Nervous System | Neurological Disorders NCLEX Quiz 53 | Attempts: 1207

2.

The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following?

Cerebellar function
Intellectual function
Cerebral function
Sensory function

Correct Answer

A. Cerebral function

Explanation

The mental status examination assesses functions governed by the cerebrum. Some of these are orientation. attention span. judgment. and abstract reasoning.Option A: Cerebellar function testing assesses coordination. equilibrium. and fine motor movement.Option B: Intellectual functioning isn’t the only cerebral activity.Option D: Sensory function testing involves assessment of pain. light-touch sensation. and temperature discrimination.

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3.

Shortly after admission to an acute care facility. a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam. if needed and prescribed?

In 30 to 45 seconds
In 10 to 15 minutes
In 30 to 45 minutes
In 1 to 2 hours

Correct Answer

A. In 10 to 15 minutes

Explanation

When used to treat status epilepticus. diazepam may be given every 10 to 15 minutes. as needed. to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours. if necessary. but the total dose shouldn’t exceed 100 mg in 24 hours.Option A: The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore. the dose can’t be repeated in 30 to 45 seconds because the first dose wouldn’t have been administered completely by that time.Option B: Waiting longer than 15 minutes to repeat the dose would increase the client’s risk of complications associated with status epilepticus.

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4.

A female client complains of periorbital aching. tearing. blurred vision. and photophobia in her right eye. Ophthalmologic examination reveals a small. irregular. nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen. the physician prescribes atropine sulfate (Atropisol). two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification?

Parasympathomimetic agent
Sympatholytic agent
Adrenergic blocker
Cholinergic blocker

Correct Answer

A. Cholinergic blocker

Explanation

Atropine sulfate is a cholinergic blocker. It isn’t a parasympathomimetic agent. a sympatholytic agent. or an adrenergic blocker.

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5.

Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse. “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag.” Which intervention by the nurse has the highest priority?

Assessing the left leg
Assessing the pupils
Placing the client in Trendelenburg’s position
Assessing level of consciousness

Correct Answer

A. Assessing the left leg

Explanation

In the scenario. airway and breathing are established so the nurse’s next priority should be circulation. With a compound fracture of the femur. there is a high risk of profuse bleeding; therefore. the nurse should assess the site.Option B and D: Neurologic assessment is a secondary concern to airway. breathing. and circulation.Option C: The nurse doesn’t have enough data to warrant putting the client in Trendelenburg’s position.

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6.

An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes. and then take him to the emergency department of a nearby hospital. where he receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension). two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic). 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by:

Increasing the exudative reaction of ocular tissue.
Decreasing leukocyte infiltration at the site of ocular inflammation.
Inhibiting the action of carbonic anhydrase.
Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris.

Correct Answer

A. Decreasing leukocyte infiltration at the site of ocular inflammation.

Explanation

Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This reduces the exudative reaction of diseased tissue. lessening edema. redness. and scarring.Options C and D: Dexamethasone and other anti-inflammatory agents don’t inhibit the action of carbonic anhydrase or produce any type of miotic reaction.

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7.

Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal?

More back pain than the first postoperative day
Paresthesia in the dermatomes near the wounds
Urine retention or incontinence
Temperature of 99.2° F (37.3° C)

Correct Answer

A. Urine retention or incontinence

Explanation

Urine retention or incontinence may indicate cauda equina syndrome. which requires immediate surgery.Option A: An increase in pain on the second postoperative day is common because the long-acting local anesthetic. which may have been injected during surgery. will wear off.Option B: While paresthesia is common after surgery. progressive weakness or paralysis may indicate spinal nerve compression.Option D: A mild fever is also common after surgery but is considered significant only if it reaches 101° F (38.3° C).

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8.

After an eye examination. a male client is diagnosed with open-angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Pilocar). 0.25% gtt i. OU q.i.D. Based on this prescription. the nurse should teach the client or a family member to administer the drug by:

Instilling one drop of pilocarpine 0.25% into both eyes daily.
Instilling one drop of pilocarpine 0.25% into both eyes four times daily.
Instilling one drop of pilocarpine 0.25% into the right eye daily.
Instilling one drop of pilocarpine 0.25% into the left eye four times daily.

Correct Answer

A. Instilling one drop of pilocarpine 0.25% into both eyes four times daily.

Explanation

The abbreviation “gtt” stands for drop. “i” is the apothecary symbol for the number 1. OU signifies both eyes. and “q.i.d.” means four times a day. Therefore. one drop of pilocarpine 0.25% should be instilled into both eyes four times daily.

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9.

A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

The client leaves the side rails down.
The client uses a mirror to inspect the skin.
The client repositions only after being reminded to do so.
The client hangs the left arm over the side of the wheelchair.

Correct Answer

A. The client uses a mirror to inspect the skin.

Explanation

Using a mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members.Option A: The client should keep the side rails up to help with repositioning and to prevent falls.Option C: The paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it if needed.Option D: A client with left-side paralysis may not realize that the left arm is hanging over the side of the wheelchair. However. the nurse should call this to the client’s attention because the arm can get caught in the wheel spokes or develop impaired circulation from being in a dependent position for too long.

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10.

A male client in the emergency department has a suspected neurologic disorder. To assess gait. the nurse asks the client to take a few steps; with each step. the client’s feet make a half circle. To document the client’s gait. the nurse should use which term?

Ataxic
Dystrophic
Helicopod
Steppage

Correct Answer

A. Helicopod

Explanation

A helicopod gait is an abnormal gait in which the client’s feet make a half circle with each step.Option A: An ataxic gait is staggering and unsteady.Option B: In a dystrophic gait. the client waddles with the legs far apart.Option D: In a steppage gait. the feet. and toes raise high off the floor and the heel comes down heavily with each step.

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Nervous System | Neurological Disorders NCLEX Quiz 53

To encourage adequate nutritional intake for a female client with Alzheimer’s disease. the nurse should:

Quiz Preview

The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following?

Shortly after admission to an acute care facility. a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam. if needed and prescribed?

Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal?

After an eye examination. a male client is diagnosed with open-angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Pilocar). 0.25% gtt i. OU q.i.D. Based on this prescription. the nurse should teach the client or a family member to administer the drug by:

A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

A male client in the emergency department has a suspected neurologic disorder. To assess gait. the nurse asks the client to take a few steps; with each step. the client’s feet make a half circle. To document the client’s gait. the nurse should use which term?