HESI (NCLEX-PN) Exam - Intracranial Regulation

Intracranial Regulation

•             Initially after a brain attack (cerebrovascular accident), a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing?

•             A client is admitted to the hospital with a tentative diagnosis of a brain tumor. The nurse recalls that the diagnostic test conducted to confirm this diagnosis is what?

•             What action should be included in the nursing care of an infant with increased intracranial pressure?

•             A client who had a brain attack (CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. What does the nurse document this response as?

•             Which antiepileptic drug can cause photophobia?

•             The parents of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus are concerned about the prognosis. What information should the nurse give the parents?

•             What therapeutic effect does the nurse expect to identify when mannitol is administered parenterally to a client with cerebral edema?

•             A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP).

Which intervention should the nurse perform first?

•             A nurse is caring for a client with an underactive thyroid gland. Which responses should the nurse expect the client to exhibit as a result of decreased levels of triiodothyronine (T 3) and thyroxine (T 4)? Select all that apply.

•             Which symptom in the client indicates late-stage brain herniation?

•             The nurse is caring for a client with increased intracranial pressure (ICP). What clinical manifestations are associated with increased ICP? Select all that apply.

•             A nurse notes that a child is exhibiting signs of cerebral palsy. At what age are these signs usually first noticeable?

•             A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" What is the nurse's bestresponse?

•             A client with a 5-year history of myasthenia gravis is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. The nurse expects what client response?

•             The nurse, caring for a 3-year-old child with meningitis, should be alert for which signs and symptoms of increased intracranial pressure? Select all that apply.

•             The nurse is performing a neurologic assessment on a client and is completing the Glasgow Coma Scale (GCS). What components make up this assessment tool? Select all that apply.

•             Which drug is only beneficial for treating an absence seizure?

•             After surgery for repair of a myelomeningocele, the nurse places the infant in a side- lying position with the head slightly elevated. What is the reason this position is used?

•             The nurse is caring for a client who has a tumor of the cerebellum. What is the client most likely to exhibit?

•             A client arrives at the nursing unit with neurological deficits after a motor vehicle accident. Using the Glasgow Coma Scale, the nurse assesses what client responses? Select all that apply.