Assessing Neuro System
Which physiological barrier protects the brain from harmful substances?
a. Cerebrospinal Fluid
b. Subcutaneous Tissue
c. Immune System
d. The Skull
Answer: A Cerebrospinal Fluid
(pg. 1525 in textbook)
Which is the most frequent cause of increased intracranial pressure (IICP)?
a) Hemorrhage
b) Abscesses
c) Tissue ischemia
d) Tumors
Answer C Tissue ischemia
(MyLab)
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?
A. Hyperreflexia
B. Positive reflexes
C. Flaccid paralysis
D. Reflex emptying of the bladder
Answer C Flaccid paralysis
(Saunders NCLEX-RN pg 848, 8th edition)
A patient with meningitis is drowsy and confused. What should the nurse explain to the patient’s family as being the cause for these mental status changes?
A. Decreased intracranial pressure
B. Bleeding in the central nervous system
C. Elevated serum white blood cell count
D. Sluggish flow of cerebrospinal fluid
Answer D
Sluggish flow of cerebrospinal fluid
Textbook page 1626
True or False: Dementia and Alzheimer’s disease is a normal process of aging.
False
(pg. 1630 in textbook)
After the patient recovered from COVID, their sense of smell was impaired. Which cranial nerve is responsible for the ability to smell?
a. Cranial Nerve V
b. Cranial Nerve I
c. Cranial Nerve IV
d. Cranial Nerve VIII
Answer: B Cranial Nerve I
(pg. 1534 in textbook)
The nurse is teaching the emergency care of the patient with status epilepticus to a colleague. Which statement by the colleague indicates that teaching about airway management was effective?
a) The airway is managed after an IV is established
b) The airway may be compromised by muscle rigidity and secretions
c) Antiseizure medication must be delivered before the airway is managed
d) Oxygen should be delivered only if the pulse oximeter is below 90%
Answer B The airway may be compromised by muscle rigidity and secretions
(MyLab)
The nurse is planning care for a patient with an acute SCI. According to best practices, which medications should the nurse prepare during this patient’s initial care? (Select all that apply.)
A. Analgesics
B. Antibiotics
C. Vasopressors
D. Antihistamines
E. Corticosteroids
Answer A - Analgesics & C - Vasopressors
Textbook pg. 1625
How will the CSF results return after testing a patient with meningitis?
A. Clear, decreased protein, increased WBC and increased glucose counts
B. Cloudy, increased protein, decreased WBC, and decreased glucose counts
C. Cloudy, increased protein, increased WBC, and decreased glucose counts
D. You do not need to analyze the CSF in patients with meningitis
Answer C
Cloudy, increased protein, increased WBC, and decreased glucose counts
(Saunders NCLEX-RN pg 847, 8th edition)
In the patient with Myasthenia Gravis, a cholinergic crisis is caused by:
a. An over-dosage of anticholinesterase (cholinergic) medication
b. An under-dose and/or missed dose of anticholinesterase (cholinergic) medication
c. An elevated blood level of liver enzymes and albumin
d. A missed dose of a dopaminergic drug
Answer: A
An over-dosage of anticholinesterase (cholinergic) medication
(pg. 1658 in textbook)
PERRLA stands for:
a. Pupils, Extremity, Rotation, Reactive to Light, Abnormality
b. Pupils, Equal, Round, Red, Reactive to Sound, Accommodation
c. Pupil diameter, Extraocular, Retroactive, Rhinorrhea, Lupus, Atelectasis
d. Pupils, Equal, Round, Reactive to Light, Accommodation
Answer: D Pupils, Equal, Round, Reactive to Light, Accommodation
(pg. 1534 in textbook)
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?
a) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
b) Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
c) Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
d) Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
Answer: A
Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
(Saunders NCLEX-RN pg 916, 7th edition)
Autonomic Dysreflexia in Spinal Cord Injury
*Priority Nursing Actions | Place in Order
1. Raise the HOB and ask for PHCP be notified
2. Check for bladder distention or other noxious stimulation
3. Admin an antihypertensive med
4. Loosen tight clothing on the client
5. Document the occurrence, tx or response
Correct Order per Saunders NCLEX-RN pg 838, 8th edition)
1, 4, 2, 3, 5
What assessment findings cause the nurse to suggest the patient has encephalitis? (Select all that apply)
A. Cold sores, lesions, or ulcerations of the oral cavity
B. Fever
C. Nausea & Vomiting
D. Nuchal Rigidity
E. Altered LOC and mental status
Answer ABCDE
(Saunders NCLEX-RN pg 847, 8th edition)
Parkinson's Dz is characterized by these manifestations…Select all that apply:
a. Tremor
b. Rigidity
c. Restless Leg Syndrome
d. Pressured Speech
e. Chorea
Answer: A-Tremor, B-Rigidity, C-Restless Leg Syndrome
(pg. 1648 in textbook)