Adaptive Quizzing Neurologic and Sensory Systems

A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed w/ a seizure disorder. Which is most important for the nurse to include in a teaching program? a) explain ways to prevent physical trauma from occurring during a seizure b) teach that anticonvulsant medications should be taken on an empty stomach c) teach that the symptoms and treatment of seizure disorders are similar, regardless of the cause d) explain that it is not necessary to tell others of the illness because medications will control seizures

a) explain ways to prevent physical trauma from occurring during a seizure -client may become injured in many ways during a seizure, and trauma prevention is a priority. Anticonvulsants can cause GI distrubances, especially early in therapy, and should be taken w/ food. Seizures and seizure disorders are not similar; they vary greatly. Other should understand the condition and be taught how to help

A nurse is caring for a client who has urinary incontinence as the result of cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? a) insert a urinary retention catheter b) institute measure to prevent constipation c) encourage an increase in the intake of caffeine d) suggest that a carbonated beverage be ingested daily

b) institute measures to prevent constipation -a full rectum exert may exert pressure on the urinary bladder, which may precipitate urinary incontinence. Urinary retention catheters should not be used to manage urinary incontinence initially. The use of a catheter keeps the bladder empty, which promotes atony and incontinence. Caffeine acts as a diuretic and is a urinary bladder irritant; both promote urinary incontinence. Carbonated beverages irritate the urinary bladder, which promotes urinary incontinence

Which visual system assessment technique provides a magnified view of the retina and optic nerve head? a) keratometry b) ophthalmoscopy c) visual acuity testing d) confrontation visual field test

b) ophthalmoscopy -provides a magnified view of the retina and optic nerve heard. Keratometry measures corneal curvature. Visual acuity testing determines distance and near vision acuity. The confrontation visual field test determines if a pt has a full field of vision without obvious scotomas

The nurse is caring for a client with Parkinson disease. Which is a priority nursing concern? a) decreased physical mobility related to stooped posture b) risk for injury related to gait disturbances c) impaired skin related to drooling d) pain related to headashe

b) risk for injury related to gait disturbances -client w/ Parkinson disease may fall because of gait disturbances. Decreased mobility and impaired skin are problems but not the priority. Pain is usually not a manifestation of Parkinson ds.

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level? a) asking the client's parent b) using wong's "pain faces" c) observing the client's body language d) explaining the use of a 0 to 10 pain scale

b) using wong's "pain faces" -an adult client w/ limited mental capacity may not understand the concepts of numbers as an indicator of levels of pain; wong's "pain faces" uses pictures to which the individual can relate

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis? a) narrowed airways b) impaired immunity c) ineffective coughing d) viscosity of secretions

c) ineffective coughing -weakened muscles result in ineffective coughing; secretions are retained and provide a medium for bacterial growth. The airways are not narrowed. Immune mechanisms are not impaired directly. Viscosity of secretions depends on fluid intake and humidity.

A nurse performs preoperative teaching for a client who is to have cataract surgery. Which is most important for the nurse to include concerning what the client should do after surgery? a) remain flat for three hours b) eat a soft diet for two days c) breathe and cough deeply d) avoid bending from the waist

d) avoid bending from the waist -bending increases intraocular pressure and must be avoided. Remaining flat for three hours and eating a soft diet for two days are not necessary. Coughing deeply increases intraocular pressure and is contraindicated

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. Which diagnostic test result will the nurse check for confirmation of this diagnosis? a) myelography b) lumbar puncture c) electromyography d) computed tomography

d) computed tomography -is the most definitive test for identifying unexpected structures in the brain

A nurse is teaching a client with a diagnosis of open-angle glaucome. The nurse explains that the chief aim of treatment is to meet which goal? a) rest the eye b) dilate the pupil c) prevent secondary infections d) control the intraocular pressure

d) control the intraocular pressure -individuals w/ glaucoma have increased intraocular pressure that must be returned to the expected range, or blindness will result

A client is scheduled for a labyrinthectomy to treat Meniere syndrome. Which expected outcome of the procedure should be included in preoperative teaching? a) absence of pain b) decreased cerumen c) loss of sense of smell d) permanent irreversible deafness

d) permanent irreversible deafness -the labyrinth is the inner ear and consists of the vestibule, cochlea, semicircular canals, and other structures. A labyrinthectomy is performed to alleviate the symptom of vertigo but results in deafness on the affects side, because the organ of Corti and cochlear nerve are located in the inner ear. There is no pain associated with this.

A client who had a craniotomy is transferred to the intensive care unit from the postanesthesia care unit. Which nursing action is most important when caring for the client? a) take axillary and oral temperature b) encourage coughing, but discourage deep breathing c) administer a prescribed opioid or sedative at the first sign of irritability d) report yellow or bloody drainage on the dressing to the healthcare provider immediately

d) report yellow or bloody drainage on the dressing to the healthcare provider immediately -yellow drainage may be cerebral spinal fluid, and bloody drainage is a sign of hemorrhage