NCLEX Secrets - Neurology Board Review
46. Which of the following assessment findings indicated increased intracranial pressure? Select all that apply
a) headache
b) tachycardia
c) slow respiration
d) narrowing of pulse pressure
e) slow, bounding pulse
f) hyperthermia
47. Which of the following nursing measures should be included when caring for a client with Parkinson's disease?
a) put color on rails in going upstairs
b) provide high toilet seat
c) provide soft mattress
d) apply restraints to reduce tremors
48. Michael suddenly went into seizures. To protect a child from injury the nurse should:
a) retrain the child's arm and legs
b) place a tongue blade in the child's mouth
c) place a pillow under the child's head
d) provide a waterproof pad for the bed
49. The first nursing priority when providing nursing care for Michael is to:
a) administer antibiotic as ordered as soon as possible
b) keep the room quiet and dim
c) explain all the procedures to the patients
d) begin low-flow oxygen per mask
50. Which room should the nurse assign to Ashley?
a) room 201 with Joey, age 2 who underwent surgery for repair of hernia
b) room 206 with Rica, age one who had pneumonia
c) room 210 with Jack age 2 who has cerebral palsy
d) room 214 with no roommate
NCLEX Secrets - Neurology Board Review:
ANSWERS AND RATIONALE
46) A, C, E, F
- increased ICP is characterized by headache, nausea and vomiting, diplopia, increased systolic BP, slow respiration, slow bounding pulse, widening of pulse pressure, hyperthermia/hypothermia, altered LOC, papilledema, lateralizing sign.
47) B
- the client with Parkinson's disease experiences stiffness/rigidity due to inadequate dopamine production. Dopamine is a neurotransmitter that promotes muscle relaxation. High toilet seat facilitates the client's ability to sit during elimination.
48) C
- the child should never be restrained during a seizure because such action by the nurse can cause fracture of the bones. Tongue blade must not be inserted when the child is already having a seizure because of the risk of injury. Placing waterproof pad at this time is no longer advisable. It is correct to slip pillow under the head to protect the head of the child from banging on any hard object.
49) A
- the priority is to treat the patient with antibiotics at the soonest time possible because the longer the disease goes on without treatment, the greater the risk of seizures and of permanent neurologic damage, such as hearing loss, brain damage, blindness, loss of speech, learning disabilities and behavior problems. Non-neurologic complications may include kidney and adrenal gland failure. Bacterial infections of the central nervous system progress quickly. Within hours of the onset of symptoms, the disease can lead to shock and death.
50) D
- Bacterial meningitis is a highly contagious. Therefore the patient must be placed in a private room to prevent transmitting it to other patients. Nurses who will be in contact with patients with meningitis should wear mask, the mask should be discarded right away when it gets moist or wet. The different types of bacterial meningitis are:
- Pneumococcus - this bacterium is the most common cause of meningitis in adults and children. It most often occurs when the bacterium Streptococcus pneumoniae (pneumococcus), the same bacterium that causes pneumonia and ear infections, enters the bloodstream and migrates to the brain and spinal cord. Mode of transmission is the same as pneumonia: droplet, direct contact and through respiratory discharges.
- Meningococcus - this bacterium is another common cause of meningitis in children under age 5, in teens and in young adults. Meningococcal meningitis commonly occurs when bloodstream. It's highly contagious and may cause localized epidemics in college dormitories, boarding schools and on military bases. Five strains of the Neisseria meningitidis bacterium cause meningococcal meningitis. Mode of transmission is by direct contact and respiratory droplets. This type of meningitis is communicable until the meningococci are no longer present from nose and mouth. Prophylactic treatment is Rifampicin taken for 4 days at a dose of 20 mg/kg/day.
- Haemophilus - the Haemophilus influenzae (H. influenzae) bacterium is the leading cause of bacterial meningitis in children under age 5. The use of the Hib vaccine prevents this type of meningitis. When it occurs, it tends to follow an upper respiratory infection, ear infection (otitis media) or sinusitis. Mode of transmission is by droplet infection and discharges from nose and throat during the infectious period. This type of meningitis is no longer communicable 48 hours after starting antibiotic therapy.
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