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 prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider?
Correct Answer: A
Rationale: Shingles at the puncture site increases infection risk, requiring the nurse to notify the provider. Claustrophobia, lack of IV access, or dyspnea can be managed without canceling the procedure.
Question 2 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 3 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 4 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 5 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.