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WorksheetsNCLEX - NERVOUS SYSTEM Day3 (Part 1)
Total questions: 15
Worksheet time: 15mins
Name
Class
Date
1.
A nurse working in a neurology clinic receives the following telephone messages. Which client should the nurse call back first?
a)
Client prescribed sumatriptan who has throbbing left temple pain preceded by an aura
b)
Client taking carbidopa-levodopa who has dizziness when rising from a sitting or lying position
c)
Client with myasthenia gravis who has a fever and increasing difficulty swallowing
d)
Client with trigeminal neuralgia who reports burning cheek pain after eating ice cream
2.
The graduate nurse cares for several poststroke clients. Which of the following nursing interventions are appropriate? Select all that apply.
a)
Implement fall precautions for the client with cerebellar stroke
b)
Increase lighting for the client with cranial nerve VII affected
c)
Initiate swallow precautions for the client with cranial nerves IX and X affected
d)
Place spoon within field of vision for the client with homonymous hemianopsia
e)
Speak louder in front of the client who has receptive aphasia
3.
An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department. The client's head has hit the windshield, and the client is unconscious. What nurse actions are appropriate? Select all that apply.
a)
Assess the client for a carotid pulse
b)
Determine the client's Glasgow Coma Scale score
c)
Maintain airway with head-tilt/chin-lift maneuver
d)
Place a hard cervical collar on the client
e)
Remove the client from the car onto a backboard
4.
The nurse is assessing a client with delirium. Which of the following findings would the nurse expect to observe? Select all that apply.
a)
inability to maintain attention
b)
involuntary movements of the face
c)
spastic paralysis and hyperreflexia
d)
incoherent and disorganized speech
e)
consciousness fluctuating from drowsy to combative
5.
The emergency department nurse is assessing a client brought in after a car accident in which the client's head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? Select all that apply.
a)
Breath smells of alcohol
b)
Client disoriented to place
c)
Client reports eyes burning
d)
History of multiple sclerosis
e)
Point tenderness over spine
6.
The nurse is caring for a client who had a transsphenoidal hypophysectomy and developed diabetes insipidus. Which of the following findings would the nurse expect to observe? Select all that apply.
a)
excessive thirst
b)
increased urine output
c)
increased serum osmolality
d)
decreased serum sodium level
e)
increased urine specific gravity
7.
The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? Select all that apply.
a)
Complete activities such as bathing and dressing as quickly as possible
b)
Decrease the client's anxiety by limiting the number of choices offered
c)
Redirect the client if agitated by asking for help with a task or going for a walk
d)
Remember to interact with the client as an adult, regardless of childlike affect
e)
Use open-ended questions when communicating with the client
8.
The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include? Select all that apply.
a)
Arrange furniture to allow for free movement
b)
Keep frequently used items within easy reach
c)
Lock doors leading to stairwells and outside areas
d)
Place an identifying symbol on the bathroom door
e)
Provide a dark room free of shadows for sleeping
9.
The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.
a)
Prepare to suction the client.
b)
Turn the client to a side-lying position.
c)
Restrain the client's upper extremities.
d)
Request assistance from other staff members.
e)
Use a tongue blade to depress the client's tongue.
10.
The nurse is caring for a client who sustained a traumatic brain injury during a fall. Which of the following findings would require follow-up? Select all that apply.
a)
amnesia of the events surrounding the fall
b)
flaccidity of the upper extremities
c)
widening pulse pressure
d)
increased drowsiness
e)
projectile vomiting
11.
A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain?
a)
Expressive speech, vision
b)
Light touch, hearing
c)
Sense of position, graphesthesia
d)
Weber tuning fork test, cranial nerve I
e)
-
12.
The nurse is caring for a client who had a stroke two weeks ago and has moderate receptive aphasia. Which interventions should the nurse include in the plan of care to help the client follow simple commands regarding activities of daily living (ADL)? Select all that apply.
a)
Ask simple questions that require "yes" or "no" answers
b)
If the client becomes frustrated, seek a different care provider to complete ADL
c)
Remain calm and allow the client time to understand each instruction
d)
Show the client pictures of ADL (eg, shower, toilet, and toothbrush) or use gestures
e)
Speak slowly but loudly while looking directly at the client
13.
The nurse is caring for a client with mild Alzheimer disease who is agitated after eating breakfast. The client states, "I am hungry. You did not feed me." Which of the following actions should the nurse take?
a)
Offer the client finger foods to eat.
b)
Provide the client with additional food at mealtimes.
c)
Tell the client that the client may have a snack before lunch.
d)
Ask the dietician to evaluate the client's daily calorie requirements.
14.
A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? Select all that apply.
a)
Identify the number "8" traced on the palm
b)
Shrug the shoulders against resistance
c)
Swallow water
d)
Touch each finger of one hand to the hand's thumb
e)
Walk heel-to-toe
15.
The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions?
a)
I have a leftover prescription at home I can use if I have pain.
b)
I will cancel the wine tasting I have planned for this weekend.
c)
I will have someone drive me home and will take a couple of days off work.
d)
I will have someone stay with me and make sure I am okay.
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