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WorksheetsNCLEX - NERVOUS SYSTEM Day2 (Part 1)
Total questions: 15
Worksheet time: 15mins
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)
-
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)
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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)
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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)
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