A nurse is helping a client to develop a sleep hygiene program to improve sleep habits. Which of the following would the nurse suggest for this client as part of sleep hygiene? Select all that apply.

A client who has sustained a head injury is being evaluated in the emergency room. The nurse performs a neurological assessment and notes that the client is somnolent. Which of the following describes an somnolent client response? Select all that apply.

A client who has suffered a head injury is brought in to the emergency department. Which question will allow the nurse to best determine if the client is alert and oriented?

The nurse is assigned to an older adult client in the emergency department whose family members report she is “acting bizarre”. The nurse notes a decreasing level of consciousness and confusion. The nurse obtains vital signs which are within normal limits. What is the nurse’s next priority?

A client has been diagnosed with REM sleep behavior disorder. Which of the following is associated with this type of sleep disorder? Select all that apply.

The nurse recognizes that the client is suffering from acute delirium. What is the first action the nurse should take?

A client is dying and has become unconscious but is still breathing. While standing next to the client’s bed, his sister says, “I always wanted to tell him that I loved him, but it was so hard for me. Now it is too late.” Which response of the nurse is most appropriate?

A nurse is caring for a client who has experienced a head injury. The nurse is performing a focused neurological exam and documents that the client’s mental status is obtunded. Which best describes a client’s affect as obtunded?

An unconscious client is brought into the trauma bay after being “found down” in the community. There is no reportable history and no witnesses to any events leading up to the client being found. Which of the following tests would not be appropriate for the client in the immediate time period while in the client is in trauma bay?

A client is brought to the trauma bay after a motor vehicle collision with rollover. The client is unconscious but breathing. On the neurological assessment, the client does not respond to his/her name. The nurse performs a sternal rub and the client’s eyes open, arms flex in no particular direction, and the client mumbles incoherently. The nurse anticipates the next action to be which of the following?

A client is preparing to undergo a craniotomy for treatment of a brain bleed. The nurse performs the pre-operative assessment and includes the Glasgow Coma Scale (GCS). The client is intubated, sedated, and has an endotracheal tube in place for airway management. Which intervention should the nurse utilize to perform the pre-operative assessment?

A client has presented to the emergency department full of energy and unable to sit still. The nurse notes dilated pupils. Vital signs are normal except for tachycardia is present. These assessment findings are consistent with abuse of which substance?

A client is being cared for after a traumatic brain injury. During an initial assessment, the nurse performs the Glasgow Coma Scale and gives the client a score of 8. Which of the following responses from the nurse is appropriate to manage the client’s respiratory rate?

A nurse is completing a neurological assessment in a client with a back injury. Which of the following steps would be part of a test of motor function in this client? Select all that apply.

The nurse notes that a client in the emergency department waiting room is nodding off. The nurse takes their vital signs which are within normal limits. The nurse notes bilateral pinpoint pupils. Which substance does the nurse suspect is being abused by this client?

A nurse is performing a neurological exam on a client who is in the healthcare clinic. Which of the following is a component of assessing deep tendon reflexes? Select all that apply.

An adult client presents to the emergency department with scabs all over their skin and missing teeth. The client has dilated pupils and is sweating despite being afebrile. Which substance does the nurse correctly suspect that this client is using?

The nurse assessed the Babinski reflex on an adult client. The client’s toes fan out and extend in response to the stimulation. How does the nurse interpret this finding?

The nurse is assessing a client with suspected meningitis and needs to check for a Brudzinski’s sign. The client is lying supine. What is the nurse’s next step?

The nurse in the intensive care unit is caring for a client who is intubated and on a ventilator. The nurse needs to check brainstem reflexes by eliciting a cough. Which is the best approach?

The babinski reflex should cause which of the following to occur?

A nurse is caring for a comatose client and needs to test for brain stem function. Which test is used to test brain stem function?

Which of the following is a common cause of increased intracranial pressure (ICP)?

A nurse is evaluating a multi-trauma client in the emergency department. The initial trauma survey has been completed and the c-spine has been cleared. The following are the nurse’s assessment findings: A&0x2 (confusion to date and time), pupils are equal at 6mm, blood pressure 182/86mmHg, heart rate 44 beats/minute, respirations 22 breaths/minute. The healthcare provider orders the head of the bed to be elevated to 30 degrees. The nurse understands that which of the following is the reason for this order?

The nurse is caring for a client with a brain tumor. The client has an altered level of consciousness and is experiencing bradycardia, bradypnea, and a widening pulse pressure. Which of the following interventions are appropriate for this client? Select all that apply.

The nurse receives report on a client on blood thinners who fell down the stairs and has periorbital ecchymosis. The head CT came back with an intracerebral hemorrhage. Which of the following is the most important to monitor closely?

A client has sustained a head injury. Which of the following is part of the nursing plan? Select all that apply.

A client who has experienced a head injury is being cared for by the nurse in the ICU. The client has a monitor in place to check intracranial pressure and the nurse notes that the pressure is increasing. Which of the following interventions by the nurse should be done to control increasing intracranial pressure?

A 28-year-old client has been brought into the emergency department after suffering a closed head injury from a fall. The client is demonstrating signs of the Cushing reflex. Based on the nurse’s understanding of this condition, the nurse knows to look for which of the following signs?

A nurse is caring for a client who suffering from bilateral subdural hematomas whose ICP has been ranging from 15-20 mm Hg. Which of the following orders should the nurse question?

The nurse is working with a 39-year-old client who has suffered a head injury as a result of a fall from a scaffold. Which of the conditions listed most likely describes increased intracranial pressure as a result of increased tissue volume?

A nurse comes on to her shift in the ICU where she is assigned a client with a head injury. The client requires a ventilator and has a monitor in place to check intracranial pressure. As the nurse enters the room, the pressure monitor alarms that the client’s intracranial pressure is rising. In response, the nurse should do which of the following?

The nurse is caring for a client who is recovering from abdominal surgery. The client suddenly develops restlessness, a weak, rapid pulse and hypotension. The nurse suspects which of the following conditions has developed?

A 63-year-old client is being cared for in the ICU after a stroke. This client has invasive cardiac monitoring through a Swan-Ganz catheter. The nurse notes that the mean arterial pressure (MAP) reading has been between 100 and 112 mmHg. These pressures indicate which of the following?

A client with a head injury has an intracranial pressure monitor in place. The nurse is monitoring the cerebral perfusion pressure (CPP). Which interventions would the nurse employ while monitoring this client’s CPP? Select all that apply.

A 58-year-old client with multiple sclerosis is suffering from bowel incontinence after having a stroke. Which intervention would most likely help the client to manage this condition?

The nurse is caring for a client who is newly diagnosed with multiple sclerosis. Which of the following is appropriate teaching for this client?

The nurse is assessing a client with multiple sclerosis and notes the client is experiencing tremors and muscle weakness. The client is scheduled for several tests that require transport off the floor, as well as a physical therapy session during the shift. Which of the following nursing actions would be most helpful for this client?

A nurse is caring for a client who is experiencing trouble with coordination and balance, spastic muscles, and numbness and tingling in the extremities. This client is most likely suffering from which of the following?

The nurse is working a shift in the hospital and is assigned to care for a client with advanced multiple sclerosis. Which of the following would most contribute to the client’s overall level of functioning?

A client who has been incontinent of stool needs skin cream to prevent skin breakdown. How does application of skin barrier prevent wound development?

A client who suffers from multiple sclerosis (MS) struggles with spasticity of the leg muscles and requires assistance with ambulation. Which ambulatory assistive device would be most appropriate for a client with muscle spasticity? Select all that apply.

A client presents to the emergency department with abdominal pain. The client states she has not had a bowel movement for one week. An X-ray confirms constipation, and the provider is concerned about a blockage if the client doesn’t have a bowel movement soon. Which of the following medications pulls water into the colon to soften the stool?

A case management nurse is working in a long-term care facility. A new resident has been admitted with symptoms of Parkinson’s disease. Which of the following activities best demonstrates that the case manager is promoting client independence?

The nurse is caring for a client with Parkinson’s disease. During the physical assessment, the nurse notes that which of the following signs and symptoms are consistent with this disease? Select all that apply.

A client with Parkinson’s disease has tremors in the hands that make eating difficult. Which of the following adaptive devices could the nurse employ that would help this client eat?

The nurse is caring for a client who is newly diagnosed with Parkinson’s disease. Which of the following statements by the client’s spouse indicates that more education is needed? Select all that apply.

The nurse is caring for a client with Parkinson’s disease. The nurse anticipates that which type of medication will be administered to manage the disease?

A nurse is educating a 65-year-old client who has recently been diagnosed with Parkinson’s disease. The client asks the nurse, “Will my daughter get Parkinson’s when she is my age?” Which answer from the nurse is correct?

A client with Parkinson’s disease has been started on carbidopa-levodopa for the management of tremors and slow movement. The nurse instructs the client’s family about serious side effects of this drug, which include which of the following?

A nurse is working with a woman who cares for her mother in her home. The mother has Parkinson’s disease and has difficulty getting around. What information would most likely help this client to keep her mother safe in their home?

A 66-year-old client who has just been diagnosed with Parkinson’s disease has many questions for the nurse. Which information regarding cognitive changes is associated with early Parkinson’s disease? Select all that apply.

A 76-year-old client is being seen for a follow-up appointment after starting a prescription for Parkinson’s disease. The nurse asks the client if she experiences symptoms that indicate decreases in blood pressure. Which symptom would the nurse expect to assess if this client is experiencing this side effect?

A client with trigeminal neuralgia complains to the nurse that she feels extreme pain in her face any time she touches it. Which of the following medications would most likely be ordered for pain control for this condition?

The nurse is caring for a client who has trigeminal neuralgia. Which of the following are appropriate nursing interventions? Select all that apply.

While preparing to give a bed bath to a client with Guillain-Barre syndrome, the nurse knows that this client will likely have which of the following deficits?

The client has been diagnosed with Bell’s palsy. Which of the following is a priority nursing intervention?

The client has been diagnosed with Guillain-Barre syndrome. Which of the following are appropriate nursing interventions? Select all that apply.

A nurse is caring for a client who is experiencing gradual paralysis that started from the toes and has moved up the legs. The nurse knows that the client’s peripheral nervous system has been attacked causing disruption in communication of the nerves because this client is suffering from which of the following?

The nurse is caring for a client who had an intracerebral hemorrhagic stroke. The family members are concerned about how this could happen. Without knowing the cause of this client’s stroke, the nurse correctly informs the family that which of the following is the number one reason for intracerebral hemorrhagic stroke?

The nurse is caring for a client admitted for hemorrhagic stroke 12 hours ago. The nurse should make sure the bed is in which position?

A nurse is caring for two clients that have been admitted to the unit with a hemorrhagic stroke. The nurse assistant gives the the following vitals for the two clients. Which of the following abnormal vital signs is the most concerning?

The nurse is caring for a client who had a hemorrhagic stroke. The nurse should question which of the following orders?

A client presents to the emergency department with stroke symptoms. A stat head CT is completed. The nurse immediately prepares to give tPA (tissue plasminogen activator) as ordered. Why?

The priority nursing intervention when caring for a client with an ischemic stroke includes which of the following?

A 67-year-old client has suffered an ischemic stroke and is being assessed at a healthcare facility. Which of the following would be part of the emergency initial treatment of this client? Select all that apply.

A nurse is caring for a client who suffered from a large ischemic stroke. Which of the following assessment findings is the MOST concerning?

A client who has suffered a transient ischemic attack has been ordered to undergo a carotid duplex. Which best describes how this test is performed?

The nurse is caring for a client who was admitted to the hospital for an ischemic stroke which occurred less than 24 hours ago. The nurse should make sure this client’s bed is in which position?

A nurse is reviewing the mnemonic for stroke, which is “FAST”. The nurse remembers the “A” standing for which of the following?

A nurse assessing a client who has a new onset of stroke-like symptoms. The nurse assesses the “S” in “FAST”. This stands for which of the following?

The nurse is caring for a client whose visiting spouse suddenly becomes confused and is noted to have aphasia. What is the priority concern for this person?

The nurse is working in the emergency department and receives an older adult client with a new onset of right sided weakness, confusion and facial droop that started 30 minutes prior to arrival. The client has the following orders: Vital signs, EKG, blood work, and CT of the head. Which is the most significant and important order for this client’s situation?

A home health nurse suspects that the client has had a stroke. The nurse assesses the client using the mnemonic “FAST”. Which of the following correctly represents the “T” in this mnemonic?

A nurse is providing community education to a group about how to recognize the signs of a stroke. The nurse teaches the group that if a person thinks they are suffering a stroke, a rapid method of detection is to follow the acronym STR by performing certain tasks that can indicate dysfunction. The letters of this acronym stand for:

The nurse is caring for a client who has been admitted for a femoral-popliteal bypass graft, scheduled for the following morning. The nurse answers the call light and the client informs the nurse with clearly formed speech that the left side of his face feels numb, and his left arm and leg are really weak. What is the nurse’s next priority?

A client with hypertension reports to the hospital complaining of chest pain radiating to the back. The client is admitted for hypertensive emergency. The nurse notes the client’s vital signs have changed suddenly, and the client’s left arm is weak and cool. Based on the vital signs in the chart, what is the nurse’s priority action at this time?

A client who has had a stroke is suffering from expressive aphasia. Which interventions would most likely improve communication with this client?

A nurse has assessed 4 clients in the emergency room. Which of the following is the priority to pass on to the healthcare provider?

The nurse is working in the emergency department with a client who presented with stroke-like symptoms. A non-contrast head CT was performed and was negative for hemorrhagic stroke. The provider wants tissue plasminogen-activase administered, and has placed the following orders. Which of the following orders must be completed first?

The nurse is caring for a client who fell and hit their head. The CT results show that the client has a fracture in the zygomatic arch but is negative for a brain bleed. While the nurse is talking to the client suddenly the client doesn’t know who they are or where they are. What is the very first thing the nurse should do?

The nurse is caring for a client who has been admitted for a stroke. Vital signs and neurological exams have been stable. The client has a follow-up CT scan of the head for tomorrow, orders to see PT/OT, a diet order, and sequential compression devices to be placed. The client has also requested a glass of water. What is the nurse’s priority at this time?

A 70-year-old client has balance problems as a result of a stroke. A nurse has been seeing this client in the home for continued monitoring of medication regimens and personal care. Based on the nurse’s knowledge of the client’s medical condition, the nurse knows that balance problems can cause which of the following?

The nurse is caring for a client who is recovering from a stroke. Which of the following observations support that the patient has developed neglect syndrome? Select all that apply.

A client who had a stroke has been diagnosed as having self-care deficit and is unable to feed or groom independently. Which of the following therapeutic interventions would be most appropriate in this situation?

A nurse is caring for a client who is recovering from a stroke and has difficulties swallowing. The client must only consume liquids thickened to a nectar consistency. Which of the following is a true statement regarding nectar-thick liquids? Select all that apply.

A 79-year-old client had a stroke and needs assistance to eat. Which of the following describes how the nurse could preserve the dignity of this client? Select all that apply.

A nurse is caring for a client who is recovering from a stroke. The nurse arranges for a swallowing screening to be performed. Which best describes the purpose of this test?

Intermediate and rehabilitative care needs for a client with stroke include which of the following? Select all that apply.

A nurse is caring for a client who is having difficulties with swallowing after a stroke. Which of the following interventions should the nurse employ to help this client with PO intake?

A nurse is caring for an 80-year-old client who is in rehabilitation after having a stroke. The nurse is teaching the client about how to use a nosey cup. Which of the following best describes this device?

A client requires services from a speech and language pathologist after suffering a stroke. After the speech pathologist sees the client, the nurse notes that the therapist documents information in the client’s chart. Which response from the nurse demonstrates understanding of the role of the speech-language pathologist’s services?

The priority nursing intervention to prevent seizures is which of the following?

A client with a seizure disorder has been admitted to the hospital for surgery. The client has a seizure approximately once per month despite being on medications. This client is often triggered by environmental effects that can lead to a seizure. Which environmental condition is an example of a commonly reported seizure trigger with this disorder?

The nurse is caring for a client who had a seizure. Which of the following are common causes of a seizure? Select all that apply.

A client recently diagnosed with a seizure disorder says, “I’m so afraid I’m going to have a seizure again. How do I prevent them from happening?” Which lifestyle changes would decrease the risk of seizures? Select all that apply.

A 20-year-old client is being admitted to the hospital after a minor head injury during a seizure. During the intake assessment, the nurse asks the client her medical history. Which information would most likely be part of the client’s medical history that would increase the risk of a seizure?

The nurse is caring for a client with an order for daily lamotrigine. The nurse understands that this drug is taken for which of the following conditions?

A nurse is caring for a client who is receiving care in the acute care clinic after overdosing on diazepam. The nurse understands that excess CNS depressants can lead to complications including seizures, shock, and coma. Which of the following best describes the first intervention by the nurse?

A 25-year-old client with a seizure disorder tells the nurse that he often has an aura before a seizure starts. Which best describes a common symptom that may occur during an aura?

Which best describes a Jacksonian seizure?

A client who has a seizure disorder has been prescribed carbamazepine for control of the seizures. Which information is most important for the nurse give to the client before starting this medication?

The nurse is caring for a client who has a confirmed seizure disorder and is currently in a postictal state after a seizure. Several hours after the seizure, the client starts to develop hallucinations and becomes aggressive with caregivers. Which action is by the nurse is most appropriate for the treatment of this condition?

A client with a history of seizures takes medications to help control the seizures, but must start an additional anti-seizure medication. The client remembers that they are taking levetiracetam. However, the client cannot remember the name of the medication that the provider has just prescribed. Which of the following medications is most appropriate to help manage this client’s condition?

Which of the following medication is used for absence seizures?

A 36-year-old client with a history of epilepsy is in the hospital and experiences a seizure. For several minutes following the seizure, the client is calm but does not regain consciousness. The client then starts having another seizure. Which action is the first priority for the nurse?

A nurse is caring for a client with a seizure disorder. While in the hospital, the client experienced a tonic-clonic seizure. What interventions of the nurse are most appropriate during the postictal state? Select all that apply.

Which of the following is a priority nursing intervention following a seizure?

The nurse is caring for 4 clients who each have levetiracetam (Keppra) ordered. Which client will need this medication first?

The nurse is caring for a client who exhibits seizure-like activity. What action should the nurse do first?

The nurse is caring for a client who has a history of seizures and takes carbamazepine. Which of the following drugs does the nurse question for this client?

The nurse is expecting admission of a seizure client and is setting up the room. What is the most important thing to get ready prior to client arrival?

The nurse is caring for a client with a history of seizures. The client starts to actively seize. What is the very first thing the nurse should do?

The triage nurse has 4 clients that all have stable vital signs and patent airways. The nurse is trying to determine which client is the priority. Based on the following, which client should the nurse make a priority?

A client with epilepsy has regular tonic-clonic seizures. Which precautions would the nurse use to modify the hospital environment that would most likely keep this client safe?

A priority nursing intervention in caring for a client who is having a seizure includes what intervention?

A client is in the hospital after being recently diagnosed with a seizure disorder. The nurse is helping the client understand how to stay safe in case a seizure occurs. Which of the following information should the nurse include as part of teaching? Select all that apply.

A 54-year-old client who has suffered from a head trauma has developed seizures as a result of his condition. The client is afraid that he will have a seizure when he is away from home. Which information should the nurse give to this client that will help him to manage this situation?

A nurse is caring for a client who has Streptococcus pneumoniae infection. Which best explains why the nurse must report this condition to public health officials?

The nurse caring for a 15-year-old admitted with possible meningitis knows that which of the following infection control precautions should be put into place for the client?

A nurse is setting up a sterile field to assist with a lumbar puncture on a client suspected of having meningitis. Which practices should the nurse perform during the client’s procedure that would uphold the sterile technique? Select all that apply.

A nurse is assisting the provider with a lumbar puncture on a client with potential meningitis. Which actions are part of assisting with a lumbar puncture? Select all that apply.

A nurse is caring for a child with meningitis. What personal protective equipment (PPE) should the nurse implement?

The nurse is caring for a client with bacterial meningitis. Which of the following is a priority nursing intervention?

A client who has had a lumbar puncture develops a severe headache after attempting to sit up in bed. The nurse recognizes this complication as which of the following?