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WorksheetsNCLEX - NERVOUS SYSTEM Day2
Total questions: 25
Worksheet time: 25mins
Name
Class
Date
1.
A client with Alzheimer disease is found wandering in the middle of the street at 3 AM and is returned home by police. The community health nurse teaches the client's family members about measures to keep the client safe at home. What is the most important strategy for the nurse to include in the instruction to prevent wandering?
a)
Ensure that the family members never leave the client alone
b)
Install a door sensor to alert the family members if the client leaves the home
c)
Notify neighbors and local authorities of the client's tendency to wander
d)
Place a safe return bracelet on the client's nondominant hand
e)
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2.
The home health nurse teaches a client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which client statement indicates a need for further teaching?
a)
I should raise my chin slightly upward when swallowing food.
b)
I should sit upright for at least 30-40 minutes after every meal.
c)
I should swallow two times before taking another bite of food.
d)
I will avoid taking over-the-counter cold medications when sick.
e)
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3.
The nurse is talking with a client who is scheduled for a lumbar puncture. Which of the following statements by the client would require follow-up?
a)
I will need to lie on my stomach during the procedure.
b)
I should go to the bathroom to urinate before the procedure.
c)
I understand that a needle will be inserted between the bones in my lower spine during the procedure.
d)
I may experience a sharp pain radiating down my leg during the procedure, but it should pass quickly.
e)
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4.
Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit?
a)
Aphasia
b)
Apraxia
c)
Dysarthria
d)
Dysphagia
e)
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5.
The nurse is caring for a client who has a brain tumor. The client suddenly vomits but denies nausea. It would be a priority for the nurse to
a)
keep the head of the bed flat
b)
notify the health care provider
c)
document the amount of emesis
d)
administer antiemetic medication
e)
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6.
The nurse is providing a change-of-shift report for a client who experienced a traumatic brain injury and has a Glasgow Coma Scale (GCS) score of 10. It would be essential for the nurse to include that the client
a)
had a GCS score of 12 one hour ago
b)
is allergic to penicillin and vancomycin
c)
was unable to state the current year when asked
d)
has a blood pressure of 120/80 mm Hg and a pulse of 82/min
e)
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7.
The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, "I guess I can anticipate getting this disease myself at some point." What is an appropriate response by the nurse?
a)
Engaging in regular exercise decreases the risk of AD.
b)
Having a family history of AD is not a risk factor.
c)
Try not to worry about this now as you can't do anything to prevent AD.
d)
You should avoid aluminum cans and cookware to prevent AD.
e)
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8.
The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider?
a)
I got short of breath this morning when I worked out.
b)
I have cut down on smoking to 1/2 pack per day.
c)
I haven't been feeling well, so I have been sleeping a lot.
d)
I took an acetaminophen in the waiting room for this bad headache.
e)
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9.
A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?
a)
I am very tired, and it's hard for me to keep my eyes open.
b)
I don't feel good, and I want to be seen.
c)
I have not taken my blood pressure medicine in over a week.
d)
I have the worst headache I've ever had in my life.
e)
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10.
The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway?
a)
Head-tilt chin-lift in the supine position on a backboard
b)
Head-tilt chin-lift in the Trendelenburg position
c)
Jaw-thrust maneuver in semi-Fowler's position
d)
Jaw-thrust maneuver in the supine position on a backboard
e)
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11.
The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is most concerning and requires a nursing response?
a)
Consumes 600 mL liquid over 4 hours
b)
Insertion site dressing saturated with clear fluid
c)
Observed lying in the right-sided Sim's position
d)
Reports a headache rated 6/10
e)
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12.
A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially?
a)
Administer PRN analgesic medication
b)
Administer PRN antihypertensive medication
c)
Lower the head of the bed
d)
Palpate the client's bladder
e)
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13.
The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)?
a)
Consume a low-fat, low-salt diet
b)
Do not smoke cigarettes
c)
Exercise and lose weight
d)
Take prescribed antihypertensive medications
e)
-
14.
The nurse is assessing a client who sustained a spinal cord injury and has suspected neurogenic shock. Which of the following findings would support a diagnosis of neurogenic shock?
a)
blood pressure of 186/92 mm Hg
b)
heart rate of 48/min
c)
diaphoresis
d)
shivering
e)
-
15.
The nurse is caring for a 75-year-old client admitted to the hospital with pneumonia. What assessment finding is most consistent with the diagnosis of delirium?
a)
Client has muscle stiffness and resting hand tremors
b)
Client appears to be inattentive and disoriented
c)
Client reports decreased enjoyment in hobbies
d)
Family reports client's gradual inability to recall recent events
e)
-
16.
The nurse in the emergency department is caring for a client who sustained a traumatic head injury 30 minutes ago and has an order for insertion of a nasogastric tube. Which of the following findings would be a contraindication for nasogastric tube insertion?
a)
an ecchymotic area on the forehead
b)
frontal headache rated as 10 on a scale of 0-10
c)
moderate amount of bright red blood oozing from a cheek laceration
d)
nasal drainage collected on sterile gauze that has a red center surrounded by serous fluid
e)
-
17.
The nurse in the emergency department is caring for a client with new-onset right-sided weakness and slurred speech. Which of the following actions should the nurse take first?
a)
Ensure the client's airway is patent
b)
Determine the time of symptom onset
c)
Prepare the client for a CT scan of the head
d)
Insert a large-bore peripheral venous access device
e)
-
18.
The nurse is caring for a client who sustained a cervical spinal cord injury 1 hour ago and is paralyzed in all four extremities. Which of the following actions would be a priority for the nurse to take?
a)
Reposition the client every 2 hours
b)
Perform frequent, focused respiratory assessments
c)
Monitor the client for autonomic dysreflexia
d)
Perform passive range-of-motion exercises every 4 hours
e)
-
19.
The emergency department nurse receives several prescriptions for a client who was found unresponsive after drinking beer and consuming unidentified pills. Which prescription should the nurse implement first?
a)
Administer IV push naloxone once now
b)
Draw specimen for blood alcohol content testing STAT
c)
Initiate continuous lactated Ringer solution infusion
d)
Obtain urine sample for drug abuse screening ASAP
e)
-
20.
The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?
a)
Auscultate breath sounds to assess for crackles
b)
Monitor for >50 mL/hr urine output
c)
Monitor Glasgow Coma Scale increasing from 8/15 to 9/15
d)
Press over the tibia to assess for pitting edema
e)
-
21.
The nurse in the emergency department is caring for assigned clients. The nurse should first assess the client with
a)
unilateral facial pain that is aggravated by consumption of hot beverages
b)
an epidural hematoma who has a decreased level of consciousness
c)
Bell palsy who has unilateral facial droop and drooling
d)
multiple sclerosis who is reporting blurred vision
e)
-
22.
The nurse is assessing a client who experienced an ischemic stroke affecting the Broca area of the brain. Which of the following findings would be consistent with the condition?
a)
blurred vision
b)
expressive aphasia
c)
decreased sensation
d)
uncoordinated motor movement
e)
-
23.
The nurse is caring for a client in the immediate postoperative period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the healthcare provider immediately?
a)
Diminished gag reflex after endotracheal tube removal
b)
Increased agitation level and pulling at linens
c)
Left arm drift during bilateral arm extension
d)
Responds to verbal commands with eyes closed
e)
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24.
The nurse is talking with a client who has Huntington disease and is considering becoming pregnant. Which of the following statements would be appropriate for the nurse to make?
a)
There are alternative methods to expand your family. You should consider adoption.
b)
Genetic counseling is recommended. You will receive a referral before you leave.
c)
Huntington disease inheritance requires both biological parents to carry the gene.
d)
Huntington disease occurs spontaneously and is not likely to affect your children.
e)
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25.
The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? Select all that apply.
a)
Client coughs and gasps when swallowing food and liquids
b)
Client is easily frustrated while attempting to speak
c)
Client is unable to understand speech and is completely nonverbal
d)
Client misunderstands and inappropriately responds to verbal instruction
e)
Client's speech is limited to short phrases that require effort
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