ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 41 : Assessment of the Nervous System Questions
Question 1 of 5
A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication should prompt the nurse to contact the health care provider?
Correct Answer: B
Rationale: Nausea, vomiting, severe headache, photophobia, or altered consciousness post-LP indicate increased intracranial pressure, requiring immediate provider notification. The other findings are not specific to LP complications.
Question 2 of 5
A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client?
Correct Answer: A
Rationale: No special precautions are needed after SPECT, as radioisotopes are eliminated in urine without requiring monitoring or activity restrictions. The other options are unnecessary.
Question 3 of 5
A nurse assesses a client and notes the client's position as indicated in the illustration below: How should the nurse document this finding?
Correct Answer: A
Rationale: Decorticate posturing indicates corticospinal pathway interruption, a serious finding requiring immediate documentation and reporting. The other options do not accurately describe this abnormal posture.
Question 4 of 5
A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)
Correct Answer: A,B,C,D
Rationale: Changes in Glasgow Coma Scale score, abnormal posturing, altered cognition or speech, and nonreactive pupils indicate neurological deterioration, requiring urgent provider notification. Stable vital signs do not necessitate immediate action.
Question 5 of 5
A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)
Correct Answer: A,B,C
Rationale: Asking about allergies (especially to iodine or shellfish), evaluating renal function, and ensuring informed consent are critical to safely administer iodine-based contrast. Assessing breath sounds or hematocrit/hemoglobin is unrelated to CT preparation.