The Client with Seizures ■ The Client with a Stroke ■ The Client with Parkinson’s Disease

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The Client with Neurologic Health Problems
The Client with a Head Injury

The Client with Seizures

The Client with a Stroke

The Client with Parkinson’s Disease

The Client with Multiple Sclerosis

The Unconscious Client

The Client in Pain

Managing Care Quality and Safety

Answers, Rationales, and Test Taking Strategies

The Client with a Head Injury

1. Following a craniotomy, a client has been

admitted to the neurologic intensive care unit. The

nurse has established a goal to maintain intracranial

pressure (ICP) within the normal range. What

should the nurse do? Select all that apply.

1. Encourage the client to cough and take deep


2. Elevate the head of the bed 15 to 30 degrees.

3. Contact the health care provider if ICP is

greater than 20 mm Hg.

4. Monitor neurologic status using the Glasgow

Coma Scale.

5. Stimulate the client with active range-of-motion


2. The nurse is monitoring a client with

increased intracranial pressure (ICP). What indicators

are the most critical for the nurse to monitor?

Select all that apply.

1. Systolic blood pressure.

2. Urine output.

3. Breath sounds.

4. Cerebral perfusion pressure.

5. Level of pain.

3. A nurse is assessing a client with increasing

intracranial pressure. What is a client’s mean arterial

pressure (MAP) in mm Hg when blood pressure (BP)

is 120/60 mm Hg?

_____________________ mm Hg.

4. A client with a contusion has been admitted

for observation following a motor vehicle accident

when he was driving his wife to the hospital to

deliver their child. The next morning, instead of

asking about his wife and baby, he asked to see the

football game on television that he thinks is starting

in 5 minutes. He is agitated that the nurse will not

turn on the television. What should the nurse do

next? Select all that apply.

1. Find a television so the client can view the

football game.

2. Determine if the client’s pupils are equal and

react to light.

3. Ask the client if he has a headache.

4. Arrange for the client to be with his wife and


5. Administer a sedative.

5. An unconscious client with multiple injuries

arrives in the emergency department. Which nursing

intervention receives the highest priority?

1. Establishing an airway.

2. Replacing blood loss.

3. Stopping bleeding from open wounds.

4. Checking for a neck fracture.

6. A client is at risk for increased intracranial

pressure (ICP). Which of the following would be the

priority for the nurse to monitor?

1. Unequal pupil size.

2. Decreasing systolic blood pressure.

3. Tachycardia.

4. Decreasing body temperature.

7. What should the nurse do fi rst when a client

with a head injury begins to have clear drainage

from his nose?

1. Compress the nares.

2. Tilt the head back.

3. Give the client tissues to collect the fl uid.

4. Administer an antihistamine for postnasal


8. Which of the following respiratory patterns

indicates increasing intracranial pressure in the

brain stem?

1. Slow, irregular respirations.

2. Rapid, shallow respirations.

3. Asymmetric chest excursion.

4. Nasal fl aring.

9. Which of the following nursing interventions

is appropriate for a client with an increased intracranial

pressure (ICP) of 20 mm Hg?

1. Give the client a warming blanket.

2. Administer low-dose barbiturates.

3. Encourage the client to hyperventilate.

4. Restrict fl uids.

10. The nurse is assessing a client with increasing

intracranial pressure (ICP). The nurse should

notify the health care provider about which of the

following changes in the client’s condition?

1. Widening pulse pressure.

2. Decrease in the pulse rate.

3. Dilated, fi xed pupils.

4. Decrease in level of consciousness (LOC).

11. The client has a sustained increased intracranial

pressure (ICP) of 20 mm Hg. Which client

position would be most appropriate?

1. The head of the bed elevated 30 to 45 degrees.

2. Trendelenburg’s position.

3. Left Sims position.

4. The head elevated on two pillows.

12. The nurse administers mannitol (Osmitrol)

to the client with increased intracranial pressure.

Which parameter requires close monitoring?

1. Muscle relaxation.

2. Intake and output.

3. Widening of the pulse pressure.

4. Pupil dilation.

13. A client is being admitted with a spinal cord

transection at C7. Which of the following assessments

take priority upon the client’s arrival? Select

all that apply.

1. Refl exes.

2. Bladder function.

3. Blood pressure.

4. Temperature.

5. Respirations.

14. The nurse is assessing a client for movement

after halo traction placement for a C8 fracture.

The nurse should document which of the


1. The client’s shoulders shrug against downward

pressure of the examiner’s hands.

2. The client’s arm pulls up from a resting position

against resistance.

3. The client’s arm straightens out from a fl exed

position against resistance.

4. The client’s hand-grasp strength is equal.

15. Four days after surgery for internal fi xation of

a C3 to C4 fracture, a nurse is moving a client from

the bed to the wheelchair. The nurse is checking

the wheelchair for correct features for this client.

Which of the following features of the wheelchair

are appropriate for the needs of this client? Select

all that apply.

1. Back at the level of the client’s scapula.

2. Back and head that are high.

3. Seat that is lower than normal.

4. Seat with fi rm cushions.

5. Chair controlled by the client’s breath.

16. A male client with a head injury regains consciousness

after several days. Which of the following

nursing statements is most appropriate as the

client awakens?

1. “I’ll get your family.”

2. “Can you tell me your name and where you


3. “I’ll bet you’re a little confused right now.”

4. “You are in the hospital. You were in an accident

and unconscious.”

17. A client who is regaining consciousness

after a craniotomy becomes restless and attempts to

pull out the I.V. line. Which nursing intervention

protects the client without increasing her increased

intracranial pressure (ICP)?

1. Place her in a jacket restraint.

2. Wrap her hands in soft “mitten” restraints.

3. Tuck her arms and hands under the


4. Apply a wrist restraint to each arm.

18. Which activity should the nurse encourage

the client to avoid when there is a risk for increased

intracranial pressure (ICP)?

1. Deep breathing.

2. Turning.

3. Coughing.

4. Passive range-of-motion (ROM) exercises.

19. Which of the following is most effective in

assessing the client suspected of developing diabetes


1. Taking vital signs every 2 hours.

2. Measuring urine output hourly.

3. Assessing arterial blood gas values every

other day.

4. Checking blood glucose levels.

20. A client who had a serious head injury with

increased intracranial pressure is to be discharged

to a rehabilitation facility. Which of the following

rehabilitation outcomes would be appropriate for

the client? The client will:

1. Exhibit no further episodes of short-term

memory loss.

2. Be able to return to his construction job in

3 weeks.

3. Actively participate in the rehabilitation

process as appropriate.

4. Be emotionally stable and display pre-injury

personality traits.

21. Which of the following describes decerebrate


1. Internal rotation and adduction of arms with

fl exion of elbows, wrists, and fi ngers.

2. Back hunched over, rigid fl exion of all four

extremities with supination of arms and plantar

fl exion of feet.

3. Supination of arms, dorsifl exion of the feet.

4. Back arched, rigid extension of all four


22. A client receiving vent-assisted mode ventilation

begins to experience cluster breathing after

recent intracranial occipital bleeding. The nurse


1. Count the rate to be sure that ventilations are

deep enough to be suffi cient.

2. Notify the physician of the client’s breathing


3. Increase the rate of ventilations.

4. Increase the tidal volume on the ventilator.

23. In planning the care for a client who has had

a posterior fossa (infratentorial) craniotomy, which

of the following is contraindicated when positioning

the client?

1. Keeping the client fl at on one side or the


2. Elevating the head of the bed to 30 degrees.

3. Logrolling or turning as a unit when turning.

4. Keeping the neck in a neutral position.

The Client with Seizures

24. The nurse sees a client walking in the hallway

who begins to have a seizure. The nurse should

do which of the following in priority order?

2. Record the seizure activity observed.

3. Ease the client to the fl oor.

4. Obtain vital signs.

1. Maintain a patent airway.

25. Which of the following is contraindicated for

a client with seizure precautions?

1. Encouraging him to perform his own personal


2. Allowing him to wear his own clothing.

3. Assessing oral temperature with a glass thermometer.

4. Encouraging him to be out of bed.

26. Which of the following will the nurse

observe in the client in the ictal phase of a generalized

tonic-clonic seizure?

1. Jerking in one extremity that spreads gradually

to adjacent areas.

2. Vacant staring and abruptly ceasing all


3. Facial grimaces, patting motions, and lip


4. Loss of consciousness, body stiffening, and

violent muscle contractions.

27. It is the night before a client is to have a computed

tomography (CT) scan of the head without

contrast. The nurse should tell the client?

1. “You must shampoo your hair tonight to

remove all oil and dirt.”

2. “You may drink fl uids until midnight, but

after that drink nothing until the scan is


3. “You will have some hair shaved to attach the

small electrode to your scalp.”

4. “You will need to hold your head very still

during the examination.”

28. For breakfast on the morning a client is to

have an electroencephalogram (EEG), the client

is served a soft-boiled egg, toast with butter and

marmalade, orange juice, and coffee. Which of the

following should the nurse do?

1. Remove all the food.

2. Remove the coffee.

3. Remove the toast, butter, and marmalade only.

4. Substitute vegetable juice for the orange juice.

29. A 20-year-old who hit his head while playing

football has a tonic-clonic seizure. Upon awakening

from the seizure, the client asks the nurse,

“What caused me to have a seizure? I’ve never had

one before.” Which cause should the nurse include

in the response as a primary cause of tonic-clonic

seizures in adults older than age 20?

1. Head trauma.

2. Electrolyte imbalance.

3. Congenital defect.

4. Epilepsy.

30. Which of the following should the nurse

include in the teaching plan for a client with seizures

who is going home with a prescription for

gabapentin (Neurontin)?

1. Take all the medication until it is gone.

2. Notify the physician if vision changes occur.

3. Store gabapentin in the refrigerator.

4. Take gabapentin with an antacid to protect

against ulcers.

31. What is the priority nursing intervention in

the postictal phase of a seizure?

1. Reorient the client to time, person, and place.

2. Determine the client’s level of sleepiness.

3. Assess the client’s breathing pattern.

4. Position the client comfortably.

32. Which intervention is most effective in minimizing

the risk of seizure activity in a client who is

undergoing diagnostic studies after having experienced

several episodes of seizures?

1. Maintain the client on bed rest.

2. Administer butabarbital sodium (phenobarbital)

30 mg P.O., three times per day.

3. Close the door to the room to minimize


4. Administer carbamazepine (Tegretol) 200 mg

P.O., twice per day.

33. What nursing assessments should be documented

at the beginning of the ictal phase of a


1. Heart rate, respirations, pulse oximeter, and

blood pressure.

2. Last dose of anticonvulsant and circumstances

at the time.

3. Type of visual, auditory, and olfactory aura

the client experienced.

4. Movement of the head and eyes and muscle


34. The nurse is assessing a client in the postictal

phase of generalized tonic-clonic seizure. The nurse

should determine if the client has?

1. Drowsiness.

2. Inability to move.

3. Paresthesia.

4. Hypotension.

35. When preparing to teach a client about

phenytoin sodium (Dilantin) therapy, the nurse

should urge the client not to stop the drug suddenly


1. Physical dependency on the drug develops

over time.

2. Status epilepticus may develop.

3. A hypoglycemic reaction develops.

4. Heart block is likely to develop.

36. A client states that she is afraid she will not

be able to drive again because of her seizures. Which

response by the nurse would be best?

1. A person with a history of seizures can drive

only during daytime hours.

2. A person with evidence that the seizures are

under medical control can drive.

3. A person with evidence that seizures occur

no more often than every 12 months can


4. A person with a history of seizures can drive

if he carries a medical identifi cation card.

37. The nurse is teaching a client to recognize an

aura. The nurse should instruct the client to note:

1. A postictal state of amnesia.

2. An hallucination that occurs during a seizure.

3. A symptom that occurs just before a seizure.

4. A feeling of relaxation as the seizure begins to


38. Which statement by a client with a seizure

disorder taking topiramate (Topamax) indicates the

client has understood the nurse’s instruction?

1. “I will take the medicine before going to bed.”

2. “I will drink 6 to 8 glasses of water a day.”

3. “I will eat plenty of fresh fruits.”

4. “I will take the medicine with a meal or snack.”

39. Which clinical manifestation is a typical

reaction to long-term phenytoin sodium (Dilantin)


1. Weight gain.

2. Insomnia.

3. Excessive growth of gum tissue.

4. Deteriorating eyesight.

40. A 21-year-old female client takes clonazepam

(Klonopin). What should the nurse ask this client

about? Select all that apply.

1. Seizure activity.

2. Pregnancy status.

3. Alcohol use.

4. Cigarette smoking.

5. Intake of caffeine and sugary drinks.

The Client with a Stroke

41. A client is being monitored for transient

ischemic attacks. She is oriented, can open her eyes

spontaneously, and follows commands. What is her

Glasgow Coma Scale score?

________________________ points.

42. The nurse is teaching a client about taking

prophylactic warfarin sodium (Coumadin). Which

statement indicates that the client understands how

to take the drug? Select all that apply.

1. “The drug’s action peaks in 2 hours.”

2. “Maximum dosage is not achieved until 3 to

4 days after starting the medication.”

3. “Effects of the drug continue for 4 to 5 days

after discontinuing the medication.”

4. “Protamine sulfate is the antidote for


5. “I should have my blood levels tested


43. Regular oral hygiene is essential for the client

who has had a stroke. Which of the following nursing

measures is not appropriate when providing oral


1. Placing the client on the back with a small

pillow under the head.

2. Keeping portable suctioning equipment at the


3. Opening the client’s mouth with a padded

tongue blade.

4. Cleaning the client’s mouth and teeth with a


44. A client arrives in the emergency department

with an ischemic stroke and receives tissue plasminogen

activator (t-PA) administration. The nurse

should fi rst:

1. Ask what medications the client is taking.

2. Complete a history and health assessment.

3. Identify the time of onset of the stroke.

4. Determine if the client is scheduled for any

surgical procedures.

45. During the fi rst 24 hours after thrombolytic

treatment for an ischemic stroke, the primary goal

is to control the client’s:

1. Pulse.

2. Respirations.

3. Blood pressure.

4. Temperature.

46. What is a priority nursing assessment in the

fi rst 24 hours after admission of the client with a

thrombotic stroke?

1. Cholesterol level.

2. Pupil size and pupillary response.

3. Bowel sounds.

4. Echocardiogram.

47. A client with a hemorrhagic stroke is slightly

agitated, heart rate is 118, respirations are 22, bilateral

rhonchi are auscultated, SpO2 is 94%, blood

pressure is 144/88, and oral secretions are noted.

What order of interventions should the nurse follow

when suctioning the client to prevent increased

intracranial pressure (ICP) and maintain adequate

cerebral perfusion?

2. Hyperoxygenate.

3. Suction the mouth.

4. Provide sedation.

1. Suction the airway.

48. In planning care for the client who has had a

stroke, the nurse should obtain a history of the client’s

functional status before the stroke because?

1. The rehabilitation plan will be guided by it.

2. Functional status before the stroke will help

predict outcomes.

3. It will help the client recognize his physical


4. The client can be expected to regain much of

his functioning.

49. Which of the following techniques does the

nurse avoid when changing a client’s position in

bed if the client has hemiparalysis?

1. Rolling the client onto the side.

2. Sliding the client to move up in bed.

3. Lifting the client when moving the client up

in bed.

4. Having the client help lift off the bed using a


50. Which nursing intervention has been found

to be the most effective means of preventing plantar

fl exion in a client who has had a stroke with residual


1. Place the client’s feet against a fi rm footboard.

2. Reposition the client every 2 hours.

3. Have the client wear ankle-high tennis shoes

at intervals throughout the day.

4. Massage the client’s feet and ankles regularly.

51. The nurse is planning the care of a hemiplegic

client to prevent joint deformities of the arm

and hand. Which of the following positions are


1. Placing a pillow in the axilla so the arm is

away from the body.

2. Inserting a pillow under the slightly fl exed

arm so the hand is higher than the elbow.

3. Immobilizing the extremity in a sling.

4. Positioning a hand cone in the hand so the

fi ngers are barely fl exed.

5. Keeping the arm at the side using a pillow.

52. For the client who is experiencing expressive

aphasia, which nursing intervention is most helpful

in promoting communication?

1. Speaking loudly.

2. Using a picture board.

3. Writing directions so client can read them.

4. Speaking in short sentences.

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