Med-Surg Practice Test #6: Neurological

Answer: C. Keep the head of the bed elevated, usually about 30 degrees unless ordered otherwise, with the head and neck in a straight midline position.

Rationale: Raising the head of the bed (commonly about 30 degrees, unless the provider orders a different position or the spine is not yet cleared) and keeping the head and neck midline help blood drain from the brain through the jugular veins, which lowers ICP. Turning or bending the neck, sharp hip flexion, coughing, straining and Valsalva all raise ICP. Option A is wrong because suctioning raises ICP; it is done only when needed, kept brief, and done as the facility protocol directs. Option B is wrong because lying flat can raise ICP, and a pillow under the knees encourages hip flexion and blood clots. Option D is wrong because back-to-back activities raise ICP in steps; care is spaced out with rest periods between. Other care: a calm, quiet room, prevention of fever, stool softeners as prescribed to avoid straining, and frequent neuro checks with any decline reported right away.

Answer: A. BP 178/62 mm Hg, heart rate 48/min, irregular respirations

Rationale: Option A shows Cushing's triad: rising systolic blood pressure with a widening pulse pressure, a slowing heart rate and an irregular breathing pattern. It means the brainstem is under pressure and the brain may be about to herniate. This is a late and ominous sign, so the nurse calls the rapid response team or provider at once while continuing to support the airway. Earlier signs of rising ICP are often a change in level of consciousness (restlessness, confusion, drowsiness), headache, vomiting and pupil changes; nurses should act on these before Cushing's triad appears. Option B, low blood pressure with a fast heart rate, points to hypovolemic shock, not rising ICP. Option C is within usual ranges. Option D suggests infection or fever, which should be treated because fever raises the brain's oxygen demand, but it is not the pattern of rising ICP.

Answer: D. Keep the client NPO, including oral medications, until a swallow screen has been done according to facility protocol.

Rationale: Dysphagia is common after a stroke, and many clients aspirate without coughing (silent aspiration), which can lead to pneumonia. Stroke guidelines (American Heart Association/American Stroke Association) recommend a swallow screen before the client takes anything by mouth, including food, fluid and medications. Being alert does not mean the client can swallow safely, so option A is wrong. If the client fails the screen, the nurse keeps the client NPO, notifies the provider, a speech-language pathologist evaluates swallowing, and medications are given by another route as prescribed. Option B is wrong because thin liquids and straws are among the hardest for a client with dysphagia to control. Option C is wrong because no food should be given until the screen is passed and the diet is ordered. When eating is allowed, the client sits upright, eats slowly with small bites, and may need the chin tucked when swallowing or thickened liquids, as the speech-language pathologist recommends.

Answer: B. Breathing: respiratory effort, ability to cough and swallow, and vital capacity measurements as ordered

Rationale: Guillain-Barré syndrome is an immune attack on the peripheral nerves that often follows a viral or bacterial infection. Weakness usually starts in the legs and moves upward. When it reaches the chest and diaphragm, the client can develop respiratory failure, sometimes quickly, so breathing is the priority. The nurse checks respiratory rate and effort, the strength of the cough, the ability to swallow and handle secretions, and serial vital capacity or negative inspiratory force measurements as ordered. A falling vital capacity, a weak cough, trouble speaking in full sentences or rising carbon dioxide must be reported right away because the client may need intubation. Option A is expected: reflexes are usually reduced or absent. Options C and D matter, and pain from nerve damage can be severe, but they come after airway and breathing. The nurse also watches for autonomic problems such as swings in blood pressure and heart rate.

Answer: C. "Remove throw rugs, wear well-fitting shoes, keep your feet apart and practice taking big steps, lifting your toes."

Rationale: Parkinson disease causes slow movement, rigidity, a stooped posture and a shuffling gait with short steps, so falls are a major risk. Clearing trip hazards such as throw rugs and cords, wearing supportive shoes with nonslip soles, keeping a wider base of support, and consciously taking larger steps with the toes lifted all lower the risk. For freezing, clients are often taught to stop, then step over an imaginary line or march to a rhythm or count; a physical therapy referral helps. Option A describes the festinating gait the client is trying to avoid; quick small steps make falling forward more likely. Option B is wrong because loose, soft slippers slip and catch. Option D is wrong because clients with Parkinson disease often have orthostatic hypotension (from the disease and from medications such as carbidopa-levodopa), so they should rise slowly, and furniture may move or tip. Grab bars and a raised toilet seat also help.

Answer: A. "I'll avoid hot baths, hot tubs and saunas, because heat can make my symptoms worse for a while."

Rationale: MS damages the myelin around nerves in the brain, spinal cord and optic nerves. A rise in body temperature, from a hot bath, hot weather, exercise or fever, slows conduction in damaged nerves and can bring back or worsen symptoms for a short time (Uhthoff phenomenon, also called a pseudo-relapse). These symptoms usually ease once the body cools. Option B is wrong: regular exercise is encouraged, but in cool settings and with rest periods, because fatigue and heat both worsen symptoms. Option C is wrong because disease-modifying therapies reduce relapses and slow disease activity even when the client feels well; they are stopped or changed only with the provider. Option D is wrong because new symptoms lasting more than about a day, such as vision loss or pain with eye movement, may be a relapse and should be reported. Infections, including urinary tract infections, can also trigger worsening and should be treated.

Answer: D. Place the client in a private room on droplet precautions.

Rationale: Fever, headache, neck stiffness and a petechial or purpuric rash suggest meningococcal meningitis, which spreads through respiratory droplets. Droplet precautions in a private room protect staff and other clients; CDC guidance is to continue them until the client has received 24 hours of effective antibiotic therapy, following facility policy. Option A is wrong and dangerous: bacterial meningitis can kill within hours, so blood cultures are drawn and IV antibiotics (and often dexamethasone) are started as soon as possible, as prescribed; treatment should not wait for a lumbar puncture or CT scan. Option B is wrong because clients are often sensitive to light; a dim, quiet room adds comfort and lowers the risk of agitation. Option C is wrong because some bacterial meningitis, especially meningococcal, is contagious, and close contacts may need preventive antibiotics. The nurse also monitors level of consciousness, signs of rising ICP, seizures and signs of septic shock.

Answer: B. "It came on all at once while I was lifting weights. It's the worst headache of my life."

Rationale: A sudden, explosive headache that peaks within seconds to a minute (a thunderclap headache), especially during exertion, is the classic warning sign of a subarachnoid hemorrhage, often from a ruptured brain aneurysm. The client may also have a stiff neck, vomiting, sensitivity to light, a brief loss of consciousness or a seizure. This client needs immediate neuro checks, a quiet room with low stimulation, seizure and aspiration precautions, and notification of the provider for urgent CT imaging. Blood pressure is managed to a goal set by the provider. Option A describes a typical migraine pattern that is unchanged from the client's usual headaches. Option C describes a tension-type headache. Option D describes caffeine withdrawal. Any headache that is new, sudden, the worst ever, or comes with neuro deficits, fever or confusion needs urgent evaluation.

Answer: A. Place the call light, phone and meal tray within reach on the client's right side, and coach the client to turn the head to scan to the left.

Rationale: A right-hemisphere stroke often causes left-sided neglect (unilateral neglect): the client does not attend to the left side of the body or space. Many clients also have left visual field loss (homonymous hemianopia) and act impulsively with poor awareness of their deficits, which raises fall risk. For safety, essential items such as the call light go where the client can see and reach them, on the unaffected right side, while the nurse coaches the client to turn the head and scan to the left and reminds the client to check the position and care of the left arm and leg. As rehabilitation progresses, the team gradually encourages attention to the affected side. Option B removes access to the call light and is unsafe. Option C is wrong because restraints are a last resort, need a prescription and can increase injury and agitation. Option D is wrong because aphasia is more typical of a left-hemisphere (dominant side) stroke; speaking loudly does not help understanding.

Answer: C. Neurogenic shock from loss of sympathetic nerve control

Rationale: An injury at about T6 or above can cut off the sympathetic nerves that tighten blood vessels and speed up the heart. Without them, the blood vessels dilate and the heart rate slows, causing neurogenic shock: low blood pressure, a slow heart rate and warm, dry, flushed skin below the injury. It usually appears in the first hours to days. The nurse notifies the provider and gives treatment as prescribed, which may include IV fluids, vasopressors and atropine for a symptomatic slow heart rate, aiming for the blood pressure goal the provider sets. Option A is less likely: hypovolemic shock usually causes a fast heart rate and cool, clammy skin, although trauma clients can have both, so the nurse still assesses for bleeding. Option B causes severe high blood pressure, not low, and usually occurs after the acute phase. Option D does not fit this picture. With a C5 injury, the nurse also watches breathing closely, because the diaphragm (C3–C5) and the muscles used for coughing can be weakened.