1.

The nurse assesses a client using the

Glasgow Coma Scale. Which of the following
indicators will be used to determine the
score?
a.Eye opening, and appropriateness of verbal
ad motor responses.
b.Ability to recall recent and remote
memories and to use abstract reasoning.
c.Assessment of the 12 cranial nerves
d.Naming of objects, recall of three words,
and ability to redraw a design.
2.The clients daughter asks the nurse why
the nurse is asking her mother depressionrelated questions. The nurse explains that
even though the client has symptoms of
dementia , the Geriatric Depression Scale is
being used because
a.Depression and dementia are one in the
same disorder
b.Finding out why she is depressed will help
determine the cause of her dementia
c.Depression often mimics s/sx of dementia
d.It is the most accurate tool to determine
stage of dementia
3.The nurse documents findings from the
clients responses to the SLUMS test. The
following information will be documented as
a result of this test.
a.Mood, feelings, expressions ad perceptions
b.Orientation, memory, speech and cognitive
function
c.Energy level, satisfaction and social
participation
d.Appropriateness of dress, grooming and
eye contact
4. As part of assessing the clients LOC, the
nurse asks questions related to person, place
and time. Which of these statements is true?
a.Orientation to person is usually lost first
and orientation of time is lost last.
b.Orientation to time is usually lost first and
orientation to person usually lost last
c.Orientation to person is usually lost first
and orientation to place is lost last
d.Orientation to time is usually lost first and
orientation to place is usually ost last.
5. When the nurse asks the client to explain
similarities and differences between objects,
what cognitive ability is tested?
a.Judgement
c. concentration
b.Memory to learn new info
d. abstract
reasoning

6. Sensations of temperature, pain and crude

and light touch are carried by way of the
a. Extrapyramidal tract
c.
Spinothalamic tract
b. Corticospinal tract
d. Posterior
tract
7. The cranial nerve that has sensory fibers
for taste and fibers that result in the gag
reflex is the:
a.
Vagus
c. hypoglossal
b.
Trigeminal
d.
glossopharyngeal
8. The nurse is assessing an older adult
client when the client tells the nurse that she
has experienced transient blind spots for the
last few days. The nurse should refer the
client t a physician for possible:
a.vagus nerve damage
c. spinal
cord compression
b. stroke
d. Parkinson
disease
9. The nurse is planning a presentation to a
group of adults on the topic of strokes. Which
of the following should the nurse plan to
include in the teaching plan?
a. Strokes are the number one cause of
death in the US
b. Smoking and high cholesterol levels are
risk factors of stroke
c. Clients who smoke while taking oral
contraceptives are not at higher risk
d. Postmenopausal women taking estrogen
are at greater risk for stroke
10.The nurse is caring for a client dring the
intermediate postop period after abdominal
surgery. While performing a neuro check
the nurse should assess te clients
a.Sensation in the extremities
c.
ability to speak
b. Deep tendon reflexes
d.
recent memory
11. The nurse si preparing to percuss a
clients reflexes in his arms To use the
reinforcement technique the nurse should
ask the client to:
a. Clench his jaw
b. Stretch the opposite arm
c. hold his neck toward the floor
d. straighten his legs forward
12. Which cranial nerve is the nurse testing
when the client is asked to identify a scented
object?
a.Oculomotor
c. optic

b.Facial

d. olfactory

13.Reduced ability to sense vibrations of a

tuning fork may be present with
a.Peripheral neuropathy c. graphesthesia
b. Nystagmus
d.
stereognosis
14. While assessing the neurologic system of
a confused older adult, the nurse observes
that the client is unable to recall past events.
The nurse suspects that te client may be
exhibiting signs of:
a. Depression
c. attention deficit
disorder
b. Anxiety
d.
cerebral
cortex
disorder
15. The nurse is assessing the neurologic
system of an adult client. To test the clients
recent memory, the nurse should ask the
client
a. What did you have for breakfast?
b. How old were you when you began
working?
c. Who is the 44th president of the US?
d. Can you recall the name of your firstgrade teacher?
16. Which of the ff are examples of a
nosocomial infection that can occur in a
health care facility? SATA
1. a common cold that develops in a pt
2. sepsis that results from contaminated IV
fluids
3. a UTI that develops after catheter
insertion
4. a streptococci wound infection that
develops in a post-op pt
5.the development of clostridium tetani in
immunospressed pt
6. a respiratory infection that develops in a
pt receiving frequent respiratory treatment
and requires frequent suctioning
a. 2,3,4,5
b. 2,4,5,6

c. 1,2,3,4,5
d. 2,3,4,5,6

Situation: A pt is brought to the hospital

after vomiting bright red blood and is
admitted through the ER with bleeding
duodenal ulcer
17. While the pt is bleeding, it will be
essential for the nurse to assess frequently
for s/s of shock. Which of the ff indicator of
early signs of shock?
a. tachycardia
c.urine output
b. dry flushed skin d. loss of consciousness

18. If the pt develops sudden sharp pain in

the mid-epigastric region along with the
rigid, board-like abdomen, the nurse should
understand that these clinical manifestations
most likely indicate that:
a. an intestinal obstruction has developed
b. additional ulcers have developed
c. the esophagus has become inflamed
d. the ulcer has perforated
19. The spouse of a client with an
intracranial hemorrhage asks the nurse,
"Why
aren't
they
administering
an
anticoagulant?" How should the nurse
respond?
a. "It is contraindicated because bleeding will
increase."
b."If necessary it will be started to enhance
circulation."
c."If necessary it will be stated to prevent
pulmonary thrombosis."
d."It is inadvisable because it masks the
effects of the hemorrhage."
A. "It is contraindicated because
bleeding will increase."
Rationale: An anticoagulant should not be
administered to a client who is bleeding
because it will interfere with clotting and will
increase hemorrhage. Anticoagulants are
unsafe and will not be used to enhance the
circulation or prevent pulmonary thrombosis.
The response "It is inadvisable because it
masks the effects of the hemorrhage" is not
the reason why it is contraindicated; if given,
it will increase, not mask, the effects of the
hemorrhage.
20.
Initially
after
a
brain
attack
(cerebrovascular accident), a client's pupils
are equal and reactive to light. Later, the
nurse assesses that the right pupil is reacting
more slowly than the left and that the
systolic blood pressure is beginning to rise.
What complication should the nurse consider
that the client is developing?
A. Spinal shock
C.
Transtentorial
herniation
B. Hypovolemic shock
D. intracranial
pressure
21. A client is admitted to the hospital with
weakness in the right extremities and a
slight difficulty with speech. Vital signs are
within expected limits. What is the priority
nursing action during the first 24 hours?
a.Taking the client's temperature.
b.Evaluating the client's motor status.

c.Obtaining the client's urine for a urinalysis.

d.Monitoring the client's BP for hypertension.
B. Evaluating
status.

the

client's

motor

Rationale: Evaluating the client's motor

status will indicate whether symptoms
progress or improve and assist the health
care provider in determining the diagnosis.
An elevation in temperature is not an early
sign of an extension of a brain attack
(cerebrovascular accident [CVA]). Obtaining
a urine specimen for a urinalysis is not the
priority. The data indicate that vital signs are
within expected limits and do not reflect
hypertension; although the vital signs should
be monitored, the client's motor status in
this instance is most significant.
23. Which clinical indicator does a nurse
identify when assessing a client with
hemiplegia?
a.Paresis of both lower extremities
b.Paralysis of one side of the body
c.Paralysis of both lower extremities
d.Paresis of upper and lower extremities
24. The nurse is monitoring a client with a
severe head injury for signs and symptoms
of increasing intracranial pressure. Which
finding is most indicative of increasing
intracranial pressure?
a. Polyuria
c. Tachypnea
b. Increased restlessness
d.
Intermittent tachycardia
25. A client experiences a cerebral vascular
accident (CVA) and is admitted to the
hospital in a coma. What is the priority
nursing care for this client?
a.Monitor vital signs.
b.Maintain an open airway.
c.Monitor pupil response and equality.
d.Maintain fluid and electrolyte balance
26. A client receiving morphine is being
monitored by the nurse for signs and
symptoms of overdose. Which clinical
findings support a conclusion of overdose?
(Select all that apply.)
a.Polyuria
c. Lethargy
c. Bradycardia
d. Dilated pupils
e. Slow respirations
27. A client arrives on the nursing unit
unconscious and exhibiting decerebrate

posturing. When assessing the client, the

nurse expects to observe:
a.Hyperextension of both the upper and
lower extremities
b.Spastic paralysis of both the upper and
lower extremities
c.Hyperflexion of the upper extremities and
hyperextension of the lower extremities
d. Flaccid paralysis of the upper extremities
and spastic paralysis of the lower extremities
Rationale: A. Limbs hyperextended and arms
hyperpronated
(extension
posturing,
decerebrate
posturing)
indicate
upper
brainstem damage; this is a grave sign.
Spastic paralysis of both the upper and lower
extremities is associated with an upper
motor neuron disease or lesion. Hyperflexion
of the upper extremities and hyperextension
of the lower extremities is associated with
flexion posturing (decorticate posturing),
which indicates damage to the pyramidal
motor tract above the brainstem. Flaccid
paralysis of the upper extremities and
spastic paralysis of the lower extremities is
associated with a lower motor neuron
disease or lesion.
28. A client arrives at the nursing unit with
neurological deficits after a motor vehicle
accident. Using the Glasgow Coma Scale, the
nurse assesses what client responses?
(Select all that apply.)
a. Pupil response to light
b. Verbal response to speech
c. Eye opening in response to speech
d. Deep tendon reflexes in response to
percussion
e. Motor activity in response to a verbal
command
29. nurse uses the Glasgow Coma Scale to
assess a client's status after a head injury.
When the nurse applies pressure to the nail
bed of a finger, which movement of the
client's upper arm should cause the most
concern
a. Flexing
c. Localizing
b.Extending
d.Withdrawing
30. A health care provider prescribes
mannitol (Osmitrol) for a client with a head
injury. The nurse concludes that the purpose
of the medication is to relieve cerebral
edema by:
a. Decreasing the production of cerebrospinal
fluid

b. Limiting the metabolic requirements of the

brain
c. Drawing fluid from brain cells into the
bloodstream
d.
Preventing
uncontrolled
electrical
discharges in the brain
Rationale: Mannitol, an osmotic diuretic, pulls
fluid from the white cells of the brain to
relieve
cerebral
edema.
Preventing
uncontrolled electrical discharges in the
brain is the action of phenytoin sodium
(Dilantin), not mannitol.
31.
A
client
has
a
brain
attack
(cerebrovascular
accident
[CVA])
that
involves the right cerebral cortex and cranial
nerves. What areas of paralysis should the
nurse expect the client to exhibit? (Select all
that apply.)
a. Left leg
c.Left arm
b. Right leg d. Right arm e. Left side of face