Nervous System | Neurological Disorders NCLEX Quiz 49 | Attempts: 4452

1.

A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?

A.

Unequal pupil size
B.

Decreasing systolic blood pressure
C.

Tachycardia
D.

Decreasing body temperature

Correct Answer
A. Unequal pupil size

Explanation
Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve.Option B: Increasing ICP causes an increase in the systolic pressure. which reflects the additional pressure needed to perfuse the brain.Option C: It increases the pressure on the vagus nerve. which produces bradycardia.Option D: It causes an increase in body temperature from hypothalamic damage.

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2.

Which of the following respiratory patterns indicate increasing ICP in the brain stem?

A.

Slow. irregular respirations
B.

Rapid. shallow respirations
C.

Asymmetric chest expansion
D.

Nasal flaring

Correct Answer
A. Slow. irregular respirations

Explanation
Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns.Options B. C. and D: Rapid. shallow respirations. asymmetric chest movements. and nasal flaring are more characteristic of respiratory distress or hypoxia.

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3.

Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

A.

Give the client a warming blanket
B.

Administer low-dose barbiturate
C.

Encourage the client to hyperventilate
D.

Restrict fluids

Correct Answer
C. Encourage the client to hyperventilate

Explanation
Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction. which reduces CSF and blood volume. two important factors for reducing a sustained ICP of 20 mm Hg.Option A: A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate. which in turn increases ICP.Option B: High doses of barbiturates may be used to reduce the increased cellular metabolic demands.Option D: Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.

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4.

A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client’s condition?

A.

Widening pulse pressure
B.

Decrease in the pulse rate
C.

Dilated. fixed pupil
D.

Decrease in LOC

Correct Answer
D. Decrease in LOC

Explanation
A decrease in the client’s LOC is an early indicator of deterioration of the client’s neurological status. Changes in LOC. such as restlessness and irritability. may be subtle.Options A. B. and C: Widening of the pulse pressure. decrease in the pulse rate. and dilated. fixed pupils occur later if the increased ICP is not treated.

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5.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?

A.

Place her in a jacket restraint
B.

Wrap her hands in soft “mitten” restraints
C.

Tuck her arms and hands under the draw sheet
D.

Apply a wrist restraint to each arm

Correct Answer
B. Wrap her hands in soft “mitten” restraints

Explanation
It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation.Options A. C. and D: Using a jacket or wrist restraint or tucking the client’s arms and hands under the draw sheet restrict movement and add to feelings of being confined. all of which would increase her agitation and increase ICP.

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6.

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.

Correct Answer
D. Back arched; rigid extension of all four extremities.

Explanation
Decerebrate posturing occurs in patients with damage to the upper brain stem. midbrain. or pons and is demonstrated clinically by the arching of the back. rigid extension of the extremities. pronation of the arms. and plantar flexion of the feet.Option A: Internal rotation and adduction of arms with flexion of the elbows. wrists. and fingers described decorticate posturing. which indicates damage to corticospinal tracts and cerebral hemispheres.

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7.

A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

A.

Count the rate to be sure the ventilations are deep enough to be sufficient
B.

Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score.
C.

Call the physician to adjust the ventilator settings.
D.

Check deep tendon reflexes to determine the best motor response

Correct Answer
B. Call the pHysician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score.

Explanation
Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe. which is superior and posterior to the pons and medulla. clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease. Another nurse needs to assess vital signs and score the client according to the GCS. but time is also of the essence. Checking deep tendon reflexes is one part of the GCS analysis.

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8.

In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy. which of the following is contraindicated when positioning the client?

A.

Keeping the client flat on one side or the other
B.

Elevating the head of the bed to 30 degrees
C.

Log rolling or turning as a unit when turning
D.

Keeping the head in neutral position

Correct Answer
B. Elevating the head of the bed to 30 degrees

Explanation
Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brainstem and spinal cord. resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite of the incision. if not contraindicated by the ICP; is used for supratentorial craniotomies.

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9.

A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply.

A.

Decerebrate posturing
B.

Dilated nonreactive pupils
C.

Deep tendon reflexes
D.

Absent corneal reflex

Correct Answer(s)
B. Dilated nonreactive pupils
C. Deep tendon reflexes
D. Absent corneal reflex

Explanation
A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not be seen.

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10.

A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising?

A.

Document the onset time. nature of seizure activity. and postictal behaviors for all seizures.
B.

Administer phenytoin (Dilantin) 200 mg PO daily.
C.

Teach patient about the need for good oral hygiene.
D.

Develop a discharge plan. including physician visits and referral to the Epilepsy Foundation.

Correct Answer
B. Administer pHenytoin (Dilantin) 200 mg PO daily.

Explanation
Administration of medications is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize.Options A. C. and D: Documentation of the seizure. patient teaching. and planning of care are complex activities that require RN level education and scope of practice.

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