motor function of cranial nerves IX and X.Options A. B. and C: Cranial nerves I. II. and VIII don’t possess motor functions. The motor functions of cranial nerve III include extraocular eye movement. eyelid elevation. and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

7. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue. the nurse should tell the client to:

Take a hot bath.

Rest in an air-conditioned room.

Increase the dose of muscle relaxants.

Avoid naps during the day.

Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however. extreme cold should be avoided. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression. using occupational therapy to learn energy conservation techniques. and reducing spasticity.Option A: A hot bath or shower can increase body temperature. producing fatigue.Option C: Muscle relaxants. prescribed to reduce spasticity. can cause drowsiness and fatigue.Option D: Planning for frequent rest periods and naps can relieve fatigue.

Explanation

Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however. extreme cold should be avoided. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression. using occupational therapy to learn energy conservation techniques. and reducing spasticity.Option A: A hot bath or shower can increase body temperature. producing fatigue.Option C: Muscle relaxants. prescribed to reduce spasticity. can cause drowsiness and fatigue.Option D: Planning for frequent rest periods and naps can relieve fatigue.

8. A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination. the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

Diencephalon

Medulla

Midbrain

Cortex

Decerebrate posturing. characterized by abnormal extension in response to painful stimuli. indicates damage to the midbrain.Options A and D: With damage to the diencephalon or cortex. abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied.Option B: Damage to the medulla results in flaccidity.

Explanation

Decerebrate posturing. characterized by abnormal extension in response to painful stimuli. indicates damage to the midbrain.Options A and D: With damage to the diencephalon or cortex. abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied.Option B: Damage to the medulla results in flaccidity.

9. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis. how should the nurse respond?

“You may have difficulty believing this. but the paralysis caused by this disease is temporary.”

“You’ll have to accept the fact that you’re permanently paralyzeD. However. you won’t have any sensory loss.”

“It must be hard to accept the permanency of your paralysis.”

“You’ll first regain use of your legs and then your arms.”

The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

Explanation

The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

10. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?

Vision changes

Absent deep tendon reflexes

Tremors at rest

Flaccid muscles

Vision changes. such as diplopia. nystagmus. and blurred vision. are symptoms of multiple sclerosis.Option B: Deep tendon reflexes may be increased or hyperactive — not absent. Babinski’s sign may be positive.Option C: Tremors at rest aren’t characteristic of multiple sclerosis; however. intentional tremors. or those occurring with purposeful voluntary movement. are common in clients with multiple sclerosis.Option D: Affected muscles are spastic. rather than flaccid.

Explanation

Vision changes. such as diplopia. nystagmus. and blurred vision. are symptoms of multiple sclerosis.Option B: Deep tendon reflexes may be increased or hyperactive — not absent. Babinski’s sign may be positive.Option C: Tremors at rest aren’t characteristic of multiple sclerosis; however. intentional tremors. or those occurring with purposeful voluntary movement. are common in clients with multiple sclerosis.Option D: Affected muscles are spastic. rather than flaccid.