Nervous System | Neurological Disorders NCLEX Quiz 56

1. A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of:

Hypertension

Heart failure

Prosthetic valve replacement

Chronic obstructive pulmonary disorder

The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client. such as orthopedic hardware. pacemakers. artificial heart valves. aneurysm clips. or intrauterine devices. These may heat up. become dislodged. or malfunction during this procedure. The client may be ineligible if a significant risk exists.

Explanation

The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client. such as orthopedic hardware. pacemakers. artificial heart valves. aneurysm clips. or intrauterine devices. These may heat up. become dislodged. or malfunction during this procedure. The client may be ineligible if a significant risk exists.

2. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?

Immobilize the neck before the client is moved onto a stretcher.

Determine whether the client is allergic to iodine. contrast dyes. or shellfish.

Place a cap on the client’s head.

Administer a sedative as ordered.

Because CT commonly involves the use of a contrast agent. the nurse should determine whether the client is allergic to iodine. contrast dyes. or shellfish.Option A: Neck immobilization is necessary only if the client has a suspected spinal cord injury.Option C: Placing a cap over the client’s head may lead to misinterpretation of test results; instead. the hair should be combed smoothly.Option D: The physician orders a sedative only if the client can’t be expected to remain still during the CT scan.

Explanation

Because CT commonly involves the use of a contrast agent. the nurse should determine whether the client is allergic to iodine. contrast dyes. or shellfish.Option A: Neck immobilization is necessary only if the client has a suspected spinal cord injury.Option C: Placing a cap over the client’s head may lead to misinterpretation of test results; instead. the hair should be combed smoothly.Option D: The physician orders a sedative only if the client can’t be expected to remain still during the CT scan.

3. A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position?

Side-lying. with a pillow under the hip

Prone. with a pillow under the abdomen

Prone. in slight-Trendelenburg’s position

Side-lying. with the legs. pulled up and head bent down onto the chest.

The client undergoing lumbar puncture is positioned lying on the side. with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae.

Explanation

The client undergoing lumbar puncture is positioned lying on the side. with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae.

4. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse. "Sometimes I feel so frustrateD. I can't do anything without help!" This comment best supports which nursing diagnosis?

Anxiety

Powerlessness

Ineffective denial

Risk for disuse syndrome

This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome. characterized by an active and functioning mind locked in a body that can’t perform even simple daily tasks.Options A and D: Although Anxiety and Risk for disuse syndrome may be the nursing diagnosis associated with ALS. the client’s comment specifically refers to an inability to act autonomously.Option C: A diagnosis of Ineffective denial would be indicated if the client didn’t seem to perceive the personal relevance of symptoms or danger.

Explanation

This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome. characterized by an active and functioning mind locked in a body that can’t perform even simple daily tasks.Options A and D: Although Anxiety and Risk for disuse syndrome may be the nursing diagnosis associated with ALS. the client’s comment specifically refers to an inability to act autonomously.Option C: A diagnosis of Ineffective denial would be indicated if the client didn’t seem to perceive the personal relevance of symptoms or danger.

5. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority for this client's plan of care?

Disturbed sensory perception (visual)

Self-care deficient: Dressing/grooming

Impaired verbal communication

Risk for injury

Because the client is disoriented and restless. the most important nursing diagnosis is risk for injury.Options A. B. and C: Although the other options may be appropriate. they’re secondary because they don’t immediately affect the client’s health or safety.

Explanation

Because the client is disoriented and restless. the most important nursing diagnosis is risk for injury.Options A. B. and C: Although the other options may be appropriate. they’re secondary because they don’t immediately affect the client’s health or safety.

6. Nurse Mary witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to opens the airway in this victim by using which method?

Flexed position

Head tilt-chin lift

Jaw-thrust maneuver

Modified head tilt-chin lift

If a neck injury is suspected. the jaw thrust maneuver is used to open the airway.Option A: A flexed position is an inappropriate position for opening the airway.Option B: The head tilt–chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present.

Explanation

If a neck injury is suspected. the jaw thrust maneuver is used to open the airway.Option A: A flexed position is an inappropriate position for opening the airway.Option B: The head tilt–chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present.

7. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain?

Sternal rub

Nail bed pressure

Pressure on the orbital rim

Squeezing of the sternocleidomastoid muscle

Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response.Options A. C. and D: Cerebral responses to pain are tested using the sternal rub. placing upward pressure on the orbital rim. or squeezing the clavicle or sternocleidomastoid muscle.

Explanation

Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response.Options A. C. and D: Cerebral responses to pain are tested using the sternal rub. placing upward pressure on the orbital rim. or squeezing the clavicle or sternocleidomastoid muscle.

8. During a routine physical examination to assess a male client's deep tendon reflexes. the nurse should make sure to:

Use the pointed end of the reflex hammer when striking the Achilles’ tendon.

Support the joint where the tendon is being tested.

Tap the tendon slowly and softly

Hold the reflex hammer tightly.

To prevent the attached muscle from contracting. the nurse should support the joint where the tendon is being tested.Option A: The nurse should use the flat. not pointed. end of the reflex hammer when striking the Achilles’ tendon. (The pointed end is used to strike over small areas. such as the thumb placed over the biceps tendon.).Option C: Tapping the tendon slowly and softly wouldn’t provoke a deep tendon reflex response.Option D: The nurse should hold the reflex hammer loosely. not tightly. between the thumb and fingers so it can swing in an arc.

Explanation

To prevent the attached muscle from contracting. the nurse should support the joint where the tendon is being tested.Option A: The nurse should use the flat. not pointed. end of the reflex hammer when striking the Achilles’ tendon. (The pointed end is used to strike over small areas. such as the thumb placed over the biceps tendon.).Option C: Tapping the tendon slowly and softly wouldn’t provoke a deep tendon reflex response.Option D: The nurse should hold the reflex hammer loosely. not tightly. between the thumb and fingers so it can swing in an arc.

9. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?

Head midline

Head turned to the side

Neck in neutral position

Head of bed elevated 30 to 45 degrees

The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client’s neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

Explanation

The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client’s neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

10. For a male client with suspected increased intracranial pressure (ICP). a most appropriate respiratory goal is to:

Prevent respiratory alkalosis.

Lower arterial pH.

Promote carbon dioxide elimination.

Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP.Options A and B: Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis. an undesirable condition in this case.Option D: It isn’t necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.

Explanation

The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP.Options A and B: Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis. an undesirable condition in this case.Option D: It isn’t necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.