Neurologic System
Upon neurological assessment, the nurse notes quick back and forth oscillation of the eye at the end points of each direction, what is the patient experiencing?
Nystagmus
Rationale: Nystagmus causes rapid eye-movement that results in a slow drift back toward midline followed by a rapid "back and forth” oscillation.
The nurse is caring for a patient who has paralysis and loss of sensory perception that include both arms and both legs. How would you describe the patient?
Tetraplegic/quadriplegic
Rationale: Tetraplegia/quadriplegia involves paralysis of all four extremities. Paraplegia would only affect the lower two extremities.
What is the acronym for the warning signs of a stroke, and what do the letters stand for?
FAST (facial drooping, arm weakness, speech impairment, time to call for help)
Rationale: FAST is a quick tool to recognize stroke signs: facial drooping, arm weakness, speech difficulty, and emphasizes calling for help immediately because early treatment can reduce disability and death.
This acute autoimmune disorder of the peripheral nervous system causes progressive ascending paralysis and may involve cranial nerves, placing the patient at risk for respiratory failure.
Guillain-Barré syndrome
Rationale:GBS is an acute autoimmune disorder where the immune system attacks peripheral nerves, causing ascending weakness. It can progress to involve cranial and respiratory muscles, leading to possible respiratory failure.
This autoimmune disorder involves destruction of the myelin sheath in the CNS and is characterized by relapsing and remitting neurologic symptoms
Multiple sclerosis
Rationale: MS is an autoimmune disorder where the immune system destroys the CNS myelin, disrupting nerve signals. This causes relapsing and remitting neurologic symptoms that vary by lesion location.
This drug is a first-line treatment for focus-seizures, generalized tonic-clinic seizures, trigeminal neuralgia, and bipolar disorder
A. Carbodopa-Levodopa
B. Carbamazepine
C. Finasteride
D. Famotidine
B. Carbamazepine
Rationale: The other options are incorrect: A (Carbidopa-Levodopa) is for Parkinson's disease, C (Finasteride) is for benign prostatic hyperplasia, and D (Famotidine) is a histamine-2 blocker for acid reflux.
A client with traumatic brain injury is receiving mannitol IV for elevated intracranial pressure (ICP). Which assessment finding requires immediate intervention by the nurse?
A. Urine output of 50 mL/hr
B. Crackles in the lung bases
C. Heart rate of 99 bpm.
D. Blood pressure 140/90 mmHg
B. Crackles in the Lungs.
Rationale: A significant adverse effect of mannitol is fluid overload, leading to pulmonary edema or heart failure. Crackles in the lungs indicate fluid overload.
The nurse provides care for a client who is diagnosed with epilepsy and prescribed multiple anticonvulsant medications, including valproic acid, levetiracetam, and topamax. Which is the priority action by the nurse when assessing the client based on the prescribed levetiracetam?
A. Skin turgor due to risk for dehydration
B. Dietary intake due to the risk for malnutrition
C. Mobility due to the risk for loss of coordination
D. Bowel elimination due to the risk for watery stools
C. Mobility due to the risk for loss of coordination
Rationale: Levetiracetam can cause impaired coordination, increasing the risk of falls. The priority is to assess mobility and ensure patient safety.
A patient with myasthenia gravis complains of excessive salivation, diarrhea, and sweating shortly after taking pyridostigmine. The nurse recognizes this as a sign of?
A. Myasthenic crisis
B. Cholinergic crisis
C. Allergic reaction
D. Medication noncompliance
B. Cholinergic crisis
Rationale: Excess pyridostigmine increases acetylcholine, leading to a cholinergic crisis. This causes symptoms like salivation, diarrhea, sweating, and risk of respiratory distress.
A patient with Amyotrophic lateral sclerosis is taking Riluzole. The nurse should monitor which laboratory value regularly?
A. Serum potassium
B. Liver function tests (AST/ALT)
C. Blood glucose
D. Serum sodium
B. Liver function tests (AST/ALT)
Rationale: Riluzole can cause liver toxicity, so liver function tests must be monitored regularly. Elevated AST/ALT levels may indicate liver damage.
A nurse is caring for a patient who is 24 hours post-operative following a craniotomy for a brain tumor. The patient suddenly reports a severe headache and begins vomiting. The nurse notes that the patient is lethargic and difficult to arouse. Which intervention should the nurse implement first
A. Administer an antiemetic as prescribed by the provider
B. Check the patient's pupil size and reactivity
C. Raise the head of the bed to 30 degrees.
D. Reassure the patient that vomiting is completely normal after brain surgery.
B. Check the patient's pupil size and reactivity.
Rationale: The combination of sudden severe headache, vomiting, lethargy, and decreased arousal level is concerning for increased intracranial pressure (ICP) , possibly due to cerebral edema or postoperative bleeding. Checking pupil size and reactivity is a rapid, non-invasive bedside assessment that provides critical information about cranial nerve III function and brainstem herniation risk. Asymmetric or nonreactive pupils are a late sign of elevated ICP and require immediate intervention. While raising the head of the bed to 30 degrees (C) is an appropriate intervention to reduce ICP, it should not delay performing the priority nursing action—the neurologic assessment (pupils) to determine the patient's current status. Administering an antiemetic (A) may temporarily relieve vomiting but does not address the underlying development. Reassuring the patient (D) is inappropriate given the concerning clinical picture.
The nurse is caring for a patient experiencing a hemorrhagic stroke, what position should they avoid putting the patient in?
Supine
Rationale: The supine position should be avoided in a client with a hemorrhagic stroke, as it can increase intracranial pressure (ICP) and worsen cerebral edema. The appropriate position is to elevate the head of the bed to approximately 30 degrees, which promotes venous drainage and helps reduce ICP.
A patient experienced a tonic-clonic seizure. They are now confused and sleepy. What is the priority nursing action?
A. Restrain the patient to prevent injury
B. Place the patient on their side and maintain airway
C. Offer water or a soft snack to restore hydration
D. Assist the patient to sit upright to prevent falls
B. Place the patient on their side and maintain airway
Rationale: After a seizure, the patient is at risk for airway obstruction and aspiration due to confusion and drowsiness. Placing them on their side helps maintain airway and ensures safety. Secondary interventions, such as offering food or assisting with mobility, are addressed only after the airway is secured.
The priority nursing assessment of a patient with MG would be to:
A. Determine the degree of fatigue
B. Assess the level of knowledge about the disease
C. Monitor the adequacy of respiratory function
D. Check the patient’s swallowing, speech, and protective reflexes
C. Monitor the adequacy of respiratory function
Rationale: MG causes muscle weakness due to impaired acetylcholine at the neuromuscular junction, which can affect respiratory muscles. This puts the patient at risk for respiratory failure, making respiratory assessment the priority.
The nurse provides care for a client who is newly prescribed an anticholinergic medication for the treatment of Parkinson disease. Which is the priority teaching point to decreasing the client’s risk for falling in the home environment due to the prescribed medication?
A. “Be sure to wear non-skid slippers.”
B. “Use over-the-counter drops for dry eyes.”
C. “Wear cotton clothing due to increased sweating.”
D. “Change positions slowly when getting up in the morning.”
D. “Change positions slowly when getting up in the morning.”
Rationale: Anticholinergic medications prescribed for Parkinson’s disease can cause orthostatic hypotension, which increases the risk of dizziness and falls. Teaching the client to change positions slowly, such as moving from lying or sitting to standing gradually, helps prevent falls.
With an open hand, you press over the flaccid bladder of a patient. When questioned regarding this nursing action, an appropriate response would be:
A. “The technique increases the muscle tone of the bladder.”
B. “The maneuver facilitates removal of urinary sediments.”
C. “The technique assists with complete bladder emptying.”
D. “The technique reduces the incidence of bladder irritation.”
C. “The technique assists with complete bladder emptying.”
Rationale: The Credé maneuver assists in emptying the bladder completely. While some urinary sediments may be expelled with urine, the purpose of the maneuver is not to encourage sediment release.
Your patient has just returned from a discectomy 5-minutes ago, what is the priority post-operative nursing intervention?
A. Turn the patient on the side that the discectomy occurred to prevent dehiscence.
B. Provide a commode so they can empty their bladder and bowels with minimal physical movement to prevent spinal injury.
C. Ensure that the spinal cord is in alignment to encourage healing.
D. Administer an ordered anticholinergic (eg., Imodium) to prevent bowel movements due to the difficulty and inherent risks involved with moving the patient for perineal cleaning due to the spinal cord surgery.
C. Ensure that the spinal cord is in alignment to encourage healing.
Rationale: Postoperatively, the major concern after discectomy is to keep the spinal column in alignment so that healing can take place and no further injury occurs to the spinal cord. While repositioning may be important, it is not a priority — early ambulation is a critical component to recovery.
The nurse receives a patient diagnosed with meningitis, which of the following is a priority nursing intervention?
A. Decreasing fluid intake
B. Conserving the patient’s strength
C. Encourage emesis due to GI paralysis caused by meningitis
D. Educate the patient that they will be confused and delirious, and that fear regarding these emotions is common.
B. Conserving the patient’s strength
Rationale: Care and treatments are coordinated to provide as much rest as possible. Increased fluid intake is generally encouraged as fluid volume deficits and dehydration are a common problem. Emesis is not encouraged. Educating the patient that they will be confused is not a priority nursing intervention and may not be effective if they are currently confused and delirious.
Which of the following is NOT an appropriate nursing intervention for a myasthenic crisis?
A. Administer anticholinesterase therapy as prescribed.
B. Administer atropine as prescribed.
C. Notify provider and prepare for endotracheal intubation and mechanical ventilation.
D. Position the patient in high fowlers.
B. Administer atropine as prescribed.
Rationale: Preparing for intubation and mechanical ventilation, while repositioning the patient in high fowlers will address the patient’s difficulty breathing, due to the diaphragm’s inability to contract properly. Administering anticholinesterase therapy will inactivate acetylcholinesterase, which prevents accumulations of ACh at the neuromuscular junction. This will increase the amount of ACh and allow the diaphragm to contract. Atropine is an intervention for a cholinergic crisis, in which too much ACh occurs.
A nurse is caring for a patient with moderate-stage Huntington's disease who exhibits severe chorea, weight loss, and frequent falls. The patient's family reports that the patient refuses to eat because "it takes too much effort and food falls out of my mouth." Which nursing intervention should the nurse prioritize?
A. Administer tetrabenazine as prescribed to reduce chorea severity before meals
B. Place the patient on a mechanical soft diet with thickened liquids of nectar consistency
C. Reach out to multidisciplinary care personnel, including SLP, OT, and the dietitian.
D. Educate the family to position the patient in high-Fowler's with chin tuck during meals.
C. Reach out to multidisciplinary care personnel, including SLP, OT, and the dietitian.
Rationale: The priority is to coordinate with the patient’s multidisciplinary care team including: Speech-language pathologist (SLP): Formal swallow evaluation, aspiration risk assessment, and specific texture/positioning recommendations; Occupational therapist (OT): Adaptive utensils, plate guards, and energy conservation techniques to reduce effort; Dietitian: Caloric density optimization, nutritional supplementation, and weight monitoring. This collaborative approach ensures interventions are individualized, safe, and patient-centered.
A is incorrect: Tetrabenazine is a first-line treatment for chorea in Huntington's disease, and reducing chorea may improve eating. However,. the patient's dysphagia may persist even with reduced chorea if oromotor incoordination is present.
B is incorrect: Placing the patient on a mechanical soft diet is not in the scope of the LPN to independently prescribe.
D is incorrect: High-Fowler's with chin tuck is a correct positioning strategy for dysphagia, and family education is valuable. However, this is only one component of a comprehensive plan. Positioning alone will not address severe chorea, oromotor incoordination, hypermetabolism, or the need for adaptive equipment.
Which are true regarding a stroke? (select all that apply)
A. Timing of treatment is important.
B. A fibrinolytic drug will be given.
C. Clinical signs and symptoms determine if the stroke is ischemic or hemorrhagic.
D. A CT scan should be done within 20 minutes of arrival at the hospital.
E. It may occur as a complication of atrial fibrillation.
A, D, E
Rationale: Stroke is a time-sensitive emergency, so early recognition and treatment are critical. A CT scan within 20 minutes helps identify whether the stroke is ischemic or hemorrhagic, guiding therapy. Strokes can be a complication of atrial fibrillation due to emboli. Fibrinolytic therapy is only given for ischemic strokes, and clinical signs alone cannot reliably distinguish stroke type.
The classic signs of increased ICP include which of the following? Select all that apply.
A. Rising systolic blood pressure
B. Widening pulse pressure
C. Bradycardia
D. Positive Babinski sign
A, B, C
Rationale: Rising systolic blood pressure, widening pulse pressure, and bradycardia are key signs of increased intracranial pressure (ICP), known as Cushing’s triad. A positive Babinski sign indicates central nervous system damage.
Which of the following are signs of right sided brain damage? Select all that apply.
A. Quick and impulsive in behavior
B. Short attention span
C. Difficulty in following verbal commands.
D. Neglects left side of brain
E. Easily distracted
A, B, D, E
Rationale: Right sided brain damage often causes impulsivity, poor judgment, short attention span, and neglect of the left side of the body. Difficulty following verbal commands is usually seen with left-sided brain damage, which affects language and communication.
While providing care for the client diagnosed with Guillain-Barré syndrome, which intervention will the nurse implement to prevent complications of immobility? Select all that apply.
A. Massage reddened skin areas hourly
B. Turn and reposition client every two hours
C. Implement passive range-of motion exercises
D. Perform skin assessment every shift
E. Apply warm compresses to reddened skin areas
B, C, D
Rationale: Patients with GBS often experience limited mobility due to progressive muscle weakness, which occurs because the immune system attacks the peripheral nerves, disrupting the signals between the brain and muscles. Immobility increases the risk of pressure injuries, contractures, and skin breakdown, which is why nursing interventions are implemented to prevent these complications.
A patient with PD has been taking cabidopa-levodopa for 3 months and is being seen for follow-up. You would expect to observe which of the following? Select all that apply.
A. Dark Urine
B. Bradykinesia
C. Weight Maintained
D. Rigidity
E. Walking without assistance.
F. Tremors
A,C,E
Rationale: Dark urine is an expected side effect of carbidopa-levodopa. The medication should improve swallowing, maintain nutrition, and improve walking and balance. Persistent bradykinesia, rigidity, or tremors may indicate a dosage adjustment, as these symptoms should be reduced or eliminated.