NCLEX QUESTIONS FOR MID EXAM

Topics : Neurological disorder

No Question Rational
1 Regular oral hygiene is an essential intervention for the A helpless client should be
client who has had a stroke. Which of the following nursing positioned on the side, not on
measures is inappropriate when providing oral hygiene? the back. This lateral position
a. Placing the client on the back with a small pillow helps secretions escape from
under the head. the throat and mouth,
b. Keeping portable suctioning equipment at the minimizing the risk of
bedside. aspiration. It may be necessary
c. Opening the client’s mouth with a padded tongue to suction, so having suction
blade. equipment at the bedside is
d. Cleaning the client’s mouth and teeth with a necessary. Padded tongue
toothbrush. blades are safe to use. A
toothbrush is appropriate to
use.
2 A 78 year old client is admitted to the emergency A CT scan will determine if the
department with numbness and weakness of the left arm client is having a stroke or has a
and slurred speech. Which nursing intervention is priority? brain tumor or another
a. Prepare to administer recombinant tissue neurological disorder. This
plasminogen activator (rt-PA). would also determine if it is a
b. Discuss the precipitating factors that caused the hemorrhagic or ischemic
symptoms. accident and guide the
c. Schedule for A STAT computer tomography (CT) treatment, because only an
scan of the head. ischemic stroke can use rt-PA.
d. Notify the speech pathologist for an emergency This would make (1) not the
consult. priority since if a stroke was
determined to be hemorrhagic,
rt-PA is contraindicated. Discuss
the precipitating factors for
teaching would not be a
priority and slurred speech
would as indicate interference
for teaching. Referring the
client for speech therapy would
be an intervention after the
CVA emergency treatment is
administered according to
protocol.
3 A client arrives in the emergency department with an The time of onset of a stroke to
ischemic stroke and receives tissue plasminogen activator t-PA administration is critical.
(t-PA) administration. Which is the priority nursing Administration within 3 hours
assessment? has better outcomes. A
a. Current medications. complete history is not possible
b. Complete physical and history. in emergency care. Upcoming
c. Time of onset of current stroke. surgical procedures will need to
d. Upcoming surgical procedures. be delay if t-PA is administered.
Current medications are
relevant, but onset of current
 stroke takes priority.
4 During the first 24 hours after thrombolytic therapy for Controlling the blood pressure
ischemic stroke, the primary goal is to control the client’s: is critical because an
a. Pulse intracerebral hemorrhage is the
b. Respirations major adverse effect of
c. Blood pressure thrombolytic therapy. Blood
d. Temperature pressure should be maintained
according to physician and is
specific to the client’s ischemic
tissue needs and risks of
bleeding from treatment. Other
vital signs are monitored, but
the priority is blood pressure.
5 What is a priority nursing assessment in the first 24 hours It is crucial to monitor the pupil
after admission of the client with a thrombotic stroke? size and pupillary response to
a. Cholesterol level indicate changes around the
b. Pupil size and pupillary response cranial nerves. Cholesterol level
c. Bowel sounds is an assessment to be
d. Echocardiogram addressed for long-term
healthy lifestyle rehabilitation.
Bowel sounds need to be
assessed because an ileus or
constipation can develop, but is
not a priority in the first 24
hours. An echocardiogram is
not needed for the client with a
thrombotic stroke.
6 What is the expected outcome of thrombolytic drug Thrombolytic therapy is use to
therapy? dissolve emboli and reestablish
a. Increased vascular permeability. cerebral perfusion
b. Vasoconstriction.
c. Dissolved emboli.
d. Prevention of hemorrhage
7 The client diagnosed with atrial fibrillation has experienced Thrombi form secondary to
a transient ischemic attack (TIA). Which medication would atrial fibrillation, therefore, an
the nurse anticipate being ordered for the client on anticoagulant would be
discharge? anticipated to prevent thrombi
a. An oral anticoagulant medication. formation; and oral (warfarin
b. A beta-blocker medication. [Coumadin]) at discharge verses
c. An anti-hyperuricemic medication. intravenous. Beta blockers slow
d. A thrombolytic medication. the heart rate and lower the
blood pressure. Anti-
hyperuricemic medication is
given to clients with gout.
Thrombolytic medication might
have been given at initial
presentation but would not be
a drug prescribed at discharge.
8 Which client would the nurse identify as being most at risk Africana Americans have twice
for experiencing a CVA? the rate of CVA’s as Caucasians;
a. A 55-year-old African American male. males are more likely to have
 b. An 84-year-old Japanese female. strokes than females except in
c. A 67-year-old Caucasian male. advanced years. Oriental’s have
d. A 39-year-old pregnant female. a lower risk, possibly due to
their high omega-3 fatty acids.
Pregnancy is a minimal risk
factor for CVA.
9 Which assessment data would indicate to the nurse that the Uncontrolled hypertension is a
client would be at risk for a hemorrhagic stroke? risk factor for hemorrhagic
a. A blood glucose level of 480 mg/dl. stroke, which is a rupture blood
b. A right-sided carotid bruit. vessel in the cranium. A bruit in
c. A blood pressure of 220/120 mmHg. the carotid artery would
d. The presence of bronchogenic carcinoma. predispose a client to an
embolic or ischemic stroke.
High blood glucose levels could
predispose a patient to
ischemic stroke, but not
hemorrhagic. Cancer is not a
precursor to stroke.
10 The nurse and unlicensed assistive personnel (UAP) are This action is inappropriate and
caring for a client with right-sided paralysis. Which action by would require intervention by
the UAP requires the nurse to intervene? the nurse because pulling on a
a. The assistant places a gait belt around the client’s flaccid shoulder joint could
waist prior to ambulating. cause shoulder dislocation; as
b. The assistant places the client on the back with the always use a lift sheet for the
client’s head to the side. client and nurse safety. All the
c. The assistant places her hand under the client’s other actions are appropriate.
right axilla to help him/her move up in bed.
d. The assistant praises the client for attempting to
perform ADL’s independently.
11 An 18-year-old client is admitted with a closed head injury The nurse should first attempt
sustained in a MVA. His intracranial pressure (ICP) shows an nursing interventions, such as
upward trend. Which intervention should the nurse perform repositioning the client to avoid
first? neck flexion, which increases
a. Reposition the client to avoid neck flexion venous return and lowers ICP. If
b. Administer 1 g Mannitol IV as ordered nursing measures prove
c. Increase the ventilator’s respiratory rate to 20 ineffective, notify the physician,
breaths/minute who may prescribe mannitol,
d. Administer 100 mg of pentobarbital IV as ordered pentobarbital, or
hyperventilation therapy.
12 A client with a subarachnoid hemorrhage is prescribed a Dilantin IV shouldn’t be given at
1,000-mg loading dose of Dilantin IV. Which consideration is a rate exceeding 50 mg/minute.
most important when administering this dose? Rapid administration can
a. Therapeutic drug levels should be maintained depress the myocardium,
between 20 to 30 mg/ml. causing arrhythmias.
b. Rapid dilantin administration can cause cardiac Therapeutic drug levels range
arrhythmias. from 10 to 20 mg/ml. Dilantin
c. Dilantin should be mixed in dextrose in water shouldn’t be mixed in solution
before administration. for administration. However,
d. Dilantin should be administered through an IV because it’s compatible with
catheter in the client’s hand. normal saline solution, it can be
injected through an IV line
 containing normal saline. When
given through an IV catheter
hand, dilantin may cause purple
glove syndrome.
13 A client with head trauma develops a urine output of 300 Urine output of 300 ml/hr may
ml/hr, dry skin, and dry mucous membranes. Which of the indicate diabetes insipidus,
following nursing interventions is the most appropriate to which is a failure of the
perform initially? pituitary to produce anti-
a. Evaluate urine specific gravity diuretic hormone. This may
b. Anticipate treatment for renal failure occur with increased
c. Provide emollients to the skin to prevent intracranial pressure and head
breakdown trauma; the nurse evaluates for
d. Slow down the IV fluids and notify the physician low urine specific gravity,
increased serum osmolarity,
and dehydration. There’s no
evidence that the client is
experiencing renal failure.
Providing emollients to prevent
skin breakdown is important,
but doesn’t need to be
performed immediately.
Slowing the rate of IV fluid
would contribute to
dehydration when polyuria is
present.
14 When evaluating an ABG from a client with a subdural A normal PaCO2 value is 35 to
hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which 45 mm Hg. CO2 has
of the following responses best describes this result? vasodilating properties;
a. Appropriate; lowering carbon dioxide (CO2) therefore, lowering PaCO2
reduces intracranial pressure (ICP). through hyperventilation will
b. Emergent; the client is poorly oxygenated. lower ICP caused by dilated
c. Normal cerebral vessels. Oxygenation is
d. Significant; the client has alveolar hypoventilation. evaluated through PaO2 and
oxygen saturation. Alveolar
hypoventilation would be
reflected in an increased
PaCO2.
15 A client who had a transsphenoidal hypophysectomy should Frequent swallowing after brain
be watched carefully for hemorrhage, which may be shown surgery may indicate fluid or
by which of the following signs? blood leaking from the sinuses
a. Bloody drainage from the ears into the oropharynx. Blood or
b. Frequent swallowing fluid draining from the ear may
c. Guaiac-positive stools indicate a basilar skull fracture.
d. Hematuria
16 After a hypophysectomy, vasopressin is given IM for which After hypophysectomy, or
of the following reasons? removal of the pituitary gland,
a. To treat growth failure the body can’t synthesize ADH.
b. To prevent syndrome of inappropriate antidiuretic Somatropin or growth
hormone (SIADH) hormone, not vasopressin is
c. To reduce cerebral edema and lower intracranial used to treat growth failure.
pressure SIADH results from excessive
 d. To replace antidiuretic hormone (ADH) normally ADH secretion. Mannitol or
secreted by the pituitary. corticosteroids are used to
decrease cerebral edema.
17 A client comes into the ER after hitting his head in an MVA. All clients with a head injury are
He’s alert and oriented. Which of the following nursing treated as if a cervical spine
interventions should be done first? injury is present until x-rays
a. Assess full ROM to determine extent of injuries confirm their absence. ROM
b. Call for an immediate chest x-ray would be contraindicated at
c. Immobilize the client’s head and neck this time. There is no indication
d. Open the airway with the head-tilt chin-lift that the client needs a chest x-
maneuver ray. The airway doesn’t need to
be opened since the client
appears alert and not in
respiratory distress. In addition,
the head-tilt chin-lift maneuver
wouldn’t be used until the
cervical spine injury is ruled
out.
18 A client with a C6 spinal injury would most likely have which Tetraplegia occurs as a result of
of the following symptoms? cervical spine injuries.
a. Aphasia Paraplegia occurs as a result of
b. Hemiparesis injury to the thoracic cord and
c. Paraplegia below.
d. Tetraplegia
19 A 30-year-old was admitted to the progressive care unit After a spinal cord injury,
with a C5 fracture from a motorcycle accident. Which of the ascending cord edema may
following assessments would take priority? cause a higher level of injury.
a. Bladder distension The diaphragm is innervated at
b. Neurological deficit the level of C4, so assessment
c. Pulse ox readings of adequate oxygenation and
d. The client’s feelings about the injury ventilation is necessary.
Although the other options
would be necessary at a later
time, observation for
respiratory failure is the
priority.
20 While in the ER, a client with C8 tetraplegia develops a Symptoms of neurogenic shock
blood pressure of 80/40, pulse 48, and RR of 18. The nurse include hypotension,
suspects which of the following conditions? bradycardia, and warm, dry skin
a. Autonomic dysreflexia due to the loss of adrenergic
b. Hemorrhagic shock stimulation below the level of
c. Neurogenic shock the lesion. Hypertension,
d. Pulmonary embolism bradycardia, flushing, and
sweating of the skin are seen
with autonomic dysreflexia.
Hemorrhagic shock presents
with anxiety, tachycardia, and
hypotension; this wouldn’t be
suspected without an injury.
Pulmonary embolism presents
with chest pain, hypotension,
 hypoxemia, tachycardia, and
hemoptysis; this may be a later
complication of spinal cord
injury due to immobility.
21 A client is admitted with a spinal cord injury at the level of High doses of Solu-Medrol are
T12. He has limited movement of his upper extremities. used within 24 hours of spinal
Which of the following medications would be used to injury to reduce cord swelling
control edema of the spinal cord? and limit neurological deficit.
a. Acetazolamide (Diamox) The other drugs aren’t
b. Furosemide (Lasix) indicated in this circumstance.
c. Methylprednisolone (Solu-Medrol)
d. Sodium bicarbonate
22 A 22-year-old client with quadriplegia is apprehensive and Anxiety, flushing above the
flushed, with a blood pressure of 210/100 and a heart rate level of the lesion, piloerection,
of 50 bpm. Which of the following nursing interventions hypertension, and bradycardia
should be done first? are symptoms of autonomic
a. Place the client flat in bed dysreflexia, typically caused by
b. Assess patency of the indwelling urinary catheter such noxious stimuli such as a
c. Give one SL nitroglycerin tablet full bladder, fecal impaction, or
d. Raise the head of the bed immediately to 90 decubitus ulcer. Putting the
degrees client flat will cause the blood
pressure to increase even
more. The indwelling urinary
catheter should be assessed
immediately after the HOB is
raised. Nitroglycerin is given to
reduce chest pain and reduce
preload; it isn’t used for
hypertension or dysreflexia.
23 A client with a cervical spine injury has Gardner-Wells tongs Gardner-Wells, Vinke, and
inserted for which of the following reasons? Crutchfield tongs immobilize
a. To hasten wound healing the spine until surgical
b. To immobilize the cervical spine stabilization is accomplished.
c. To prevent autonomic dysreflexia
d. To hold bony fragments of the skull together
24 Which of the following interventions describes an Intermittent catherization
appropriate bladder program for a client in rehabilitation for should begin every 2 to 4 hours
spinal cord injury? early in the treatment. When
a. Insert an indwelling urinary catheter to straight residual volume is less than 400
drainage ml, the schedule may advance
b. Schedule intermittent catheterization every 2 to 4 to every 4 to 6 hours.
hours Indwelling catheters may
c. Perform a straight catheterization every 8 hours predispose the client to
while awake infection and are removed as
d. Perform Crede’s maneuver to the lower abdomen soon as possible. Crede’s
before the client voids. maneuver is not used on
people with spinal cord injury.
25 A client is admitted to the ER for head trauma is diagnosed Epidural hematoma or
with an epidural hematoma. The underlying cause of extradural hematoma is usually
epidural hematoma is usually related to which of the caused by laceration of the
following conditions? middle meningeal artery. An
 a. Laceration of the middle meningeal artery embolic stroke is a
b. Rupture of the carotid artery thromboembolism from a
c. Thromboembolism from a carotid artery carotid artery that ruptures.
d. Venous bleeding from the arachnoid space Venous bleeding from the
arachnoid space is usually
observed with subdural
hematoma.
26 A 23-year-old client has been hit on the head with a Clear fluid from the nose or ear
baseball bat. The nurse notes clear fluid draining from his can be determined to be
ears and nose. Which of the following nursing interventions cerebral spinal fluid or mucous
should be done first? by the presence of dextrose.
a. Position the client flat in bed Placing the client flat in bed
b. Check the fluid for dextrose with a dipstick may increase ICP and promote
c. Suction the nose to maintain airway patency pulmonary aspiration. The nose
d. Insert nasal and ear packing with sterile gauze wouldn’t be suctioned because
of the risk for suctioning brain
tissue through the sinuses.
Nothing is inserted into the
ears or nose of a client with a
skull fracture because of the
risk of infection.
27 When discharging a client from the ER after a head trauma, A lucid interval is described as a
the nurse teaches the guardian to observe for a lucid brief period of unconsciousness
interval. Which of the following statements best described a followed by alertness; after
lucid interval? several hours, the client again
a. An interval when the client’s speech is garbled. loses consciousness. Garbled
b. An interval when the client is alert but can’t recall speech is known as dysarthria.
recent events. An interval in which the client is
c. An interval when the client is oriented but then alert but can’t recall recent
becomes somnolent. events is known as amnesia.
d. An interval when the client has a “warning” Warning symptoms or auras
symptom, such as an odor or visual disturbance. typically occur before seizures.
28 Which of the following clients on the rehab unit is most Autonomic dysreflexia refers to
likely to develop autonomic dysreflexia? uninhibited sympathetic
a. A client with a brain injury outflow in clients with spinal
b. A client with a herniated nucleus pulposus cord injuries about the level of
c. A client with a high cervical spine injury T10. The other clients aren’t
d. A client with a stroke prone to dysreflexia.
29 Which of the following conditions indicates that spinal Spasticity, the return of
shock is resolving in a client with C7 quadriplegia? reflexes, is a sign of resolving
a. Absence of pain sensation in chest shock. Spinal or neurogenic
b. Spasticity shock is characterized by
c. Spontaneous respirations hypotension, bradycardia, dry
d. Urinary continence skin, flaccid paralysis, or the
absence of reflexes below the
level of injury. The absence of
pain sensation in the chest
doesn’t apply to spinal shock.
Spinal shock descends from the
injury, and respiratory
difficulties occur at C4 and
 above.
30 A nurse assesses a client who has episodes of autonomic Noxious stimuli, such as a full
dysreflexia. Which of the following conditions can cause bladder, fecal impaction, or a
autonomic dysreflexia? decub ulcer, may cause
a. Headache autonomic dysreflexia. A
b. Lumbar spinal cord injury headache is a symptom of
c. Neurogenic shock autonomic dysreflexia, not a
d. Noxious stimuli cause. Autonomic dysreflexia is
most commonly seen with
injuries at T10 or above.
Neurogenic shock isn’t a cause
of dysreflexia.
31 During an episode of autonomic dysreflexia in which the Putting the client in the high-
client becomes hypertensive, the nurse should perform Fowler’s position will decrease
which of the following interventions? cerebral blood flow, decreasing
a. Elevate the client’s legs hypertension. Elevating the
b. Put the client flat in bed client’s legs, putting the client
c. Put the client in the Trendelenburg’s position flat in bed, or putting the bed in
d. Put the client in the high-Fowler’s position the Trendelenburg’s position
places the client in positions
that improve cerebral blood
flow, worsening hypertension.
32 A client with a T1 spinal cord injury arrives at the emergency Loss of sympathetic control and
department with a BP of 82/40, pulse 34, dry skin, and unopposed vagal stimulation
flaccid paralysis of the lower extremities. Which of the below the level of injury
following conditions would most likely be suspected? typically cause hypotension,
a. Autonomic dysreflexia bradycardia, pallor, flaccid
b. Hypervolemia paralysis, and warm, dry skin in
c. Neurogenic shock the client in neurogenic shock.
d. Sepsis Hypervolemia is indicated by
rapid and bounding pulse and
edema. Autonomic dysreflexia
occurs after neurogenic shock
abates. Signs of sepsis would
include elevated temperature,
increased heart rate, and
increased respiratory rate.
33 A client has a cervical spine injury at the level of C5. Which The diaphragm is stimulated by
of the following conditions would the nurse anticipate nerves at the level of C4.
during the acute phase? Initially, this client may need
a. Absent corneal reflex mechanical ventilation due to
b. Decerebrate posturing cord edema. This may resolve
c. Movement of only the right or left half of the body in time. Absent corneal
d. The need for mechanical ventilation reflexes, decerebrate posturing,
and hemiplegia occur with
brain injuries, not spinal cord
injuries.
34 A client with C7 quadriplegia is flushed and anxious and Hypertension, bradycardia,
complains of a pounding headache. Which of the following anxiety, blurred vision, and
symptoms would also be anticipated? flushing above the lesion occur
a. Decreased urine output or oliguria with autonomic dysreflexia due
 b. Hypertension and bradycardia to uninhibited sympathetic
c. Respiratory depression nervous system discharge. The
d. Symptoms of shock other options are incorrect.
35 A 40-year-old paraplegic must perform intermittent Intermittent catheterization
catheterization of the bladder. Which of the following may be performed chronically
instructions should be given? with clean technique, using
a. “Clean the meatus from back to front.” soap and water to clean the
b. “Measure the quantity of urine.” urinary meatus. The meatus is
c. “Gently rotate the catheter during removal.” always cleaned from front to
d. “Clean the meatus with soap and water.” back in a woman, or in
expanding circles working
outward from the meatus in a
man. It isn’t necessary to
measure the urine. The
catheter doesn’t need to be
rotated during removal.
36 An 18-year-old client was hit in the head with a baseball Changes in LOC (loss of
during practice. When discharging him to the care of his consciousness) may indicate
mother, the nurse gives which of the following instructions? expanding lesions such as
a. “Watch him for keyhole pupil the next 24 hours.” subdural hematoma;
b. “Expect profuse vomiting for 24 hours after the orientation and LOC are
injury.” assessed frequently for 24
c. “Wake him every hour and assess his orientation hours. A keyhole pupil is found
to person, time, and place.” after iridectomy. Profuse or
d. “Notify the physician immediately if he has a projectile vomiting is a
headache.” symptom of increased ICP and
should be reported
immediately. A slight headache
may last for several days after
concussion; severe or
worsening headaches should be
reported.
37 Which neurotransmitter is responsible for may of the The frontal lobe primarily
functions of the frontal lobe? functions to regulate thinking,
a. Dopamine planning, and affect. Dopamine
b. GABA is known to circulate widely
c. Histamine throughout this lobe, which is
d. Norepinephrine why it’s such an important
neurotransmitter in
schizophrenia.
38 The nurse is discussing the purpose of an An EEG measures the electrical
electroencephalogram (EEG) with the family of a client with activity of the brain. Extent of
massive cerebral hemorrhage and loss of consciousness. It intracranial bleeding and
would be most accurate for the nurse to tell family location of the injury site would
members that the test measures which of the following be determined by CT or MRI.
conditions? Percent of functional brain
a. Extent of intracranial bleeding tissue would be determined by
b. Sites of brain injury a series of tests.
c. Activity of the brain
d. Percent of functional brain tissue
39 A client arrives at the ER after slipping on a patch of ice and An epidural hematoma occurs
 hitting her head. A CT scan of the head shows a collection of when blood collects between
blood between the skull and dura mater. Which type of the skull and the dura mater. In
head injury does this finding suggest? a subdural hematoma, venous
a. Subdural hematoma blood collects between the
b. Subarachnoid hemorrhage dura mater and the arachnoid
c. Epidural hematoma mater. In a subarachnoid
d. Contusion hemorrhage, blood collects
between the pia mater and
arachnoid membrane. A
contusion is a bruise on the
brain’s surface.
40 After falling 20’, a 36-year-old man sustains a C6 fracture A client with a spinal cord injury
with spinal cord transaction. Which other findings should at levels C5 to C6 has
the nurse expect? quadriplegia with gross arm
a. Quadriplegia with gross arm movement and movement and diaphragmatic
diaphragmatic breathing breathing. Injury levels C1 to C4
b. Quadriplegia and loss of respiratory function leads to quadriplegia with total
c. Paraplegia with intercostal muscle loss loss of respiratory function.
d. Loss of bowel and bladder control Paraplegia with intercostal
muscle loss occurs with injuries
at T1 to L2. Injuries below L2
cause paraplegia and loss of
bowel and bladder control.
41 A 20-year-old client who fell approximately 30’ is If the client has a suspected
unresponsive and breathless. A cervical spine injury is cervical spine injury, a jaw-
suspected. How should the first-responder open the client’s thrust maneuver should be
airway for rescue breathing? used to open the airway. If the
a. By inserting a nasopharyngeal airway tongue or relaxed throat
b. By inserting a oropharyngeal airway muscles are obstructing the
c. By performing a jaw-thrust maneuver airway, a nasopharyngeal or
d. By performing the head-tilt, chin-lift maneuver oropharyngeal airway can be
inserted; however, the client
must have spontaneous
respirations when the airway is
open. The head-tilt, chin-lift
maneuver requires neck
hyperextension, which can
worsen the cervical spine
injury.
42 The nurse is caring for a client with a T5 complete spinal The client has signs and
cord injury. Upon assessment, the nurse notes flushed skin, symptoms of autonomic
diaphoresis above the T5, and a blood pressure of 162/96. dysreflexia. The potentially life-
The client reports a severe, pounding headache. Which of threatening condition is caused
the following nursing interventions would be appropriate by an uninhibited response
for this client? Select all that apply. from the sympathetic nervous
a. Elevate the HOB to 90 degrees system resulting from a lack of
b. Loosen constrictive clothing control over the autonomic
c. Use a fan to reduce diaphoresis nervous system. The nurse
d. Assess for bladder distention and bowel impaction should immediately elevate the
e. Administer antihypertensive medication HOB to 90 degrees and place
extremities dependently to
 decrease venous return to the
heart and increase venous
return from the brain. Because
tactile stimuli can trigger
autonomic dysreflexia, any
constrictive clothing should be
loosened. The nurse should
also assess for distended
bladder and bowel impaction,
which may trigger autonomic
dysreflexia, and correct any
problems. Elevated blood
pressure is the most life-
threatening complication of
autonomic dysreflexia because
it can cause stroke, MI, or
seizures. If removing the
triggering event doesn’t reduce
the client’s blood pressure, IV
antihypertensives should be
administered. A fan shouldn’t
be used because cold drafts
may trigger autonomic
dysreflexia.
43 The client with a head injury has been urinating copious A complication of a head injury
amounts of dilute urine through the Foley catheter. The is diabetes insipidus, which can
client’s urine output for the previous shift was 3000 ml. The occur with insult to the
nurse implements a new physician order to administer: hypothalamus, the antidiuretic
a. Desmopressin (DDAVP, stimate) storage vesicles, or the
b. Dexamethasone (Decadron) posterior pituitary gland. Urine
c. Ethacrynic acid (Edecrin) output that exceeds 9 L per day
d. Mannitol (Osmitrol) generally requires treatment
with desmopressin.
Dexamethasone, a
glucocorticoid, is administered
to treat cerebral edema. This
medication may be ordered for
the head injured patient.
Ethacrynic acid and mannitol
are diuretics, which would be
contraindicated.
44 The nurse is caring for the client in the ER following a head The changes in neurological
injury. The client momentarily lost consciousness at the signs from an epidural
time of the injury and then regained it. The client now has hematoma begin with a loss of
lost consciousness again. The nurse takes quick action, consciousness as arterial blood
knowing this is compatible with: collects in the epidural space
a. Skull fracture and exerts pressure. The client
b. Concussion regains consciousness as the
c. Subdural hematoma cerebral spinal fluid is
d. Epidural hematoma reabsorbed rapidly to
compensate for the rising
 intracranial pressure. As the
compensatory mechanisms fail,
even small amounts of
additional blood can cause the
intracranial pressure to rise
rapidly, and the client’s
neurological status deteriorates
quickly.
45 The nurse is caring for a client who suffered a spinal cord After spinal cord injury, the
injury 48 hours ago. The nurse monitors for GI client can develop paralytic
complications by assessing for: ileus, which is characterized by
a. A flattened abdomen the absence of bowel sounds
b. Hematest positive nasogastric tube drainage and abdominal distention.
c. Hyperactive bowel sounds Development of a stress ulcer
d. A history of diarrhea can be detected by hematest
positive NG tube aspirate or
stool. A history of diarrhea is
irrelevant.
46 A client with a spinal cord injury is prone to experiencing The most frequent cause of
autonomic dysreflexia. The nurse would avoid which of the autonomic dysreflexia is a
following measures to minimize the risk of recurrence? distended bladder. Straight
a. Strict adherence to a bowel retraining program catherization should be done
b. Limiting bladder catheterization to once every 12 every 4 to 6 hours, and Foley
hours catheters should be checked
c. Keeping the linen wrinkle-free under the client frequently to prevent kinks in
d. Preventing unnecessary pressure on the lower limbs the tubing. Constipation and
fecal impaction are other
causes, so maintaining bowel
regularity is important. Other
causes include stimulation of
the skin from tactile, thermal,
or painful stimuli. The nurse
administers care to minimize
risk in these areas.
47 The nurse is planning care for the client in spinal shock. Reflex vasodilation below the
Which of the following actions would be least helpful in level of the spinal cord injury
minimizing the effects of vasodilation below the level of the places the client at risk for
injury? orthostatic hypotension, which
a. Monitoring vital signs before and during position may be profound. Measures to
changes minimize this include
b. Using vasopressor medications as prescribed measuring vital signs before
c. Moving the client quickly as one unit and during position changes,
d. Applying Teds or compression stockings. use of a tilt-table with early
mobilization, and changing the
client’s position slowly. Venous
pooling can be reduced by
using Teds (compression
stockings) or pneumatic boots.
Vasopressor medications are
administered per protocol.
48 The nurse is caring for a client admitted with spinal cord Spinal immobilization is
 injury. The nurse minimizes the risk of compounding the necessary after spinal cord
injury most effectively by: injury to prevent further
a. Keeping the client on a stretcher damage and insult to the spinal
b. Logrolling the client on a firm mattress cord. Whenever possible, the
c. Logrolling the client on a soft mattress client is placed on a Stryker
d. Placing the client on a Stryker frame frame, which allows the nurse
to turn the client to prevent
complications of immobility,
while maintaining alignment of
the spine. If a Stryker frame is
not available, a firm mattress
with a bed board should be
used.
49 The nurse is evaluating neurological signs of the male client Resolution of spinal shock is
in spinal shock following spinal cord injury. Which of the occurring when there is a
following observations by the nurse indicates that spinal return of reflexes (especially
shock persists? flexors to noxious cutaneous
a. Positive reflexes stimuli), a state of hyperreflexia
b. Hyperreflexia rather than flaccidity, reflex
c. Inability to elicit a Babinski’s reflex emptying of the bladder, and a
d. Reflex emptying of the bladder positive Babinski’s reflex.
50 A client with a spinal cord injury suddenly experiences an Autonomic dysreflexia is
episode of autonomic dysreflexia. After checking the client’s characterized by severe
vital signs, list in order of priority, the nurse’s actions hypertension, bradycardia,
(Number 1 being the first priority and number 5 being the severe headache, nasal
last priority). stuffiness, and flushing. The
A. Check for bladder distention cause is a noxious stimulus,
B. Raise the head of the bed most often a distended bladder
C. Contact the physician or constipation. Autonomic
D. Loosen tight clothing on the client dysreflexia is a neurological
E. Administer an antihypertensive medication emergency and must be
treated promptly to prevent a
a. A, B, C, D, E hypertensive stroke. Immediate
b. B, D, A, C, E. nursing actions are to sit the
c. C, A, D, E, B client up in bed in a high-
d. C, D, A, B, E Fowler’s position and remove
the noxious stimulus. The nurse
should loosen any tight clothing
and then check for bladder
distention. If the client has a
foley catheter, the nurse should
check for kinks in the tubing.
The nurse also would check for
a fecal impaction and disimpact
if necessary. The physician is
contacted especially if these
actions do not relieve the signs
and symptoms.
Antihypertensive medications
may be prescribed by the
physician to minimize cerebral
 hypertension.
51 A client is at risk for increased ICP. Which of the following Increasing ICP causes unequal
would be a priority for the nurse to monitor? pupils as a result of pressure on
a. Unequal pupil size the third cranial nerve.
b. Decreasing systolic blood pressure Increasing ICP causes an
c. Tachycardia increase in the systolic
d. Decreasing body temperature pressure, which reflects the
additional pressure needed to
perfuse the brain. It increases
the pressure on the vagus
nerve, which produces
bradycardia, and it causes an
increase in body temperature
from hypothalamic damage.
52 Which of the following respiratory patterns indicate Neural control of respiration
increasing ICP in the brain stem? takes place in the brain stem.
a. Slow, irregular respirations Deterioration and pressure
b. Rapid, shallow respirations produce irregular respiratory
c. Asymmetric chest expansion patterns. Rapid, shallow
d. Nasal flaring respirations, asymmetric chest
movements, and nasal flaring
are more characteristic of
respiratory distress or hypoxia.
53 Which of the following nursing interventions is appropriate Normal ICP is 15 mm Hg or less.
for a client with an ICP of 20 mm Hg? Hyperventilation causes
a. Give the client a warming blanket vasoconstriction, which reduces
b. Administer low-dose barbiturate CSF and blood volume, two
c. Encourage the client to hyperventilate important factors for reducing
d. Restrict fluids a sustained ICP of 20 mm Hg. A
cooling blanket is used to
control the elevation of
temperature because a fever
increases the metabolic rate,
which in turn increases ICP.
High doses of barbiturates may
be used to reduce the
increased cellular metabolic
demands. Fluid volume and
inotropic drugs are used to
maintain cerebral perfusion by
supporting the cardiac output
and keeping the cerebral
perfusion pressure greater than
80 mm Hg.
54 A client has signs of increased ICP. Which of the following is A decrease in the client’s LOC is
an early indicator of deterioration in the client’s condition? an early indicator of
a. Widening pulse pressure deterioration of the client’s
b. Decrease in the pulse rate neurological status. Changes in
c. Dilated, fixed pupil LOC, such as restlessness and
d. Decrease in LOC irritability, may be subtle.
Widening of the pulse pressure,
 decrease in the pulse rate, and
dilated, fixed pupils occur later
if the increased ICP is not
treated.
55 A client who is regaining consciousness after a craniotomy It is best for the client to wear
becomes restless and attempts to pull out her IV line. Which mitts which help prevent the
nursing intervention protects the client without increasing client from pulling on the IV
her ICP? without causing additional
a. Place her in a jacket restraint agitation. Using a jacket or
b. Wrap her hands in soft “mitten” restraints wrist restraint or tucking the
c. Tuck her arms and hands under the draw sheet client’s arms and hands under
d. Apply a wrist restraint to each arm the draw sheet restrict
movement and add to feelings
of being confined, all of which
would increase her agitation
and increase ICP.
56 Which of the following describes decerebrate posturing? Decerebrate posturing occurs in
a. Internal rotation and adduction of arms with flexion patients with damage to the
of elbows, wrists, and fingers upper brain stem, midbrain, or
b. Back hunched over, rigid flexion of all four pons and is demonstrated
extremities with supination of arms and plantar clinically by arching of the back,
flexion of the feet rigid extension of the
c. Supination of arms, dorsiflexion of feet extremities, pronation of the
d. Back arched; rigid extension of all four extremities. arms, and plantar flexion of the
feet. Internal rotation and
adduction of arms with flexion
of the elbows, wrists, and
fingers described decorticate
posturing, which indicates
damage to corticospinal tracts
and cerebral hemispheres.
57 A client receiving vent-assisted mode ventilation begins to luster breathing consists of
experience cluster breathing after recent intracranial clusters of irregular breaths
occipital bleeding. Which action would be most followed by periods of apnea
appropriate? on an irregular basis. A lesion in
a. Count the rate to be sure the ventilations are deep the upper medulla or lower
enough to be sufficient pons is usually the cause of
b. Call the physician while another nurse checks the cluster breathing. Because the
vital signs and ascertains the patient’s Glasgow client had a bleed in the
Coma score. occipital lobe, which is superior
c. Call the physician to adjust the ventilator settings. and posterior to the pons and
d. Check deep tendon reflexes to determine the best medulla, clinical manifestations
motor response that indicate a new lesion are
monitored very closely in case
another bleed ensues. The
physician is notified
immediately so that treatment
can begin before respirations
cease. Another nurse needs to
assess vital signs and score the
client according to the GCS, but
 time is also of the essence.
Checking deep tendon reflexes
is one part of the GCS analysis.
58 In planning the care for a client who has had a posterior Elevating the HOB to 30
fossa (infratentorial) craniotomy, which of the following is degrees is contraindicated for
contraindicated when positioning the client? infratentorial craniotomies
a. Keeping the client flat on one side or the other because it could cause
b. Elevating the head of the bed to 30 degrees herniation of the brain down
c. Log rolling or turning as a unit when turning onto the brainstem and spinal
d. Keeping the head in neutral position cord, resulting in sudden death.
Elevation of the head of the
bed to 30 degrees with the
head turned to the side
opposite of the incision, if not
contraindicated by the ICP; is
used for supratentorial
craniotomies.
59 A client has been pronounced brain dead. Which findings A client who is brain dead
would the nurse assess? Check all that apply. typically demonstrates
a. Decerebrate posturing nonreactive dilated pupils and
b. Dilated nonreactive pupils nonreactive or absent corneal
c. Deep tendon reflexes and gag reflexes. The client may
d. Absent corneal reflex still have spinal reflexes such as
deep tendon and Babinski
reflexes in brain death.
Decerebrate or decorticate
posturing would not be seen.
60 A 23-year-old patient with a recent history of encephalitis is Administration of medications
admitted to the medical unit with new onset generalized is included in LPN education
tonic-clonic seizures. Which nursing activities included in and scope of practice.
the patient’s care will be best to delegate to an LPN/LVN Collection of data about the
whom you are supervising? seizure activity may be
a. Document the onset time, nature of seizure activity, accomplished by an LPN/LVN
and postictal behaviors for all seizures. who observes initial seizure
b. Administer phenytoin (Dilantin) 200 mg PO daily. activity. An LPN/LVN would
c. Teach patient about the need for good oral hygiene. know to call the supervising RN
d. Develop a discharge plan, including physician visits immediately if a patient started
and referral to the Epilepsy Foundation. to seize. Documentation of the
seizure, patient teaching, and
planning of care are complex
activities that require RN level
education and scope of
practice.
61 A client admitted to the hospital with a subarachnoid Sudden removal of CSF results
hemorrhage has complaints of severe headache, nuchal in pressures lower in the
rigidity, and projectile vomiting. The nurse knows lumbar lumbar area than the brain and
puncture (LP) would be contraindicated in this client in favors herniation of the brain;
which of the following circumstances? therefore, LP is contraindicated
a. Vomiting continues with increased ICP. Vomiting
b. Intracranial pressure (ICP) is increased may be caused by reasons
c. The client needs mechanical ventilation other than increased ICP;
 d. Blood is anticipated in the cerebrospinal fluid (CSF) therefore, LP isn’t strictly
contraindicated. An LP may be
performed on clients needing
mechanical ventilation. Blood in
the CSF is diagnostic for
subarachnoid hemorrhage and
was obtained before signs and
symptoms of ICP.
62 A client with a subdural hematoma becomes restless and Mannitol promotes osmotic
confused, with dilation of the ipsilateral pupil. The physician diuresis by increasing the
orders mannitol for which of the following reasons? pressure gradient, drawing fluid
a. To reduce intraocular pressure from intracellular to
b. To prevent acute tubular necrosis intravascular spaces. Although
c. To promote osmotic diuresis to decrease ICP mannitol is used for all the
d. To draw water into the vascular system to increase reasons described, the
blood pressure reduction of ICP in this client is
a concern.
63 A client with subdural hematoma was given mannitol to Mannitol promotes osmotic
decrease intracranial pressure (ICP). Which of the following diuresis by increasing the
results would best show the mannitol was effective? pressure gradient in the renal
a. Urine output increases tubes. Fixed and dilated pupils
b. Pupils are 8 mm and nonreactive are symptoms of increased ICP
c. Systolic blood pressure remains at 150 mm Hg or cranial nerve damage. No
d. BUN and creatinine levels return to normal information is given about
abnormal BUN and creatinine
levels or that mannitol is being
given for renal dysfunction or
blood pressure maintenance.
64 Which of the following values is considered normal for ICP? Normal ICP is 0-15 mm Hg.
a. 0 to 15 mm Hg
b. 25 mm Hg
c. 35 to 45 mm Hg
d. 120/80 mm Hg
65 Which of the following symptoms may occur with a A therapeutic phenytoin level is
phenytoin level of 32 mg/dl? 10 to 20 mg/dl. A level of 32
a. Ataxia and confusion mg/dl indicates toxicity.
b. Sodium depletion Symptoms of toxicity include
c. Tonic-clonic seizure confusion and ataxia. Phenytoin
d. Urinary incontinence doesn’t cause hyponatremia,
seizure, or urinary
incontinence. Incontinence may
occur during or after a seizure.
66 Which of the following signs and symptoms of increased ICP The earliest symptom of
after head trauma would appear first? elevated ICP is a change in
a. Bradycardia mental status. Bradycardia,
b. Large amounts of very dilute urine widened pulse pressure, and
c. Restlessness and confusion bradypnea occur later. The
d. Widened pulse pressure client may void large amounts
of very dilute urine if there’s
damage to the posterior
pituitary.
67 Problems with memory and learning would relate to which The temporal lobe functions to
of the following lobes? regulate memory and learning
a. Frontal problems because of the
b. Occipital integration of the
c. Parietal hippocampus. The frontal lobe
d. Temporal primarily functions to regulate
thinking, planning, and
judgment. The occipital lobe
functions regulate vision. The
parietal lobe primarily functions
with sensory function.
68 While cooking, your client couldn’t feel the temperature of The parietal lobe regulates
a hot oven. Which lobe could be dysfunctional? sensory function, which would
a. Frontal include the ability to sense hot
b. Occipital or cold objects. The frontal lobe
c. Parietal regulates thinking, planning,
d. Temporal and judgment, and the occipital
lobe is primarily responsible for
vision function. The temporal
lobe regulates memory.
69 The nurse is assessing the motor function of an unconscious Motor testing on the
client. The nurse would plan to use which of the following to unconscious client can be done
test the client’s peripheral response to pain? only by testing response to
a. Sternal rub painful stimuli. Nail Bed
b. Pressure on the orbital rim pressure tests a basic
c. Squeezing the sternocleidomastoid muscle peripheral response. Cerebral
d. Nail bed pressure responses to pain are testing
using sternal rub, placing
upward pressure on the orbital
rim, or squeezing the clavicle or
sternocleidomastoid muscle.
70 The client is having a lumbar puncture performed. The The client undergoing lumbar
nurse would plan to place the client in which position for puncture is positioned lying on
the procedure? the side, with the legs pulled up
a. Side-lying, with legs pulled up and head bent down to the abdomen, and with the
onto the chest head bent down onto the
b. Side-lying, with a pillow under the hip chest. This position helps to
c. Prone, in a slight Trendelenburg’s position open the spaces between the
d. Prone, with a pillow under the abdomen vertebrae.
71 A nurse is assisting with caloric testing of the Caloric testing provides
oculovestibular reflex of an unconscious client. Cold water is information about
injected into the left auditory canal. The client exhibits eye differentiating between
conjugate movements toward the left followed by a rapid cerebellar and brainstem
nystagmus toward the right. The nurse understands that lesions. After determining
this indicates the client has: patency of the ear canal, cold
a. A cerebral lesion or warm water is injected in the
b. A temporal lesion auditory canal. A normal
c. An intact brainstem response that indicates intact
d. Brain death function of cranial nerves III, IV,
and VIII is conjugate eye
movements toward the side
 being irrigated, followed by
rapid nystagmus to the
opposite side. Absent or
disconjugate eye movements
indicate brainstem damage.
72 The nurse is caring for the client with increased intracranial A change in vital signs may be a
pressure. The nurse would note which of the following late sign of increased
trends in vital signs if the ICP is rising? intracranial pressure. Trends
a. Increasing temperature, increasing pulse, increasing include increasing temperature
respirations, decreasing blood pressure. and blood pressure and
b. Increasing temperature, decreasing pulse, decreasing pulse and
decreasing respirations, increasing blood pressure. respirations. Respiratory
c. Decreasing temperature, decreasing pulse, irregularities also may arise.
increasing respirations, decreasing blood pressure.
d. Decreasing temperature, increasing pulse,
decreasing respirations, increasing blood pressure.
73 The nurse is evaluating the status of a client who had a Signs of meningeal irritation
craniotomy 3 days ago. The nurse would suspect the client compatible with meningitis
is developing meningitis as a complication of surgery if the include nuchal rigidity, positive
client exhibits: Brudzinski’s sign, and positive
a. A positive Brudzinski’s sign Kernig’s sign.Nuchal rigidity is
b. A negative Kernig’s sign characterized by a stiff neck
c. Absence of nuchal rigidity and soreness, which is
d. A Glascow Coma Scale score of 15 especially noticeable when the
neck is fixed.Kernig’s sign is
positive when the client feels
pain and spasm of the
hamstring muscles when the
knee and thigh are extended
from a flexed-right angle
position.Brudzinski’s sign is
positive when the client flexes
the hips and knees in response
to the nurse gently flexing the
head and neck onto the chest.A
Glascow Coma Scale of 15 is a
perfect score and indicates the
client is awake and alert with
no neurological deficits.
74 A client is arousing from a coma and keeps saying, “Just stop The client’s innate responses to
the pain.” The nurse responds based on the knowledge that pain are directed initially
the human body typically and automatically responds to toward escaping from the
pain first with attempts to: source of pain. Variations in
a. Tolerate the pain individuals’ tolerance and
b. Decrease the perception of pain perception of pain are apparent
c. Escape the source of pain only in conscious clients, and
d. Divert attention from the source of pain. only conscious clients are able
to employ distraction to help
relieve pain.
75 During the acute stage of meningitis, a 3-year-old child is A child in the acute stage of
restless and irritable. Which of the following would be most meningitis is irritable and
 appropriate to institute? hypersensitive to loud noise
a. Limiting conversation with the child and light. Therefore,
b. Keeping extraneous noise to a minimum extraneous noise should be
c. Allowing the child to play in the bathtub minimized and bright lights
d. Performing treatments quickly avoided as much as possible.
There is no need to limit
conversations with the child.
However, the nurse should
speak in a calm, gentle,
reassuring voice. The child
needs gentle and calm bathing.
Because of the acuteness of the
infection, sponge baths would
be more appropriate than tub
baths. Although treatments
need to be completed as
quickly as possible to prevent
over stressing the child, any
treatments should be
performed carefully and at a
pace that avoids sudden
movements to prevent startling
the child and subsequently
increasing intracranial pressure.
76 Which of the following would lead the nurse to suspect that DIC is characterized by skin
a child with meningitis has developed disseminated petechiae and a purpuric skin
intravascular coagulation? rash caused by spontaneous
a. Hemorrhagic skin rash bleeding into the tissues. An
b. Edema abnormal coagulation
c. Cyanosis phenomenon causes the
d. Dyspnea on exertion condition.
77 When interviewing the parents of a 2-year-old child, a Organisms that cause bacterial
history of which of the following illnesses would lead the meningitis, such as
nurse to suspect pneumococcal meningitis? pneumococci or meningococci,
a. Bladder infection are commonly spread in the
b. Middle ear infection body by vascular dissemination
c. Fractured clavicle from a middle ear infection.
d. Septic arthritis The meningitis may also be a
direct extension from the
paranasal and mastoid sinuses.
The causative organism is a
pneumococcus. A chronically
draining ear is frequently also
found.
78 The nurse is assessing a child diagnosed with a brain tumor. Head tilt, vomiting, and
Which of the following signs and symptoms would the nurse lethargy are classic signs
expect the child to demonstrate? Select all that apply. assessed in a child with a brain
a. Head tilt tumor. Clinical manifestations
b. Vomiting are the result of location and
c. Polydipsia size of the tumor.
d. Lethargy
 e. Increased appetite
f. Increased pulse
79 A lumbar puncture is performed on a child suspected of A diagnosis of meningitis is
having bacterial meningitis. CSF is obtained for analysis. A made by testing CSF obtained
nurse reviews the results of the CSF analysis and determines by lumbar puncture. In the case
that which of the following results would verify the of bacterial meningitis, findings
diagnosis? usually include an elevated
a. Cloudy CSF, decreased protein, and decreased pressure, turbid or cloudy CSF,
glucose elevated leukocytes, elevated
b. Cloudy CSF, elevated protein, and decreased protein, and decreased glucose
glucose levels.
c. Clear CSF, elevated protein, and decreased glucose
d. Clear CSF, decreased pressure, and elevated protein
80 A nurse is planning care for a child with acute bacterial A major priority of nursing care
meningitis. Based on the mode of transmission of this for a child suspected of having
infection, which of the following would be included in the meningitis is to administer the
plan of care? prescribed antibiotic as soon as
a. No precautions are required as long as antibiotics it is ordered. The child is also
have been started placed on respiratory isolation
b. Maintain enteric precautions for at least 24 hours while
c. Maintain respiratory isolation precautions for at culture results are obtained and
least 24 hours after the initiation of antibiotics the antibiotic is having an
d. Maintain neutropenic precautions effect.
81 A nurse is reviewing the record of a child with increased ICP Decerebrate posturing is
and notes that the child has exhibited signs of decerebrate characterized by the rigid
posturing. On assessment of the child, the nurse would extension and pronation of the
expect to note which of the following if this type of arms and legs.
posturing was present?
a. Abnormal flexion of the upper extremities and
extension of the lower extremities
b. Rigid extension and pronation of the arms and legs
c. Rigid pronation of all extremities
d. Flaccid paralysis of all extremities
82 Which of the following assessment data indicated nuchal A positive Kernig’s sign
rigidity? indicated nuchal rigidity,
a. Positive Kernig’s sign caused by an irritative lesion of
b. Negative Brudzinski’s sign the subarachnoid space.
c. Positive homan’s sign Brudzinski’s sign is also
d. Negative Kernig’s sign indicative of the condition.
83 Meningitis occurs as an extension of a variety of bacterial Extension of a variety of
infections due to which of the following conditions? bacterial infections is a major
a. Congenital anatomic abnormality of the meninges causative factor of meningitis
b. Lack of acquired resistance to the various etiologic and occurs as a result of a lack
organisms of acquired resistance to the
c. Occlusion or narrowing of the CSF pathway etiologic organisms. Preexisting
d. Natural affinity of the CNS to certain pathogens CNS anomalies are factors that
contribute to susceptibility.
84 Which of the following pathologic processes is often Aseptic meningitis is caused
associated with aseptic meningitis? principally by viruses and is
a. Ischemic infarction of cerebral tissue often associated with other
b. Childhood diseases of viral causation such as diseases such as measles,
 mumps mumps, herpes, and leukemia.
c. Brain abscesses caused by a variety of pyogenic Incidences of brain abscess are
organisms high in bacterial meningitis, and
d. Cerebral ventricular irritation from a traumatic brain ischemic infarction of cerebral
injury tissue can occur with tubercular
meningitis. Traumatic brain
injury could lead to bacterial
(not viral) meningitis.
85 You are preparing to admit a patient with a seizure disorder. The LPN/LVN can set up the
Which of the following actions can you delegate to equipment for oxygen and
LPN/LVN? suctioning. The RN should
a. Complete admission assessment. perform the complete initial
b. Set up oxygen and suction equipment. assessment. Padded side rails
c. Place a padded tongue blade at bedside. are controversial in terms of
d. Pad the side rails before patient arrives. whether they actually provide
safety and ay embarrass the
patient and family. Tongue
blades should not be at the
bedside and should never be
inserted into the patient’s
mouth after a seizure begins.