1. The nurse is assessing a client for bacterial meningitis.

Which of the following assessments

should the nurse perform? Select all that apply.
i. Oral temperature
ii. Patellar reflex
iii. Weber and Rinne tests
iv. Orthostatic blood pressure
A.i,ii,iii,iv
B.I, iv
C.ii, iii, iv
D.I, v
2.The nurse is developing a plan of care for a client who has epilepsy and is undergoing an
electroencephalogram. Which of the ff. should the nurse include in the clients plan of care?
Select all that apply.
i. Provide padding to the side rails.
ii. Verify suction is at bedside and working properly.
iii. Keep bite block at bedside in case of seizure,
iv. Ensure nasal cannula is available and working at the bedside
v. Establish peripheral vascular access
A. i, ii, iv, v
B. i, ii, ili, iv
C. iii, iv
D. i, i, i, v

Situation: Kurdapya, a 22-year-old client, was with friends at a restaurant and reportedly started
acting
odd and then had uncontrollable and uncoordinated movements. This lasted 3 minutes. Once
these
actions were terminated, EMS was called, and this occurred again and lasted for 4 minutes. EMS
administered lorazepam. The patient does not have any medical history or take any medications.
GCS
revealed 14/15. The client was admitted for recurrent seizures.

3. The doctor ordered MRI (Magnetic Resonance Imaging) for Kurdapya. Which of the following
Is the appropriate nursing intervention for the procedure?
A. Ensure the client has a negative pregnancy test prior to the exam.
B. Assess if the client has a claustrophobia prior to the exam.
C. Have the client nothing by mouth (NPO) eight hours prior to the exam.
D. Have the client drink 2 liters of water and on full bladder prior the procedure

4.During Kurdapya's ward stay, the physician orders for loading dose of intravenous
(V)phenytoin. What is the priority nursing intervention related to the client's treatment?
A. Re-checking for the GCS status of the client before giving the medication.
B. Monitor the client's lung sounds for pulmonary edema.
C. Establish continuous cardiac monitoring during the infusion.
D. Insert an indwelling urinary catheter to monitor intake and output.

5.A client is admitted to an emergency department (ED). A nurse in the ED documents that thee
client is postictal upon transfer" as evidenced by which observation?
A. Yellowing of the skin.
B. Recently experienced a seizure and is in a drowsy or confused state.
C. Severe itching of the eyes.
D. Abnormal sensations including tingling of the skin.

6.A client with epilepsy is prescribed phenytoin-sodium (Dilantin) 100 mg 3 times per day orally
as anticonvulsant therapy. The most precise method for a nurse to determine if this is the proper
dose for the client is:
A. observation of the client for seizure,
B. observation of the client for adverse effects.
C. determining whether the client is able to participate in usual activities,
D. monitoring serum phenytoin levels.

7.An 11-year old child is hospitalized for elective surgery. The child has neurogenic bladder from
a spinal cord injury with a lower motor neuron lesion occurring 2 years previously. In planning
care, the nurse considers that the optimal treatment for neurogenic bladder in the hospitalized
child is:
A. intermittent catheterization
B. insertion of a retention catheter
C. insertion of a suprapubic catheter
D. administration of an anticholinergic medication
8.An adolescent male with a history of spinal cord injury-reports a leaking of urine at fairly
regular intervals. A nurse should document in the client's plan of care a nursing diagnosis of.
A._functional urinary incontinence
B. reflex urinary incontinence
C. stress-urinary incontinence
D. urge urinary incontinence

9.A nurse in an emergency department assesses a client injured in a diving accident 2 hours
earlier. A computed tomography (CT) scan reveals a fracture of the C4 cervical yertebra. The
client is breathing independently but has no movement or muscle tone from below the area of
injury. The nurse understands that the client:
A.has suffered a complete spinal cord injury (SCI)
B. is experiencing a spinal shock
C has sustained an upper-motor neuron injury
D. will be quadriplegic

10. A client with Guillain-Barre Syndrome (GBS) has an order for low dose anticoagulation. Which
finding best indicates that this treatment is having the desired effect on this client?
Client reports of paresthesia have decreased.
B. Client's blood pressure is stable.
C. Client's cerebrospinal fluid is clear.
D. Client is free of signs and symptoms of thromboembolism,

11.Which characteristic must an antibiotic have in order to be sued in the treatment of

meningitis?
A. Low protein binding in the-blood stream.
B. Ability to cross the blood-brain-barrier.
C. Effectiveness against gram-negative organisms.
D. Resistance to neurotransmitter effects.

12.Occurrence of which symptom best differentiates between mild and severe concussion?
A.Loss-of consciousness
B. Tremor
C. Unstable gait
D. Impaired speech

13.Which direction would be included when teaching a client with multiple sclerosis?
A. Use strict aseptic technique for self-catheterization.
B. Report slurred speech to the health care provider.
C. Eat a high-protein, low fiber diet.
D. Avoid extremes of heat such as hot tubs or saunas if alone

14.What direction regarding nutrition should the nurse give to a client with trigeminal neuralgia?
A. Drink large amounts of clear fluids each day.
B. Eat three meals per day taking an analgesic a half hour before each.
C.Stick to a full liquid diet until pain is relieved
D. Use unaffected side of the mouth to manage food and chew.

15.The nurse is caring for a client diagnosed with Multiple Sclerosis (MS). The nurse should
anticipate a prescription of which of the following medications?
A. Topiramate
B. Risperidone
C.Prazosin
D.Baclofen

16.The nurse is caring for a client immediately following the administration of prescribed
Sumatriptan. Which clihical finding would require folow-up by the nurse?
A.Blood pressure-189/98 mmHg
B.Headache pain 4/10
C.Client's skin appears flushed
D. Reports of nausea
17.The nurse is caring for a client receiving intravenous (I1V) alteplase for a cerebrovascular
accident (CVA). The nurse understands that this medication has reached its therapeutic effect
when the client is assessed to have_____
A. increase in Glasgow Coma Scale (GCS)
B. unintelible speech
C. bleeding at.their gum line
D.increase in pulse and decrease in blood pressure,

18.The nurse is caring for a client experiencing a tonic-clonic seizure. Which of the following
medications should the nurse be prepared to administer?
A. Lorazepam
B.Phenytoin
C. Carbamazepine
D. Benztropine

19.The nurse is caring for a client with an acute exacerbation of Bell's palsy. Which of the
following prescriptions would the nurse anticipate?
A. Prednisone and Donepezil
B.Donepezil and_Pyridostigmine
C. Valacyclovir and Topiramate
D. Prednisolone and Valacyclovir

20. The nurse would assess for which symptoms of morphine overdose in a client receiving
patient-controlled analgesia?
A. A decrease in blood pressure and respiration rate; constricted pupils and sedation;
lethargy and depressed reflexes
B. A decreased in blood pressure and respiration rate; dilated pupils and restlessness;
profuse sweating and a state of deep sleep
C.Constricted pupils and sedation; profuse sweating and a state of deep sleep; dilated
pupils and restlessness
D. Lethargy and depressed reflexes; constricted pupils and sedation; dilated pupils and
restlessness

21.Damage to the VIl cranial nerve results in which of the following?

A. Facial pain
B. Absence of ability to smell
C. Absence of eye movement
D. Tinnitus

22.The client has sustained a traumatic brain injury (TBI)_secondary to motor vehicle accident.
Which signs/symptoms would the emergency department,(ED) nurse expect the client to exhibit?
A.Blurred vision, nausea, and right-sided hemiparesis
B.Increased urinary output, negative Babinski, and ptosis
C.Autonomic dysreflexia, positive Brudzinski, and- hyperpyrexia
D. Negative dextrostik, nuchal-rigidity, and-.nystagmus

23.The intensive care nurse is caring for a client

diagnosed with a closed-head injury. Which data
would warrant immediate intervention?
A. The client refuses to cough and deep-breathe
B.The client's GCS goes from 13 to 7.
C. The client complains of frontal headache.
D. The client's Mini Mental Status Exam is 30.

24.The rehabilitation nurse is caring for the client with a closed head injury. Which cognitive goal
would be most appropriate for this client?
A. The client will be able to feed himself/herself independently.
B. The client wlill attend therapy session 3 hours a day.
C. The client will interact appropriately with staff members,.
D. The client will be able to stay on task for 15 minutes.
25. The intensive care nurse is caring for a client diagnosed with a TBI who is exhibiting
decorticate posturing. Three hours later, the client has flaccid-posturing,. Which action should
the nurse implement first?
A. Notify the client's healthcare provider immediately.
B Prepare to administer mannitol (Osmitrol), an osmotic diuretic
C.Complete a thorough neurological assessment on the client.
D. Reassess the client in 1 hour, including calculating the Glasgow Coma Scale

26.Which clinical manifestation would the nurse assess in the client with a T-12 spinalcord injury
(SCI) who is experiencing spinal_shock?
A.Flaccid paralysis below the waist
B. Lower extremity muscle spasticity
C, Complaints of pounding headache
D.Hypertension and bradycardia

27.The rehabilitation nurse is caring for the young client with a T-12 SCL is developing the
nursing care plan. Which priority-intervention-should the nurse implement?
A.Monitor the client's indwelling urinary catheter.
B. Insert a rectal stimulant at the same time every morning
C. Encourage active lower extremity range of motion (ROM) exercises.
D. Refer the client to a vocational training assistance program.

28. The nurse is caring for a client with a C-6 SCNin the neurological intensive care unit. Which
nursing intervention should be implemented?
A.Monitor the client's heparin drip.
B. Assess the neurological status every shift.
C.Maintain the client's ice saline infusion.
D. Administer corticosteroids intrathecally.

29.The intensive care nurse is caring for a client diagnosed with a TBI who is exhibiting
decorticate posturing. Three hours later, the client has flaccid-posturing,. Which action should
the nurse implement first?
A. Notify the client's healthcare provider immediately.
B. Prepare to administer mannitol (Osmitrol), an osmotic diuretic
C.Complete a thorough neurological assessment on the client.
D. Reassess the client in 1 hour, including calculating the Glasgow Coma Scale

30. Which clinical manifestation would the nurse assess in the client with a T-12 spinalcord injury
(SCI) who is experiencing spinal_shock?
A.Flaccid paralysis below the waist
B. Lower extremity muscle spasticity
C, Complaints of pounding headache
D.Hypertension and bradycardia

31.The rehabilitation nurse is caring for the young client with a T-12 SCL is developing the
nursing care plan.
Which priority-intervention-should the nurse implement?
A.Monitor the client's indwelling urinary catheter.
B. Insert a rectal stimulant at the same time every morning
C. Encourage active lower extremity range of motion (ROM) exercises.
D. Refer the client to a vocational training assistance program.

32.Client newly diagnosed with epilepsy who works in an office asks the nurse, "What can I to
prevent having seizures?" Which statement is the nurse's best response?
A."I recommend getting about 4 hours of sleep a night"
B. "Ask your supervisor to have someone else make copies"
C. "Request your employer to provide a work area with dim lighting"
D, "You should get your serum blood level checked every month"

33.The client diagnosed with seizure disorder is prescribed phenytoin (Dilantin), an

anticonvulsant. Which statement indicates the client needs more teaching concerning this
medication?
A. I will brush my teeth after every meal"
B. "I wlill get my Dilantin level checked regularly"
C. "My urine will turn orange while on Dilantin"
D. "This medication will help prevent my seizures
34.The client is admitted to the intensive care unit (ICU) experiencing status epilepticus. Which
intervention should the nurse anticipate implementing first?
A.Assess the client's neurological status frequently.
B. Monitor the client's heart rhythm via telemetry.
C.Administer diazepam (Valium), a benzodiazepine.
D.Prepare to administer anticonvulsant medication.

35. The mother of a child who had febrile seizure tells the pediatric clinic nurse "I am so upset
because now my child has epilepsy". Which statement is the clinic nurse's best response?
A. "Your child had a seizure due to high fever, not due to epilepsy"
B. "You are upset about your child having epilepsy. Let's talk.
C. "The Epilepsy Foundation provides good information
D. "I would recommend you to attend the local epilepsy support group"

36. The 85-year old client is admitted to the ER with numbness andiweakness of the left arm and
slurred speech. The computed tomography (CT) scan was negatiye for_bleeding. Which nursing
intervention is priority?
A.Prepare to administer tissue plasminogen activator (tPA)
B. Discuss the precipitating factors that caused the symptoms.
C. Determine the exact time the symptoms-occurred
D. Notify the speech pathologist for an emergency consuft.

37. The nurse is assessing the client experiencing a left-sided cerebrovascular accident (CVA).
Which clinical manifestations would the nurse expect the client to exhibit?
A. Hemiparesis of the left arm and apraxia
B. Paralysis of the right side of the body and aphasia,
C.Inability to recognize and use familiar objects.
D. Impulsive behavior and hostility toward family,

38. The HCP has discussed a carotid endarterectomy with the client who has experienced two
transient ischemic attacks (TIAs). The client tells the nurse "1 really don't understand why I need
this procedure, and don't want to have it." Which scientific rationale would support the nurse's
response?
A.This surgery is indicated for the clients with symptoms of a TIA due to carotid artery
stenosis.
B. This surgical procedure will ensure the client does not have a cerebrovascular accident,.
C. This surgery will remove all atherosclerotic plaque from the carotid arteries.
D. This surgical procedure will increase the elasticity of the carotid arterial wall.

39. Nurse is planning care for the client experiencing dysphagia secondary to CVÀ. Which
intervention should be included in the plan of care?
A.Evaluate the client during mealtime.
B. Position the client in a semi-Fowler's position.
C. Administer oxygen during meals.
D. Refer the client to a physical therapist.

40.The client diagnosed with a CVA has hemiparesis. Which problem would be priority for the
client?
A.Impaired>skin integrity
B. Fluid volume overload
C. High risk for aspiration
D: High risk for injury

41.The nurse has received the morning shift report. Which client should the nurse assess first?
A.The client who is complaining of a headache at a 3 on a scale of 1-10.
B. The client who has an apical pulse of 56 and a blood pressure of 210/146 mmHg.
C. The client who is reporting not having a bowel movement in 3 days
D. The client who is angry because the call light was not answered for 1 hour.

42. The client diagnosed with a brain tumor was admitted to the ICU with decorticate posturing?
Which indicates that the client's condition is improving?
A. The client has purposeful movement with painful stimuli.
B. The client assumes adduction of the upper extremities.
C. The client assumes the decerebrate posture upon painful stimuli.
D.The client has become flaccid and does not respond to stimuli.
43.The nurse is assessing the client diagnosed with bacterial meningitis. In addition to nuchal
rigidity, which clinical manifestations would the nurse assess?
A. Positive Cushing's sign and ascending paralysis.
B. Negative Kernig sign and facial tingling.
C. Positive Brudzinski sign and photophobia
D. Negative Trousseau sign and descending paralysis

44. The nurse is admitting a client diagnosed with meningococcal meningitis and notes lesions
over the face- and extremities. Which priority intervention should the nurse implement?
A. Initiate the intravenous antibiotics stat.
B. Obtain a skin biopsy for culture and sensitivity.
C. Perform a complete neurological assessment.
D. Close all the curtains in the room and turn off lights.

45.The 18-year old client is admitted to the medical floor with a diagnosis of meningitis. Which
priority intervention should the nurse assess?
A.Assess the client's neurovascular status
B. Assess the client's cranial nerve IX function.
C. Assess the client's brachioradialis reflex.
D. Assess the client's neurological status.

46.The nurse is admitting a client diagnosed with meningitis who has AIDS. Which
signs/symptoms would the nurse expect the client to exhibit?
A. A positive Brudzinski sign.
B. Diplopia and blurred vision
C.Auditory deficits
D. The client may be asymptomatic

47. What clinical manifestations would the nurse expect to assess in the client with diagnosed
Parkinson disease (PD)?
A.Nausea, vomiting, diarrhea
B.Polyuria, polydipsia, and polyphagia
C, Dysphonia, dysphagia, and scanning speech
D. Tremors, rigidity, and bradykinesia

48. The nurse caring for a client with Parkinson disease writes a problem of "Impaired Nutrition".
Which nursing intervention would be included in the plan of care?
A . Give the client a pureed diet.
B. Request a low-residue heart-healthy diet.
C. Provide an 1800-calorie diabetic diet.
D. Offer bite-sized foods on a plate warmer.

49.The nurse is planning the care for a client diagnosed with Parkinson disease. Which goal
would be appropriate for the client problem of "impaired_ mobility"?
A. The client will experience periods of akinesia throughout the day.
B. The client will be able to turn from side to side in bed
C. The client will be able to ambulate in the hall three times a day.
D. The client will be able to carry out ADLs.

50. The client diagnosed with Parkinson disease is being discharged. Which statement made by
the client's significant other indicated a need for more teaching?
A. "I know that my husband may have some emotional mood swings"
B. "My spouse may experience hallucinations until the medication starts working"
C."I will schedule appointments late in the morning after his morning bath".
D. "My spouse must take his medication at the same time every day".

51.The client has been diagnosed with Parkinson disease for 12 years and has been taking
levodopa (L-dopa) for the last 8 years. Which symptom would alert the nurse to a possible
medication complication?
A. The client is unable to initiate voluntary movement.
B. The client has recently developed dyskinesia.
C. The client has masklike facies and cogwheel movements.
D. The client has excessive saliva production.
52.The nurse is caring for client diagnosed with Guillain-E Barre syndrome (GBS) after a recent
gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this
client?
A.Diaphoresis with facial flushing
B. Hypoactive or absent bowel sounds
C.Inability to cough or lift the head
D. Warm, tender, and swollen leg

53.A client is brought to the emergency department by emergency medical services with a
flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The
nurse is takes which priority action?
A. Determine onset of symptoms.
B.Ensure that the client has 2 large-bore intravenous (IV) lines.
C.Maintain patent airway.
D. Prepare for head CT scan

54. Client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the
healthcare provider. Which intervention does the nurse add to this client's care plan?
A. Encourage client to drink cold beverages.
B. Encourage client to eat high-fiber diet.
C. Encourage client to perform facial massage.
D. Encourage client to report any fever or sore throat.

55. The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment
is most concerning and requires a nursing response?.
A.Consumes 600 mL liquid over 4 hours.
B.Insertion site dressing saturated with clear fluid.
C. Observed lying in the right-sided Sim's position,
D. Reports a headache rated 6/10

56. The nurse is caring for a client in the acute phase of meningococcal meningitis. Which
nursing actions should be included in the plan of care?
A. Assign client to a private room; elevate head of t the bed 45 degrees; maintain well-lit and
brightroom
B. Donmask before entering room; assign client to private room; elevate head of the
bed 10-30 degrees
C. Maintain dimmed room lighting; keep padded tongue blade at bedside; assign client with
other client infected with hepatitis
D. Elevate head of the bed 10-30 degrees; don mask before entering room; kéep restrain and
padded tongue blade at bedside,

57.A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse
ask the client to perform to assess if cerebellar function is within the defined limits?
A. Identify the number "8" traced on the palm and shrug the shoulder against resistance
B. Swallow water and touch each finger of one hand to the hand's thumb
C. Shrug the shoulder against resistance and walk heel-to-toe
D. Touch each finger of one hand to the hand's thumb and walk heel-to-toe

58. The nurse assesses several clients using the Glasgow Coma Scale. Which scenario best
demonstrated a correct application of this scale?
A. The nurse applies pressure to the nail bed, and the client tries to push the nurse's
hand away. The nurse scores motor response as “Localization of pain"
B. The nurse asks the client what day it is and the client says "banana". The nurse scores verbal
response as "confused".
C. The nurse speaks with client and then the client's eyes open. The nurse scores eye opening as
"spontaneous"
D. The nurse walks in the room and the client says "hi honey. How are you?" the nurse scores
verbal response as "oriented".

59. The client has increased intracranial pressure with edema, and mannitol is administered.
Which assessment should the nurse make to evaluate if a complication,from the mannitol is
occurring?
A. Auscultate breath sounds to assess for crackles.
B. Monitor for >50 mL/hr urine output.
C. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15.
D. Press over the tibia to assess for pitting edema,
60. A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluated the
medication as having the intended effect if which finding is noted?
A. Improvement in short-term memory
B. Improvement in spontaneous activity
C. Reduction in number if visual hallucinations
D. Reduction of dizziness with standing

61. Nurse iS caring for a client with Bell palsy. Which of the following assessment findings the
nurse expect?
A. Severe pain along the cheekbone; inability to smile symmetrically; flattening of the nasolabial
fold
B. Inability to smile symmetrically; flattening of the nasolabial fold ; electric shock-like pain in the
lips and gums
C. Flattening of the nasolabial fold; electric shock-like pain in the lips and gums; change in
D. Change UN on the affected side lacrimation lacrimation on the affected side;
flattening of t the nasolabial fold, fnability to smile symmetrically

62. Which nursing action IS specific to the plan of care

for a client with trigeminal-neuralgia?
A. Be alert to prevent dehydration or starvation.
B. Initiate exercises of the jaw and facial muscles.
C. Apply_ice compress to the affected body area.
D. Emphasize the importance of brushing the teeth

63. Which clinical indicators does the nurse expect to identify when assessing a client with tic
douloureux?
A.Multiple petechiae, exeruciating-facial pain, unilateral muscle weakness
B. Fine motor tremors of the eyelid, excruciating faciat pain
C. Excruciating facial-pain, twitching of the mouth
D. Fine motor tremors of the eyelid, twitching of the mouth, excruciating-facial_ pain.

64. What should the nurse monitor to evaluate the effectiveness of carbamazepine (Tegretol) in
the management of clients with tic douloureux?
A. Pain intensity
B.Liver function
C. Cardiac output
D. Seizure activity

65. Which clinical indicators does the nurse expect to identify when assessing a client with
trigeminal
neuralgia (tic douloureux)?
A. Exhaustion and fatigue because of extreme pain; excessive talkativeness because of anxiety
and apprehension
B. Prolonged periods of sleep because of anxiety; hyperactivity because of medications received
C. Exhaustion and fatigue because of the extreme pain; inadequate nutrition because
of fear of precipitating an attack
D. Excessive talkativeness because of anxiety and apprehension; inadequate nutritionalintake
because of fear of precipitating an attack

66.Which clinical findings does the nurse anticipate a client with an exacerbation of multiple
sclerosis to experience?.
A. Double vision, resting tremors
B. Double vision, scanning speech
C. Flaccid paralysis, mental retardation
D. Resting tremors, scanning speech

67. Which statement by a client with multiple sclerosis indicates to the nurse that the client
needs
further teaching?
A. "I use a straw to drink liquids"
B."I wil take a hot bath to help relax my muscles"
C. "I plan to use an incontinence pad when I go out"
D. "I may be having a rough time now, but I hope tomorrow will be better
68. Client with multiple sclerosis iS voicing concerns to the nurse about incoordination when
walking. Which of the following instructions by the nurse would be most appropriate at this time?
A."Avoid excessive stretching of your lower extremities"
B. "Build strength by increasing the duration of daily exercise"
C. "Let me speak with your healthcare provider about getting a wheelchair"
D. "You should keep your feet apart and use a cane when walking

69. The nurse is assessing the cranial nerve and begins testing the facial nerve (cranial nerve
VII). Which direction should the nurse give the client to test this cranial nerve?
A. "close your eyes and identify this smell"
B."follow my finger with your eyes without moving your head"
C."look straight ahead and let me know when you can see my finger"
D. "raise your eyebrows, smile, and frown"

70. The nurse is planning care for a client with suspected stroke who has just arrived at the
emergency department with slurred speech, facial drooping, and right arm weakness that began
1 hour ago. Which of the following interventions should the nurse anticipate including in the
initial plan of care?
A. Arrange for speech pathologist consult; obtain a STAT CT scan of the head: discuss
community resources with the family
B. Prepare to initiate alteplase within the next 5 hours; perform baseline neurologic assessment;
obtain STAT CT scan of the head
C. Discuss community resources with the family; prepare to initiate alteplase; perform baseline
neurologic assessment
D. Obtain a STAT CT scan of the head; perform neurologic assessment as baseline; of
prepare to initiate alteplase within the next 3 hours

71. The emergency department nurse assesses a client involved in a motor vehicle accident who
sustained a coup-countercoup head injury. Which statement is consistent with injury to the
occipital lobe?
A. Decreased rate and depth of respirations
B. Deficits in visual perception
C. Expressive aphasia
D. Inability to recognize touch

72. A client comes to the emergency department with diplopia and recent onset of nausea.
Which
statement by the client would indicate to the nurse that this is an emergency?
A. I am very tired, and it's hard for me to Keep my eyes open"
B."I don't feel good, and I want to be seen"
C. "I have not taken my blood pressure medicine in over a week"
D. "I have the worst headache I've ever had in my life"

73. A client develops hydrocephalus 2 weeks after cranial surgery for a ruptured cerebral
aneurysm. The nurse concludes that the hydrocephalus probably is related to which
physiologic response?
A. Vasospasm of adjacent cerebral arteries
B. Ischemic changes in the Broca speech center
C. Increased production of cerebrospinal fluid
D. Blocked absorption of fluid from the arachnoid space

74. What clinical indicator is the nurse most likely to identify when assessing a client with a
ruptured cerebral aneurysm?
A. Tonic-clonic seizures
B. Decerebrate posturing
C. Sudden severe headache
D. Narrowed pulse pressure

75. What position should the nurse initially place a client who has experience a brain attack?
A.Prone
B.Lateral
C. Supine
D.Trendelenburg
76. A client with a brain-attack has right hemiplegia. What occurs if the nurse uses the client's
right
arm to obtain a blood pressure reading?
A. Produces inaccurate readings
B. Hinders restoration of function
C. Precipitates the formation of a thrombus
D, Causes excessive pressure on the brachial artery

77. Patient Salaki is admitted with signs of stroke (CVA). On admission, vital signs were blood
pressure 128/70 mmHg, pulse 68 bpm, and respiration 20 cpm. Two hours later, the patient is
not awake, has a blood pressure of 170/70 mrlig, pulse of 52 bpm and the left pupil is now
slower than the right pupil in reacting to light. These findings suggest which of the following?
A.Impending brain-death.
B. Decreasing intracraniak pressure
C. Stabilization of the patient's condition.
D. Increased intracranial pressure

78. A client is diagnosed with expressive_ aphasia. What type of impairment does the nurse
expect
the client to exhibit?
A. Speaking and/or writing
B. Following specific instructions
Understanding speech and/or writing k
D. Recognizing words for familiar objects

79. A client is diagnosed with trigeminal neuralgia. Which medication should the nurse anticipate
will be prescribed for this client?
A. Ascorbic acid
B. Morphine sulfate
C. Allopurinol (Zyloprim)
D. Carbamazepine (Tegretol)

80.A nurse enters the room of a client with myasthenia gravis and identifies that the client is
experiencing increased dysphagia. What should the nurse do first?
A.Administer oxygen
B. Raise the head of the bed
C. Perform tracheal suctioning
D. Call the healthcare provider

81. To what does the nurse attribute the increased risk of respiratory complications in client with
myasthenia gravis?
A. Narrowed airways
B.Impaired-immunity
C.Ineffective coughing
D. Viscosity of secretions

82. A client with myasthenia gravis has been receiving neostigmine-(Prostigmin) and asks about
its action. What information about this action should the nurse consider when formulating a
response?
A.Stimulates the cerebral cortex.
B. Blocks the action of cholinesterase
C.Replaces deficient neurotransmitter.
D. Accelerates transmission along neural sheaths.

83.You finds a victim under the wreckage of a collapsed building. The individual is conscious,
breathing, satisfactorily, and reporting back pain and an. inability to move the egs. What action
should the nurse take first?
A. Leave the individual lying on the back with instructions not to move, and seek
additional help.
B. Roll the individual onto the abdomen, place a pad under the head, and cover with any material
available,
C.Gently raise the individual to sitting position to see whether the pain either diminishes or
increases in intensity.
D. Gently lift the individual onto a flat piece of lumber and, using any available transportation,
rush to the closest medical institution.
84.A client with spinal cord injury has paraplegia , The nurse assesses for which major problem
the client may experience early in the recovery period?
A.Bladder control
B.Nutritionfal intake
C. Quadriceps setting
D. Use of aids for ambulation

85.A client with brain attack becomes incontinent of feces. What is the most important nursing
action to support the success of bowel training program?
A. Using medication to induce elimination.
B. Adhering to definite time for attempted evacuations.
C.Considering previous habits associated with defecation.
D. Timing of elimination to take advantage of the gastrocolic reflex.

86. What is the primary responsibility of a nurse during a client's generalized motor seizure?
A.Inserting a plastic airway between the teeth.
B. Determining whether an aura was experienced
C. Administering the prescribed PRN anticonvulsant.
D. Clearing the immediate environment for client safety.

87.A nurse may find that, for optimum nutrition, a client with brain attack-needs assistance with
eating. What should the` nurse do?
A. Request the client's food be pureed.
B. Feed the client-to-conserve the client's energy.
C. Have a family member assist the client with each meal.
D. Encourage the client to participate in the feeding process.

88. Which clinical indicators does the nurse identify that suggest that a client is experiencing,
urinary retention and overflow after a_ brain attack?
A.Frequent voiding, suprapubic distention
B. Edema, oliguria
C. Continual incontinence, suprapubic distention ~
D. Frequent voiding, edema, oliguria

89.Which of the following describes decerebrate posturing?

A. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers
B. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar
flexion of the feet.
C. Supination of arms, dorsiflexion of feet.
D. Back arched; rigid extension of all four extremities.

90.The nurse is admitting a client with possible diagnosis of Guillain-Barre syndrome. When
collecting data to develop a plan of care for the client, the nurse should give priority to which of
the following items?
A.Orthostatic blood pressure changes
B. Presence or absence of knee reflexes
C. Pupil size and reaction to light
D. Rate and depth of respirations

91. Client was struck on the head by a baseball bat during a robbery attempt. The nurse gives
this report to the oncoming nurse at shift change and conveys that the client's current Glasgow
Coma Scale (GCS) score is a "10". Which client assessment is most important for the reporting
nurse to include?
A. Belief that the current surroundings are a racetrack.
B. GCS score was "11" one hour ago,
C.Recent vital signs show blood pressure of 120/80 mmHg and pulse of 82/min.
D. Reported allergy to penicillin and vancomycin.

92. What actions should the nurse include when planning for the long-term care of a client with
expressive aphasia?
A. Begin helping the client to associate words with physical objects.
B. Encourage the client to acknowledge that this disability is permanent
C.Wait for communication to be initiated by the client even if it takes a long time
D. Assist family members to accept the fact that they cannot communicate verbally with the
client.

93. The clinic nurse is assessing a previously healthy 60-year-old client when the client says, "My
hand has been shaking when try to cut food. I did some research online. Could I have Parkinson's
disease?" Which response from the nurse is the most helpful?
A. It can't be Parkinson's disease because you aren't old enough'
B. "make sure you tell the physician about your concerns"
C. "Parkinson's disease does not cause that kind of hand shaking'
D. "Tell me more about your symptoms. When did they start?"

94.The nurse at the radiological imaging center is admitting a client for an MRI of the head.
Which
information obtained by the nurse should be reported immediately to the prescribing.health
care provider?
A.The client ate a full breakfast that morning
B. The client has an implantable cardioverter defibrillator (ICD).
C. The client is allergic to povidone-iodine.
D. The client took all prescribed cardiac medications before arriving.

95.A client with a history of headaches is scheduled for a lumbar puncture to assess the
cerebrospinal fluid pressure. The nurse iS preparing the client for the procedure. Which
statement by the client indicates a need for further teaching by the nurse?
A." I may feel a sharp pain that shoots to my leg, but it should pass soon.
B. "I will- go to the bathroom and try to urinate before the procedure".
C. "I will need to lie on my stomach during the procedure".
D. "The physician will insert a needle between the bones in my lower spine"

96.The client is brought to the emergency department after falling off a rook and landing on his
back. A T1 spinal fracture is diagnosed. The client's blood pressure is 75/40 mm Hg, pulse is
50/min, and skin is pink and dry. What nursing action is a priority?
A. Administer IV normal saline.
B. Determine if urinary occult blood is present.
C.Perform a neurological assessment.
D. Verify that there is no stool impaction.

97. A nurse is caring for a client on a droplet precaution who has a prescription for a CT scan.
The transporting in the radiology, the nurse should ensure that the transporter uses protective
equipment correctly to reduce the environment spread of infection when the client is outside the
room. Which instruction should the nurse give the transporter?
A. Have the client wear mask.
B. have the client wear gloves
C. wear mask
D. Wear an isolation gown.

98.The nurse cares for a client who has an abdominal aortic aneurysm repair 6 hours ago. Which
assessment would require immediate follow-up?
A.Abdomen is soft, non-distended, and tender to touch.
B.Blood pressure is 96/66 mm Hg and apical pulse is 112/min.
C. Client rates pain as 4 on a scale of 0-10.
D. Green bile is draining from the nasogastric tube.

99.The cardiac care unit has standing instructions that the health care provider (HCP) should be
notified of an abnormal mean arterial pressure (MAP) The nurse will need to notify the HCP about
which client?
A.A client from the cardiac catheterization lab wíth blood pressure (BP) of 102/58 mmHg.
B. A client just admitted from the emergency department with a BP, of 150/72 mmHg
C. A client with-BP-of 92/60 mmHg who just received a dose of nitroglycerin
D.A client with heart failure on metoprolol with a BP of,106/42 mmHg.
100. The nurse is planning care for a client being admitted with newly diagnosed quadriplegia
(tetraplegia). Which action should the nurse prioritize?
A.Frequent, focused respiratory assessments.
B. Monitoring for autonomic dysreflexia.
C Passive range-of-motion exercises every 4 hours.
D. Repositioning the client every 2 hours.