1.

Regular oral hygiene is an essential intervention for the client who

has had a stroke. Which of the following nursing measures is
inappropriate when providing oral hygiene?

1. Placing the client on the back with a small pillow under the head.
2. Keeping portable suctioning equipment at the bedside.
3. Opening the clients mouth with a padded tongue blade.
4. Cleaning the clients mouth and teeth with a toothbrush.

2. A 78-year-old client is admitted to the emergency department with

numbness and weakness of the left arm and slurred speech. Which
nursing intervention is a priority?

1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).

2. Discuss the precipitating factors that caused the symptoms.
3. Schedule for A STAT computer tomography (CT) scan of the head.
4. Notify the speech pathologist for an emergency consult.

3. A client arrives in the emergency department with an

ischemic stroke and receives tissue plasminogen activator (t-PA)
administration. Which is the priority nursing assessment?

1. Current medications.
2. Complete physical and history.
3. Time of onset of current stroke.
4. Upcoming surgical procedures.
4. During the first 24 hours after thrombolytic therapy for
ischemic stroke, the primary goal is to control the clients:

1. Pulse
2. Respirations
3. Blood pressure
4. Temperature

5. What is a priority nursing assessment in the first 24 hours after

admission of the client with a thrombotic stroke?

1. Cholesterol level
2. Pupil size and pupillary response
3. Bowel sounds
4. Echocardiogram

6. What is the expected outcome of thrombolytic drug therapy?

1. Increased vascular permeability.

2. Vasoconstriction.
3. Dissolved emboli.
4. Prevention of hemorrhage

7. The client diagnosed with atrial fibrillation has experienced a

transient ischemic attack (TIA). Which medication would the nurse
anticipate being ordered for the client on discharge?

1. An oral anticoagulant medication.

2. A beta-blocker medication.
3. An anti-hyperuricemic medication.
4. A thrombolytic medication.
8. Which client would the nurse identify as being most at risk for
experiencing a CVA?

1. A 55-year-old African American male.

2. An 84-year-old Japanese female.
3. A 67-year-old Caucasian male.
4. A 39-year-old pregnant female.

9. Which assessment data would indicate to the nurse that the client
would be at risk for a hemorrhagic stroke?

1. A blood glucose level of 480 mg/dl.

2. A right-sided carotid bruit.
3. A blood pressure of 220/120 mmHg.
4. The presence of bronchogenic carcinoma.

10. The nurse and unlicensed assistive personnel (UAP) are caring for a
client with right-sided paralysis. Which action by the UAP requires the
nurse to intervene?

1. The assistant places a gait belt around the clients waist prior to ambulating.
2. The assistant places the client on the back with the clients head to the side.
3. The assistant places her hand under the clients right axilla to help him/her
move up in bed.
4. The assistant praises the client for attempting to perform ADLs
independently.

1. An 18-year-old client is admitted with a closed head injury sustained

in a MVA. His intracranial pressure (ICP) shows an upward trend. Which
intervention should the nurse perform first?

1. Reposition the client to avoid neck flexion

2. Administer 1 g Mannitol IV as ordered
3. Increase the ventilators respiratory rate to 20 breaths/minute
4. Administer 100 mg of pentobarbital IV as ordered.

2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg

loading dose of Dilantin IV. Which consideration is most important
when administering this dose?

1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml.

2. Rapid Dilantin administration can cause cardiac arrhythmias.
3. Dilantin should be mixed in dextrose in water before administration.
4. Dilantin should be administered through an IV catheter in the clients hand.

3. A client with head trauma develops a urine output of 300 ml/hr, dry
skin, and dry mucous membranes. Which of the following nursing
interventions is the most appropriate to perform initially?

1. Evaluate urine specific gravity

2. Anticipate treatment for renal failure
3. Provide emollients to the skin to prevent breakdown
4. Slow down the IV fluids and notify the physician

4. When evaluating an ABG from a client with a subdural hematoma,

the nurse notes the PaCO2 is 30 mm Hg. Which of the following
responses best describes this result?

1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure

(ICP).
2. Emergent; the client is poorly oxygenated.
3. Normal
4. Significant; the client has alveolar hypoventilation.
5. A client who had a transsphenoidal hypophysectomy should be
watched carefully for hemorrhage, which may be shown by which of the
following signs?

1. Bloody drainage from the ears

2. Frequent swallowing
3. Guaiac-positive stools
4. Hematuria

6. After a hypophysectomy, vasopressin is given IM for which of the

following reasons?

1. To treat growth failure

2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH)
3. To reduce cerebral edema and lower intracranial pressure
4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.

7. A client comes into the ER after hitting his head in an MVA. Hes alert
and oriented. Which of the following nursing interventions should be
done first?

1. Assess full ROM to determine extent of injuries

2. Call for an immediate chest x-ray
3. Immobilize the clients head and neck
4. Open the airway with the head-tilt-chin-lift maneuver

8. A client with a C6 spinal injury would most likely have which of the
following symptoms?

1. Aphasia
2. Hemiparesis
3. Paraplegia
4. Tetraplegia
9. A 30-year-old was admitted to the progressive care unit with a
C5 fracturefrom a motorcycle accident. Which of the following
assessments would take priority?

1. Bladder distension
2. Neurological deficit
3. Pulse ox readings
4. The clients feelings about the injury

10. While in the ER, a client with C8 tetraplegia develops

a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects
which of the following conditions?

1. Autonomic dysreflexia
2. Hemorrhagic shock
3. Neurogenic shock
4. Pulmonary embolism

11. A client is admitted with a spinal cord injury at the level of T12. He
has limited movement of his upper extremities. Which of the following
medications would be used to control edema of the spinal cord?

1. Acetazolamide (Diamox)
2. Furosemide (Lasix)
3. Methylprednisolone (Solu-Medrol)
4. Sodium bicarbonate

12. A 22-year-old client with quadriplegia is apprehensive and flushed,

with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of
the following nursing interventions should be done first?

1. Place the client flat in bed

2. Assess patency of the indwelling urinary catheter
3. Give one SL nitroglycerin tablet
4. Raise the head of the bed immediately to 90 degrees

13. A client with a cervical spine injury has Gardner-Wells tongs

inserted for which of the following reasons?

1. To hasten wound healing

2. To immobilize the cervical spine
3. To prevent autonomic dysreflexia
4. To hold bony fragments of the skull together

14. Which of the following interventions describes an appropriate

bladder program for a client in rehabilitation for spinal cord injury?

1. Insert an indwelling urinary catheter to straight drainage

2. Schedule intermittent catheterization every 2 to 4 hours
3. Perform a straight catheterization every 8 hours while awake
4. Perform Credes maneuver to the lower abdomen before the client voids.

15. A client is admitted to the ER for head trauma is diagnosed with an

epidural hematoma. The underlying cause of epidural hematoma is
usually related to which of the following conditions?

1. Laceration of the middle meningeal artery

2. Rupture of the carotid artery
3. Thromboembolism from a carotid artery
4. Venous bleeding from the arachnoid space

16. A 23-year-old client has been hit on the head with a baseball bat.
The nurse notes clear fluid draining from his ears and nose. Which of
the following nursing interventions should be done first?
1. Position the client flat in bed
2. Check the fluid for dextrose with a dipstick
3. Suction the nose to maintain airway patency
4. Insert nasal and ear packing with sterile gauze

17. When discharging a client from the ER after a head trauma, the
nurse teaches the guardian to observe for a lucid interval. Which of the
following statements best described a lucid interval?

1. An interval when the clients speech is garbled

2. An interval when the client is alert but cant recall recent events
3. An interval when the client is oriented but then becomes somnolent
4. An interval when the client has a warning symptom, such as an odor or
visual disturbance.

18. Which of the following clients on the rehab unit is most likely to
develop autonomic dysreflexia?

1. A client with a brain injury

2. A client with a herniated nucleus pulposus
3. A client with a high cervical spine injury
4. A client with a stroke

19. Which of the following conditions indicates that spinal shock is

resolving in a client with C7 quadriplegia?

1. Absence of pain sensation in chest

2. Spasticity
3. Spontaneous respirations
4. Urinary continence
20. A nurse assesses a client who has episodes of autonomic
dysreflexia. Which of the following conditions can cause autonomic
dysreflexia?

1. Headache
2. Lumbar spinal cord injury
3. Neurogenic shock
4. Noxious stimuli

21. During an episode of autonomic dysreflexia in which the client

becomes hypertensive, the nurse should perform which of the following
interventions?

1. Elevate the clients legs

2. Put the client flat in bed
3. Put the client in the Trendelenburgs position
4. Put the client in the high-Fowlers position

22. A client with a T1 spinal cord injury arrives at the emergency

department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis
of the lower extremities. Which of the following conditions would most
likely be suspected?

1. Autonomic dysreflexia
2. Hypervolemia
3. Neurogenic shock
4. Sepsis

23. A client has a cervical spine injury at the level of C5. Which of the
following conditions would the nurse anticipate during the acute phase?

1. Absent corneal reflex

2. Decerebrate posturing
3. Movement of only the right or left half of the body
4. The need for mechanical ventilation

24. A client with C7 quadriplegia is flushed and anxious and complains

of a pounding headache. Which of the following symptoms would also
be anticipated?

1. Decreased urine output or oliguria

2. Hypertension and bradycardia
3. Respiratory depression
4. Symptoms of shock

25. A 40-year-old paraplegic must perform

intermittent catheterization of the bladder. Which of the following
instructions should be given?

1. Clean the meatus from back to front.

2. Measure the quantity of urine.
3. Gently rotate the catheter during removal.
4. Clean the meatus with soap and water.

26. An 18-year-old client was hit in the head with a baseball during
practice. When discharging him to the care of his mother, the nurse
gives which of the following instructions?

1. Watch him for keyhole pupil the next 24 hours.

2. Expect profuse vomiting for 24 hours after the injury.
3. Wake him every hour and assess his orientation to person, time, and place.
4. Notify the physician immediately if he has a headache.

27. Which neurotransmitter is responsible for may of the functions of

the frontal lobe?
1. Dopamine
2. GABA
3. Histamine
4. Norepinephrine

28. The nurse is discussing the purpose of an electroencephalogram

(EEG) with the family of a client with massive cerebral hemorrhage and
loss of consciousness. It would be most accurate for the nurse to tell
family members that the test measures which of the following
conditions?

1. Extent of intracranial bleeding

2. Sites of brain injury
3. Activity of the brain
4. Percent of functional brain tissue

29. A client arrives at the ER after slipping on a patch of ice and hitting
her head. A CT scan of the head shows a collection of blood between
the skulland dura mater. Which type of head injury does this finding
suggest?

1. Subdural hematoma
2. Subarachnoid hemorrhage
3. Epidural hematoma
4. Contusion

30. After falling 20, a 36-year-old man sustains a

C6 fracture with spinal cord transaction. Which other findings should
the nurse expect?

1. Quadriplegia with gross arm movement and diaphragmatic breathing

2. Quadriplegia and loss of respiratory function
3. Paraplegia with intercostal muscle loss
4. Loss of bowel and bladder control

31. A 20-year-old client who fell approximately 30 is unresponsive and

breathless. A cervical spine injury is suspected. How should the first-
responder open the clients airway for rescue breathing?

1. By inserting a nasopharyngeal airway

2. By inserting a oropharyngeal airway
3. By performing a jaw-thrust maneuver
4. By performing the head-tilt, chin-lift maneuver

32. The nurse is caring for a client with a T5 complete spinal

cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis
above the T5, and a blood pressure of 162/96. The client reports a
severe, pounding headache. Which of the following nursing
interventions would be appropriate for this client? Select all that apply.

1. Elevate the HOB to 90 degrees

2. Loosen constrictive clothing
3. Use a fan to reduce diaphoresis
4. Assess for bladder distention and bowel impaction
5. Administer antihypertensive medication
6. Place the client in a supine position with legs elevated

33. The client with a head injury has been urinating copious amounts of
dilute urine through the Foley catheter. The clients urine output for the
previous shift was 3000 ml. The nurse implements a new physician
order to administer:

1. Desmopressin (DDAVP, Stimate)

2. Dexamethasone (Decadron)
3. Ethacrynic acid (Edecrin)
4. Mannitol (Osmitrol)

34. The nurse is caring for the client in the ER following a head injury.
The client momentarily lost consciousness at the time of the injury and
then regained it. The client now has lost consciousness again. The
nurse takes quick action, knowing this is compatible with:

1. Skull fracture
2. Concussion
3. Subdural hematoma
4. Epidural hematoma

35. The nurse is caring for a client who suffered a spinal cord injury 48
hours ago. The nurse monitors for GI complications by assessing for:

1. A flattened abdomen
2. Hematest positive nasogastric tube drainage
3. Hyperactive bowel sounds
4. A history of diarrhea

36. A client with a spinal cord injury is prone to experiencing autonomic

dysreflexia. The nurse would avoid which of the following measures to
minimize the risk of recurrence?

1. Strict adherence to a bowel retraining program

2. Limiting bladder catheterization to once every 12 hours
3. Keeping the linen wrinkle-free under the client
4. Preventing unnecessary pressure on the lower limbs

37. The nurse is planning care for the client in spinal shock. Which of
the following actions would be least helpful in minimizing the effects of
vasodilation below the level of the injury?
1. Monitoring vital signs before and during position changes
2. Using vasopressor medications as prescribed
3. Moving the client quickly as one unit
4. Applying Teds or compression stockings.

38. The nurse is caring for a client admitted with spinal cord injury. The
nurse minimizes the risk of compounding the injury most effectively by:

1. Keeping the client on a stretcher

2. Logrolling the client on a firm mattress
3. Logrolling the client on a soft mattress
4. Placing the client on a Stryker frame

39. The nurse is evaluating neurological signs of the male client in

spinal shock following spinal cord injury. Which of the following
observations by the nurse indicates that spinal shock persists?

1. Positive reflexes
2. Hyperreflexia
3. Inability to elicit a Babinskis reflex
4. Reflex emptying of the bladder

40. A client with a spinal cord injury suddenly experiences an episode

of autonomic dysreflexia. After checking the clients vital signs, list in
order of priority, the nurses actions (Number 1 being the first priority
and number 5 being the last priority).

1. Check for bladder distention (2,4,1,3,5)

2. Raise the head of the bed
3. Contact the physician
4. Loosen tight clothing on the client
5. Administer an antihypertensive medication
41. A client is at risk for increased ICP. Which of the following would be
a priority for the nurse to monitor?

1. Unequal pupil size

2. Decreasing systolic blood pressure
3. Tachycardia
4. Decreasing body temperature

42. Which of the following respiratory patterns indicate increasing ICP

in the brain stem?

1. Slow, irregular respirations

2. Rapid, shallow respirations
3. Asymmetric chest expansion
4. Nasal flaring

43. Which of the following nursing interventions is appropriate for a

client with an ICP of 20 mm Hg?

1. Give the client a warming blanket

2. Administer low-dose barbiturate
3. Encourage the client to hyperventilate
4. Restrict fluids

44. A client has signs of increased ICP. Which of the following is

an early indicator of deterioration in the clients condition?

1. Widening pulse pressure

2. Decrease in the pulse rate
3. Dilated, fixed pupil
4. Decrease in LOC
45. 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?

1. Place her in a jacket restraint

2. Wrap her hands in soft mitten restraints
3. Tuck her arms and hands under the draw sheet
4. Apply a wrist restraint to each arm

46. Which of the following describes decerebrate posturing?

1. Internal rotation and adduction of arms with flexion of elbows, wrists, and
fingers
2. Back hunched over, rigid flexion of all four extremities with supination of
arms and plantar flexion of the feet
3. Supination of arms, dorsiflexion of feet
4. Back arched; rigid extension of all four extremities.

47. A client receiving vent-assisted mode ventilation begins to

experience cluster breathing after recent intracranial occipital bleeding.
Which action would be most appropriate?

1. Count the rate to be sure the ventilations are deep enough to be sufficient
2. Call the physician while another nurse checks the vital signs and ascertains
the patients Glasgow Coma score.
3. Call the physician to adjust the ventilator settings.
4. Check deep tendon reflexes to determine the best motor response

48. 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?
1. Keeping the client flat on one side or the other
2. Elevating the head of the bed to 30 degrees
3. Log rolling or turning as a unit when turning
4. Keeping the head in neutral position

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

1. Decerebrate posturing
2. Dilated nonreactive pupils
3. Deep tendon reflexes
4. Absent corneal reflex

50. 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 patients care will be
best to delegate to an LPN/LVN whom you are supervising?

1. Document the onset time, nature of seizure activity, and postictal behaviors
for all seizures.
2. Administer phenytoin (Dilantin) 200 mg PO daily.
3. Teach patient about the need for good oral hygiene.
4. Develop a discharge plan, including physician visits and referral to
the Epilepsy Foundation.

1. A client admitted to the hospital with a subarachnoid hemorrhage

has complaints of severe headache, nuchal rigidity, and projectile
vomiting. The nurse knows lumbar puncture (LP) would be
contraindicated in this client in which of the following circumstances?

1. Vomiting continues
2. Intracranial pressure (ICP) is increased
3. The client needs mechanical ventilation
4. Blood is anticipated in the cerebrospinal fluid (CSF)

2. A client with a subdural hematoma becomes restless and confused,

with dilation of the ipsilateral pupil. The physician orders mannitol for
which of the following reasons?

1. To reduce intraocular pressure

2. To prevent acute tubular necrosis
3. To promote osmotic diuresis to decrease ICP
4. To draw water into the vascular system to increase blood pressure

3. A client with subdural hematoma was given mannitol to decrease

intracranial pressure (ICP). Which of the following results would best
show the mannitol was effective?

1. Urine output increases

2. Pupils are 8 mm and nonreactive
3. Systolic blood pressure remains at 150 mm Hg
4. BUN and creatinine levels return to normal

4. Which of the following values is considered normal for ICP?

1. 0 to 15 mm Hg
2. 25 mm Hg
3. 35 to 45 mm Hg
4. 120/80 mm Hg

5. Which of the following symptoms may occur with a phenytoin level of

32 mg/dl?

1. Ataxia and confusion

2. Sodium depletion
3. Tonic-clonic seizure
4. Urinary incontinence

6. Which of the following signs and symptoms of increased ICP after

head trauma would appear first?

1. Bradycardia
2. Large amounts of very dilute urine
3. Restlessness and confusion
4. Widened pulse pressure

7. Problems with memory and learning would relate to which of the

following lobes?

1. Frontal
2. Occipital
3. Parietal
4. Temporal

8. While cooking, your client couldnt feel the temperature of a hot

oven. Which lobe could be dysfunctional?

1. Frontal
2. Occipital
3. Parietal
4. Temporal

9. The nurse is assessing the motor function of an unconscious client.

The nurse would plan to use which of the following to test the clients
peripheral response to pain?

1. Sternal rub
2. Pressure on the orbital rim
3. Squeezing the sternocleidomastoid muscle
4. Nail bed pressure

10. The client is having a lumbar puncture performed. The nurse would
plan to place the client in which position for the procedure?

1. Side-lying, with legs pulled up and head bent down onto the chest
2. Side-lying, with a pillow under the hip
3. Prone, in a slight Trendelenburgs position
4. Prone, with a pillow under the abdomen.

11. A nurse is assisting with caloric testing of the oculovestibular reflex

of an unconscious client. Cold water is injected into the left auditory
canal. The client exhibits eye conjugate movements toward the left
followed by a rapid nystagmus toward the right. The nurse understands
that this indicates the client has:

1. A cerebral lesion
2. A temporal lesion
3. An intact brainstem
4. Brain death

12. The nurse is caring for the client with increased intracranial
pressure. The nurse would note which of the following trends in vital
signs if the ICP is rising?

1. Increasing temperature, increasing pulse, increasing respirations,

decreasing blood pressure.
2. Increasing temperature, decreasing pulse, decreasing respirations,
increasing blood pressure.
3. Decreasing temperature, decreasing pulse, increasing respirations,
decreasing blood pressure.
4. Decreasing temperature, increasing pulse, decreasing respirations,
increasing blood pressure.

13. The nurse is evaluating the status of a client who had a craniotomy
3 days ago. The nurse would suspect the client is
developing meningitis as a complication of surgery if the client exhibits:

1. A positive Brudzinskis sign

2. A negative Kernigs sign
3. Absence of nuchal rigidity
4. A Glascow Coma Scale score of 15

14. A client is arousing from a coma and keeps saying, Just stop
the pain. The nurse responds based on the knowledge that the human
body typically and automatically responds to pain first with attempts
to:

1. Tolerate the pain

2. Decrease the perception of pain
3. Escape the source of pain
4. Divert attention from the source of pain.

15. During the acute stage of meningitis, a 3-year-old child is restless

and irritable. Which of the following would be most appropriate to
institute?

1. Limiting conversation with the child

2. Keeping extraneous noise to a minimum
3. Allowing the child to play in the bathtub
4. Performing treatments quickly

16. Which of the following would lead the nurse to suspect that a child
with meningitis has developed disseminated intravascular coagulation?
1. Hemorrhagic skin rash
2. Edema
3. Cyanosis
4. Dyspnea on exertion

17. When interviewing the parents of a 2-year-old child, a history of

which of the following illnesses would lead the nurse to suspect
pneumococcal meningitis?

1. Bladder infection
2. Middle ear infection
3. Fractured clavicle
4. Septic arthritis

18. The nurse is assessing a child diagnosed with a brain tumor. Which
of the following signs and symptoms would the nurse expect the child
to demonstrate? Select all that apply.

1. Head tilt
2. Vomiting
3. Polydipsia
4. Lethargy
5. Increased appetite
6. Increased pulse

19. A lumbar puncture is performed on a child suspected of

having bacterial meningitis. CSF is obtained for analysis. A nurse
reviews the results of the CSF analysis and determines that which of
the following results would verify the diagnosis?

1. Cloudy CSF, decreased protein, and decreased glucose

2. Cloudy CSF, elevated protein, and decreased glucose
3. Clear CSF, elevated protein, and decreased glucose
4. Clear CSF, decreased pressure, and elevated protein

20. A nurse is planning care for a child with acute bacterial meningitis.
Based on the mode of transmission of this infection, which of the
following would be included in the plan of care?

1. No precautions are required as long as antibiotics have been started

2. Maintain enteric precautions
3. Maintain respiratory isolation precautions for at least 24 hours after the
initiation of antibiotics
4. Maintain neutropenic precautions

21. A nurse is reviewing the record of a child with increased ICP and
notes that the child has exhibited signs of decerebrate posturing. On
assessment of the child, the nurse would expect to note which of the
following if this type of posturing was present?

1. Abnormal flexion of the upper extremities and extension of the lower

extremities
2. Rigid extension and pronation of the arms and legs
3. Rigid pronation of all extremities
4. Flaccid paralysis of all extremities

22. Which of the following assessment data indicated nuchal rigidity?

1. Positive Kernigs sign

2. Negative Brudzinskis sign
3. Positive homans sign
4. Negative Kernigs sign

23. Meningitis occurs as an extension of a variety of bacterial infections

due to which of the following conditions?
1. Congenital anatomic abnormality of the meninges
2. Lack of acquired resistance to the various etiologic organisms
3. Occlusion or narrowing of the CSF pathway
4. Natural affinity of the CNS to certain pathogens

24. Which of the following pathologic processes is often associated with

aseptic meningitis?

1. Ischemic infarction of cerebral tissue

2. Childhood diseases of viral causation such as mumps
3. Brain abscesses caused by a variety of pyogenic organisms
4. Cerebral ventricular irritation from a traumatic brain injury

25. You are preparing to admit a patient with a seizure disorder. Which
of the following actions can you delegate to LPN/LVN?

1. Complete admission assessment.

2. Set up oxygen and suction equipment.
3. Place a padded tongue blade at bedside.
4. Pad the side rails before patient arrives.

1. 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.
D. Thinking and reasoning.

2. A female client admitted to an acute care facility after a car accident

develops signs and symptoms of increased intracranial pressure (ICP).
The client is intubated and placed on mechanical ventilation to help
reduce ICP. To prevent a further rise in ICP caused by suctioning, the
nurse anticipates administering which drug endotracheally before
suctioning?

A. Phenytoin (Dilantin)
B. Mannitol (Osmitrol)
C. Lidocaine (Xylocaine)
D. Furosemide (Lasix)

3. After striking his head on a tree while falling from a ladder, a young
man age 18 is admitted to the emergency department. Hes
unconscious and his pupils are nonreactive. Which intervention would
be the most dangerous for the client?

A. Give him a barbiturate.

B. Place him on mechanical ventilation.
C. Perform a lumbar puncture.
D. Elevate the head of his bed.

4. When obtaining the health history from a male client with retinal
detachment, the nurse expects the client to report:

A. Light flashes and floaters in front of the eye.

B. A recent driving accident while changing lanes.
C. Headaches, nausea, and redness of the eyes.
D. Frequent episodes of double vision.

5. Which nursing diagnosis takes highest priority for a client with

Parkinsons crisis?

A. Imbalanced nutrition: Less than body requirements

B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury

6. To encourage adequate nutritional intake for a female client with

Alzheimers disease, the nurse should:

A. Stay with the client and encourage him to eat.

B. Help the client fill out his menu.
C. Give the client privacy during meals.
D. Fill out the menu for the client.

7. The nurse is performing a mental status examination on a male client

diagnosed with a subdural hematoma. This test assesses which of the
following?

A. Cerebellar function
B. Intellectual function
C. Cerebral function
D. Sensory function

8. Shortly after admission to an acute care facility, a male client with

a seizure disorder develops status epilepticus. The physician
orders diazepam(Valium) 10 mg I.V. stat. How soon can the nurse
administer the second dose of diazepam, if needed and prescribed?

A. In 30 to 45 seconds
B. In 10 to 15 minutes
C. In 30 to 45 minutes
D. In 1 to 2 hours

9. A female client complains of periorbital aching, tearing,

blurred vision, and photophobia in her right eye. Ophthalmologic
examination reveals a small, irregular, nonreactive pupil a condition
resulting from acute iris inflammation (iritis). As part of the clients
therapeutic regimen, the physician prescribes atropine sulfate
(Atropisol), two drops of 0.5% solution in the right eye twice
daily. Atropine sulfate belongs to which drug classification?

A. Parasympathomimetic agent
B. Sympatholytic agent
C. Adrenergic blocker
D. Cholinergic blocker

10. Emergency medical technicians transport a 27-year-old iron worker

to the emergency department. They tell the nurse, He fell from a two-
story building. He has a large contusion on his left chest and a
hematoma in the left parietal area. He has a compound fracture of his
left femur and hes comatose. We intubated him and hes maintaining
an arterial oxygen saturation of 92% by pulse oximeter with a manual
resuscitation bag. Which intervention by the nurse has the highest
priority?

A. Assessing the left leg

B. Assessing the pupils
C. Placing the client in Trendelenburgs position
D. Assessing level of consciousness

11. An auto mechanic accidentally has battery acid splashed in his eyes.
His coworkers irrigate his eyes with water for 20 minutes, and then
take him to the emergency department of a nearby hospital, where he
receives emergency care for the corneal injury. The physician
prescribes dexamethasone (Maxidex Ophthalmic Suspension), two
drops of 0.1% solution to be instilled initially into the conjunctival sacs
of both eyes every hour; and polymyxin B sulfate (Neosporin
Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of
both eyes every 3 hours. Dexamethasoneexerts its therapeutic effect
by:

A. Increasing the exudative reaction of ocular tissue.

B. Decreasing leukocyte infiltration at the site of ocular inflammation.
C. Inhibiting the action of carbonic anhydrase.
D. Producing a miotic reaction by stimulating and contracting the sphincter
muscles of the iris.

12. Nurse Amber is caring for a client who underwent a lumbar

laminectomy two (2) days ago. Which of the following findings should
the nurse consider abnormal?

A. More back pain than the first postoperative day

B. Paresthesia in the dermatomes near the wounds
C. Urine retention or incontinence
D. Temperature of 99.2 F (37.3 C)

13. After an eye examination, a male client is diagnosed with open-

angle glaucoma. The physician prescribes Pilocarpine ophthalmic
solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the
nurse should teach the client or a family member to administer the drug
by:

A. Instilling one drop of pilocarpine 0.25% into both eyes daily.

B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily.
C. Instilling one drop of pilocarpine 0.25% into the right eye daily.
D. Instilling one drop of pilocarpine 0.25% into the left eye four times daily.

14. A female client whos paralyzed on the left side has been receiving
physical therapy and attending teaching sessions about safety. Which
behavior indicates that the client accurately understands safety
measures related to paralysis?
A. The client leaves the side rails down.
B. The client uses a mirror to inspect the skin.
C. The client repositions only after being reminded to do so.
D. The client hangs the left arm over the side of the wheelchair.

15. A male client in the emergency department has a suspected

neurologic disorder. To assess gait, the nurse asks the client to take a
few steps; with each step, the clients feet make a half circle. To
document the clients gait, the nurse should use which term?

A. Ataxic
B. Dystrophic
C. Helicopod
D. Steppage

16. A client, age 22, is admitted with bacterial meningitis. Which

hospital room would be the best choice for this client?

A. A private room down the hall from the nurses station

B. An isolation room three doors from the nurses station
C. A semi private room with a 32-year-old client who has viral meningitis
D. A two-bed room with a client who previously had bacterial meningitis

17. A physician diagnoses a client with myasthenia gravis,

prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours.
Before administering this anticholinesterase agent, the nurse reviews
the clients history. Which preexisting condition would contraindicate
the use of pyridostigmine?

A. Ulcerative colitis
B. Blood dyscrasia
C. Intestinal obstruction
D. Spinal cord injury
18. A female client is admitted to the facility for investigation of
balance and coordination problems, including possible Mnires
disease. When assessing this client, the nurse expects to note:

A. Vertigo, tinnitus, and hearing loss.

B. Vertigo, vomiting, and nystagmus
C. Vertigo, pain, and hearing impairment.
D. Vertigo, blurred vision, and fever.

19. A male client with a conductive hearing disorder caused by

ankylosis of the stapes in the oval window undergoes a stapedectomy
to remove the stapes and replace the impaired bone with a prosthesis.
After the stapedectomy, the nurse should provide which client
instruction?

A. Lie in bed with your head elevated, and refrain from blowing your nose for
24 hours.
B. Try to ambulate independently after about 24 hours.
C. Shampoo your hair every day for ten (10) days to help prevent
ear infection.
D. Dont fly in an airplane, climb to high altitudes, make sudden movements,
or expose yourself to loud sounds for 30 days.

20. Nurse Marty is monitoring a client for adverse reactions

to dantrolene(Dantrium). Which adverse reaction is most common?

A. Excessive tearing
B. Urine retention
C. Muscle weakness
D. Slurred speech

21. The nurse is monitoring a male client for adverse reactions

to atropinesulfate (Atropine Care) eyedrops. Systemic absorption
of atropine sulfate through the conjunctiva can cause which adverse
reaction?

A. Tachycardia
B. Increased salivation
C. Hypotension
D. Apnea

22. A male client is admitted with a cervical spine injury sustained

during a diving accident. When planning this clients care, the nurse
should assign the highest priority to which nursing diagnosis?

A. Impaired physical mobility

B. Ineffective breathing pattern
C. Disturbed sensory perception (tactile)
D. Self-care deficit: Dressing/grooming

23. A male client has a history of painful, continuous muscle spasms. He

has taken several skeletal muscle relaxants without experiencing relief.
His physician prescribes diazepam (Valium), two (2) mg P.O. twice
daily. In addition to being used to relieve painful muscle spasms,
Diazepam also is recommended for:

A. long-term treatment of epilepsy.

B. postoperative pain management of laminectomy clients.
C. postoperative pain management of diskectomy clients
D. treatment of spasticity associated with spinal cord lesions.

24. A female client who was found unconscious at home is brought to

the hospital by a rescue squaD. In the intensive care unit, the nurse
checks the clients oculocephalic (dolls eye) response by:
A. Introducing ice water into the external auditory canal.
B. Touching the cornea with a wisp of cotton.
C. Turning the clients head suddenly while holding the eyelids open.
D. Shining a bright light into the pupil.

25. While reviewing a clients chart, the nurse notices that the female
client has myasthenia gravis. Which of the following statements about
neuromuscular blocking agents is true for a client with this condition?

A. The client may be less sensitive to the effects of a neuromuscular blocking

agent.
B. Succinylcholine shouldnt be used; pancuronium may be used in a lower
dosage.
C. Pancuronium shouldnt be used; succinylcholine may be used in a lower
dosage.
D. Pancuronium and succinylcholine both require cautious administration.

26. A male client is color blind. The nurse understands that this client
has a problem with:

A. Rods.
B. Cones.
C. Lens.
D. Aqueous humor.

27. A female client who was trapped inside a car for hours after a head-
on collision is rushed to the emergency department with multiple
injuries. During the neurologic examination, the client responds to
painful stimuli with decerebrate posturing. This finding indicates
damage to which part of the brain?

A. Diencephalon
B. Medulla
C. Midbrain
D. Cortex

28. The nurse is assessing a 37-year-old client diagnosed with multiple

sclerosis. Which of the following symptoms would the nurse expect to
find?

A. Vision changes
B. Absent deep tendon reflexes
C. Tremors at rest
D. Flaccid muscles

29. The nurse is caring for a male client diagnosed with a cerebral
aneurysmwho reports a severe headache. Which action should the
nurse perform?

A. Sit with the client for a few minutes.

B. Administer an analgesic.
C. Inform the nurse manager.
D. Call the physician immediately.

30. During recovery from a cerebrovascular accident (CVA), a female

client is given nothing by mouth, to help prevent aspiration. To
determine when the client is ready for a liquid diet, the nurse assesses
the clients swallowing ability once each shift. This assessment
evaluates:

A. Cranial nerves I and II.

B. Cranial nerves III and V.
C. Cranial nerves VI and VIII.
D. Cranial nerves IX and X.
1. A white female client is admitted to an acute care facility with a
diagnosis of cerebrovascular accident (CVA). Her history
reveals bronchial asthma, exogenous obesity, and iron
deficiency anemia. Which history finding is a risk factor for CVA?

A. Caucasian race
B. Female sex
C. Obesity
D. Bronchial asthma

2. The nurse is teaching a female client with multiple sclerosis. When

teaching the client how to reduce fatigue, the nurse should tell the
client to:

A. Take a hot bath.

B. Rest in an air-conditioned room.
C. Increase the dose of muscle relaxants.
D. Avoid naps during the day.

3. A male client is having tonic-clonic seizures. What should the nurse

do first?

A. Elevate the head of the bed.

B. Restrain the clients arms and legs.
C. Place a tongue blade in the clients mouth.
D. Take measures to prevent injury.

4. A female client with Guillain-Barr syndrome has paralysis affecting

the respiratory muscles and requires mechanical ventilation. When the
client asks the nurse about the paralysis, how should the nurse
respond?
A. You may have difficulty believing this, but the paralysis caused by this
disease is temporary.
B. Youll have to accept the fact that youre permanently paralyzeD. However,
you wont have any sensory loss.
C. It must be hard to accept the permanency of your paralysis.
D. Youll first regain use of your legs and then your arms.

5. The nurse is working on a surgical floor. The nurse must log roll a
male client following a:

A. Laminectomy.
B. Thoracotomy.
C. Hemorrhoidectomy.
D. Cystectomy.

6. A female client with a suspected brain tumor is scheduled for

computed tomography (CT). What should the nurse do when preparing
the client for this test?

A. Immobilize the neck before the client is moved onto a stretcher.

B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
C. Place a cap on the clients head.
D. Administer a sedative as ordered.

7. During a routine physical examination to assess a male clients deep

tendon reflexes, the nurse should make sure to:

A. Use the pointed end of the reflex hammer when striking the Achilles tendon.
B. Support the joint where the tendon is being tested.
C. Tap the tendon slowly and softly
D. Hold the reflex hammer tightly.
8. A female client is admitted in a disoriented and restless state after
sustaining a concussion during a car accident. Which nursing diagnosis
takes highest priority for this clients plan of care?

A. Disturbed sensory perception (visual)

B. Self-care deficient: Dressing/grooming
C. Impaired verbal communication
D. Risk for injury

9. A female client with amyotrophic lateral sclerosis (ALS) tells the

nurse, Sometimes I feel so frustrateD. I cant do anything without
help! This comment best supports which nursing diagnosis?

A. Anxiety
B. Powerlessness
C. Ineffective denial
D. Risk for disuse syndrome

10. For a male client with suspected increased intracranial pressure

(ICP), a most appropriate respiratory goal is to:

A. Prevent respiratory alkalosis.

B. Lower arterial pH.
C. Promote carbon dioxide elimination.
D. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

11. Nurse Mary witnesses a neighbors husband sustain a fall from the
roof of his house. The nurse rushes to the victim and determines the
need to opens the airway in this victim by using which method?

A. Flexed position
B. Head tilt-chin lift
C. Jaw-thrust maneuver
D. Modified head tilt-chin lift

12. The nurse is assessing the motor function of an unconscious male

client. The nurse would plan to use which plan to use which of the
following to test the clients peripheral response to pain?

A. Sternal rub
B. Nail bed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle

13. A female client admitted to the hospital with a neurological problem

asks the nurse whether magnetic resonance imaging may be done. The
nurse interprets that the client may be ineligible for this diagnostic
procedure based on the clients history of:

A. Hypertension
B. Heart failure
C. Prosthetic valve replacement
D. Chronic obstructive pulmonary disorder

14. A male client is having a lumbar puncture performed. The nurse

would plan to place the client in which position?

A. Side-lying, with a pillow under the hip

B. Prone, with a pillow under the abdomen
C. Prone, in slight-Trendelenburgs position
D. Side-lying, with the legs, pulled up and head bent down onto the chest.

15. The nurse is positioning the female client with increased

intracranial pressure. Which of the following positions would the nurse
avoid?
A. Head midline
B. Head turned to the side
C. Neck in neutral position
D. Head of bed elevated 30 to 45 degrees

16. A female client has clear fluid leaking from the nose following a
basilar skull fracture. The nurse assesses that this is cerebrospinal
fluid if the fluid:

A. Is clear and tests negative for glucose

B. Is grossly bloody in appearance and has a pH of 6
C. Clumps together on the dressing and has a pH of 7
D. Separates into concentric rings and test positive of glucose

17. A male client with a spinal cord injury is prone to experiencing

automatic dysreflexia. The nurse would avoid which of the following
measures to minimize the risk of recurrence?

A. Strict adherence to a bowel retraining program

B. Keeping the linen wrinkle-free under the client
C. Preventing unnecessary pressure on the lower limbs
D. Limiting bladder catheterization to once every 12 hours

18. The nurse is caring for the male client who begins to
experience seizureactivity while in beD. Which of the following actions
by the nurse would be contraindicated?

A. Loosening restrictive clothing

B. Restraining the clients limbs
C. Removing the pillow and raising padded side rails
D. Positioning the client to side, if possible, with the head flexed forward
19. The nurse is assigned to care for a female client with complete
right-sided hemiparesis. The nurse plans care knowing that this
condition:

A. The client has complete bilateral paralysis of the arms and legs.
B. The client has weakness on the right side of the body, including the face and
tongue.
C. The client has lost the ability to move the right arm but can walk
independently.
D. The client has lost the ability to move the right arm but can walk
independently.

20. The client with a brain attack (stroke) has residual dysphagia.
When a diet order is initiated, the nurse avoids doing which of the
following?

A. Giving the client thin liquids

B. Thickening liquids to the consistency of oatmeal
C. Placing food on the unaffected side of the mouth
D. Allowing plenty of time for chewing and swallowing

21. The nurse is assessing the adaptation of the female client to

changes in functional status after a brain attack (stroke). The nurse
assesses that the client is adapting most successfully if the client:

A. Gets angry with family if they interrupt a task

B. Experiences bouts of depression and irritability
C. Has difficulty with using modified feeding utensils
D. Consistently uses adaptive equipment in dressing self

22. Nurse Kristine is trying to communicate with a client

with brain attack (stroke) and aphasia. Which of the following actions
by the nurse would be least helpful to the client?
A. Speaking to the client at a slower rate
B. Allowing plenty of time for the client to respond
C. Completing the sentences that the client cannot finish
D. Looking directly at the client during attempts at speech

23. A female client has experienced an episode of myasthenic crisis.

The nurse would assess whether the client has precipitating factors
such as:

A. Getting too little exercise

B. Taking excess medication
C. Omitting doses of medication
D. Increasing intake of fatty foods

24. The nurse is teaching the female client with myasthenia gravis
about the prevention of myasthenic and cholinergic crises. The nurse
tells the client that this is most effectively done by:

A. Eating large, well-balanced meals

B. Doing muscle-strengthening exercises
C. Doing all chores early in the day while less fatigued
D. Taking medications on time to maintain therapeutic blood levels

25. A male client with Bells Palsy asks the nurse what has caused this
problem. The nurses response is based on an understanding that the
cause is:

A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune

problem
B. Unknown, but possibly includes long-term tissue malnutrition and cellular
hypoxia
C. Primary genetic in origin, triggered by exposure to meningitis
D. Primarily genetic in origin, triggered by exposure to neurotoxins
26. The nurse has given the male client with Bells palsy instructions on
preserving muscle tone in the face and preventing denervation. The
nurse determines that the client needs additional information if the
client states that he or she will:

A. Exposure to cold and drafts

B. Massage the face with a gentle upward motion
C. Perform facial exercises
D. Wrinkle the forehead, blow out the cheeks, and whistle

27. A female client is admitted to the hospital with a diagnosis of

Guillain-Barre syndrome. The nurse inquires during the nursing
admission interview if the client has a history of:

A. Seizures or trauma to the brain

B. Meningitis during the last five (5 years
C. Back injury or trauma to the spinal cord
D. Respiratory or gastrointestinal infection during the previous month.

28. A female client with Guillain-Barre syndrome has 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?

A. Giving client full control over care decisions and restricting visitors
B. Providing positive feedback and encouraging active range of motion
C. Providing information, giving positive feedback and encouraging relaxation
D. Providing intravenously administered sedatives, reducing distractions and
limiting visitors

29. A male client has an impairment of cranial nerve II. Specific to this
impairment, the nurse would plan to do which of the following to
ensure client to ensure client safety?
A. Speak loudly to the client
B. Test the temperature of the shower water
C. Check the temperature of the food on the delivery tray.
D. Provide a clear path for ambulation without obstacles

30. A female client has a neurological deficit involving the limbic

system. Specific to this type of deficit, the nurse would document which
of the following information related to the clients 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