NUR 2214 Module 4 EAQs
- A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of
a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record?
Answer
"Exhibits a positive Babinski sign"
- A client has a tonic-clonic seizure at work and is admitted to the emergency department.
Which question is most useful when planning nursing care related to the client's seizure?
Answer
"Were you aware of anything different or unusual just before your seizure began?"
- On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus,
an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action?
Answer
Removing excess clothing from the infant
- A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a
coma. What is the priority nursing care for this client?
Answer
Main- tain an open airway.
- A 50-year-old male client has difficulty communicating because of expressive aphasia
after a cerebrovascular accident (CVA, also known as a "brain attack").When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior? 1 / 4
Answer
Acknowledge the wife but look at the client for a response.
- A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched
jaw. What is the best initial action by the nurse?
Answer
Placing the child on the floor
- A client has inflammation of the facial nerve, causing facial paralysis on one side. Which
diagnosis will the nurse most likely observe written in the medical record?
Answer
Bell palsy
- Which antiepileptic drug is used as the first-line treatment for absence seizures?
Answer
valproic acid
- During an annual physical assessment a client reports not being able to smell coffee and
most foods. Which cranial nerve function should the nurse assess?
Answer
I
- Which statement indicates a nurse has a correct understanding about trigeminal autonomic
cephalalgia (cluster headaches)?
Answer 2 / 4
It is caused by an overactive hypothalamus.
- A client who takes four 325-mg tablets of buffered aspirin four times a day for severe
arthritis complains of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably is experiencing?
Answer
Salicylate toxicity
- Which cranial nerve damage may lead to a decrease in the client's olfactory acuity?
Answer
Cranial nerve I
- A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury.
When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern?
Answer
extend- ing
- The nurse caring for a 3-year-old child with meningitis should be alert for which signs and
symptoms of increased intracranial pressure? Select all that apply.
Answer
vomiting
headache irritability 3 / 4
- A nurse should plan to maintain a client who has experienced a subarach- noid hemorrhage
in what position?
Answer
In bed with the head of the bed elevated
- During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds
followed by confusion. Which statement about this type of seizures is true? Select all that apply.
Answer
These seizures increase the risk of injuries due to fall.
These seizures are most resistant to drug therapy.
- A client has a tonic-clonic seizure that involves all extremities. The nurse anticipates that
the healthcare provider will prescribe the intravenous admin- istration of which drug?
Answer
Diazepam
- A primary healthcare provider diagnoses late-stage (tertiary) syphilis in a client. Which
statement made by the client supports this diagnosis?
Answer
"I'm having trouble keeping my balance."
- A client is taking phenytoin to treat clonic-tonic seizures. The client's phenytoin level is 16
mg/L. Which action should the nurse take?
Answer
Administer the next dose of the medication as prescribed.
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