SEIZURES FROM NCLEX Flashcards by John Roger Villegas

Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene?

A. Placing the client on the back with a small pillow under the head.
B. Keeping portable suctioning equipment at the bedside.
C. Opening the client’s mouth with a padded tongue blade.
D. Cleaning the client’s mouth and teeth with a toothbrush.

A. Placing the client on the back with a small pillow under the head.

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A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?

A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for A STAT computer tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consultation.

C. Schedule for A STAT computer tomography (CT) scan of the head.

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A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?

A. Time of onset of current stroke
B. Complete physical and history
C. Current medications
D. Upcoming surgical procedures

A. Time of onset of current stroke

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What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

A. Cholesterol level
B. Pupil size and pupillary response
C. Bowel sounds
D. Echocardiogram

B. Pupil size and pupillary response

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What is the expected outcome of thrombolytic drug therapy?

A. Increased vascular permeability
B. Vasoconstriction
C. Dissolved emboli
D. Prevention of hemorrhage

C. Dissolved emboli

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The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

A. A thrombolytic medication
B. A beta-blocker medication
C. An anti-hyperuricemic medication
D. An oral anticoagulant medication

D. An oral anticoagulant medication

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Which client would the nurse identify as being most at risk for experiencing a CVA?

A. A 39-year-old pregnant female.
B. A 67-year-old Caucasian male.
C. An 84-year-old Japanese female.
D. A 55-year-old African American male.

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

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

A. The assistant places a gait belt around the client’s waist prior to ambulating.
B. The assistant places the client on the back with the client’s head to the side.
C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.
D. The assistant praises the client for attempting to perform ADL’s independently.

C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.

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A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?

A. Vomiting continues.
B. Intracranial pressure (ICP) is increased.
C. The client needs mechanical ventilation.
D. Blood is anticipated in the cerebrospinal fluid (CSF).

B. Intracranial pressure (ICP) is increased.

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A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?

A. To reduce intraocular pressure.
B. To prevent acute tubular necrosis.
C. To promote osmotic diuresis to decrease ICP.
D. To draw water into the vascular system to increase blood pressure.

C. To promote osmotic diuresis to decrease ICP.

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Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?

A. Ataxia and confusion
B. Sodium depletion
C. Tonic-clonic seizure
D. Urinary incontinence

A. Ataxia and confusion

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Which of the following signs and symptoms of increased ICP after head trauma would appear first?

A. Bradycardia
B. Large amounts of very dilute urine
C. Restlessness and confusion
D. Widened pulse pressure

C. Restlessness and confusion

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While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional?

A. Frontal
B. Occipital
C. Parietal
D. Temporal

C. Parietal

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

A. A cerebral lesion
B. A temporal lesion
C. An intact brainstem
D. Brain death

C. An intact brainstem

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

A. Tolerate the pain.
B. Decrease the perception of pain.
C. Escape the source of pain.
D. Divert attention from the source of pain.
D. Divert attention from the source of pain.

C. Escape the source of pain.

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

A. Complete admission assessment.
B. Place a padded tongue blade at the bedside.
C. Set up oxygen and suction equipment.
D. Pad the side rails before the patient arrives.

C. Set up oxygen and suction equipment.

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If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with:

A. Body temperature control
B. Balance and equilibrium
C. Visual acuity
D. Thinking and reasoning

A. Body temperature control

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

A. phenytoin (Dilantin)
B. mannitol (Osmitrol)
C. lidocaine (Xylocaine)
D. furosemide (Lasix)

C. lidocaine (Xylocaine)

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

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

C. Perform a lumbar puncture.

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A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client’s behavior.

A. Is disoriented to person, place, and time.
B. Affect is flat, with periods of emotional lability.
C. Cannot recall what was eaten for breakfast today.
D. Demonstrate inability to add and subtract; does not know who is the president.

B. Affect is flat, with periods of emotional lability.

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Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except?

A. acetaminophen (Tylenol)
B. dexamethasone (Decadron)
C. mannitol (Osmitrol)
D. phenytoin (Dilantin)
E. nitroglycerin (Nitrostat)

E. nitroglycerin (Nitrostat)

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Which of the following symptoms would you expect to a client with a phenytoin level of 35 mg/dL?

A. Ataxia
B. Potassium deficit
C. Neglect syndrome
D. Tetraplegia

A. Ataxia

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The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following?

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

C. Cerebral function

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Emergency medical technicians transport a 27-year-old ironworker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag.” Which intervention by the nurse has the highest priority?

A. Assessing the left leg.
B. Assessing the pupils.
C. Placing the client in Trendelenburg’s position.
D. Assessing level of consciousness.

A. Assessing the left leg.

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Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal? A. More back pain than the first postoperative day. B. Paresthesia in the dermatomes near the wounds. C. Urine retention or incontinence. D. Temperature of 99.2° F (37.3° C).

C. Urine retention or incontinence.

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

B. The client uses a mirror to inspect the skin.

A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half-circle. To document the client's gait, the nurse should use which term? A. Ataxic B. Dystrophic C. Helicopod D. Steppage

C. Helicopod

Nurse Marty is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? A. Excessive tearing B. Urine retention C. Muscle weakness D. Slurred speech

C. Muscle weakness

A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), two (2) mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, Diazepam also is recommended for: A. Long-term treatment of epilepsy. B. Postoperative pain management of laminectomy clients. C. Postoperative pain management of diskectomy clients. D. Treatment of spasticity associated with spinal cord lesions.

D. Treatment of spasticity associated with spinal cord lesions.

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

C. Midbrain

The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the physician immediately.

D. Call the physician immediately.

A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? A. Caucasian race B. Female sex C. Obesity D. Bronchial asthma

C. Obesity

A male client is having tonic-clonic seizures. What should the nurse do first? A. Elevate the head of the bed. B. Restrain the client's arms and legs. C. Place a tongue blade in the client's mouth. D. Take measures to prevent injury.

D. Take measures to prevent injury.

The nurse is working on a surgical floor. The nurse must log roll a male client following a: A. Laminectomy. B. Thoracotomy. C. Hemorrhoidectomy. D. Cystectomy.

A. Laminectomy.

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? A. Immobilize the neck before the client is moved onto a stretcher. B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. C. Place a cap on the client's head. D. Administer a sedative as ordered.

B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: A. Use the pointed end of the reflex hammer when striking the Achilles' tendon. B. Support the joint where the tendon is being tested. C. Tap the tendon slowly and softly. D. Hold the reflex hammer tightly.

B. Support the joint where the tendon is being tested.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: A. Prevent respiratory alkalosis. B. Lower arterial pH. C. Promote carbon dioxide elimination. D. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.

C. Promote carbon dioxide elimination.

A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of: A. Hypertension B. Heart failure C. Prosthetic valve replacement D. Chronic obstructive pulmonary disorder

C. Prosthetic valve replacement

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

B. Head turned to the side

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: A. Is clear and tests negative for glucose. B. Is grossly bloody in appearance and has a pH of 6. C. Clumps together on the dressing and has a pH of 7. D. Separates into concentric rings and tests positive for glucose.

D. Separates into concentric rings and tests positive for glucose.

A male client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program. B. Keeping the linen wrinkle-free under the client. C. Preventing unnecessary pressure on the lower limbs. D. Limiting bladder catheterization to once every 12 hours.

D. Limiting bladder catheterization to once every 12 hours.

The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? A. Loosening restrictive clothing. B. Restraining the client's limbs. C. Removing the pillow and raising padded side rails. D. Positioning the client to the side, if possible, with the head flexed forward.

B. Restraining the client's limbs

The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: A. The client has complete bilateral paralysis of the arms and legs. B. The client has weakness on the right side of the body, including the face and tongue. C. The client has lost the ability to move the right arm but can walk independently. D. The client has lost the ability to move the right arm but can walk independen

B. The client has weakness on the right side of the body, including the face and tongue.

The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? A. Giving the client thin liquids. B. Thickening liquids to the consistency of oatmeal. C. Placing food on the unaffected side of the mouth. D. Allowing plenty of time for chewing and swallowing.

A. Giving the client thin liquids

The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: A. Gets angry with family if they interrupt a task. B. Experiences bouts of depression and irritability. C. Has difficulty with using modified feeding utensils. D. Consistently uses adaptive equipment in dressing self.

D. Consistently uses adaptive equipment in dressing self.

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

C. Completing the sentences that the client cannot finish.

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? A. Reposition the client to avoid neck flexion. B. Administer 1 g Mannitol IV as ordered. C. Increase the ventilator's respiratory rate to 20 breaths/minute. D. Administer 100 mg of pentobarbital IV as ordered.

A. Reposition the client to avoid neck flexion.

A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? A. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. B. Rapid Dilantin administration can cause cardiac arrhythmias. C. Dilantin should be mixed in dextrose in water before administration. D. Dilantin should be administered through an IV catheter in the client's hand.

B. Rapid Dilantin administration can cause cardiac arrhythmias.

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? A. Evaluate urine specific gravity. B. Anticipate treatment for renal failure. C. Provide emollients to the skin to prevent breakdown. D. Slow down the IV fluids and notify the physician.

A. Evaluate urine specific gravity.

A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? A. Bloody drainage from the ears B. Frequent swallowing C. Guaiac-positive stools D. Hematuria

B. Frequent swallowing

A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? A. Assess full ROM to determine extent of injuries. B. Call for an immediate chest x-ray. C. Immobilize the client's head and neck. D. Open the airway with the head-tilt-chin-lift maneuver.

C. Immobilize the client's head and neck.

A client with a C6 spinal injury would most likely have which of the following symptoms? A. Aphasia B. Hemiparesis C. Paraplegia D. Tetraplegia

D. Tetraplegia

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? A. Bladder distension B. Neurological deficit C. Pulse ox readings D. The client's feelings about the injury

C. Pulse ox readings

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? A. Autonomic dysreflexia B. Hemorrhagic shock C. Neurogenic shock D. Pulmonary embolis

C. Neurogenic shock

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? A. Place the client flat in bed. B. Assess patency of the indwelling urinary catheter. C. Give one SL nitroglycerin tablet. D. Raise the head of the bed immediately to 90 degrees.

D. Raise the head of the bed immediately to 90 degrees.

A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? A. To hasten wound healing. B. To immobilize the cervical spine. C. To prevent autonomic dysreflexia. D. To hold bony fragments of the skull together.

B. To immobilize the cervical spine.

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A. Insert an indwelling urinary catheter to straight drainage. B. Schedule intermittent catheterization every 2 to 4 hours. C. Perform a straight catheterization every 8 hours while awake. D. Perform Crede's maneuver to the lower abdomen before the client voids.

B. Schedule intermittent catheterization every 2 to 4 hours.

A client who is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? A. Laceration of the middle meningeal artery. B. Rupture of the carotid artery. C. Thromboembolism from a carotid artery. D. Venous bleeding from the arachnoid space.

A. Laceration of the middle meningeal artery.

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

B. Check the fluid for dextrose with a dipstick.

Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? A. A client with a brain injury. B. A client with a herniated nucleus pulposus. C. A client with a high cervical spine injury. D. A client with a stroke.

C. A client with a high cervical spine injury.

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? A. Absence of pain sensation in chest B. Spasticity C. Spontaneous respirations D. Urinary continence

B. Spasticity

During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? A. Elevate the client's legs. B. Put the client flat in bed. C. Put the client in Trendelenburg's position. D. Put the client in the high-Fowler's position.

D. Put the client in the high-Fowler's position.

A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A. Autonomic dysreflexia B. Hypervolemia C. Neurogenic shock D. Sepsis

C. Neurogenic shock

A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase?A. Absent corneal reflex. A. Absent corneal reflex. B. Decerebrate posturing. C. Movement of only the right or left half of the body. D. The need for mechanical ventilation.

D. The need for mechanical ventilation.

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? A. Decreased urine output or oliguria B. Hypertension and bradycardia C. Respiratory depression D. Symptoms of shock

B. Hypertension and bradycardia

A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? A. "Clean the meatus from back to front." B. "Measure the quantity of urine." C. "Gently rotate the catheter during removal." D. "Clean the meatus with soap and water."

D. "Clean the meatus with soap and water."

An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? A. "Watch him for a keyhole pupil the next 24 hours." B. "Expect profuse vomiting for 24 hours after the injury." C. "Wake him every hour and assess his orientation to person, time, and place." D. "Notify the physician immediately if he has a headache."

C. "Wake him every hour and assess his orientation to person, time, and place."

Which neurotransmitter is responsible for many of the functions of the frontal lobe? A. Dopamine B. GABA C. Histamine D. Norepinephrine

A. Dopamine

The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? A. Extent of intracranial bleeding. B. Sites of brain injury. C. Activity of the brain. D. Percent of functional brain tissue.

C. Activity of the brain.

A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? A. Subdural hematoma B. Subarachnoid hemorrhage C. Epidural hematoma D. Contusion

C. Epidural hematoma

After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? A. Quadriplegia with gross arm movement and diaphragmatic breathing. B. Quadriplegia and loss of respiratory function. C. Paraplegia with intercostal muscle loss. D. Loss of bowel and bladder control.

A. Quadriplegia with gross arm movement and diaphragmatic breathing.

The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: A. Skull fracture B. Concussion C. Subdural hematoma D. Epidural hematoma

D. Epidural hematoma

The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: A. A flattened abdomen. B. Hematest positive nasogastric tube drainage. C. Hyperactive bowel sounds. D. A history of diarrhe

B. Hematest positive nasogastric tube drainage.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program. B. Limiting bladder catheterization to once every 12 hours. C. Keeping the linen wrinkle-free under the client. D. Preventing unnecessary pressure on the lower limbs.

B. Limiting bladder catheterization to once every 12 hours

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

C. Moving the client quickly as one unit.

The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: A. Keeping the client on a stretcher. B. Logrolling the client on a firm mattress. C. Logrolling the client on a soft mattress. D. Placing the client on a Stryker frame.

D. Placing the client on a Stryker frame.

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? A. Positive reflexes B. Hyperreflexia C. Inability to elicit a Babinski's reflex. D. Reflex emptying of the bladder.

C. Inability to elicit a Babinski's reflex.

A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia D. Decreasing body temperature

A. Unequal pupil size

Which of the following respiratory patterns indicate increasing ICP in the brain stem? A. Slow, irregular respirations B. Rapid, shallow respirations C. Asymmetric chest expansion D. Nasal flaring

A. Slow, irregular respirations

Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? A. Give the client a warming blanket. B. Administer low-dose barbiturate. C. Encourage the client to hyperventilate. D. Restrict fluids.

C. Encourage the client to hyperventilate.

A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? A. Widening pulse pressure B. Decrease in the pulse rate C. Dilated, fixed pupil D. Decrease in LOC

D. Decrease in LOC

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? A. Place her in a jacket restraint. B. Wrap her hands in soft "mitten" restraints. C. Tuck her arms and hands under the draw sheet. D. Apply a wrist restraint to each arm.

B. Wrap her hands in soft "mitten" restraints.

Which of the following describes decerebrate posturing? A. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers. B. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet. C. Supination of arms, dorsiflexion of feet. D. Back arched; rigid extension of all four extremities.

D. Back arched; rigid extension of all four extremities.

A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? A. Count the rate to be sure the ventilations are deep enough to be sufficient. B. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. C. Call the physician to adjust the ventilator settings. D. Check deep tendon reflexes to determine the best motor response.

B. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score.

SEIZURES FROM NCLEX Flashcards

(84 cards)