Neurological Problems of the Adult Client

1. The nurse is assessing the motor and sensory 5. A client with a spinal cord injury is prone to
function of an unconscious client who sustained a experiencing autonomic dysreflexia. The nurse
head injury. The nurse should use which technique should include which measures in the plan of care
to test the client’s peripheral response to pain? to minimize the risk of occurrence? Select all that
a. Sternal rub apply.
b. Nailbed pressure a. Keeping the linens wrinkle-free under the
c. Pressure on the orbital rim client
d. Squeezing of the sternocleidomastoid b. Preventing unnecessary pressure on the
muscle lower limbs
2. The nurse is caring for the client with increased c. Limiting bladder catheterization to once
intracranial pressure as a result of a head injury? every 12 hours
The nurse would note which trend in vital signs if d. Turning and repositioning the client at
the intracranial pressure is rising? least every 2 hours 5. Ensuring that the
a. Increasing temperature, increasing pulse, client has a bowel movement at least once
increasing respirations, decreasing blood a week
pressure 6. The nurse is evaluating the neurological signs of a
b. Increasing temperature, decreasing pulse, client in spinal shock following spinal cord injury.
decreasing respirations, increasing blood Which observation indicates that spinal shock
pressure persists?
c. Decreasing temperature, decreasing pulse, a. Hyperreflexia
increasing respirations, decreasing blood b. Positive reflexes
pressure c. Flaccid paralysis
d. Decreasing temperature, increasing pulse, d. Reflex emptying of the bladder
decreasing respirations, increasing blood 7. The nurse is caring for a client who begins to
pressure experience seizure activity while in bed. Which
3. A client recovering from a head injury is actions should the nurse take? Select all that apply.
participating in care. The nurse determines that the a. Loosening restrictive clothing.
client understands measures to prevent elevations b. Restraining the client’s limbs.
in intracranial pressure if the nurse observes the c. Removing the pillow and raising padded
client doing which activity? side rails.
a. Blowing the nose d. Positioning the client to the side, if
b. Isometric exercises possible, with the head flexed forward.
c. Coughing vigorously e. Keeping the curtain around the client and
d. Exhaling during repositioning the room door open so when help arrives
4. A client has clear fluid leaking from the nose they can quickly enter to assist.
following a basilar skull fracture. Which finding 8. The nurse is assigned to care for a client with
would alert the nurse that cerebrospinal fluid is complete right-sided hemiparesis from a stroke
present? (brain attack). Which characteristics are associated
a. Fluid is clear and tests negative for with this condition? Select all that apply.
glucose. a. The client is aphasic.
b. Fluid is grossly bloody in appearance and b. The client has weakness on the right side
has a pH of 6. of the body.
c. Fluid clumps together on the dressing and c. The client has complete bilateral paralysis
has a pH of 7. of the arms and legs.
d. Fluid separates into concentric rings and d. The client has weakness on the right side
tests positive for glucose. of the face and tongue.

1
 Neurological Problems of the Adult Client

e. The client has lost the ability to move the b. “I try to exercise every day and rest when
right arm but is able to walk I’m tired.”
independently. c. “My son removed all loose rugs from my
f. The client has lost the ability to ambulate bedroom.”
independently but is able to feed and bathe d. “I don’t need to use my walker to get to
herself or himself without assistance. the bathroom.”
9. The nurse has instructed the family of a client with 13. The nurse has given suggestions to a client with
stroke (brain attack) who has homonymous trigeminal neuralgia about strategies to minimize
hemianopsia about measures to help the client episodes of pain. The nurse determines that the
overcome the deficit. Which statement suggests client needs further teaching if the client makes
that the family understands the measures to use which statement?
when caring for the client? a. “I will wash my face with cotton pads.”
a. “We need to discourage him from wearing b. “I’ll have to start chewing on my
eyeglasses.” unaffected side.”
b. “We need to place objects in his impaired c. “I should rinse my mouth if toothbrushing
field of vision.” is painful.”
c. “We need to approach him from the d. “I’ll try to eat my food either very warm or
impaired field of vision.” very cold.”
d. “We need to remind him to turn his head 14. The client is admitted to the hospital with a
to scan the lost visual field.” diagnosis of Guillain-Barré syndrome. Which past
10. The nurse is assessing the adaptation of a client to medical history finding makes the client most at
changes in functional status after a stroke (brain risk for this disease?
attack). Which observation indicates to the nurse a. Meningitis or encephalitis during the last 5
that the client is adapting most successfully? years
a. Gets angry with family if they interrupt a b. Seizures or trauma to the brain within the
task last year
b. Experiences bouts of depression and c. Back injury or trauma to the spinal cord
irritability during the last 2 years
c. Has difficulty with using modified feeding d. Respiratory or gastrointestinal infection
utensils during the previous month
d. Consistently uses adaptive equipment in 15. A client with Guillain-Barré syndrome has
dressing self ascending paralysis and is intubated and receiving
11. The nurse is teaching a client with myasthenia mechanical ventilation. Which strategy should the
gravis about the prevention of myasthenic and nurse incorporate in the plan of care to help the
cholinergic crises. Which client activity suggests client cope with this illness?
that teaching is most effective? a. Giving client full control over care
a. Taking medications as scheduled decisions and restricting visitors
b. Eating large, well-balanced meals b. Providing positive feedback and
c. Doing muscle-strengthening exercises encouraging active range of motion
d. Doing all chores early in the day while c. Providing information, giving positive
less fatigued feedback, and encouraging relaxation
12. The nurse is instructing a client with Parkinson’s d. Providing intravenously administered
disease about preventing falls. Which client sedatives, reducing distractions, and
statement reflects a need for further teaching? limiting visitors
a. “I can sit down to put on my pants and 16. A client has a neurological deficit involving the
shoes.” limbic system. On assessment, which finding is
specific to this type of deficit?
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 Neurological Problems of the Adult Client

a. Is disoriented to person, place, and time. nurse should bring which most essential items into
b. Affect is flat, with periods of emotional the client’s room?
lability. a. Nebulizer and pulse oximeter
c. Cannot recall what was eaten for breakfast b. Blood pressure cuff and flashlight
today. c. Nasal cannula and incentive spirometer
d. Demonstrates inability to add and subtract; d. Electrocardiographic monitoring
does not know who is the president of the electrodes and intubation tray
United States. 21. Carbidopa-levodopa is prescribed for a client with
17. The nurse is instituting seizure precautions for a Parkinson’s disease. The nurse monitors the client
client who is being admitted from the emergency for side and adverse effects of the medication.
department. Which measures should the nurse Which finding indicates that the client is
include in planning for the client’s safety? Select experiencing an adverse effect?
all that apply. a. Pruritus
a. Padding the side rails of the bed. b. Tachycardia
b. Placing an airway at the bedside. c. Hypertension
c. Placing the bed in the high position. d. Impaired voluntary movements
d. Putting a padded tongue blade at the head 22. The home health nurse visits a client who is taking
of the bed. phenytoin for control of seizures. During the
e. Placing oxygen and suction equipment at assessment, the nurse notes that the client is taking
the bedside. birth control pills. Which information should the
f. Flushing the intravenous catheter to ensure nurse include in the teaching plan?
that the site is patent. a. Pregnancy must be avoided while taking
18. The nurse is evaluating the status of a client who phenytoin.
had a craniotomy 3 days ago. Which assessment b. The client may stop the medication if it is
finding would indicate that the client is developing causing severe gastrointestinal effects.
meningitis as a complication of surgery? c. There is the potential of decreased
a. A negative Kernig’s sign effectiveness of birth control pills while
b. Absence of nuchal rigidity taking phenytoin.
c. A positive Brudzinski’s sign d. There is the increased risk of
d. A Glasgow Coma Scale score of 15 thrombophlebitis while taking phenytoin
19. The nurse has completed discharge instructions for and birth control pills together.
a client with application of a halo device who 23. The nurse is caring for a client in the emergency
sustained a cervical spinal cord injury. Which department who has been diagnosed with Bell’s
statement indicates that the client needs further palsy. The client has been taking acetaminophen,
clarification of the instructions? and acetaminophen overdose is suspected. Which
a. “I will use a straw for drinking.” antidote should the nurse prepare for
b. “I will drive only during the daytime.” administration if prescribed?
c. “I will be careful because the device alters a. Pentostatin
balance.” b. Auranofin
d. I will wash the skin daily under the lamb’s c. Fludarabine
wool liner of the vest.” d. Acetylcysteine
20. The nurse is admitting a client with Guillain-Barré 24. Meperidine has been prescribed for a client to treat
syndrome to the nursing unit. The client has pain. Which side and adverse effects should the
complaints of inability to move both legs and nurse monitor for? Select all that apply.
reports a tingling sensation above the waistline. a. Diarrhea
Knowing the complications of the disorder, the b. Tremors
c. Drowsiness
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 Neurological Problems of the Adult Client

d. Hypotension a. “Alcohol is not contraindicated while

e. Urinary frequency taking this medication.”
f. Increased respiratory rate b. “Good oral hygiene is needed, including
25. A client is taking the prescribed dose of phenytoin brushing and flossing.”
to control seizures. Results of a phenytoin blood c. “The medication dose may be self-
level study reveal a level of 35 mcg/mL (140 adjusted, depending on side effects.”
mcmol/L). Which finding would be expected as a d. “The morning dose of the medication
result of this laboratory result? should be taken before a serum medication
a. Hypotension level is drawn.”
b. Tachycardia 30. A client with myasthenia gravis has become
c. Slurred speech increasingly weaker. The primary health care
d. No abnormal finding provider prepares to identify whether the client is
26. The client arrives at the emergency department reacting to an overdose of the medication
complaining of back spasms. The client states, “I (cholinergic crisis) or an increasing severity of the
have been taking 2 to 3 aspirin every 4 hours for disease (myasthenic crisis). An injection of
the last week, and it hasn’t helped my back.” Since edrophonium is administered. Which finding
acetylsalicylic acid intoxication is suspected, the would indicate that the client is in cholinergic
nurse should assess the client for which crisis?
manifestation? a. No change in the condition
a. Tinnitus b. Complaints of muscle spasms
b. Diarrhea c. An improvement of the weakness
c. Constipation d. A temporary worsening of the condition
d. Photosensitivity. 31. A client with trigeminal neuralgia tells the nurse
27. A client with trigeminal neuralgia is being treated that acetaminophen is taken daily for the relief of
with carbamazepine, 400 mg orally daily. Which generalized discomfort. Which laboratory value
value indicates that the client is experiencing an would indicate toxicity associated with the
adverse effect to the medication? medication?
a. Sodium level, 140 mEq/L (140 mmol/L) a. Sodium level of 140 mEq/L (140 mmol/L)
b. Uric acid level, 4.0 mg/dL (240 mcmol/L) b. Platelet count of 400,000 mm3 (400 × 10 9
c. White blood cell count, 3000 mm3 (3.0 × /L)
10 9 /L) c. Prothrombin time of 12 seconds (12
d. Blood urea nitrogen level, 10 mg/dL (3.6 seconds)
mmol/L) d. Direct bilirubin level of 2 mg/dL (34
28. The nurse is caring for a client with chronic back mcmol/L)
pain. Codeine has been prescribed for the client.
Specific to this medication, which intervention
should the nurse include in the plan of care while
the client is taking this medication?
a. Monitor radial pulse.
b. Monitor bowel activity.
c. Monitor apical heart rate.
d. Monitor peripheral pulses.
29. The nurse has given medication instructions to a
client receiving phenytoin. Which statement
indicates that the client has an adequate
understanding of the instructions?

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 Neurological Problems of the Adult Client

ANSWERS 7. Answer: A, C, D Rationale: Nursing actions during

a seizure include providing for privacy, loosening
1. Answer: B Rationale: Nailbed pressure tests a
restrictive clothing, removing the pillow and
basic motor and sensory peripheral response.
raising padded side rails in the bed, and placing the
Cerebral responses to pain are tested using a
client on 1 side with the head flexed forward, if
sternal rub, placing upward pressure on the orbital
possible, to allow the tongue to fall forward and
rim, or squeezing the clavicle or
facilitate drainage. The limbs are never restrained
sternocleidomastoid muscle.
because the strong muscle contractions could
2. Answer: B Rationale: A change in vital signs may
cause the client harm. If the client is not in bed
be a late sign of increased intracranial pressure.
when seizure activity begins, the nurse lowers the
Trends include increasing temperature and blood
client to the floor, if possible; protects the head
pressure and decreasing pulse and respirations.
from injury; and moves furniture that may injure
Respiratory irregularities also may occur.
the client.
3. Answer: D Rationale: Activities that increase
8. Answer: A, B, D Rationale: Hemiparesis is a
intrathoracic and intraabdominal pressures cause
weakness of one side of the body that may occur
an indirect elevation of the intracranial pressure.
after a stroke. It involves weakness of the face and
Some of these activities include isometric
tongue, arm, and leg on one side. These clients are
exercises, Valsalva’s maneuver, coughing,
also aphasic, unable to discriminate words and
sneezing, and blowing the nose. Exhaling during
letters. They are generally very cautious and get
activities such as repositioning or pulling up in bed
anxious when attempting a new task. Complete
opens the glottis, which prevents intrathoracic
bilateral paralysis does not occur in hemiparesis.
pressure from rising.
The client with right-sided hemiparesis has
4. Answer: D Rationale: Leakage of cerebrospinal
weakness of the right arm and leg and needs
fluid (CSF) from the ears or nose may accompany
assistance with feeding, bathing, and ambulating.
basilar skull fracture. CSF can be distinguished
9. Answer: D Rationale: Homonymous hemianopsia
from other body fluids, because the drainage will
is loss of half of the visual field. The client with
separate into bloody and yellow concentric rings
homonymous hemianopsia should have objects
on dressing material, called a halo sign. The fluid
placed in the intact field of vision, and the nurse
also tests positive for glucose.
also should approach the client from the intact
5. Answer: A, B, D Rationale: The most frequent
side. The nurse instructs the client to scan the
cause of autonomic dysreflexia is a distended
environment to overcome the visual deficit and
bladder. Straight catheterization should be done
does client teaching from within the intact field of
every 4 to 6 hours (catheterization every 12 hours
vision. The nurse encourages the use of personal
is too infrequent), and urinary catheters should be
eyeglasses, if they are available.
checked frequently to prevent kinks in the tubing.
10. Answer: D Rationale: Clients are evaluated as
Constipation and fecal impaction are other causes,
coping successfully with lifestyle changes after a
so maintaining bowel regularity is important.
stroke if they make appropriate lifestyle
Ensuring a bowel movement once a week is much
alterations, use the assistance of others, and have
too infrequent. Other causes include stimulation of
appropriate social interactions. Options 1 and 2 are
the skin from tactile, thermal, or painful stimuli.
not adaptive behaviors; option 3 indicates a not yet
The nurse administers care to minimize risk in
successful attempt to adapt.
these areas.
11. Answer: A Rationale: Clients with myasthenia
6. Answer: C Rationale: Resolution of spinal shock is
gravis are taught to space out activities over the
occurring when there is return of reflexes
day to conserve energy and restore muscle
(especially flexors to noxious cutaneous stimuli), a
strength. Taking medications correctly to maintain
state of hyper-reflexia rather than flaccidity, and
blood levels that are not too low or too high is
reflex emptying of the bladder.
important. Muscle-strengthening exercises are not
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 Neurological Problems of the Adult Client

helpful and can fatigue the client. Overeating is a 17. Answer: A, B, E, F Rationale: Seizure precautions
cause of exacerbation of symptoms, as is exposure may vary from agency to agency, but they
to heat, crowds, erratic sleep habits, and emotional generally have some common features. Usually, an
stress. airway, oxygen, and suctioning equipment are kept
12. Answer: D Rationale: The client with Parkinson’s available at the bedside. The side rails of the bed
disease should be instructed regarding safety are padded, and the bed is kept in the lowest
measures in the home. The client should use her or position. The client has an intravenous access in
his walker as support to get to the bathroom place to have a readily accessible route if
because of bradykinesia. The client should sit antiseizure medications must be administered, and
down to put on pants and shoes to prevent falling. as part of the routine assessment the nurse should
The client should exercise every day in the be checking patency of the catheter. The use of
morning when energy levels are highest. The client padded tongue blades is highly controversial, and
should have all loose rugs in the home removed to they should not be kept at the bedside. Forcing a
prevent falling. tongue blade into the mouth during a seizure more
13. Answer: D Rationale: Facial pain can be likely will harm the client who bites down during
minimized by using cotton pads to wash the face seizure activity. Risks include blocking the airway
and using room temperature water. The client from improper placement, chipping the client’s
should chew on the unaffected side of the mouth, teeth, and subsequent risk of aspirating tooth
eat a soft diet, and take in foods and beverages at fragments. If the client has an aura before the
room temperature. If brushing the teeth triggers seizure, it may give the nurse enough time to place
pain, an oral rinse after meals may be helpful an oral airway before seizure activity begins.
instead. 18. Answer: C Rationale: Signs of meningeal irritation
14. Answer: D Rationale: Guillain-Barré syndrome is compatible with meningitis include nuchal rigidity,
a clinical syndrome of unknown origin that a positive Brudzinski’s sign, and positive Kernig’s
involves cranial and peripheral nerves. Many sign. Nuchal rigidity is characterized by a stiff
clients report a history of respiratory or neck and soreness, which is especially noticeable
gastrointestinal infection in the 1 to 4 weeks before when the neck is flexed. Kernig’s sign is positive
the onset of neurological deficits. On occasion, the when the client feels pain and spasm of the
syndrome can be triggered by vaccination or hamstring muscles when the leg is fully flexed at
surgery. the knee and hip. Brudzinski’s sign is positive
15. Answer: C Rationale: The client with Guillain- when the client flexes the hips and knees in
Barré syndrome experiences fear and anxiety from response to the nurse gently flexing the head and
the ascending paralysis and sudden onset of the neck onto the chest. A Glasgow Coma Scale score
disorder. The nurse can alleviate these fears by of 15 is a perfect score and indicates that the client
providing accurate information about the client’s is awake and alert, with no neurological deficits.
condition, giving expert care and positive feedback 19. Answer: B Rationale: The halo device alters
to the client, and encouraging relaxation and balance and can cause fatigue because of its
distraction. The family can become involved with weight. The client should cleanse the skin daily
selected care activities and provide diversion for under the vest to protect the skin from ulceration
the client as well. and should avoid the use of powder or lotions. The
16. Answer: B Rationale: The limbic system is liner should be changed if odor becomes a
responsible for feelings (affect) and emotions. problem. The client should have food cut into
Calculation ability and knowledge of current small pieces to facilitate chewing and use a straw
events relate to function of the frontal lobe. The for drinking. Pin care is done as instructed. The
cerebral hemispheres, with specific regional client cannot drive at all, because the device
functions, control orientation. Recall of recent impairs the range of vision.
events is controlled by the hippocampus.
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 Neurological Problems of the Adult Client

20. Answer: D Rationale: The client with Guillain- prescribed but may be used for acute pain and as a
Barré syndrome is at risk for respiratory failure preoperative medication.
because of ascending paralysis. An intubation tray 25. Answer: C Rationale: The therapeutic phenytoin
should be available for use. Another complication level is 10 to 20 mcg/mL (40 to 79 mcmol/L). At a
of this syndrome is cardiac dysrhythmias, which level higher than 20 mcg/mL, involuntary
necessitates the use of electrocardiographic movements of the eyeballs (nystagmus) occur. At a
monitoring. Because the client is immobilized, the level higher than 30 mcg/mL (120 mcmol/L),
nurse should assess for deep vein thrombosis and ataxia and slurred speech occur.
pulmonary embolism routinely. Although items in 26. Answer: B Rationale: Mild intoxication with
the incorrect options may be used in care, they are acetylsalicylic acid is called salicylism and is
not the most essential items from the options experienced commonly when the daily dosage is
provided. higher than 4 g. Tinnitus (ringing in the ears) is the
21. Answer: D Rationale: Dyskinesia and impaired most frequent effect noted with intoxication.
voluntary movements may occur with high Hyperventilation may occur, because salicylate
carbidopa-levodopa dosages. Nausea, anorexia, stimulates the respiratory center. Fever may result,
dizziness, orthostatic hypotension, 2090 because salicylate interferes with the metabolic
bradycardia, and akinesia are frequent side effects pathways coupling oxygen consumption and heat
of the medication. production. Options 2, 3, and 4 are not associated
22. Answer: C Rationale: Phenytoin enhances the rate specifically with toxicity.
of estrogen metabolism, which can decrease the 27. Answer: C Rationale: Carbamazepine, classified as
effectiveness of some birth control pills. Options 1, an antiseizure medication, is used to treat nerve
2, and 4 are inappropriate instructions. Pregnancy pain. Adverse effects of carbamazepine appear as
does not need to be “avoided” while taking blood dyscrasias, including aplastic anemia,
phenytoin; however, because phenytoin may cause agranulocytosis, thrombocytopenia, and
some risk to the fetus (Pregnancy Category D leukopenia; cardiovascular disturbances, including
medication), consultation with the primary health thrombophlebitis and dysrhythmias; and
care provider should be done if pregnancy is dermatological effects. The low white blood cell
considered. Telling a client that there is an count reflects agranulocytosis. The laboratory
increased risk of thrombophlebitis is incorrect and values in options 1, 2, and 4 are normal values.
inappropriate and could cause anxiety in the client. 28. Answer: B Rationale: While the client is taking
A client should not be instructed to stop antiseizure codeine, the nurse would monitor vital signs and
medication. assess for hypotension. The nurse also should
23. Answer: D Rationale: The antidote for increase fluid intake, palpate the bladder for
acetaminophen is acetylcysteine. The normal urinary retention, auscultate bowel sounds, and
therapeutic serum level of acetaminophen is 10 to monitor the pattern of daily bowel activity and
20 mcg/mL. A toxic level is higher than 50 stool consistency, because the medication causes
mcg/mL, and levels higher than 200 mcg/mL 4 constipation. The nurse should monitor respiratory
hours after ingestion indicates that there is risk for status and initiate deep breathing and coughing
liver damage. Auranofin is a gold preparation that exercises. In addition, the nurse monitors the
may be used to treat rheumatoid arthritis. effectiveness of the pain medication.
Pentostatin and fludarabine are antineoplastic 29. Answer: B Rationale: Typical antiseizure
agents. medication instructions include taking the
24. Answer: B, C, D Rationale: Meperidine is an prescribed daily dosage to keep the blood level of
opioid analgesic. Side and adverse effects include the medication constant and having a sample
respiratory depression, drowsiness, hypotension, drawn for serum medication level determination
constipation, urinary retention, nausea, vomiting, before taking the morning dose. The client is
and tremors. Meperidine is not commonly taught not to stop the medication abruptly, to avoid
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 Neurological Problems of the Adult Client

alcohol, to check with a primary health care

provider before taking over-the-counter
medications, to avoid activities in which alertness
and coordination are required until medication
effects are known, to provide good oral hygiene,
and to obtain regular dental care. The client should
also wear a MedicAlert bracelet.
30. Answer: D Rationale: An edrophonium injection
makes the client in cholinergic crisis temporarily
worse. An improvement in the weakness indicates
myasthenia crisis. Muscle spasms are not
associated with this test.
31. Answer: D Rationale: In adults, overdose of
acetaminophen causes liver damage. The correct
option is an indicator of liver function and is the
only option that indicates an abnormal laboratory
value. The normal direct bilirubin level is 0.1 to
0.3 mg/dL (1.7 to 5.1 mcmol/L). The normal
sodium level is 135 to 145 mEq/L (135 to 145
mmol/L). The normal prothrombin time is 11 to
12.5 seconds (11 to 12.5 seconds). The normal
platelet count is 150,000 to 400,000 mm3 (150 to
400 × 10 9 /L).