Deck 20: Advanced Neurologic Care

Question 1

The nurse is caring for four clients. Which does the nurse assess first?

A) CPP: 42 mm Hg
B) CPP: 49 mm Hg
C) CPP: 54 mm Hg
D) CPP: 68 mm Hg

Answer 1

CPP: 42 mm Hg

Question 2

The nurse reads a client's medical record and the last assessment documented the client's pupils as having consensual pupillary reflex. What does the nurse understand this to mean?

A) Normal: When a light is shined in one eye, the other pupil constricts too.
B) Normal: When looking at a distant object, both pupils constrict
C) Abnormal: Indicates return of a primitive reflex due to cerebral ischemia
D) Abnormal: Indicates impending brain herniation

Answer 2

Normal: When a light is shined in one eye, the other pupil constricts too.

Question 3

The nurse assesses a client's pupils to be 7 mm. What action by the nurse is best?

A) Document the findings in the client's chart
B) Compare this finding to previous assessments
C) Notify the provider immediately
D) Prepare the client for surgical intervention

Answer 3

Compare this finding to previous assessments

Question 4

Which assessment finding requires the nurse to conduct further assessments?

A) Neurological Pupil Index (NPi): 4
B) NPi: 2
C) Right pupil 5 mm, left pupil 5.5 mm
D) Pupil response sluggish at 0700, brisk at 1200

Question 5

A nurse is caring for a client with dysarthria. What assessment finding is consistent with this diagnosis?

A) Cannot understand spoken language
B) Understands but cannot express self verbally
C) Slurred speech with a new lisp
D) Inability to recognize drawings

Question 6

When the nurse places a stethoscope on an unconscious client's chest, the client reacts as shown. What does the nurse interpret from this observation?

A) Seizure
B) Primitive startle reflex
C) Severe brain damage
D) Meningeal irritation

Question 7

The nurse is assessing a client's motor responses and applies pressure to the client's nailbed. The client responds by reaching over with the other hand to brush the nurse away. How does the nurse chart this finding?

A) Decorticate posturing
B) Decerebrate posturing
C) Withdrawal
D) Localization

Question 8

The nurse is caring for a client who is getting a lumbar puncture (LP). The client also has COPD. Which assessment takes priority for this client during the exam?

A) Airway
B) Breathing
C) Circulation
D) Pain

Question 9

The nurse reviews the client's daily laboratory results and the results of a lumbar puncture. The client's serum glucose was 136 mg/dL and the spinal glucose was 75 mg/dL. What action does the nurse take?

A) Document the findings in the client's chart.
B) Assess the client for infection.
C) Anticipate a work up for diabetes.
D) Compare the serum and CSF protein levels.

Question 10

An hour after a client has a lumbar puncture (LP), the client reports a headache. What action does the nurse take first?

A) Place the client on Droplet Precautions.
B) Call the Rapid Response Team.
C) Assess for neck stiffness.
D) Administer pain medication.

Question 11

The nurse is assessing a client's intracranial pressure via an external ventricular drain (EVD). The reading is markedly different from the previous one. What action does the nurse take next?

A) Ensures the transducer is at the level of the tragus
B) Confirms the CSF drain is open during the readings
C) Facilitates the client getting a stat skull x-ray
D) Irrigates the drain tubing with sterile normal saline

Question 12

The nurse is caring for a client who had a stroke and has damage to Broca's area of the brain. What intervention does the nurse use for this client?

A) Repeat questions slowly if the client doesn't answer.
B) Communicate by writing on a tablet.
C) Assess the client for aspiration.
D) Be patient with client frustration.

Question 13

A nurse assesses a client's blood pressure to be 180/68 mm Hg. Earlier in the day, the client's blood pressure was 142/86 mm Hg. What action by the nurse is most appropriate?

A) Administer an antihypertensive medication.
B) Assess the client's heart rate.
C) Assess the client for pain or anxiety.
D) Perform a MEND examination.

Question 14

A student is teaching a client about risk factors for stroke. What information provided by the student demonstrates a need to review the information?

A) "Continue to take your blood pressure medication as prescribed."
B) "Let's ask your provider about smoking cessation medications."
C) "A lot of your relatives had strokes; good thing family history is not important."
D) "You should have your cholesterol checked on a routine basis."

Question 15

Which statement about intracranial pressure waves is correct?

A) P1 corresponds to diastolic blood pressure.
B) P2 demonstrates brain compliance.
C) P3 is the largest of the three waves.
D) P4 occurs when the aortic valve closes.

Question 16

The nurse is caring for a client whose intracranial pressure waveform appears as shown. What action by the nurse is best?

A) Calculate the client's CPP.
B) Ensure the client's neck is midline.
C) Document the findings in the chart.
D) Call an RRT.

Question 17

A client has an external ventricular drain (EVD). What assessment findings indicate to the nurse that a priority outcome has been met?

A) Client's CSF is clear and colorless.
B) Client's pain is controlled with medication.
C) Client is able to sleep uninterrupted for 4 hours.
D) Clients' CSF glucose is 1/2 the serum glucose.

Question 18

A client has a seizure. What action does the nurse take first?

A) Insert a padded tongue blade into the client's mouth.
B) Administer IV diazepam or lorazepam as prescribed.
C) Roll the client onto his or her side.
D) Obtain a set of vital signs.

Question 19

The nurse is performing a neurological exam on a client and observes the following: Pupils: equal, round, reactive to light and accommodation; eyes open to verbal command; uses inappropriate words to answer questions; obeys commands; hand grasps are weak but equal bilaterally. Calculate the client's Glasgow Coma Score.

A) 3
B) 6
C) 9
D) 12

Question 20

A client has the following data: Blood pressure: 116/72, Pulse: 68 beats/min, Respirations: ventilator rate 18 breaths/min, Temperature: 37 $\degree$ C (98.6 $\degree$ F), ICP 56, oxygen saturation 97%. Calculate the client's cerebral perfusion pressure. Round to the nearest whole number.The client's cerebral perfusion pressure is:

A) 31
B) 46
C) 142
D) 203

Question 21

Which of the following terms are correctly matched to the description? (Select all that apply.)

A) Lethargic: Client may require noxious stimulation to induce very limited interaction
B) Obtunded: Client with most arousable state of lethargy if stimulated
C) Somnolent: Client requires more stimulation and will drift back to sleep quickly without stimulation
D) Stupor: Client definitely requires noxious stimulation and may only respond with a groan
E) Vegetative state: Client unresponsive to persistent noxious stimulation; lacks sleep and wake cycles

Question 22

The nurse is conducting a BE-FAST exam on a client suspected of having a stroke. What does this assessment include? (Select all that apply.)

A) Balance
B) Face
C) Additional signs
D) Eyes
E) Suddenness

Question 23

The nurse observing a client during a seizure reports which findings to the provider? (Select all that apply.)

A) Presentation of the seizure
B) Duration of the seizure
C) MEND score
D) Mental status after the seizure
E) Client behavior prior to the seizure

Question 24

The nurse is placing a client on seizure precautions. What actions does this entail? (Select all that apply.)

A) Padding all side rails of the bed
B) Removing sharp objects from the environment
C) Taping padded tongue blades to the wall
D) Placing all four side rails up on the bed
E) Placing a "seizure precautions" sign on the door

Question 25

The nurse is caring for a client with increased intracranial pressure (ICP). What interventions does the nurse include in the client's plan of care? (Select all that apply.)

A) Provide a calm, quiet environment.
B) Use a continuous rectal probe for temperature.
C) Avoid using restraints unless absolutely needed.
D) Position client side-lying with hips and knees flexed.
E) Maintain elevation of the head of the bed to 30 degrees.