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

The nurse
should plan to use which technique to test the client's peripheral response to pain? 
1. Sternal rub 
2. Nail bed pressure 
3. Pressure on the orbital rim 
4. Squeezing of the sternocleidomastoid muscle

2.Nail bed pressure

2. The nurse is caring for the client with increased intracranial pressure. The nurse
would note which trend in vital signs if the intracranial pressure 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

2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood

pressure

3. A client recovering from a head injury is participating in care. The nurse determines
that the client understands measures to prevent elevations in intracranial pressure if
the nurse observes the client doing which activity? 
1. Blowing the nose 
2. Isometric exercises 
3. Coughing vigorously 
4. Exhaling during repositioning

4. Exhaling during repositioning

4. A client has clear fluid leaking from the nose following a basilar skull fracture. Which
finding would alert the nurse that cerebrospinal fluid is present? 
1. Fluid is clear and tests negative for glucose. 
2. Fluid is grossly bloody in appearance and has a pH of 6. 
3. Fluid clumps together on the dressing and has a pH of 7. 
4. Fluid separates into concentric rings and tests positive for glucose.

4. Fluid separates into concentric rings and tests positive for glucose.

5. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The
nurse should avoid which measure to minimize the risk of occurrence? 
1. Strict adherence to a bowel retraining program 
2. Keeping the linen wrinkle-free under the client 
3. Preventing unnecessary pressure on the lower limbs 
4. Limiting bladder catheterization to once every 12 hours
 4. Limiting bladder catheterization to once every 12 hours

6. The nurse is evaluating the neurological signs of a client in spinal shock following
spinal cord injury. Which observation indicates that spinal shock persists? 
1. Hyperreflexia 
2. Positive reflexes 
3. Flaccid paralysis 
4. Reflex emptying of the bladder

3. Flaccid paralysis

7. The nurse is caring for a client who begins to experience seizure activity while in
bed. Which action by the nurse is contraindicated? 
1. Loosening restrictive clothing 
2. Restraining the client's limbs 
3. Removing the pillow and raising padded side rails 
4. Positioning the client to the side, if possible, with the head flexed forward

2. Restraining the client's limbs

8. The nurse is assigned to care for a client with complete right-sided hemiparesis.
Which characteristics are associated with this condition?Select all that apply. 
1. The client is aphasic. 
2. The client has weakness in the face and tongue. 
3. The client has weakness on the right side of the body. 
4. The client has complete bilateral paralysis of the arms and legs. 
5. The client has lost the ability to move the right arm but is able to walk
independently. 
6. The client has lost the ability to ambulate independently but is able to feed and
bathe himself or herself without assistance.
o 1. The client is aphasic. 
o 2. The client has weakness in the face and tongue. 
o 3. The client has weakness on the right side of the body.
9. The nurse has instructed the family of a client with stroke (brain attack) who has
homonymous hemianopsia about measures to help the client overcome the deficit.
Which statement suggests that the family understands the measures to use when
caring for the client? 
1. "We need to discourage him from wearing eyeglasses." 
2. "We need to place objects in his impaired field of vision." 
3. "We need to approach him from the impaired field of vision." 
4. "We need to remind him to turn his head to scan the lost visual field."

4. "We need to remind him to turn his head to scan the lost visual field."

10. The nurse is assessing the adaptation of a client to changes in functional status after
a stroke (brain attack). Which observation indicates to the nurse that the client is
adapting most successfully? 
1. Gets angry with family if they interrupt a task 
 2. Experiences bouts of depression and irritability 
3. Has difficulty with using modified feeding utensils 
4. Consistently uses adaptive equipment in dressing self

4. Consistently uses adaptive equipment in dressing self

11. The nurse is teaching a client with myasthenia gravis about the prevention of
myasthenic and cholinergic crises. Which client activity suggests that teaching
is most effective? 
1. Eating large, well-balanced meals 
2. Doing muscle-strengthening exercises 
3. Doing all chores early in the day while less fatigued 
4. Taking medications on time to maintain therapeutic blood levels

4. Taking medications on time to maintain therapeutic blood levels

12. The nurse has given instructions to a client with Parkinson's disease about
maintaining mobility. Which action demonstrates that the client understands the
directions? 
1. Sits in soft, deep chairs to promote comfort. 
2. Exercises in the evening to combat fatigue. 
3. Rocks back and forth to start movement with bradykinesia. 
4. Buys clothes with many buttons to maintain finger dexterity.

3. Rocks back and forth to start movement with bradykinesia.

13. The nurse has given suggestions to a client with trigeminal neuralgia about
strategies to minimize episodes of pain. The nurse determines that the client needs
further education if the client makes which statement? 
1. "I will wash my face with cotton pads." 
2. "I'll have to start chewing on my unaffected side." 
3. "I'll try to eat my food either very warm or very cold." 
4. "I should rinse my mouth if toothbrushing is painful."

3. "I'll try to eat my food either very warm or very cold."

14. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome.
Which past medical history finding makes the client most at risk for this disease? 
1. Meningitis or encephalitis during the last 5 years 
2. Seizures or trauma to the brain within the last year 
3. Back injury or trauma to the spinal cord during the last 2 years 
4. Respiratory or gastrointestinal infection during the previous month

4. Respiratory or gastrointestinal infection during the previous month

15. A client with Guillain-Barré syndrome has ascending paralysis and is intubated and
receiving mechanical ventilation. Which strategy should the nurse incorporate in the
plan of care to help the client cope with this illness? 
 1. Giving client full control over care decisions and restricting visitors 
2. Providing positive feedback and encouraging active range of motion 
3. Providing information, giving positive feedback, and encouraging relaxation 
4. Providing intravenously administered sedatives, reducing distractions, and limiting
visitors

3. Providing information, giving positive feedback, and encouraging relaxation

16. A client has a neurological deficit involving the limbic system. Which assessment
finding is specific to this type of deficit? 
1. Is disoriented to person, place, and time 
2. Affect is flat, with periods of emotional lability 
3. Cannot recall what was eaten for breakfast today 
4. Demonstrates inability to add and subtract; does not know who is the president of
the United States

2. Affect is flat, with periods of emotional lability

17. The nurse is planning to institute seizure precautions for a client who is being
admitted from the emergency department. Which measures should the nurse include
in planning for the client's safety?Select all that apply. 
1. Padding the side rails of the bed 
2. Placing an airway at the bedside 
3. Placing the bed in the high position 
4. Putting a padded tongue blade at the head of the bed 
5. Placing oxygen and suction equipment at the bedside 
6. Having intravenous equipment ready for insertion of an intravenous catheter
o 1. Padding the side rails of the bed 
o 2. Placing an airway at the bedside 
o 5. Placing oxygen and suction equipment at the bedside 
o 6. Having intravenous equipment ready for insertion of an intravenous catheter
18. The nurse is evaluating the status of a client who had a craniotomy 3 days ago.
Which assessment finding would indicate that the client is developing meningitis as a
complication of surgery? 
1. A negative Kernig sign 
2. Absence of nuchal rigidity 
3. A positive Brudzinski sign 
4. A Glasgow Coma Scale score of 15

3. A positive Brudzinski sign

19. The nurse has completed discharge instructions for a client with application of a halo
device. Which action indicates that the client needs further clarification of the
instructions? 
1. Uses a straw for drinking 
2. Drives only during the daytime 
3. Uses caution because the device alters balance 
4. Washes the skin daily under the lamb's wool liner of the vest
 2. Drives only during the daytime

20. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The
client has ascending paralysis to the level of the waist. Knowing the complications of
the disorder, the nurse should bring which most essential items into the client's
room? 
1. Nebulizer and pulse oximeter 
2. Blood pressure cuff and flashlight 
3. Flashlight and incentive spirometer 
4. Electrocardiographic monitoring electrodes and intubation tray

4. Electrocardiographic monitoring electrodes and intubation tray

21. A client is about to undergo a lumbar puncture. The nurse describes to the client that
which position will be used during the procedure? 
1. Side-lying with a pillow under the hip 
2. Prone with a pillow under the abdomen 
3. Prone in slight Trendelenburg's position 
4. Side-lying with the legs pulled up and the head bent down onto the chest

4. Side-lying with the legs pulled up and the head bent down onto the chest

22. The nurse has just admitted to the nursing unit a client with a basilar skull fracture
who is at risk for increased intracranial pressure. Pending specific health care
provider prescriptions, the nurse should safely place the client in which
positions? Select all that apply. 
1. Head midline 
2. Neck in neutral position 
3. Head of bed elevated 30 to 45 degrees 
4. Head turned to the side when flat in bed 
5. Neck and jaw flexed forward when opening the mouth
o 1. Head midline 
o 2. Neck in neutral position 
o 3. Head of bed elevated 30 to 45 degrees
23. The nurse is assessing the nasal dressing on a client who had a transsphenoidal
resection of the pituitary gland. The nurse notes a small amount of serosanguineous
drainage that is surrounded by clear fluid on the nasal dressing. Which nursing
action is most appropriate? 
1. Document the findings. 
2. Reinforce the dressing. 
3. Notify the health care provider (HCP). 
4. Mark the area of drainage with a pen and monitor for further drainage.

3. Notify the health care provider (HCP).

24. The nurse is providing diet instructions to a client with Ménière's disease who is
being discharged from the hospital after admission for an acute attack. Which
statement, if made by the client, indicates an understanding of the dietary measures
 to take to help prevent further attacks? 
1. "I need to restrict my carbohydrate intake." 
2. "I need to drink at least 3 L of fluid per day." 
3. "I need to maintain a low-fat and low-cholesterol diet." 
4. "I need to be sure to consume foods that are low in sodium."

4. "I need to be sure to consume foods that are low in sodium."

25. The nurse in the neurological unit is caring for a client who was in a motor vehicle
crash and sustained a blunt head injury. On assessment of the client, the nurse
notes the presence of bloody drainage from the nose. Which nursing action is most
appropriate? 
1. Insert nasal packing. 
2. Document the findings. 
3. Contact the health care provider (HCP). 
4. Monitor the client's blood pressure and check for signs of increased intracranial
pressure.

3. Contact the health care provider (HCP).

26. A client has dysfunction of the cochlear division of the vestibulocochlear nerve
(cranial nerve VIII). The nurse should determine that the client is adequately
adapting to this problem if he or she states a plan to obtain which item? 
1. A walker 
2. Eyeglasses 
3. A hearing aid 
4. A bath thermometer

3. A hearing aid

27. The nurse is planning care for a client who displays confusion secondary to a
neurological problem. Which approach by the nurse would be least helpful in
assisting this client? 
1. Providing sensory cues 
2. Giving simple, clear directions 
3. Providing a stable environment 
4. Encouraging multiple visitors at one time

4. Encouraging multiple visitors at one time

28. The nurse has determined that a client with a neurological disorder also has difficulty
breathing.Which activities would be appropriate components of the care plan for this
client? Select all that apply. 
1. Keep suction equipment at the bedside. 
2. Elevate the head of the bed 30 degrees. 
3. Keep the client lying in a supine position. 
4. Keep the head and neck in good alignment. 
5. Administer prescribed respiratory treatments as needed.
 o 1. Keep suction equipment at the bedside. 
o 2. Elevate the head of the bed 30 degrees. 
o 4. Keep the head and neck in good alignment. 
o 5. Administer prescribed respiratory treatments as needed.
29. The nurse is trying to help the family of an unconscious client cope with the situation.
Which intervention should the nurse plan to incorporate into the care routine for the
client and family? 
1. Discouraging the family from touching the client 
2. Explaining equipment and procedures on an ongoing basis 
3. Ensuring adherence to visiting hours to ensure the client's rest 
4. Encouraging the family not to "give in" to their feelings of grief

2. Explaining equipment and procedures on an ongoing basis

30. Members of the family of an unconscious client with increased intracranial pressure
are talking at the client's bedside. They are discussing the client's condition and
wondering whether the client will ever recover. The nurse intervenes on the basis of
which interpretation? 
1. It is possible the client can hear the family. 
2. The family needs immediate crisis intervention. 
3. The client might have wanted a visit from the hospital chaplain. 
4. The family could benefit from a conference with the health care provider.

1. It is possible the client can hear the family.

31. The nurse is conducting home visits with a head-injured client with residual cognitive
deficits. The client has problems with memory, has a shortened attention span, is
easily distracted, and processes information slowly. The nurse plans to talk with the
primary health care provider about referring the client to which professional? 
1. A psychologist 
2. A social worker 
3. A neuropsychologist 
4. A vocational rehabilitation specialist

3. A neuropsychologist

32. The nurse is caring for a client who has undergone a craniotomy and has a
supratentorial incision. The nurse should place the client in which position
postoperatively? 
1. Head of bed flat, head and neck midline 
2. Head of bed flat, head turned to the nonoperative side 
3. Head of bed elevated 30 to 45 degrees, head and neck midline 
4. Head of bed elevated 30 to 45 degrees, head turned to the operative side

3. Head of bed elevated 30 to 45 degrees, head and neck midline

33. The nurse is assessing fluid balance in a client who has undergone a craniotomy.
The nurse should assess for which finding as a sign of overhydration, which would
 aggravate cerebral edema? 
1. Unchanged weight 
2. Shift intake 950 mL, output 900 mL 
3. Blood urea nitrogen (BUN) 10 mg/dL 
4. Serum osmolality 280 mOsm/kg H2O

4. Serum osmolality 280 mOsm/kg H2O

34. The nurse is reviewing a discharge teaching plan for a postcraniotomy client that
was prepared by a nursing student. The nurse would intervene and provide teaching
to the student if the student included which home care instruction? 
1. Sounds will not be heard clearly unless they are loud. 
2. Obtain assistance with ambulation if client is lightheaded. 
3. Tub bath or shower is permitted, but the scalp is kept dry until the sutures are
removed. 
4. Use a check-off system for administering anticonvulsant medications to avoid
missing doses.

1. Sounds will not be heard clearly unless they are loud.

35. The nurse has made a judgment that a client who had a craniotomy is experiencing
a problem with body image. The nurse develops goals for the client but determines
that the client has not met the outcome criteria by discharge if the client performs
which action? 
1. Wears a turban to cover the incision 
2. Indicates that facial puffiness will be a permanent problem 
3. Verbalizes that periorbital bruising will disappear over time 
4. States an intention to purchase a hairpiece until hair has grown back

2. Indicates that facial puffiness will be a permanent problem

36. A client with a spinal cord injury at the level of C5 has a weakened respiratory effort
and ineffective cough and is using accessory neck muscles in breathing. The nurse
carefully monitors the client and suspects the presence of which complication? 
1. Altered breathing pattern 
2. Increased likelihood of injury 
3. Ineffective oxygen consumption 
4. Increased susceptibility to aspiration

1. Altered breathing pattern

37. A client with a spinal cord injury becomes angry and belligerent whenever the nurse
tries to administer care. The nurse should perform which action? 
1. Ask the family to deliver the care. 
2. Leave the client alone until ready to participate. 
3. Advise the client that rehabilitation progresses more quickly with cooperation. 
4. Acknowledge the client's anger and continue to encourage participation in care.
 4. Acknowledge the client's anger and continue to encourage participation in care.

38. The nurse is planning to put aneurysm precautions in place for a client with a
cerebral aneurysm. Which nursing measure would be a potentially unsafe
component of the precautions? 
1. Provide physical aspects of care. 
2. Prevent pushing or straining activities. 
3. Maintain the head of the bed at 15 degrees. 
4. Limit caffeinated coffee to one cup per day.

4. Limit caffeinated coffee to one cup per day.

39. A client with trigeminal neuralgia asks the nurse what causes the painful episodes
associated with the condition. The nurse's response is based on an understanding
that the symptoms can be triggered by which process? 
1. A local reaction to nasal stuffiness 
2. A hypoglycemic effect on the cranial nerve 
3. Release of catecholamines with infection or stress 
4. Stimulation of the affected nerve by pressure and temperature

4. Stimulation of the affected nerve by pressure and temperature

40. The home health nurse has been discussing interventions to prevent constipation in
a client with multiple sclerosis. The nurse determines that the client is using the
information most effectively if the client reports which action? 
1. Drinking a total of 1000 mL/day 
2. Giving herself an enema every morning before breakfast 
3. Taking stool softeners daily and a glycerin suppository once a week 
4. Initiating a bowel movement every other day, 45 minutes after the largest meal of
the day

4. Initiating a bowel movement every other day, 45 minutes after the largest meal of the day

41. A client has a cerebellar lesion. The nurse determines that the client is adapting
successfully to this problem if the client demonstrates proper use of which item? 
1. Walker 
2. Slider board 
3. Raised toilet seat 
4. Adaptive eating utensils

1. Walker

42. The nurse is assessing a client's gait, which is characterized by unsteadiness and
staggering steps. The nurse determines the presence of which type of gait? 
1. Spastic 
2. Ataxic 
3. Festinating 
4. Dystrophic or broad-based
 2. Ataxic

43. A client with a neurological impairment experiences urinary incontinence. Which

nursing action would be most helpful in assisting the client to adapt to this
alteration? 
1. Using adult diapers 
2. Inserting a Foley catheter 
3. Establishing a toileting schedule 
4. Padding the bed with an absorbent cotton pad

3. Establishing a toileting schedule

44. A client with a neurological problem is experiencing hyperthermia. Which measure

would be least appropriate for the nurse to use in trying to lower the client's body
temperature? 
1. Giving tepid sponge baths 
2. Applying a hypothermia blanket 
3. Placing ice packs in the axilla and groin areas 
4. Administering acetaminophen (Tylenol) per protocol

3. Placing ice packs in the axilla and groin areas

45. A client is somewhat nervous about undergoing magnetic resonance imaging (MRI).
Which statement by the nurse would provide the most reassurance to the client
about the procedure? 
1. "The MRI machine is a long, narrow, hollow tube and may make you feel
somewhat claustrophobic." 
2. "You will be able to eat before the procedure unless you get nauseated easily. If
so, you should eat lightly." 
3. "Even though you are alone in the scanner, you will be in voice communication
with the technologist at all times during the procedure." 
4. "It is necessary to remove any metal or metal-containing objects before having the
MRI done to avoid the metal being drawn into the magnetic field."

3. "Even though you are alone in the scanner, you will be in voice communication with the
technologist at all times during the procedure."

46. The nurse is administering mouth care to an unconscious client. The nurse should
perform which actions in the care of this person? Select all that apply. 
1. Position the client on his or her side. 
2. Use products that contain alcohol. 
3. Brush the teeth with a small, soft toothbrush. 
4. Cleanse the mucous membranes with soft sponges. 
5. Use lemon glycerin swabs when performing mouth care.
o 1. Position the client on his or her side. 
o 3. Brush the teeth with a small, soft toothbrush. 
o 4. Cleanse the mucous membranes with soft sponges.
47. The nurse assigned to the care of an unconscious client is making initial daily
rounds. On entering the client's room, the nurse observes that the client is lying
 supine in bed, with the head of the bed elevated approximately 5 degrees. The
nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses
the client and auscultates adventitious breath sounds. Which judgment should the
nurse formulate for the client? 
1. Impaired nutritional intake 
2. Increased risk for aspiration 
3. Increased likelihood for injury 
4. Susceptibility to fluid volume deficit

2. Increased risk for aspiration

48. Which intervention should the nurse include in a postoperative teaching plan for a
client who underwent a spinal fusion and will be wearing a brace? 
1. Tell the client to inspect the environment for safety hazards. 
2. Inform the client about the importance of sitting as much as possible. 
3. Inform the client that lotions and body powders can be used for skin breakdown. 
4. Instruct the client to tighten the brace during meals and to loosen it for the first 30
minutes after each meal.

1. Tell the client to inspect the environment for safety hazards.

49. The nurse is preparing to care for a client after a lumbar puncture. The nurse should
plan to place the client in which best position immediately after the procedure? 
1. Prone in semi-Fowler's position 
2. Supine in semi-Fowler's position 
3. Prone with a small pillow under the abdomen 
4. Lateral with the head slightly lower than the rest of the body

3. Prone with a small pillow under the abdomen

50. The student nurse develops a plan of care for a client after a lumbar puncture. The
nursing instructor corrects the student if the student documents which incorrect
intervention in the plan? 
1. Maintain the client in a flat position. 
2. Restrict fluid intake for a period of 2 hours. 
3. Assess the client's ability to void and move the extremities. 
4. Inspect the puncture site for swelling, redness, and drainage.

2. Restrict fluid intake for a period of 2 hours.

51. The nurse is monitoring a client who has returned to the nursing unit after a
myelogram. Which client complaint would indicate the need to notify the health care
provider (HCP)? 
1. Backache 
2. Headache 
3. Neck stiffness 
4. Feelings of fatigue
 3. Neck stiffness

52. The nurse caring for a client with a head injury is monitoring for signs of increased
intracranial pressure. The nurse reviews the record and notes that the intracranial
pressure (cerebrospinal fluid) is averaging 8 mm Hg. The nurse plans care, knowing
that these results are indicative of which condition? 
1. Normal condition 
2. Increased pressure 
3. Borderline situation 
4. Compensating condition

1. Normal condition

53. The nurse in the neurological unit is monitoring a client for signs of increased
intracranial pressure (ICP). The nurse reviews the assessment findings for the client
and notes documentation of the presence of Cushing's reflex. The nurse determines
that the presence of this reflex is obtained by assessing which item? 
1. Blood pressure 
2. Motor response 
3. Pupillary response 
4. Level of consciousness

1. Blood pressure

54. The nurse is assisting the neurologist in performing an assessment on a client who is
unconscious after sustaining a head injury. The nurse understands that the
neurologist would avoid performing the oculocephalic response (doll's-eyes
maneuver) if which condition is present in the client? 
1. Dilated pupils 
2. Lumbar trauma 
3. A cervical cord injury 
4. Altered level of consciousness

3. A cervical cord injury

55. The nurse is performing the oculocephalic response (doll's-eyes maneuver) test on
an unconscious client. The nurse turns the client's head and notes movement of the
eyes in the same direction as for the head. How should the nurse document these
findings? 
1. Normal 
2. Abnormal 
3. Insignificant 
4. Inconclusive

2. Abnormal

56. The nurse is performing a neurological assessment on a client and is assessing the
function of cranial nerves III, IV, and VI. Assessment of which aspect of function by
 the nurse will yield the best information about these cranial nerves? 
1. Eye movements 
2. Response to verbal stimuli 
3. Affect, feelings, or emotions 
4. Insight, judgment, and planning

1. Eye movements

57. The nurse is reviewing the medical records of a client admitted to the nursing unit
with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to
note that which is documented in the assessment data section of the record? 
1. Sudden loss of consciousness occurred. 
2. Signs and symptoms occurred suddenly. 
3. The client experienced paresthesias a few days before admission to the hospital. 
4. The client complained of a severe headache, which was followed by sudden onset
of paralysis.

3. The client experienced paresthesias a few days before admission to the hospital.

58. The nurse in the health care clinic is providing medication instructions to a client with
a seizure disorder who will be taking divalproex sodium (Depakote). The nurse
should instruct the client about the importance of returning to the clinic for monitoring
of which laboratory study? 
1. Electrolyte panel 
2. Liver function studies 
3. Renal function studies 
4. Blood glucose level determination

2. Liver function studies

59. The home care nurse is preparing to visit a client with a diagnosis of trigeminal
neuralgia (tic douloureux). When performing the assessment, the nurse should plan
to ask the client which question to elicit the most specific information regarding this
disorder? 
1. "Do you have any visual problems?" 
2. "Are you having any problems hearing?" 
3. "Do you have any tingling in the face region?" 
4. "Is the pain experienced a stabbing type of pain?"

4. "Is the pain experienced a stabbing type of pain?"

60. The home care nurse is performing an assessment on a client with a diagnosis of
Bell's palsy. Which assessment question will elicit the most specific information
regarding this client's disorder? 
1. "Do your eyes feel dry?" 
2. "Do you have any spasms in your throat?" 
3. "Are you having any difficulty chewing food?" 
4. "Do you have any tingling sensations around your mouth?"
 3. "Are you having any difficulty chewing food?"

61. The nurse is performing an assessment on a client admitted to the nursing unit with
a diagnosis of stroke (brain attack). On assessment, the nurse notes that the client is
unable to understand spoken language. The nurse plans care, understanding that
the client is experiencing impairment of which areas? 
1. The occipital lobe 
2. The auditory association areas 
3. The frontal lobe and optic nerve tracts 
4. Concept formation and abstraction areas

2. The auditory association areas

62. The nurse develops a plan of care for a client with a brain aneurysm who will be
placed on aneurysm precautions. Which interventions should be included in the
plan? Select all that apply. 
1. Leave the lights on in the client's room at night. 
2. Place a blood pressure cuff at the client's bedside. 
3. Close the shades in the client's room during the day. 
4. Allow the client to drink one cup of caffeinated coffee a day. 
5. Allow the client to ambulate four times a day with assistance.
o 2. Place a blood pressure cuff at the client's bedside. 
o 3. Close the shades in the client's room during the day.
63. The nurse is providing instructions to a client with a seizure disorder who will be
taking phenytoin (Dilantin). Which statement, if made by the client, would indicate an
understanding of the information about this medication? 
1. "I need to perform good oral hygiene, including flossing and brushing my teeth." 
2. "I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in
moderation." 
3. "I should take my medication before coming to the laboratory to have a blood level
drawn." 
4. "I should monitor for side effects and adjust my medication dose depending on
how severe the side effects are."

1. "I need to perform good oral hygiene, including flossing and brushing my teeth."

64. The nurse is performing an assessment on a client with a diagnosis of thrombotic

brain attack (stroke). Which assessment question would elicit data specific to this
type of stroke? 
1. "Have you had any headaches in the past few days?" 
2. "Have you recently been having difficulty with seeing at nighttime?" 
3. "Have you had any sudden episodes of passing out in the past few days?" 
4. "Have you had any numbness or tingling or paralysis-type feelings in any of your
extremities recently?"

4. "Have you had any numbness or tingling or paralysis-type feelings in any of your
extremities recently?"
65. The nurse is developing a plan of care for a client with dysphagia following a stroke
(brain attack). Which should the nurse include in the plan? Select all that apply. 
1. Thicken liquids. 
2. Assist the client with eating. 
3. Assess for the presence of a swallow reflex. 
4. Place the food on the affected side of the mouth. 
5. Provide ample time for the client to chew and swallow.
o 1. Thicken liquids. 
o 2. Assist the client with eating. 
o 3. Assess for the presence of a swallow reflex. 
o 5. Provide ample time for the client to chew and swallow.
66. The nurse is developing a plan of care for a client with a stroke (brain attack) who
has right homonymous hemianopsia. Which should the nurse include in the plan of
care for the client? 
1. Place an eye patch on the left eye. 
2. Place personal articles on the client's right side. 
3. Approach the client from the right field of vision. 
4. Instruct the client to turn the head to scan the right visual field.

4. Instruct the client to turn the head to scan the right visual field.

67. The nurse is performing an assessment on a client suspected of having trigeminal

neuralgia (tic douloureux). Which assessment question would elicit data specific to
this disorder? 
1. "Have you had any facial paralysis?" 
2. "Have you noticed that your eyelid has been drooping?" 
3. "Have you had any numbness and tingling in your face?" 
4. "Have you had any sharp pain or any twitching in any part of your face?"

4. "Have you had any sharp pain or any twitching in any part of your face?"

68. The nurse is providing instructions to the client with trigeminal neuralgia regarding
measures to take to prevent the episodes of pain. Which should the nurse instruct
the client to do? 
1. Prevent stressful situations. 
2. Avoid activities that may cause fatigue. 
3. Avoid contact with people with an infection. 
4. Avoid activities that may cause pressure near the face.

4. Avoid activities that may cause pressure near the face.

69. The nurse is performing an assessment on a client with a diagnosis of Bell's palsy.
The nurse should expect to observe which finding in the client? 
1. Facial drooping 
2. Periorbital edema 
3. Ptosis of the eyelid 
4. Twitching on the affected side of the face
 1. Facial drooping

70. The nurse is developing a plan of care for an older client that addresses
interventions to prevent cold discomfort and the development of accidental
hypothermia. The nurse should document which desired outcome in the plan of
care? 
1. The client's body temperature is 98° F. 
2. The client's fingers and toes are cool to touch. 
3. The client remains in a fetal position when in bed. 
4. The client complains of coolness in the hands and feet only.

1. The client's body temperature is 98° F.

71. The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic
lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely
dysphagic. Which intervention should be included in the care plan for this
client? Select all that apply. 
1. Provide oral hygiene after each meal. 
2. Assess swallowing ability frequently. 
3. Allow the client sufficient time to eat. 
4. Maintain a suction machine at the bedside. 
5. Provide a full liquid diet for ease in swallowing.
o 1. Provide oral hygiene after each meal. 
o 2. Assess swallowing ability frequently. 
o 3. Allow the client sufficient time to eat. 
o 4. Maintain a suction machine at the bedside.
72. The nurse is reviewing the record for a client seen in the health care clinic and notes
that the health care provider has documented a diagnosis of amyotrophic lateral
sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse
expect to see documented in the record? 
1. Muscle wasting 
2. Mild clumsiness 
3. Altered mentation 
4. Diminished gag reflex

2. Mild clumsiness

73. The nurse in the neurological unit is caring for a client with a supratentorial lesion.
The nurse assesses which measurement as the most critical index of central
nervous system (CNS) dysfunction? 
1. Temperature 
2. Blood pressure 
3. Ability to speak 
4. Level of consciousness

4. Level of consciousness
74. The nurse is caring for a client after a craniotomy and monitors the client for signs of
increased intracranial pressure (ICP). Which finding, if noted in the client, would
indicate an early sign of increased ICP? 
1. Confusion 
2. Bradycardia 
3. Sluggish pupils 
4. A widened pulse pressure

1. Confusion

75. Acetazolamide (Diamox) is prescribed for a client hospitalized with a diagnosis of a

supratentorial lesion. The nurse understands that which is the primary action of the
medication? 
1. Prevention of hypertension 
2. Prevention of hyperthermia 
3. Decrease in cerebrospinal fluid production 
4. Maintenance of blood pressure adequate for cerebral perfusion

3. Decrease in cerebrospinal fluid production

76. The nurse is preparing for the admission to the unit of a client with a diagnosis of
seizures and is preparing to institute full seizure precautions. Which item is
contraindicated for use if a seizure occurs? 
1. Oxygen source 
2. Suction machine 
3. Padded tongue blade 
4. Padding for the side rails

3. Padded tongue blade

77. The clinic nurse is reviewing the record of a client scheduled to be seen in the clinic.
The nurse notes that the client is taking selegiline hydrochloride (Eldepryl). The
nurse suspects that the client has which disorder? 
1. Diabetes mellitus 
2. Parkinson's disease 
3. Alzheimer's disease 
4. Coronary artery disease

2. Parkinson's disease

78. The nurse is reviewing the record of a client with a suspected diagnosis of
Huntington's disease. The nurse should expect to note documentation of
which early symptom of this disease? 
1. Aphasia 
2. Agnosia 
3. Difficulty with swallowing 
4. Balance and coordination problems
 4. Balance and coordination problems

79. The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The
client has been taking oxybutynin (Ditropan XL). The nurse evaluates the
effectiveness of the medication by asking the client which assessment question? 
1. "Are you consistently fatigued?" 
2 ."Are you having muscle spasms?" 
3. "Are you getting up at night to urinate?" 
4. "Are you having normal bowel movements?"

3. "Are you getting up at night to urinate?"

80. The nurse is preparing for the admission of a client with a suspected diagnosis of
Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse
reviews the health care provider's documentation. The nurse expects to note
documentation of which hallmark clinical manifestation of this syndrome? 
1. Multifocal seizures 
2. Altered level of consciousness 
3. Abrupt onset of a fever and headache 
4. Development of progressive muscle weakness

4. Development of progressive muscle weakness

81. A thymectomy accomplished via a median sternotomy approach is performed in a

client with a diagnosis of myasthenia gravis. The nurse develops a postoperative
plan of care for the client that should include which intervention? 
1. Monitor the chest tube drainage. 
2. Restrict visitors for 24 hours postoperatively. 
3. Maintain intravenous infusion of lactated Ringer's solution. 
4. Avoid administering pain medication to prevent respiratory depression.

1. Monitor the chest tube drainage.

82. The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric
stroke. The nurse notes that the client is alert and oriented to time and place. On the
basis of these assessment findings, the nurse should make which interpretation? 
1. Had a very mild stroke 
2. Most likely suffered a transient ischemic attack 
3. May have difficulty with language abilities only 
4. Is likely to have perceptual and spatial disabilities

4. Is likely to have perceptual and spatial disabilities

83. The nurse is preparing a plan of care for a client with a diagnosis of brain attack
(stroke). On reviewing the client's record, the nurse notes an assessment finding of
anosognosia. The nursing care plan should address which manifestation related to
this finding? 
1. The client will be easily fatigued. 
 2. The client will have difficulty speaking. 
3. The client will have difficulty swallowing. 
4. The client will exhibit neglect of the affected side.

4. The client will exhibit neglect of the affected side.

84. The nurse is preparing a plan of care for a client with a brain attack (stroke) who has
global aphasia. The nurse should incorporate communication strategies into the plan
of care because the client's speech will be characteristic of which finding? 
1. Intact 
2. Rambling 
3. Characterized by literal paraphasia 
4. Associated with poor comprehension

4. Associated with poor comprehension

85. The nurse is developing a plan of care for a client with a diagnosis of brain attack
(stroke) with anosognosia. To meet the needs of the client with this deficit, the nurse
should include activities that will achieve which outcome? 
1. Encourage communication. 
2. Provide a consistent daily routine. 
3. Promote adequate bowel elimination. 
4. Increase the client's awareness of the affected side.

4. Increase the client's awareness of the affected side.

86. The nurse is caring for a client who sustained a spinal cord injury. During
administration of morning care, the client begins to exhibit signs and symptoms of
autonomic dysreflexia. Which initial nursing action should the nurse take? 
1. Elevate the head of the bed. 
2. Examine the rectum digitally. 
3. Assess the client's blood pressure. 
4. Place the client in the prone position.

1. Elevate the head of the bed.

87. The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The
client is taking benztropine mesylate (Cogentin) orally daily. The nurse provides
information to the spouse regarding the side effects of this medication and should tell
the spouse to report which side effect if it occurs? 
1. Shuffling gait 
2. Inability to urinate 
3. Decreased appetite 
4. Irregular bowel movements

2. Inability to urinate
88. The nurse is documenting nursing observations in the record of a client who
experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most
likely note in the clonic phase of the seizure? 
1. Body stiffening 
2. Spasms of the entire body 
3. Sudden loss of consciousness 
4. Brief flexion of the extremities

2. Spasms of the entire body

89. The home care nurse is making a visit to a client who is wheelchair bound after a
spinal cord injury sustained 4 months earlier. Just before leaving the home, the
nurse ensures that which intervention has been done to prevent an episode of
autonomic dysreflexia (hyperreflexia)? 
1. Updating the home safety sheet 
2. Leaving the client in an unchilled area of the room 
3. Noting a bowel movement on the client progress note 
4. Recording the amount of urine obtained with catheterization

2. Leaving the client in an unchilled area of the room

90. A client who had cranial surgery 5 days earlier to remove a brain tumor has a few
cognitive deficits and does not seem to be progressing as quickly as the client or
family hoped. The nurse plans to implement which approach as most helpful to the
client and family at this time? 
1. Emphasize progress in a realistic manner. 
2. Set high goals to give the client something to "aim for." 
3. Tell the family to be extremely optimistic with the client. 
4. Inform the client and family of standardized goals of care.

1. Emphasize progress in a realistic manner.

91. A client who has had a brain attack (stroke) is being managed on the medical
nursing unit. At 0800, the client was awake and alert with vital signs of temperature
98° F orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure
138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli,
and vital signs are temperature 99° F orally, pulse 62 beats/min, respirations 20
breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which
action? 
1. Reorient the client. 
2. Retake the vital signs. 
3. Call the health care provider (HCP). 
4. Administer an antihypertensive PRN.

3. Call the health care provider (HCP).

92. The nurse is teaching a client hospitalized with a seizure disorder and the client's
spouse about safety precautions after discharge. The nurse determines that the
 client needs more information if he or she states an intention to take which action? 
1. Refrain from smoking alone. 
2. Take all prescribed medications on time. 
3. Have the spouse nearby when showering. 
4. Drink alcohol in small amounts and only on weekends.

4. Drink alcohol in small amounts and only on weekends.

93. A client had a transsphenoidal resection of the pituitary gland. The nurse notes
drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the
nurse should look for drainage that is of which characteristic? 
1. Serosanguineous only 
2. Bloody with very small clots 
3. Sanguineous only with no clot formation 
4. Serosanguineous, surrounded by clear to straw-colored fluid

4. Serosanguineous, surrounded by clear to straw-colored fluid

94. A client arrives in the hospital emergency department with a closed head injury to the
right side of the head caused by an assault with a baseball bat. The nurse assesses
the client neurologically, looking primarily for motor response deficits that involve
which area? 
1. The left side of the body 
2. The right side of the body 
3. Both sides of the body equally 
4. Cranial nerves only, such as speech and pupillary response

1. The left side of the body

95. The nurse has a prescription to begin aneurysm precautions for a client with a
subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to
incorporate which intervention in controlling the environment for this client? 
1. Keep the window blinds open. 
2. Turn on a small spotlight above the client's head. 
3. Make sure the door to the room is open at all times. 
4. Prohibit or limit the use of a radio or television and reading.

4. Prohibit or limit the use of a radio or television and reading.

96. The nurse is caring for a client who is on bed rest as part of aneurysm precautions.
The nurse should avoid doing which action when giving respiratory care to this
client? 
1. Encourage hourly coughing. 
2. Assist with incentive spirometer. 
3. Encourage hourly deep breathing. 
4. Reposition gently side to side every 2 hours.

1. Encourage hourly coughing.

97. At the end of the work shift, the nurse is reviewing the respiratory status of a client
admitted with acute brain attack (stroke) earlier in the day. The nurse determines
that the client's airway is patent if which data are identified? 
1. Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear 
2. Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear 
3. Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally 
4. Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath
sounds in lung bases

2. Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear

98. At the beginning of the work shift, the nurse assesses the status of the client wearing
a halo device. The nurse determines that which assessment finding requires
intervention? 
1. Tightened screws 
2. Red skin areas under the jacket 
3. Clean and dry lamb's wool jacket lining 
4. Finger-width space between the jacket and the skin

2. Red skin areas under the jacket

99. A client who has a spinal cord injury that resulted in paraplegia experiences a
sudden onset of severe headache and nausea. The client is diaphoretic with
piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is
210 mm Hg. What should the nurse immediately suspect? 
1. Return of spinal shock 
2. Malignant hypertension 
3. Impending brain attack (stroke) 
4. Autonomic dysreflexia (hyperreflexia)

4. Autonomic dysreflexia (hyperreflexia)

100. A client who had a brain attack (stroke) has right-sided hemianopsia. What
should the nurse plan to do to help the client adapt to this problem? 
1. Teach the client to scan the environment. 
2. Place all objects within the left visual field. 
3. Place all objects within the right visual field. 
4. Ensure that the family brings the client's eyeglasses to hospital.

1. Teach the client to scan the environment.

1. The nurse is assisting with caloric testing of the oculovestibular reflex in an
unconscious client. Cold water is injected into the left auditory canal. The client
exhibits eye conjugate movements toward the left, followed by eye movement back
to midline. The nurse understands that this finding indicates which situation? 
1. Brain death 
2. A cerebral lesion 
3. A temporal lesion 
4. An intact brainstem

4. An intact brainstem

2. The nurse is caring for a client who is brought to the hospital emergency department
with a spinal cord injury. The nurse minimizes the risk of compounding the
injury most effectively by performing which action? 
1. Keeping the client on a stretcher 
2. Logrolling the client onto a soft mattress 
3. Logrolling the client onto a firm mattress 
4. Placing the client on a bed that provides spinal immobilization

4. Placing the client on a bed that provides spinal immobilization

3. The nurse is assessing a client who is experiencing seizure activity. The nurse
understands that it is necessary to determine information about which items as part
of routine assessment of seizures? Select all that apply. 
1. Postictal status 
2. Duration of the seizure 
3. Changes in pupil size or eye deviation 
4. Seizure progression and type of movements 
5. What the client ate in the 2 hours preceding seizure activity
o 1. Postictal status 
o 2. Duration of the seizure 
o 3. Changes in pupil size or eye deviation 
o 4. Seizure progression and type of movements
4. A client with myasthenia gravis is having difficulty with airway clearance and difficulty
with maintaining an effective breathing pattern. The nurse should keep which items
available at the client's bedside? 
1. Oxygen and metered-dose inhaler 
2. Ambu bag and suction equipment 
3. Pulse oximeter and cardiac monitor 
4. Incentive spirometer and cough pillow
 2. Ambu bag and suction equipment

5. The home health nurse is visiting a client with myasthenia gravis and is discussing
methods to minimize the risk of aspiration during meals related to decreased muscle
strength. Which suggestions should the nurse give to the client? Select all that
apply. 
1. Chew food thoroughly. 
2. Cut food into very small pieces. 
3. Sit straight up in the chair while eating. 
4. Lift the head while swallowing liquids. 
5. Swallow when the chin is tipped slightly downward to the chest.
o 1. Chew food thoroughly. 
o 2. Cut food into very small pieces. 
o 3. Sit straight up in the chair while eating. 
o 5. Swallow when the chin is tipped slightly downward to the chest.
6. The nurse has instructed a client with myasthenia gravis about strategies for self-
management at home. The nurse determines a need for more information if the
client makes which statement? 
1. "Here's the Medic-Alert bracelet I obtained." 
2. "I should take my medications an hour before mealtime." 
3. "Going to the beach will be a nice, relaxing form of activity." 
4. "I've made arrangements to get a portable resuscitation bag and home suction
equipment."

3. "Going to the beach will be a nice, relaxing form of activity."

7. A client with recent-onset Bell's palsy is upset and crying about the change in facial
appearance. The nurse plans to support the client emotionally by making which
statement to the client? 
1. This is caused by a small tumor, which can be removed easily. 
2. This is not a brain attack (stroke), and many clients recover in 3 to 5 weeks. 
3. This is a temporary problem, with treatment similar to that for migraine
headaches. 
4. This is similar to a brain attack (stroke), but all symptoms will reverse without
treatment.

2. This is not a brain attack (stroke), and many clients recover in 3 to 5 weeks.

8. A client is admitted with an exacerbation of multiple sclerosis. The nurse is

assessing the client for possible precipitating risk factors. Which factor, if reported by
the client, should the nurse identify as being unrelated to the exacerbation? 
1. Annual influenza vaccination 
2. Ingestion of increased fruits and vegetables 
3. An established routine of walking 2 miles each evening 
4. A recent period of extreme outside ambient temperatures

2. Ingestion of increased fruits and vegetables

9. A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an
ataxic gait. On the basis of this information, the nurse should include which client
problem in the plan of care? 
1. Inability to care for self 
2. Interruption in skin integrity 
3. Interruption in physical mobility 
4. Inability to perform daily activities

3. Interruption in physical mobility

10. The nurse is planning care for the client with a neurogenic bladder caused by
multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day.
Which plan would be most helpful to this client? 
1. 400 to 500 mL with each meal and 500 to 600 mL in the evening before bedtime 
2. 400 to 500 mL with each meal and additional fluids in the morning but not after
midday 
3. 400 to 500 mL with each meal, with all extra fluid concentrated in the afternoon
and evening 
4. 400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon,
and late afternoon

4. 400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late
afternoon

11. The nurse has taught a client with a herniated lumbar disk about proper body
mechanics and other items pertinent to low back care. The nurse determines
that further instruction is needed if the client states the need to take which action? 
1. Bend at the knees to pick up objects. 
2. Increase fiber and fluid intake in the diet. 
3. Strengthen the back muscles by swimming or walking. 
4. Get out of bed by sitting straight up and swinging the legs over the side of the bed.

4. Get out of bed by sitting straight up and swinging the legs over the side of the bed.

12. A client who experienced a brain attack (stroke) several months ago still exhibits
some difficulty with chewing food. The nurse plans care, knowing that the client has
residual dysfunction of which cranial nerve? 
1. Vagus (cranial nerve X) 
2. Trigeminal (cranial nerve V) 
3. Hypoglossal (cranial nerve XII) 
4. Spinal accessory (cranial nerve XI)

2. Trigeminal (cranial nerve V)

13. The nurse has applied a hypothermia blanket to a client with a fever. The nurse
should inspect the skin frequently to detect which condition that is a complication of
hypothermia blanket use? 
1. Frostbite 
 2. Skin breakdown 
3. Arterial insufficiency 
4. Venous insufficiency

2. Skin breakdown

14. The nurse is caring for an unconscious client who is experiencing persistent
hyperthermia with no signs of infection. The nurse interprets that the hyperthermia
may be related to damage to the client's thermoregulatory center in which structure? 
1. Cerebrum 
2. Cerebellum 
3. Hippocampus 
4. Hypothalamus

4. Hypothalamus

15. A nurse has a prescription to administer a medication to a client who is experiencing

shivering as a result of hyperthermia. Which medication should the nurse anticipate
to be prescribed? 
1. Buspirone (BuSpar) 
2. Chlorpromazine (Thorazine) 
3. Prochlorperazine (Compazine) 
4. Fluphenazine (Prolixin Decanoate)

2. Chlorpromazine (Thorazine)

16. A nurse is caring for a client with an intracranial pressure (ICP) monitoring device.
The nurse should become most concerned if the ICP readings drifted to and stayed
in the vicinity of which finding? 
1. 5 mm Hg 
2. 8 mm Hg 
3. 14 mm Hg 
4. 22 mm Hg

4. 22 mm Hg

17. The nurse is planning care for a client with intracranial pressure (ICP) monitoring.
Which intervention is appropriate to include in the plan of care? 
1. Place the client in Sims position. 
2. Change the drainage tubing every 48 hours. 
3. Level the transducer at the lowest point of the ear. 
4. Use strict aseptic technique when touching the monitoring system.

4. Use strict aseptic technique when touching the monitoring system.

18. A client is being hyperventilated by a mechanical ventilator to decrease the client's

intracranial pressure (ICP). On monitoring arterial blood gas results, the nurse
should expect values that are within which ranges? 
 1. Pao2 60 to 100 mm Hg, Paco2 25 to 30 mm Hg 
2. Pao2 60 to 100 mm Hg, Paco2 30 to 35 mm Hg 
3. Pao2 80 to 100 mm Hg, Paco2 25 to 30 mm Hg 
4. Pao2 80 to 100 mm Hg, Paco2 35 to 40 mm Hg

3. Pao2 80 to 100 mm Hg, Paco2 25 to 30 mm Hg

19. The nurse is providing care to a client with increased intracranial pressure (ICP).
Which approach is beneficial in controlling the client's ICP from an environmental
viewpoint? 
1. Reduce environmental noise. 
2. Allow visitors as desired by the client and family. 
3. Cluster nursing activities to reduce the number of interruptions. 
4. Awaken the client every 2 to 3 hours to monitor mental status.

1. Reduce environmental noise.

20. The home care nurse is making extended follow-up visits to a client discharged from
the hospital after a moderately severe head injury. The family states that the client is
behaving differently than before the accident. The client is more fatigued and irritable
and has some memory problems. The client, who was previously very even-
tempered, is prone to outbursts of temper now. The nurse counsels the family on the
basis of an understanding that these behaviors are indicative of which condition? 
1. Indicate a worsening of the original injury 
2. Will probably be a long-term sequela of the injury 
3. Will come and go as intracranial pressure changes 
4. Are short-term problems that will resolve in about 1 month

2. Will probably be a long-term sequela of the injury

21. A client was seen and treated in the hospital emergency department for treatment of
a concussion. The nurse determines that the family needs reinforcement of the
discharge instructions if they verbalize to call the health care provider (HCP) for
which client sign or symptom? 
1. Vomiting 
2. Minor headache 
3. Difficulty speaking 
4. Difficulty awakening

2. Minor headache

22. A client with a spinal cord injury expresses little interest in food and is very particular
about the choice of meals that are actually eaten. How should the nurse interpret this
information? 
1. Anorexia is a sign of clinical depression, and a referral to a psychologist is
needed. 
2. The client has compulsive habits that should be ignored so long as they are not
harmful. 
 3. The client probably has a naturally slow metabolism, and the decreased nutritional
intake will not matter. 
4. Meal choices represent an area of client control and should be encouraged as
much as is nutritionally reasonable.

4. Meal choices represent an area of client control and should be encouraged as much as is
nutritionally reasonable.

23. The nurse is teaching a client with paraplegia measures to maintain skin integrity.
Which instruction will be most helpful to the client? 
1. Shift weight every 2 hours while in a wheelchair. 
2. Change bed sheets every other week to maintain cleanliness. 
3. Place a pillow on the seat of the wheelchair to provide extra comfort. 
4. Use a mirror to inspect for redness and skin breakdown twice a week.

1. Shift weight every 2 hours while in a wheelchair.

24. The nurse is caring for a client with an intracranial aneurysm who was previously
alert. Which sign is anearly indication that the level of consciousness (LOC) is
deteriorating? Select all that apply. 
1. Mild drowsiness 
2. Drooping eyelids 
3. Ptosis of the left eyelid 
4. Slight slurring of speech 
5. Less frequent spontaneous speech
o 1. Mild drowsiness 
o 4. Slight slurring of speech 
o 5. Less frequent spontaneous speech
25. The nurse has provided instructions to a client with a diagnosis of myasthenia gravis
about home care measures. Which client statement indicates the need for further
instruction? 
1. "I will rest each afternoon after my walk." 
2. "I should cough and deep breathe many times during the day." 
3. "I can change the time of my medication on the mornings when I feel strong." 
4. "If I get abdominal cramps and diarrhea, I should call my health care provider."

3. "I can change the time of my medication on the mornings when I feel strong."

26. A client is diagnosed with Bell's palsy. The nurse assessing the client expects to
note which symptom? 
1. A symmetrical smile 
2. Difficulty closing the eyelid on the affected side 
3. Narrowing of the palpebral fissure on the affected side 
4. Paroxysms of excruciating pain in the lips and cheek on the affected side

2. Difficulty closing the eyelid on the affected side

27. The nurse is performing an assessment on a client with Guillain-Barré syndrome.
The nurse determines that which finding would be of most concern? 
1. Difficulty articulating words 
2. Lung vital capacity of 10 mL/kg 
3. Paralysis progressing from the toes to the waist 
4. A blood pressure (BP) decrease from 110/78 to 102/70 mm Hg

2. Lung vital capacity of 10 mL/kg

28. A client with multiple sclerosis tells a home health care nurse that she is having
increasing difficulty in transferring from the bed to a chair. What is the initial nursing
action? 
1. Observe the client demonstrating the transfer technique. 
2. Start a restorative nursing program before an injury occurs. 
3. Seize the opportunity to discuss potential nursing home placement. 
4. Determine the number of falls that the client has had in recent weeks.

1. Observe the client demonstrating the transfer technique.

29. A nurse is performing an assessment on a client with a head injury and notes that
the client is assuming this posture. The nurse contacts the health care provider and
reports that the client is exhibiting which posture?

1. Opisthotonos 
2. Decorticate rigidity 
3. Decerebrate rigidity 
4. Flaccid quadriplegia

2. Decorticate rigidity

30. An older man is brought to the hospital emergency department by a neighbor who
heard him talking and found him wandering in the street at 3 am. The nurse
should first determine which data about the client? 
1. His insurance status 
2. Blood toxicology levels 
3. Whether he ate his evening meal 
4. Whether this is a change in his usual level of orientation

4. Whether this is a change in his usual level of orientation

31. An 84-year-old client in an acute state of disorientation is brought to the hospital
emergency department by his or her daughter. The daughter states that the client
was "clear as a bell this morning." The nurse determines from this piece of
information that which is an unlikely cause of the disorientation? 
1. Hypoglycemia 
2. Alzheimer's disease 
3. Medication dosage error 
4. Impaired circulation to the brain

2. Alzheimer's disease

32. A nurse is evaluating the neurological status of a client. To assess the function of the
limbic system, the nurse should gather data about which item? 
1. Experience of pain 
2. Affect or emotions 
3. Response to verbal stimuli 
4. Insight, judgment, and planning

2. Affect or emotions

33. A client is experiencing delirium. The nurse concludes that which areas of the
nervous system are affected? 
1. Temporal lobe and frontal lobe 
2. Hippocampus and frontal lobe 
3. Limbic system and cerebral hemispheres 
4. Reticular activating system and cerebral hemispheres

4. Reticular activating system and cerebral hemispheres

34. The nurse is assessing a client with a neurological deficit involving the hippocampus.
Which finding is indicative of this deficit? 
1. Disoriented to client, place, and time 
2. Affect flat, with periods of emotional lability 
3. Cannot recall what was eaten for breakfast today 
4. Unable to add and subtract; does not know who is president

3. Cannot recall what was eaten for breakfast today

35. A client has sustained damage to Wernicke's area in the temporal lobe from a stroke
(brain attack). The nurse anticipates that the client will have difficulty with which
function? 
1. Articulating words 
2. Understanding language 
3. Moving one side of the body 
4. Recalling events in the remote past

2. Understanding language
36. A client with a neurological deficit is able, with eyes closed, to identify a set of keys
placed in his or her hands. A nurse observing the client interprets this to mean that
which area of the brain is intact? 
1. Frontal lobe 
2. Parietal lobe 
3. Temporal lobe 
4. Occipital lobe

2. Parietal lobe

37. A client has suffered a head injury affecting the occipital lobe of the brain. The nurse
anticipates that the client may experience difficulty with which sense? 
1. Smell 
2. Taste 
3. Vision 
4. Hearing

3. Vision

38. A client has suffered damage to Broca's area of the brain. The nurse providing care
for this client anticipates that which area will be affected? 
1. Speech 
2. Hearing 
3. Balance 
4. Level of consciousness

1. Speech

39. A nurse notes that a client who has suffered a brain injury has an adequate heart
rate, blood pressure, fluid balance, and body temperature. The nurse concludes that
which area of the client's brain is functioning adequately? 
1. Thalamus 
2. Hypothalamus 
3. Limbic system 
4. Reticular activating system

2. Hypothalamus

40. A client has a high level of carbon dioxide (CO 2) in the bloodstream, as measured by
arterial blood gases. A nurse reviewing the client's record plans care, knowing that a
high CO2 level will have which effect on circulation to the brain? 
1. It will cause arteriovenous shunting. 
2. It will cause vasodilation of blood vessels in the brain. 
3. It will cause blood vessels in the circle of Willis to collapse. 
4. It will cause hyperresponsiveness of blood vessels in the brain.

2. It will cause vasodilation of blood vessels in the brain.

41. A client is anxious about an upcoming diagnostic procedure. The client's pupils are
dilated, and the respiratory rate, heart rate, and blood pressure are increased from
baseline. The nurse plans care, knowing that these changes are the result of which
response? 
1. Vagal response 
2. Peripheral nervous system response 
3. Sympathetic nervous system response 
4. Parasympathetic nervous system response

3. Sympathetic nervous system response

42. A client who is experiencing an inferior wall myocardial infarction has had a drop in
heart rate into the range of 50 to 56 beats/minute. The client also is complaining of
nausea. The nurse understands that these symptoms are caused by stimulation of
which cranial nerve (CN)? 
1. Vagus (CN X) 
2. Hypoglossal (CN XII) 
3. Spinal accessory (CN XI) 
4. Glossopharyngeal (CN IX)

1. Vagus (CN X)

43. A nurse overhears a neurologist saying that a client has an aneurysm located in the
circle of Willis. The nurse understands that which blood vessels are parts of the
circle of Willis? Select all that apply. 
1. Basilar artery 
2. Vertebral artery 
3. Anterior cerebral artery 
4. Posterior cerebral artery 
5. Anterior communicating artery
o 3. Anterior cerebral artery 
o 4. Posterior cerebral artery 
o 5. Anterior communicating artery
44. A client has been diagnosed with Alzheimer's disease. The nurse concludes that the
client has a pathological condition of which components of the nervous system? 
1. Glia 
2. Peripheral nerves 
3. Neuronal dendrites 
4. Monoamine oxidase

3. Neuronal dendrites

45. To promote optimal cerebral tissue perfusion in the postoperative phase following
cranial surgery, the nurse should place the client with an incision in the anterior or
middle fossa, in which position? 
1. In 15 degrees of Trendelenburg 
2. Side-lying with the head of the bed flat 
 3. With the head of the bed elevated at least 30 degrees 
4. With the head of the bed elevated no more than 10 degrees

3. With the head of the bed elevated at least 30 degrees

46. An adult client has a diagnosis of hydrocephalus. The nurse plans care, knowing that
this condition leads to more serious neurological consequences in adults as a result
of closure of which structures? 
1. Cranial sutures 
2. Arachnoid villi 
3. Foramen of Monro 
4. Aqueduct of Sylvius

1. Cranial sutures

47. A nurse is testing the spinal reflexes of a client during neurological assessment.
Which reflex will assist in determining that the client has an adequate spinal reflex? 
1. Cough reflex 
2. Withdrawal reflex 
3. Accommodation reflex 
4. Munroe-Kellie reflex

2. Withdrawal reflex

48. A client with neck and upper extremity pain has been diagnosed with cervical
radiculitis. The nurse understands that the client's symptoms must be caused by
pressure on which structures of the vertebral column? 
1. Spinous process 
2. Spinal nerve root 
3. Central spinal cord 
4. Posterior facet joints

2. Spinal nerve root

49. A client had a seizure 1 hour ago. Family members were present during the episode
and reported that the client's jaw was moving as though grinding food. In helping to
determine the origin of this seizure, what should the nurse include in the client's
assessment? 
1. Presence of diaphoresis 
2. Loss of consciousness 
3. History of prior trauma 
4. Rotating eye movements

3. History of prior trauma

50. The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The client
asks for a snack and something to drink. The nurse should offer which best snack to
the client? 
 1. Cocoa with honey and toast 
2. Hot herbal tea with graham crackers 
3. Iced coffee and peanut butter and crackers 
4. Vanilla wafers and room-temperature water

4. Vanilla wafers and room-temperature water

51. The nurse is assessing a client with a brainstem injury. In addition to obtaining the
client's vital signs and determining the Glasgow Coma Scale score,
what priority intervention should the nurse plan to implement? 
1. Check cranial nerve functioning. 
2. Determine the cause of the accident. 
3. Draw blood for arterial blood gas analysis. 
4. Perform a pulmonary wedge pressure measurement.

3. Draw blood for arterial blood gas analysis.

52. A client who suffered a stroke is prepared for discharge from the hospital. The health
care provider has prescribed range-of-motion (ROM) exercises for the client's right
side. What nursing action should the nurse include in the client's plan of care? 
1. Implement ROM exercises to the point of pain for the client. 
2. Consider the use of active, passive, or active-assisted exercises in the home. 
3. Encourage the client to be dependent on the home care nurse to complete the
exercise program. 
4. Develop a schedule of ROM exercises every 2 hours while awake even if the
client is fatigued.

2. Consider the use of active, passive, or active-assisted exercises in the home.

53. The nurse is performing an assessment on a client with the diagnosis of Brown-
Séquard syndrome. The nurse would expect to note which assessment finding? 
1. Bilateral loss of pain and temperature sensation 
2. Ipsilateral paralysis and loss of touch and vibration 
3. Contralateral paralysis and loss of touch, pressure, and vibration 
4. Complete paraplegia or quadriplegia, depending on the level of injury

2. Ipsilateral paralysis and loss of touch and vibration

54. The nurse reviews the health care provider's (HCP) prescriptions for a client with
Guillain-Barré syndrome. Which prescription written by the HCP should the nurse
question? 
1. Clear liquid diet 
2. Bilateral calf measure 
3. Monitor vital signs frequently 
4. Passive range-of-motion (ROM) exercises

1. Clear liquid diet

55. A client with myasthenia gravis arrives at the hospital emergency department in
suspected crisis. The health care provider plans to administer edrophonium to
differentiate between myasthenic and cholinergic crises. The nurse ensures that
which medication is available in the event that the client is in cholinergic crisis? 
1. Atropine sulfate 
2. Morphine sulfate 
3. Protamine sulfate 
4. Pyridostigmine bromide

1. Atropine sulfate

56. A client admitted to the nursing unit from the hospital emergency department has a
C4 spinal cord injury. In conducting the admission assessment, what is the
nurse's priority action? 
1. Take the temperature. 
2. Listen to breath sounds. 
3. Observe for dyskinesias. 
4. Assess extremity muscle strength.

2. Listen to breath sounds.

57. The nurse is assessing the function of cranial nerve XII in a client who sustained a
stroke. To assess function of this nerve, which action should the nurse ask the client
to perform? 
1. Extend the arms. 
2. Extend the tongue. 
3. Turn the head toward the nurse's arm. 
4. Focus the eyes on the object held by the nurse.

2. Extend the tongue.

58. The nurse is caring for a client who has just been admitted to the hospital with a
diagnosis of a hemorrhagic stroke. The nurse should plan to place the client in which
position? 
1. Prone 
2. Supine 
3. Semi-Fowler's with the hip and the neck flexed 
4. Head of the bed elevated 30 degrees with the head in midline position

4. Head of the bed elevated 30 degrees with the head in midline position

59. The nurse is preparing to care for a client who had a supratentorial craniotomy. The
nurse should plan to place the client in which position? 
1. Prone 
2. Supine 
3. Side-lying 
4. Semi-Fowler's
 4. Semi-Fowler's

60. The nurse is admitting a client to the hospital emergency department from a nursing
home. The client is unconscious with an apparent frontal head injury. A medical
diagnosis of epidural hematoma is suspected. Which question is of the highest
priority for the emergency department nurse to ask of the transferring nurse at the
nursing home? 
1. "When did the injury occur?" 
2. "Was the client awake and talking right after the injury?" 
3. "What medications has the client received since the fall?" 
4. "What was the client's level of consciousness before the injury?"

2. "Was the client awake and talking right after the injury?"

61. The nurse has just admitted to the nursing unit a client with a basilar skull fracture
who is at risk for increased intracranial pressure (ICP). Pending specific health care
provider prescriptions, the nurse should avoid placing the client in which positions? 
1. Head midline 
2. Neck in neutral position 
3. Flat, with head turned to the side 
4. Head of bed elevated 30 to 45 degrees

3. Flat, with head turned to the side

62. The nurse is caring for a client who is at risk for increased intracranial pressure (ICP)
after a stroke. Which activities performed by the nurse will assist with preventing
increases in ICP? Select all that apply. 
1. Clustering nursing activities 
2. Hyperoxygenating before suctioning 
3. Maintaining 20 degree flexion of the knees 
4. Maintaining the head and neck in midline position 
5. Maintaining the head of the bed (HOB) at 30 degrees elevation
o 2. Hyperoxygenating before suctioning 
o 4. Maintaining the head and neck in midline position 
o 5. Maintaining the head of the bed (HOB) at 30 degrees elevation
63. The nurse is trying to communicate with a client with brain attack and aphasia.
Which action by the nurse would be least helpful to the client? 
1. Speaking to the client at a slower rate 
2. Allowing plenty of time for the client to respond 
3. Completing the sentences that the client cannot finish 
4. Looking directly at the client during attempts at speech

3. Completing the sentences that the client cannot finish

64. The nurse has given the client with Bell's palsy instructions on preserving muscle
tone in the face and preventing denervation. The nurse determines that the
client needs additional teaching if the client makes which statements? 
1. "I will perform facial exercises." 
 2. "I will expose my face to cold to decrease the pain." 
3. "I will massage my face with a gentle upward motion." 
4. "I will wrinkle my forehead, blow out my cheeks, and whistle frequently."

2. "I will expose my face to cold to decrease the pain."

65. The client with a cervical spine injury has cervical tongs applied in the emergency
department. What should the nurse avoid when planning care for this client? 
1. Using a Roto-Rest bed 
2. Removing the weights to reposition the client 
3. Assessment of the integrity of the weights and pulleys 
4. Comparing the amount of prescribed traction with the amount in use

2. Removing the weights to reposition the client

66. The nurse is caring for the client who suffered a spinal cord injury 48 hours ago.
What should the nurse assess for when monitoring for gastrointestinal
complications? 
1. A history of diarrhea 
2. A flattened abdomen 
3. Hyperactive bowel sounds 
4. Hematest-positive nasogastric tube drainage

4. Hematest-positive nasogastric tube drainage

67. The client has an impairment of cranial nerve II. Specific to this impairment, what
should the nurse should plan to do to ensure client safety? 
1. Speak loudly to the client. 
2. Test the temperature of the shower water. 
3. Check the temperature of the food on the dietary tray. 
4. Provide a clear path for ambulation without obstacles.

4. Provide a clear path for ambulation without obstacles.

68. Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with
pain, and the nurse instructs the client about the purpose of the TENS unit. Which
statement by the client indicates the need for further instruction? 
1. "The unit relieves pain." 
2. "Electrodes are attached to the skin." 
3. "The unit will reduce the need for analgesics." 
4. "Hospitalization is required because the unit is not portable."

4. "Hospitalization is required because the unit is not portable."

69. The post–head injury client opens eyes to sound, has no verbal response, and
localizes to painful stimuli when applied to each extremity. How should the nurse
document the Glasgow Coma Scale (GCS) score? 
1. GCS = 3 
 2. GCS = 6 
3. GCS = 9 
4. GCS = 11

3. GCS = 9

70. The client with a spinal cord injury at the level of T4 is experiencing a severe
throbbing headache with a blood pressure of 180/100 mm Hg. What is
the priority nursing intervention? 
1. Notify the health care provider. 
2. Loosen tight clothing on the client. 
3. Place the client in a sitting position. 
4. Check the urinary catheter tubing for kinks or obstruction.

3. Place the client in a sitting position.

71. The nurse is caring for a client who is in the chronic phase of stroke (brain attack)
and has a right-sided hemiparesis. The nurse identifies that the client is unable to
feed self. Which is a priority nursing intervention? 
1. Assist the client to eat with the left hand to build strength. 
2. Provide a pureed diet that is easy for the client to swallow. 
3. Inform the client that a feeding tube will be placed if progress is not made. 
4. Provide a variety of foods on the meal tray to stimulate the client's appetite.

1. Assist the client to eat with the left hand to build strength.

72. A client is newly admitted to the hospital with a diagnosis of brain attack (stroke)
manifested by complete hemiplegia. Which item in the medical history of the client
should the nurse be most concerned? 
1. Glaucoma 
2. Emphysema 
3. Hypertension 
4. Diabetes mellitus

2. Emphysema

73. A client with Parkinson's disease is at risk for falls because of an abnormal gait. The
nurse assesses the client, expecting to observe which type of gait? 
1. Unsteady and staggering 
2. Shuffling and propulsive 
3. Broad-based and waddling 
4. Accelerating with walking on the toes

2. Shuffling and propulsive

74. The nurse is evaluating the respiratory outcomes for a client with Guillain-Barré
syndrome. The nurse determines that which is the least optimal outcome for the
client? 
 1. Spontaneous breathing 
2. Oxygen saturation of 98% 
3. Adventitious breath sounds 
4. Vital capacity within normal range

3. Adventitious breath sounds

75. A client with a history of myasthenic gravis presents at a clinic with bilateral ptosis
and is drooling, and myasthenia crisis is suspected. The nurse assesses the client
for which precipitating factor? 
1. Getting too little exercise 
2. Taking excess medication 
3. Omitting doses of medication 
4. Increasing intake of fatty foods

3. Omitting doses of medication

76. The nurse is positioning a client who has increased intracranial pressure. Which
position should the nurse avoid? 
1. Head midline 
2. Head turned to the side 
3. Neck in neutral position 
4. Head of bed elevated 30 to 45 degrees

2. Head turned to the side

77. A client who has had a stroke (brain attack) has residual dysphagia. When a diet
prescription is initiated, the nurse should avoid which action? 
1. Giving the client thin liquids 
2. Thickening liquids to the consistency of oatmeal 
3. Placing food on the unaffected side of the mouth 
4. Allowing plenty of time for chewing and swallowing

1. Giving the client thin liquids

78. A postoperative craniotomy client who sustained a severe head injury is admitted to
the neurological unit. What important nursing intervention is necessary for this
client? 
1. Take and record vital signs every 4 to 8 hours. 
2. Prophylactically hyperventilate during the first 20 hours. 
3. Treat a central fever with the administration of antipyretic medications such as
acetaminophen (Tylenol). 
4. Keep the head of the bed elevated at least 30 degrees, and position the client to
avoid extreme flexion or extension of the neck and head.

4. Keep the head of the bed elevated at least 30 degrees, and position the client to avoid
extreme flexion or extension of the neck and head.
79. A client has a cerebellar lesion. The nurse would plan to obtain which item for use by
this client? 
1. Walker 
2. Slider board 
3. Raised toilet seat 
4. Adaptive eating utensils

1. Walker

80. A client has sustained damage to Wernicke's area in the temporal lobe from a brain
attack (stroke). Which should the nurse anticipate when caring for this client? 
1. The client will be unable to recall past events. 
2. The client will have difficulty understanding language. 
3. The client will demonstrate difficulty articulating words. 
4. The client will have difficulty moving one side of the body.

2. The client will have difficulty understanding language.

81. A nurse is preparing to administer a prescribed antibiotic to a client with bacterial

meningitis. The nurse understands that the selection of an antibiotic to treat
meningitis is based on which fact? 
1. It has a long half-life. 
2. It acts within minutes to hours. 
3. It can be easily excreted in the urine. 
4. It is able to cross the blood-brain barrier.

4. It is able to cross the blood-brain barrier.

82. A client who is experiencing an inferior wall myocardial infarction has had a drop in
heart rate into the 50 to 56 beats/min range. The client is also complaining of
nausea. The nurse interprets that these symptoms are because of stimulation of
which cranial nerve (CN)? 
1. Vagus (CN X) 
2. Hypoglossal (CN XII) 
3. Spinal accessory (CN XI) 
4. Glossopharyngeal (CN IX)

1. Vagus (CN X)

83. A nurse is caring for a client who is scheduled to have electroencephalography. The
nurse determines that the client is ready for the procedure after noting which
finding? 
1. The client has not had any breakfast. 
2. The client's hair has been shampooed. 
3. The client has had two cups of coffee with breakfast. 
4. The morning dose of an anticonvulsant has been administered.

2. The client's hair has been shampooed.

84. A nurse is assessing a client's muscle strength and notes that when asked, the client
cannot maintain his or her hands in a supinated position with the arms extended and
eyes closed. How should the nurse correctly document this finding on the medical
record? 
1. Client is demonstrating ataxia. 
2. Client is exhibiting pronator drift. 
3. Client appears to have nystagmus. 
4. Client examination reveals hyperreflexia.

2. Client is exhibiting pronator drift.

85. A nurse caring for a client following craniotomy who has a supratentorial incision
understands that the client should most likely be maintained in which position? 
1. Prone position 
2. Supine position 
3. Semi-Fowler's position 
4. Dorsal recumbent position

3. Semi-Fowler's position

86. A student nurse is assisting with an assessment of a client's level of consciousness

using the Glasgow Coma Scale. The student understands that which categories of
client functioning are included in this assessment? Select all that apply. 
1. Eye opening 
2. Reflex response 
3. Best verbal response 
4. Best motor response 
5. Pupil size and reaction
o 1. Eye opening 
o 3. Best verbal response 
o 4. Best motor response