■ 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
■ 5. Stimulate the client with active range-of-motion
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?
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
■ 1. Find a television so the client can view the
■ 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
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
■ 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
indicates increasing intracranial pressure in the
■ 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).
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
■ 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.
after several days. Which of the following
nursing statements is most appropriate as the
■ 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.”
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.
the client to avoid when there is a risk for increased
■ 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
■ 4. Checking blood glucose levels.
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
■ 2. Be able to return to his construction job in
■ 3. Actively participate in the rehabilitation
process as appropriate.
■ 4. Be emotionally stable and display pre-injury
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
begins to experience cluster breathing after
recent intracranial occipital bleeding. The nurse
deep enough to be suffi cient.
■ 2. Notify the physician of the client’s breathing
■ 4. Increase the tidal volume on the ventilator.
a posterior fossa (infratentorial) craniotomy, which
of the following is contraindicated when positioning
■ 1. Keeping the client fl at on one side or the
■ 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
■ 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
■ 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.”
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
■ 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
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.
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
■ 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
■ 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
if he carries a medical identifi cation card.
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.
ischemic attacks. She is oriented, can open her eyes
spontaneously, and follows commands. What is her
Glasgow Coma Scale score?
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
pillow under the head.
■ 2. Keeping portable suctioning equipment at the
■ 4. Cleaning the client’s mouth and teeth with a
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
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
■ 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
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
■ 3. It will help the client recognize his physical
■ 4. The client can be expected to regain much of
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
■ 4. Having the client help lift off the bed using a
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.
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.