Neuro 1
Neuro 2
Neuro 3
Neuro 4
Neuro 5
100
The priority nursing diagnosis for a client experiencing a migraine headache. Acute Pain related to biologic and chemical factors/ Anxiety relate to change in or threat to health status/ Hopelessness related to deteriorating physiologic condition/ Risk for Injury related to side effects of medical therapy
What is acute pain related to biologic and chemical factors?
100
The action can you delegate to the nursing assistant after a client has a seizure. Document the seizure/ Perform neurologic checks/ Take the client’s vital signs/ Restrain the client for protection
What is taking the client’s vital signs?
100
The nursing action to implement first when client has a generalized tonic-clonic seizure. Turn the client to one side/ Give lorazepam (Ativan) 1 mg IV/ Administer oxygen via nonrebreather mask/ Assess the client’s level of consciousness
What is turning the client to one side?
100
The client to assess first after receiving report. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching./ A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching/ A 59-year-old with Parkinson disease who will need a swallowing assessment before breakfast/ A 63-year-old with MS who has an oral temperature of 101.8 F (38.8 C) and flank pain
What is a 63-year-old with MS who has an oral temperature of 101.8 F (38.8 C) and flank pain?
100
The best neuro ICU client to assign to an RN who has been pulled from the medical unit. A 26-year-old with a basilar skull fracture who has clear drainage coming out of the nose/ A 42-year-old admitted several hours ago with a headache and a diagnosis of ruptured berry aneurysm/ A 46-year-old who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due/ A 65-year-old with an astrocytoma who has just returned to the unit after undergoing craniotomy
What is a 46-year-old who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due?
200
Item to remove from a teaching plan for a client with newly diagnosed migraine headaches. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided/ Drugs like cimetidine (Tagamet), nitroglucerin (Nitrostat), and nifedepine (Procardia) should be avoided/ Abortive therapy is aimed at eliminating the pain during the aura/ Estrogen therapy should be continued as prescribed by your physician
What is estrogen therapy should be continued as prescribed by your physician?
200
Action to delegate to an LPN/LVN for an admit with a seizure disorder. Completing the admission assessment/ Setting up oxygen and suction equipment/ Placing a padded tongue blade at the bedside/ Padding the side rails before the client arrives
What is setting up oxygen and suction equipment?
200
Statement that the nursing student makes to client and family about epilepsy that the nurse should intervene. “You should avoid consumption of all forms of alcohol.”/ “Wear your medical alert bracelet at all times.”/ “Protect your loved one’s airway during a seizure.”/ “It’s ok to take over-the-counter medications.”
What is “It’s ok to take over-the-counter medications”?
200
Statement made by a client with chronic low back pain. that indicates the need for additional teaching. “I will avoid exercise because the pain gets worse.”/ “I will use heat or ice to help control the pain.” /I will not wear high-heeled shoes at home or work.”/ “I will purchase a firm mattress to replace my old one.”
What is “I will avoid exercise because the pain gets worse"?
200
Strategy not to use with a client with an SCI for a bladder-retraining program. Stroke the client’s inner thigh./ Pull on the client’s pubic hair./ Initiate intermittent straight catheterization./ Pour warm water over the client’s perineum.
What is initiating intermittent straight catheterization?
300
The action by the NA with a client with Parkinson disease has received a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment that must be corrected. Helping the client ambulate to the bathroom and back to bed/ Reminding the client not to look at his feet when he is walking/ Performing the client’s complete bathing and oral care/ Setting up the client’s tray and encouraging the client to feed himself
What is performing the client’s complete bathing and oral care?
300
The client the charge nurse should assign to a new RN graduate who is on orientation to the neurologic unit. A 28-year-old newly admitted client with an SCI/ A 67-year-old who had a stroke 3 days ago and has let-sided weakness/ An 85-year-old- with dementia who is to be transferred to long-term care today/ A 54-year-old with Parkinson disease who needs assistance with bathing
What is a 67-year-old who had a stroke 3 days ago and has let-sided weakness?
300
The priority assessment for a client with an SCI at level C3-C4. Determine the level at which the client has intact sensation/ Assess the level at which the client has retained mobility/ Check blood pressure and pulse for signs of spinal shock/ Monitor respiratory effort and oxygen saturation level
What is monitor respiratory effort and oxygen saturation level?
300
Action delegate to a nursing assistant when providing nursing care for a client with an SCI. Assess the client’s respiratory status every 4 hours/ Take the client’s vital signs and record every 4 hours / Monitor the client’s nutritional status, including calorie counts/ Instruct the client how to turn, cough and breathe deeply every 2 hours
What is taking the client’s vital signs and record every 4 hours?
300
The observation that the LPN should be instructed to report immediately for a client with GBS. Complaints of numbness and tingling/ Facial weakness and difficulty speaking/ Rapid heart rate of 102 beats/min/ Shallow respirations and decreased breath sounds
What is shallow respirations and decreased breath sounds?
400
The client to assign to the traveling nurse who is new to neurologic nursing care. A 34 –year-old with newly diagnosed multiple sclerosis (MS)/ A 68-year-old wit chronic amyotrophic lateral sclerosis/ A 56-year-old with Guillain-Barre syndrome/ A 25-year-old admitted with C4-level SCI
What is a 68-year-old wit chronic amyotrophic lateral sclerosis?
400
The priority nursing diagnosis for a client with MS who tells the nursing assistant after physical therapy that she is too tired to take a bath. Fatigue related to disease state/ Activity Intolerance due to generalized weakness/ Impaired Physical Mobility related to neuromuscular impairment/ Self-Care Deficit related to fatigue and neuromuscular weakness
What is Self-Care Deficit related to fatigue and neuromuscular weakness?
400
The action not delegated to an experienced nursing assistant caring for a client with thrombotic stroke who has residual left-sided weakness. Assist the client to reposition every 2 hours/ Reapply pneumatic compression boots/ Remind the client to perform active ROM exercises / Assess the extremities for redness and edema
What is assessing the extremities for redness and edema?
400
Instruction given to the nursing assistant who will feed a client who had a stroke. Position the client sitting up in bed before you feed him./ Check the client’s gag and swallowing reflexes./ Feed the client quickly, because there are three more you must feed/ Suction the client’s secretions between bites of food
What is position the client sitting up in bed before you feed him?
400
Action by the student caring for a client with meningococcal meningitis requiring intervention. The student enters the room with out putting on a mask and gown./ The student instructs the family that visits are restricted to 10 minutes/ The student gives the clients a warm blanket when he says he feels cold/ The student check the client’s pupil light every 30 minutes
What is the student entering the room with out putting on a mask and gown?
500
Action to be taken first with client with a spinal cord injury (SCI) complains about a sudden, severe throbbing headache and increased blood pressure (168/94 mm HG) and decreased heart rate (48 beats/min), diaphoresis and flushing of the face and neck. Administer the ordered acetaminophen (Tylenol)/ Check the Foley tubing for kinks or obstruction/ Adjust the temperature in the client’s room/ Notify the physician about the change in status
What is checking the Foley tubing for kinks or obstruction?
500
The best first action for a client with myasthenia gravis has an elevated temperature (102.2 F) [39C], an increased hear rate (120beats/min), a rise in blood pressure (158/94) mm HG), and was incontinent of urine and stool. Administer an acetaminophen suppository/ Notify the physician immediately/ Recheck vital signs in 1 hour/ Reschedule the client’s physical therapy
What is notifying the physician immediately?
500
The best response for the husband of a client with an acute hemorrhagic stroke who asks why his wife has not received alteplase ( Activase). “Your wife was not admitted with in the time frame that altplase is usually given.”/ “This drug is used primarily for clients who experience an acute heart attack.”/ “Alteplase dissolves clots and may cause more bleeding into your wife’s brain.”/ “Your wife had gallbladder surgery just 6 months ago, and this prevents the use of alteplase.”
What is “Alteplase dissolves clots and may cause more bleeding into your wife’s brain"?
500
The nursing diagnosis most appropriate for the client who has Alzheimer disease and is hospitalized with new onset angina whose husband tells you he does not sleep well because he needs to be sure she does not wander during the night and insists on checking each of the medications you five the client to be sure they are “the same pills she takes at home.” Decreased Cardiac Output related to poor myocardial contractility/ Caregiver Role Strain related to continuous need for providing care/ Risk for Falls related to client wandering behavior during the night/ Ineffective Therapeutic Regimen Management related to poor client memory
What is Caregiver Role Strain related to continuous need for providing care?
500
The most concerning assessment information when caring for a client with glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. The client no longer recognizes family members./ The blood glucose level is 234mg/dL./ The client complains of continuing headache./ The daily weight has increased 1kg.
What is the client no longer recognizes family members?
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