1.
Regular oral hygiene is an essential intervention for the client who
has had a stroke. Which of the following nursing measures is 9. Which assessment data would indicate to the nurse
inappropriate when providing oral hygiene? that the
A. Placing the client on the back with a small pillow under the head client would be at risk for a hemorrhagic stroke?
B. Keeping portable suctioning equipment at the bedside. A. A blood glucose level of 480 mg/dl.
C. Opening the client’s mouth with a padded tongue blade. B B. A right-sided carotid bruit.
D. Cleaning the client’s mouth and teeth with a toothbrush. C. A blood pressure of 220/120 mmHg.
D. The presence of bronchogenic carcinoma.
2. A 78-year-old client is admitted to the emergency
department with numbness and weakness of the left arm 10. The nurse and unlicensed assistive personnel (UAP)
and slurred speech. Which nursing intervention is a are caring for a client with right-sided paralysis. Which
priority? action by the UAP requires the nurse to intervene?
A. The assistant places a gait belt around the client’s
A. Prepare to administer recombinant tissue plasminogen activator (rt-
waist prior to ambulating
PA).
B. The assistant places the client on the back with the
B. Discuss the precipitating factors that caused the symptoms. client’s head to the side.
C. Schedule for A STAT computer tomography (CT) scan of the head. C. The assistant places her hand under the client’s
D. Notify the speech pathologist for an emergency consultation. right axilla to help him/her move up in bed.
D. The assistant praises the client for attempting to
3.A client arrives in the emergency department with an ischemic stroke perform ADL’s independently.
and receives tissue plasminogen activator (t-PA) administration. Which
is the priority nursing assessment? 11. A client admitted to the hospital with a subarachnoid
A. Time of onset of current stroke hemorrhage has complaints of severe headache, nuchal
B. Complete physical and histor rigidity, and projectile vomiting. The nurse knows lumbar
C. Current medications puncture (LP) would be contraindicated in this client in
D. Upcoming surgical procedures which of the following circumstances?
A. Vomiting continues.
4. During the first 24 hours after thrombolytic therapy for ischemic B. Intracranial pressure (ICP) is increased
stroke, the primary goal is to control the client’s: C. The client needs mechanical ventilation.
A. Pulse D. Blood is anticipated in the cerebrospinal fluid (CSF).
B. Respiration
C. Blood pressure 12. A client with a subdural hematoma becomes restless
and
D. Temperature
confused, with dilation of the ipsilateral pupil. The
physician orders mannitol for which of the following
5. What is a priority nursing assessment in the first 24 hours after reasons?
admission of the client with a thrombotic stroke? A. To reduce intraocular pressure.
A. Cholesterol level B. To prevent acute tubular necrosis.
B. Pupil size and pupillary response C. To promote osmotic diuresis to decrease ICP.
C. Bowel sounds D. To draw water into the vascular system to increase
D. Echocardiogram blood
pressure
6. What is the expected outcome of thrombolytic drug
therapy? 13. A client with subdural hematoma was given
A. Increased vascular permeability mannitol to decrease intracranial pressure (ICP).
B. Vasoconstriction Which of the following results would best show
C. Dissolved emboli the mannitol was effective?
D. Prevention of hemorrhage A. Urine output increases.
B. Pupils are 8 mm and nonreactive.
7. The client diagnosed with atrial fibrillation has C. Systolic blood pressure remains at 150 mm Hg.
experienced a D. BUN and creatinine levels return to normal.
transient ischemic attack (TIA). Which medication would
the nurse anticipate being ordered for the client on 14. Which of the following values is considered normal
discharge? for ICP?
a. A thrombolytic medication A. 0 to 15 mmHG
b. B. A beta-blocker medication B. 25 mmHG
c. C. An anti-hyperuricemic medication C. 35 to 45 mmHG
d. D. An oral anticoagulant medication D. 120/80 mmHG
8. Which client would the nurse identify as being most at 15. Which of the following symptoms may occur with a
risk for experiencing a CVA? phenytoin level of 32 mg/dl?
A. A 39-year-old pregnant female. A. Ataxia and confusion
B. A 67-year-old Caucasian male B. Sodium depletion
C. An 84-year-old Japanese female. C. Tonic-clonic seizure
D. A 55-year-old African American male. D. Urinary incontinence
16. Which of the following signs and symptoms of
increased ICP after head trauma would appear first?
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B. Large amounts of very dilute urine B. A positive Brudzinski’s sign.
C. Restlessness and confusion C. Absence of nuchal rigidity.
D. Widened pulse pressure D. A Glascow Coma Scale score of 15.
17. Problems with memory and learning would relate to 24. A client is arousing from a coma and keeps saying,
which of the following lobes? “Just stop the pain.” The nurse responds based on the
A. Frontal knowledge that the human body typically and
B. Occipital automatically responds to pain first with attempts to:
C. Pariental A. Tolerate the pain.
D. Temporal B. Decrease the perception of pain.
C. Escape the source of pain.
18. While cooking, your client couldn’t feel the D. Divert attention from the source of pain.
temperature of a hot oven. Which lobe could be
dysfunctional? 25. During the acute stage of meningitis, a 3-year-old
A. Frontal child is restless and irritable. Which of the following
B. Occipital would be most appropriate to institute?
C. Pariental A. Limiting conversation with the child.
B. Allowing the child to play in the bathtub.
D. Temporal
C. Keeping extraneous noise to a minimum.
D. Performing treatments quickly.
19. The nurse is assessing the motor function of an
unconscious client. The nurse would plan to use which of
26. Which of the following would lead the nurse to
the following to test the client’s peripheral response to
suspect that a child with meningitis has developed
pain?
disseminated intravascular coagulation?
A. Sternal rub
A. Hemorrhagic skin rash
B. Pressure on the orbital rim
B. Edema
C. Squeezing the sternocleidomastoid muscle
C. Cyanosis
D. Nail bed pressure
D. Dyspnea on exertion
20. The client is having a lumbar puncture performed.
27. When interviewing the parents of a 2-year-old child,
The nurse would plan to place the client in which position
a history of which of the following illnesses would lead
for the procedure?
the nurse to suspect pneumococcal meningitis?
A. Side-lying, with legs pulled up and head
A. Bladder infection
bent down onto the chest.
B. Middle ear infection
B. Side-lying, with a pillow under the hip.
C. Fractured clavicle
C. Prone, in a slight Trendelenburg’s position.
D. Septic arthritis
D. Prone, with a pillow under the abdomen.
28. The nurse is assessing a child diagnosed with a brain
21. A nurse is assisting with caloric testing of the
tumor. Which of the following signs and symptoms would
oculovestibular reflex of an unconscious client. Cold
the nurse expect the child to demonstrate? Select all
water is injected into the left auditory canal. The client
that apply.
exhibits eye conjugate movements toward the left
A. Increased appetite
followed by a rapid nystagmus toward the right. The
B. Vomiting
nurse understands that this indicates the client has:
C. Polydipsia
A. A cerebral lesion
D. Lethargy
B. A temporal lesion
E. Head tilt
C. An intact brainstem
F. Increased pulse
D. Brain death
29. A lumbar puncture is performed on a child suspected
22. The nurse is caring for the client with increased
of having bacterial meningitis. CSF is obtained for
intracranial pressure. The nurse would note which of the
analysis. A nurse reviews the results of the CSF analysis
following trends in vital signs if the ICP is rising?
and determines which of the following results would
A. Increasing temperature, increasing pulse,
verify the diagnosis?
increasing respirations, decreasing blood
A. Cloudy CSF, decreased protein, and decreased
pressure.
glucose.
B. Increasing temperature, decreasing pulse,
B. Cloudy CSF, elevated protein, and decreased
decreasing respirations, increasing blood
glucose.
pressure.
C. Clear CSF, elevated protein, and decreased
C. Decreasing temperature, decreasing pulse,
glucose
increasing respirations, decreasing blood
D. Clear CSF, decreased pressure, and elevated
pressure.
protein.
D. Decreasing temperature, increasing pulse,
30. A nurse is planning care for a child with acute
decreasing respirations, increasing blood
bacterial meningitis. Based on the mode of transmission
pressure.
of this infection, which of the following would be included
23. The nurse is evaluating the status of a client who had
in the plan of care?
a craniotomy 3 days ago. The nurse would suspect the
A. No precautions are required as long as antibiotics
client is developing meningitis as a complication of
have been started.
surgery if the client exhibits:
B. Maintain enteric precautions.
A. A negative Kernig’s sign
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C. Maintain respiratory isolation precautions b. mannitol (Osmitrol)
for at least 24 hours after the initiation of c. lidocaine (Xylocaine)
antibiotics. d. furosemide (Lasix)
D. Maintain neutropenic precautions.
38. After striking his head on a tree while falling from a
31. A nurse is reviewing the record of a child with ladder, a young man age 18 is admitted to the
increased ICP and notes that the child has exhibited signs emergency department. He’s unconscious and his pupils
of decerebrate posturing. On assessment of the child, the are nonreactive. Which intervention would be
nurse would expect to note which of the following if this the most dangerous for the client?
type of posturing was present? A. Give him a barbiturate.
A. Abnormal flexion of the upper extremities and B. Place him on mechanical ventilation.
extension of the lower extremities. C. Perform a lumbar puncture.
B. Rigid extension and pronation of the arms D. Elevate the head of his bed
and legs.
C. Rigid pronation of all extremities 39. When obtaining the health history from a male client
D. Flaccid paralysis of all extremities. with retinal detachment, the nurse expects the client to
report:
32. Which of the following assessment data indicated A. Light flashes and floaters in front of the eye.
nuchal rigidity? B. A recent driving accident while changing lanes.
A. Positive Kernig’s sign C. Headaches, nausea, and redness of the eyes.
B. Negative Brudzinski’s sign D. Frequent episodes of double vision.
C. Positive homan’s sign
D. Negative Kernig’s sign 40. Which nursing diagnosis takes highest priority for a
client with Parkinson’s crisis?
33. Meningitis occurs as an extension of a variety of A. Imbalanced nutrition: Less than body requirements
bacterial infections due to which of the following B. Ineffective airway clearance
conditions? C. Impaired urinary elimination
A. Congenital anatomic abnormality of the meninges. D. Risk for injury
B. Lack of acquired resistance to the various
etiologic organisms. 41. The nurse has given the male client with Bell’s palsy
C. Occlusion or narrowing of the CSF pathway. instructions on preserving muscle tone in the face and
D. Natural affinity of the CNS to certain pathogens. preventing denervation. The nurse determines that the
client needs additional information if the client states
34. Which of the following pathologic processes is often that he or she will:
associated with aseptic meningitis? A. Wrinkle the forehead, blow out the cheeks, and
A. Ischemic infarction of cerebral tissue. whistle.
B. Childhood diseases of viral causation such B. Massage the face with a gentle upward motion.
as mumps. C. Perform facial exercises.
C. Brain abscesses caused by a variety of pyogenic D. Exposure to cold and drafts.
organisms.
D. Cerebral ventricular irritation from a traumatic 42. A female client is admitted to the hospital with a
brain injury. diagnosis of Guillain-Barre syndrome. The nurse inquires
during the nursing admission interview if the client has a
35. You are preparing to admit a patient with a seizure history of:
disorder. Which of the following actions can you delegate A. Seizures or trauma to the brain
to LPN/LVN?’ B. Meningitis during the last five (5 years).
A. Complete admission assessment. C. Back injury or trauma to the spinal cord.
B. Place a padded tongue blade at the bedside. D. Respiratory or gastrointestinal infection
C. Set up oxygen and suction equipment. during the previous month.
D. Pad the side rails before the patient arrives.
36. If a male client experienced a cerebrovascular
accident (CVA) that damaged the hypothalamus, the
nurse would anticipate that the client has problems with
A. Body temperature control
B. Balance and equilibrium
C. Visual acuity 43. A female client with Guillain-Barre syndrome has
D. Thinking and reasoning ascending paralysis and is intubated and receiving
mechanical ventilation. Which of the following strategies
would the nurse incorporate in the plan of care to help
the client cope with this illness?
37. A female client admitted to an acute care facility A. Giving the client full control over care decisions
after a car accident develops signs and symptoms of and restricting visitors.
increased intracranial pressure (ICP). The client is B. Providing positive feedback and encouraging
intubated and placed on mechanical ventilation to help active range of motion.
reduce ICP. To prevent a further rise in ICP caused by C. Providing information, giving positive
suctioning, the nurse anticipates administering which feedback and encouraging relaxation.
drug endotracheally before suctioning?
a. phenytoin (Dilantin)
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D. Providing intravenously administered sedatives, 49. Which of the following medical treatments should the
reducing distractions and limiting visitors. nurse anticipate administering to a client with increased
intracranial pressure due to brain hemorrhage, except?
44. A male client has an impairment of cranial nerve II. A. acetaminophen (Tylenol)
Specific to this impairment, the nurse would plan to do B. dexamethasone (Decadron)
which of the following to ensure the client to ensure C. mannitol (Osmitrol)
client safety? D. phenytoin (Dilantin)
A. Speak loudly to the client E. Nitroglycerin (Nitrostat)
B. Test the temperature of the shower water.
C. Check the temperature of the food on the delivery 50. Which of the following symptoms would you expect
tray. to a client with a phenytoin level of 35 mg/dL?
D. Provide a clear path for ambulation without A. Ataxia
obstacles B. Potassium deficit
C. Neglect syndrome
45. A female client has a neurological deficit involving D. Tetraplegia
the limbic system. Specific to this type of deficit, the
nurse would document which of the following information
related to the client’s behavior.
A. Is disoriented to person, place, and time.
B. Affect is flat, with periods of emotional
lability.
C. Cannot recall what was eaten for breakfast today.
D. Demonstrate inability to add and subtract; does
not know who is the president
46. A client is admitted with a diagnosis of Sturge-Weber
syndrome. Which of the following information would you
expect to find in this client?
a. It is a dysfunction of the trigeminal nerve causing
a severe sharp pain in the nose, lips, gums, or
across the cheeks.
b. It is a non-progressive neurological disorder of the
seventh cranial nerve causing paralysis of one of
the sides of the face
c. It is a rare degenerative brain disorder
characterized by sudden development of
progressive neurological and neuromuscular
symptoms.
d. It is a neurocutaneous disorder with
angiomas causing abnormalities in the skin,
brain, and eyes from birth
47. A client is admitted to the emergency room with a
spinal cord injury. The client is complaining of
lightheadedness, flushed skin above the level of the
injury, and headache. The client’s blood pressure is
160/90 mm Hg. Which of the following is a priority action
for the nurse to take?
A. Loosen tight clothing or accessories
B. Assess for any bladder distention
C. Raise the head of the bed
D. Administer antihypertensive
48. A client who had a stroke is seen bumping into things
on the side and is having difficulty picking up the
beginning of the next line of what he is reading. The
client is experiencing which of the following conditions?
A. Visual neglect
B. Astigmatism
C. Blepharitis
D. Homonymous Hemianopsia
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