The nurse is assisting with a lumbar puncture and observes that when the health care provider obtains CSF, it is clear and colorless. What does this finding indicate?

• A subarachnoid hemorrhage

• An overwhelming infection

• A normal finding; the fluid will be sent for testing to determine other factors

• Local trauma from the insertion of the needle

Which finding is considered a positive finding of the Romberg test?

• Loss of balance

• Hoarseness in the voice

• Deviation of the tongue

• Tearing of the eye

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

• Risk for aspiration

• Risk for falls

• Risk for impaired skin integrity

• Decreased intracranial adaptive capacity

A client is scheduled for an electroencephalogram (EEG) in the morning. What food on the client’s tray should the nurse remove prior to the test?

• Orange juice

• Toast

• • Coffee

  
  

• Eggs

The nurse is completing a neurological assessment and uses the whisper test to assess which cranial nerve?

• Vagus (X)

• Acoustic (VIII)

• Facial (VII)

• Olfactory (I)

A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to:

• smell and identify a nonirritating, aromatic odor.

• read an eye chart from a distance of 20?

• elevate the shoulders, both with and without resistance.

• • stick out the tongue and move it rapidly from side to side and in and out.

  
  

A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headaches are caused by which of the following?

• Cerebral spinal fluid leakage at the puncture site

• Damage to the spinal cord

• Traumatic puncture

• Not ambulating soon enough after the procedure

A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the assessment?

• Loss of hearing, tinnitus, and vertigo

• Loss of vision, change in mental status, and hyperthermia

• Loss of hearing, increased sodium retention, and hypertension

• Loss of vision, headache, and tachycardia

The nurse explains to the client with projectile vomiting and severe headache that a medication is being prescribed to reduced edema surrounding the brain and lessen these symptoms. What medication is the nurse preparing to administer?

• Mannitol

• Temozolomide

• Bevacizumab

• Everolimus

A 64-year-old client has been admitted to the neurological unit after being diagnosed with a brain tumor. The client is slated for neurosurgery the following day, and the client's adult child has come to the hospital from out of state. After visiting their parent for the first time since they were diagnosed, the child is distraught and tells the nurse, “My parent has always been one of the kindest, most considerate people, and I don't remember them ever being so abrasive.” How should the nurse best respond to the child's statement?

• “Your parent has received a very stressful diagnosis, and they are likely still processing it.”

• • “Those personality changes are probably a result of the tumor's effect on their brain.”

  
  

• “Your parent may have been experiencing a partial seizure when they were speaking to you.”

• “It's most helpful if you can accept them the way they are now, even if it's more difficult than in the past.”