adult health test 10

To evaluate a client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?"

A client has been exhibiting neurological symptoms for several weeks and the neurologist is admitting the client to the hospital for extensive testing. Since diagnostics have not yet revealed the cause of the symptoms, which client statement would indicate the need for further client education?

"It's good to know the continual tingling in my fingers and toes is not connected with my nervous system!"

A family member brings the client to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer?

"Stop smoking as soon as possible."

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3

An elderly client is being discharged home. The client lives alone and has atrophy of his olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home?

A smoke detector

A client with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

Absence of reflexes along with flaccid extremities

A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school?

Absence seizure

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine

The nurse is caring for a client who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve?

Acoustic

A client with a metastatic brain tumor of the frontal lobe experiences a generalized seizure for the first time. The nurse should prepare for what action?

Administration of anticonvulsants

A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions?

Applying a protective eye shield at night

A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache?

As soon as the client senses the onset of symptoms

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?

Ask the client if he has trouble breathing.

Which nursing intervention is the priority for a client in myasthenic crisis?

Assessing respiratory effort

The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping?

Assist the family in setting appropriate short-term goals.

The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication?

Autonomic dysfunction

The nurse is caring for a client whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be prescribed to control this?

Baclofen

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

Bradycardia and hypertension

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

Bradypnea Hypertension Bradycardia

A client with a spinal cord injury has full head and neck control when the injury is at which level?

C5

At which of the following spinal cord injury levels does the patient have full head and neck control?

C5

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Call the health care provider immediately.

A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken together with warfarin will produce which type of interaction?

Can greatly increase the international normalization ratio (INR), increasing the risk of bleeding

Bleeding

Cardiac and respiratory status

A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the:

Cerebellum.

A client is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority?

Close monitoring of fluid balance

The nurse planning the care of a client with head injuries is addressing the client's nursing diagnosis of "sleep deprivation." What action should the nurse implement?

Cluster overnight nursing activities to minimize disturbances.

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP?

Decerebrate posturing and loss of corneal reflex

The physician has prescribed a somatosensory evoked responses (SERs) test for a client for whom the nurse is caring. The nurse is justified in suspecting that this client may have a history of what type of neurologic disorder?

Demyelinating disease

A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's complaints of headache?

Dimming the lights and reducing stimulation

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for?

Dyskinesia

The nurse is performing an assessment for a patient in the clinic with Parkinson's disease. The nurse determines that the patient's voice has changed since the last visit and is now more difficult to understand. How should the nurse document this finding?

Dysphonia

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?

Ecchymosis over the mastoid

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?

Electroencephalography (EEG)

Which term refers to a method of recording, in graphic form, the electrical activity of a muscle?

Electromyography

A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease?

Elevated protein levels in the CSF

A client has undergone a lumbar puncture for a neurological assessment. The client is put under the post-procedure care of a nurse. Which important post-procedure nursing interventions should be performed to ensure maximum comfort for the client? Select all that apply.

Encourage a liberal fluid intake for the client. Position the client flat for at least three hours or as directed by the physician.

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort?

Encourage the client to drink liberal amounts of fluids

Which statement reflects nursing management of the client with expressive aphasia?

Encourage the client to repeat sounds of the alphabet

A patient scheduled for a magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should:

Ensure no metal-containing objects are present.

A 25-year-old female client with brain metastases is considering her life expectancy after her most recent meeting with her oncologist. Based on the fact that the client is not receiving treatment for her brain metastases, what is the nurse's most appropriate action?

Ensuring that the client receives adequate palliative care

A client with MS has been admitted to the hospital following an acute exacerbation. When planning the client's care, the nurse addresses the need to enhance the client's bladder control. What aspect of nursing care is most likely to meet this goal?

Establish a timed voiding schedule.

Splints have been prescribed for a client who is at risk of developing foot drop following a spinal cord injury. The nurse should remove and reapply the splints when?

Every 2 hours

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what?

Evidence of hemorrhagic stroke

Bell palsy is a disorder of which cranial nerve?

Facial (VII)

The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication?

Falls

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply.

Frequent oral care Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

Frontal

Which is a nonmodifiable risk factor for ischemic stroke?

Gender

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? c

Generalized

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?

Gingival hyperplasia

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool?

Glasgow Coma scale

A patient is having a lumbar puncture and the physician has removed 20 mL of cerebrospinal fluid. What nursing intervention is a priority after the procedure?

Have the patient lie flat for 6 hours.

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness

An emergency department (ED) nurse has administered an ordered bolus of tissue plasminogen activator (tPA) to a male patient who was diagnosed with stroke. During the administration of tPA, the nurse should prioritize assessments related to what problem?

Hemorrhage

Which term refers to the shifting of brain tissue form an area of high pressure to an area of low pressure?

Herniation

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

High in protein and low in carbohydrate

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution?

Hot or cold packs

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include?

How to correctly modify the home environment

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:

Hypertension

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?

I was brushing my teeth."

The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure?

IV diazepam

A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition?

Impaired verbal communication

A nurse is providing care to a client who has been diagnosed with metastatic brain cancer. When developing the client's plan of care, which outcome would the nurse most likely identify?

Improved quality of life

The nurse in an extended care facility is planning the daily activities of a client with post-polio syndrome. The nurse recognizes the client will best benefit from physical therapy when it is scheduled at what time?

In the morning

A client is having a "fight or flight response" after receiving bad news about his prognosis. What affect will this have on the client's sympathetic nervous system?

Increase in the secretion of sweat

The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?

Increase the frequency of ROM exercises.

The nurse has admitted a new client to the unit. One of the client's admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system?

Increased heart rate

A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of:

Increased intracranial pressure (ICP)

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?

Initiate seizure precautions.

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

Irrigates the wound to remove debris

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?

It allows for stabilization of the cervical spine along with early ambulation.

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply.

Keep a food diary. Maintain a headache diary.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

Keeping the client in one position to decrease bleeding

A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of:

Leakage of cerebrospinal fluid (CSF)

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?

Lioresal (Baclofen)

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

Look for signs of increased intracranial pressure

A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?

Loss of brain stem reflexes

A client is scheduled for a myelogram and the nurse explains to the client that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests?

Lumbar puncture

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment?

Lumbar puncture

An older adult patient has been brought to the emergency department (ED) after being found unconscious by a neighbor. What action should be the ED nurse's highest priority in the care of this patient?

Maintain the patency of the patient's airway.

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Maintains a patent airway

A client is brought to the ED by her family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?

Making openings in the skull

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication?

Mannitol

Osmotic diuretics are an essential intervention for reducing cerebral edema. Which of the following drugs is most frequently prescribed for this situation?

Mannitol

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis?

Neck flexion produces flexion of knees and hips

A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?

Noncontrast computed tomogram

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury?

Pad the side rails of the client's bed.

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety?

Place the client in a side-lying position.

A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?

Place the client in a sitting position.

After a subarachnoid hemorrhage, the client's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action?

Prepare to administer 3% NaCl by IV as prescribed.

The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?

Provide thickened commercial beverages and fortified cooked cereals.

The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client?

Providing ventilatory assistance

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?

Rapid, jerky, involuntary movements

A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client?

Reduce hypertension and high blood cholesterol

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware?

Reduction in cerebral blood flow

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions?

Renal

A nurse in the ICU is providing care for a client who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the client is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding?

Report this to the health care provider as a possible sign of clinical deterioration.

A client with Parkinson disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method?

Semisolid food with thick liquids

A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration?

Semisolid food with thick liquids

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions

A patient is diagnosed with a spinal cord tumor and has had a course of radiation and chemotherapy. Two months after the completion of the radiation, the patient complains of severe pain in the back. What is pain an indicator of in a patient with a spinal cord tumor?

Spinal metastasis

A client with a malignant brain tumor comes to the clinic for a follow up. During the visit, the client asks the nurse, "Why am I so tired all the time?" When responding to the client, which information would the nurse include as possible causes? Select all that apply.

Stress Treatment being used Tumor

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

Subdural hematoma

A trauma client was admitted to the ICU with a brain injury. The client had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms?

Sympathetic storm

A client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response?

Symptom improvement that lasts a few weeks after TPE ceases

A 13 year old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. What assessment finding would rule out discharging the client?

The client's speech is slightly slurred.

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?

Uneven, labored respirations

A client had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the client and family that evening. What does this phone call enable the nurse to determine?

Whether the client has had any complications of the test

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:

body temperature control.

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields.

cranial nerve 11

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered

low.

The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to

refrain from eating or drinking for now.

A client is status post-CVA with significant residual effects. When did this client begin the recovery phase of the neurologic deficit?

upon stabilization

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences.

A public health nurse offers public education in high school classes on personal responsibility in preventing head injuries as a way of life. While avoiding alcohol and drugs not only complies with existing law for minors, it also is an available intervention to prevent head injuries. What other measures are available to prevent head injuries?

using seatbelts

A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI?

"I am trying to quit smoking and have a patch on."

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?

"I can apply powder under the liner to help with sweating."

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?

"I will stretch daily as directed by the physical therapist."

The daughter of a patient with Huntington's disease asks the nurse what the risk is of her inheriting the disease. What is the best response by the nurse?

"If one parent has the disorder, there is a 50% chance that you will inherit the disease."

An older adult has encouraged her husband to visit their primary provider, stating that she is concerned that he may have Parkinson disease. Which of the wife's descriptions of her husband's health and function is most suggestive of Parkinson disease?

"Lately he seems to move far more slowly than he ever has in the past."

The nurse is caring for a client in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is the normal range of ICP for the client?

0 to 15 mm Hg

The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding?

1+

The Glasgow Coma Scale is a common screening tool used for patients with a head injury. During the physical exam, the nurse documents that the patient is able to spontaneously open her eyes, obey verbal commands, and is oriented. The nurse records the highest score of:

15

While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak?

18 to 36 hours

A client with head trauma is taken to surgery to insert an ICP monitor as signs and symptoms indicating increased ICP have continued to worsen. What increase in ICP (from a previous measurement) is cause for concern?

2 mm Hg

Which of the following Glasgow Coma Scale scores indicates coma?

7

A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure?

A dysrhythmia in the nerve cells in one section of the brain

A nurse knows that a patient exhibiting seizure-like movements localized to one side of the body most likely has what type of tumor?

A motor cortex tumor

A client is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate?

Administer morphine sulfate as prescribed.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?

Administering a stool softener as ordered

A college student goes to the infirmary with a fever, headache, and a stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? Select all that apply.

Administration of rifampin (Rifadin) Administration of ceftriaxone sodium (Rocephin) Administration of ciprofloxacin hydrochloride (Cipro)

A client is undergoing treatment for a glioblastoma. Because of a potential risk of imbalanced nutrition, attention should be given to dietary requirements. Which nursing interventions may be taken to ensure nutritional requirements are met? Select all that apply.

Adopt techniques to modify the texture and consistency of foods. Offer liquid nutritional supplements in between meals.

A 78-year-old resident of a long-term care facility has left the majority of his supper tray untouched, and the nurse has asked him about the reason for this. The resident states, "For a long time now, food just doesn't taste as well as it used to." The nurse should be aware that the etiology of this problem is most likely to involve:

Age-related changes to the neurological system

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.

The emergency department nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered level of consciousness. Following a skull X-ray, the patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture?

Battle's sign

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

A client is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the client's bladder?

Bladder contract

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication?

Bleeding

Which signs are manifestations of the Cushing triad? Select all that apply.

Bradypnea Hypertension Bradycardia

A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?

Brain stem

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?

Burr holes

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?

CN I

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

CN II

A nurse is planning discharge education for a client who underwent a cervical discectomy. What strategies would the nurse assess that would aid in planning discharge teaching?

Care of the cervical collar

A client exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this client's health problem?

Cerebellar dysfunction

Which is the earliest sign of increasing intracranial pressure?

Change in level of consciousness

A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test?

Coffee

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

Compliance with the prescribed medication regimen

A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state?

Confusion

While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?

Confusion

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

Decorticate

The nurse is planning the care of a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon?

Decreased availability of dopamine

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image?

Depression

Which is a sympathetic effect of the nervous system?

Dilated pupils

A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care?

Disturbed sensory perception

The clinic nurse caring for a client with Parkinson disease notes that the client has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect should the nurse assess this client?

Dyskinesia

A client, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease?

Emotional and personality changes

Which lobe of the brain is responsible for concentration and abstract thought?

Frontal

A client has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The client is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment?

Gag reflex

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have?

Grade 3 concussion

What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I?

Have the client identify familiar odors with the eyes closed.

A nurse is caring for a client diagnosed with Ménière disease. While completing a neurologic examination on the client, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what?

Hearing and equilibrium

A health care provider asks a nurse to assess a patient being evaluated for aseptic meningitis for a positive Brudzinski sign. Which of the following actions should the nurse take?

Help the patient flex his neck and observe for flexion of the hips and knees.

A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following?

Hypothalamus

A client has just returned to the unit from the PACU after surgery for a tumor within the spine. The client complains of pain. When positioning the client for comfort and to reduce injury to the surgical site, the nurse will position to client in what position?

In a flat side-lying position

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?

Increased ICP

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client?

Ineffective breathing patterns related to weakness of the intercostal muscles

A patient has expressive speaking aphasia after having a stroke. Which portion of the brain does the nurse know has been affected?

Inferior posterior frontal areas

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate response?

Inform the care team and assess for further signs of possible increased ICP.

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized?

Maintain and improve cerebral tissue perfusion.

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?

Maintenance of a patent airway

A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the client shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this client?

Many symptoms can be the result of normal aging process.

Which term describes the fibrous connective tissues that cover the brain and spinal cord?

Meninges

A field hockey coach was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic testing, it was determined that the client suffered a skull fracture with moderate symptoms. What would the nurse anticipate the nursing care plan to include? Select all that apply

Monitor for a halo sign. Prepare for the possibility of a seizure.

An emergency department nurse has just received a call from EMS that they are transporting a 17-year-old male who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?

Motor vehicle accidents

A client whose diagnosis includes head trauma is being closely observed for signs and symptoms of increasing intracranial pressure. The client is exhibiting nonverbal indications of experiencing pain. Why should the nurse avoid the administration of narcotic analgesics in this case?

Narcotic analgesics increase CSF pressure.

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.

National Institutes of Health Stroke Scale (NIHSS) score LOC at time of admission Age

Following a spinal cord injury a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?

Notify the neurosurgeon of the occurrence.

A client is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the client's left eye. The nurse should associate this abnormal finding with trauma to what cerebral lobe?

Occipital

Which lobe of the brain is responsible for spatial relationships?

Parietal

The nurse teaches the client with which disorder that the disease is due to decreased levels of dopamine in the basal ganglia of the brain?

Parkinson disease

The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?

Perform passive ROM exercises as prescribed.

The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client?

Phenytoin

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply.

Positioning the patient on his or her side with head flexed forward Providing for privacy Loosening constrictive clothing

A male client presents to the clinic reporting a headache. The nurse notes that the client is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection?

Positive Kernig sign

The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly clients with MS are known to be particularly concerned about what variables? Select all that apply.

Possible nursing home placement Increasing disability Becoming a burden on the family

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?

Raise the head of the bed and place the patient in a sitting position.

A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse?

Reorient the client while gently holding their arms.

A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply.

Report changes in neurologic status as soon as a worsening trend is identified. Maintain the head of the bed at 30 degrees. Avoid any activities that cause a Valsalva maneuver.

A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following?

Respiratory function

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:

Right-sided paralysis.

A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring?

Riluzole

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

Rising blood pressure and bradycardia

A patient has suffered cerebellar trauma after falling off of a ladder. The patient has been stabilized and is now receiving care on a neurological unit. When planning this patient's care, what nursing diagnosis is most likely to result from an injury to this part of the brain?

Risk for falls

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply.

Sudden numbness Visual disturbances Confusion

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value?

The CPP is low.

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

A nurse is caring for a client with recent history of migraines. What aspect of this client's current status may rule out the safe use of triptans?

The client has angina.

Following a traumatic brain injury, a client has been in a coma for several days. Which of the following statements is true of this client's current LOC?

The client may occasionally make nonpurposeful movements.

Maintain and improve cerebral tissue perfusion.

The client should mobilize as soon as she is physically able.

The nurse is completing the physical assessment of a patient suspected of a neurologic disorder. The patient reports to the nurse that he has recently suffered a head trauma. In such a case, which of the following precautions should the nurse take for the patient? Select all that apply.

The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling.

The nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge?

The patient should perform frequent physical activity but avoid becoming fatigued.

A woman has been brought to the emergency department (ED) by her distraught husband who believes that she has had a stroke. A rapid assessment by the care team confirms that the husband's suspicions are likely accurate, and the woman is being screened for the possible administration of recombinant tissue plasminogen activator (r tPA). Which of the following factors would contraindicate the use of tPA?

The woman's stroke has a hemorrhagic etiology.

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

Which of the following would the nurse recognize as being the least likely reason for the procedure shown in the accompanying image?

To confirm a skull fracture

A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply.

Turn the client to the side. Provide verbal reassurance.

A client who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention?

Urinary catheters often lead to urinary tract infections.

The nurse is providing nonpharmacologic interventions for pain relief to a client with a tension headache. Which techniques may the nurse use? Select all that apply.

Use guided imagery. Play soothing music.

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain?

V

A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves?

VIII

The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?

VIII

A patient has been brought to the emergency department (ED) with signs and symptoms of a stroke and a stat computed tomography (CT) head scan has been ordered. The ED nurse should know that the image that results from CT indicates distinguishing differences based on which of the following variables?

Variations in tissue density

A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?

Vasopressin

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four clients who might be at risk for a stroke. Which client is likely at the highest risk for a hemorrhagic stroke?

White male, age 60, with history of uncontrolled hypertension

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?

acute

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The cerebrum is divided into two hemispheres and is further divided into four lobes per hemisphere. Which section of the brain controls and coordinates muscle movements?

cerebellum

A client receives a diagnosis of concussion. While speaking with the client, the nurse learns that this is the client's third head injury. This information is of particular significance because it puts the client at risk for:

chronic traumatic encephalopathy.

A client is experiencing severe pain related to increased ICP. Which analgesic would be ordered for this client to help alleviate pain?

codeine

A nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?

comatose

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:

complications.

A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to:

decrease the potential for brain damage.

What is one of the earliest signs of increased ICP?

decreased level of consciousness (LOC)

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness.

A typical spinal cord functions as a "highway" for sensory and descending motor neurons, providing conduction of impulses to and from the brain. The spinal cord is surrounded and protected by bony vertebrae, and ends between the:

first and second lumbar vertebrae.

To assess a client's cranial nerve function, a nurse should assess:

gag reflex.

A client who was involved in a motor vehicle collision is brought to the emergency department. After examination and diagnostics, the neurosurgeon diagnoses an epidural hematoma and orders that the client be prepared for surgery. In preparing the client for surgery, which would be the least likely nursing intervention?

preoperative sedation

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because:

shivering in hypothermia can increase ICP.

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the

supine position with the head slightly elevated.

A client reports frequent headaches and is seeing the physician to determine their cause. In client education, which type of headache does the nurse indicate is most common?

tension

The nurse is providing diet-related advice to a client who experienced a cerebrovascular accident (CVA). The client wants to minimize his volume of food and yet meet all nutritional requirements. To control the volume of food intake, the nurse should suggest that the client consume:

thickened commercial beverages and fortified cooked cereals.

The nurse is assessing the client's pupils following a sports injury. Which assessment findings indicate a neurologic concern? Select all that apply.

unequal pupils pinpoint pupils absence of pupillary response

Which is a late sign of increased intracranial pressure (ICP)?

Altered respiratory patterns

Which of the following, if left untreated, can lead to an ischemic stroke?

Atrial fibrillation

A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood tinged and asks what that means. The correct reply is which of the following?

"It can mean a traumatic puncture or a subarachnoid bleed."

The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer?

"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration <wbr /> 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated

236145

Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome?

3 hours

The nurse is completing the physical assessment of a client suspected of a neurological disorder. The client reports having recently suffered a head trauma. In such a case, the nurse should:

not move or manipulate the client's head while assessing for bleeding or swelling.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. What is the origin of the client's symptoms?

impaired cerebral circulation

The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?

80

A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply.

Administer antipyretics as prescribed Perform frequent neurologic assessments Monitor pain levels and administer analgesics

The nurse caring for an 80-year-old client knows that the client has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation?

Age-related neurologic changes

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?

Autonomic dysreflexia

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect?

Constricted pupils

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium

One defining characteristic of a complex partial seizure versus a simple partial seizure is the presence of which of the following?

Impaired consciousness

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

Ineffective airway clearance related to brain injury

A client is admitted to the neurologic ICU with a spinal cord injury. In writing the client's care plan, the nurse specifies that contractures can best be prevented by what action?

Initiating (ROM) exercises as soon as possible after the injury

A client has suffered several migraines per month for the last 4 months. The physician prescribes prophylactic drug therapy. What is the rationale behind this action? Select all that apply.

possible reduction of migraine intensity possible reduction in frequency of attacks possible reduction in migraine duration

A physician has ordered home health and physical therapy for an older adult who will be discharged home following an acute stroke. The nurse's discharge teaching should include instructions about:

reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns.

A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. What would the nurse indicate to the client is the origin of migraines?

vascular

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

An intracerebral hematoma

A client is scheduled for diagnostic testing to evaluate the possibility of a brain tumor. The nurse would anticipate preparing the client for which test?

magnetic resonance imaging (MRI)

When managing CSF drainage, which instructions should the nurse give a client with a skull fracture? Select all that apply.

Allow it to flow freely onto porous gauze. Avoid tightly plugging the orifice.

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?

Loosen the client's restrictive clothing.

A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment?

Loss of hearing, tinnitus, and vertigo

Which is the most common cause of spinal cord injury (SCI)?

Motor vehicle crashes

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action?

Prepare for interventions to increase the client's BP.

A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client?

Safety

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Semi-Fowler's

A 48-year-old client has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis?

The client needs to be assessed for MS.

Which client should the nurse assess for degenerative neurologic symptoms?

The client with Huntington disease.

A client who has been experiencing numerous episodes of unexplained headaches and vomiting has subsequently been referred for testing to rule out a brain tumor. What characteristic of the client's vomiting is most consistent with a brain tumor?

The client's vomiting is unrelated to food intake.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?

The day the patient has the stroke

A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of:

Tremors and muscle rigidity

The nurse caring for a client diagnosed with Guillain-Barré syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurse's communication with the client should reflect the possibility of what sign or symptom of the disease?

Vocal paralysis

The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client to avoid?

Washing his face

The nurse is assessing the client's pupils following a sports injury. Which assessment findings indicate a neurologic concern? Select all that apply.

absence of pupillary response pinpoint pupils unequal pupils

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?

cardio embolic

In the divisions of the nervous system, the basic structure is the neuron. The function of the neuron is determined by the direction of impulse transmission. Which part of the neuron is responsible for conducting impulses to the cell body?

dendrites

A client fell while snowboarding, sustaining a blow to the head resulting in a loss of consciousness. Upon arrival at the emergency department, the client regained consciousness within 1 hour. What signs are symptoms would indicate increased ICP? Select all that apply.

personality changes sleepiness

A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team?

spouse

A patient who has sustained a basal skull fracture is admitted to the neurological unit. The nurse should know that the patient should be observed for:

Bleeding from the ears

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client?

The client should be approached on the side where visual perception is intact.

A nurse is collaborating with the interdisciplinary team to help manage a client's recurrent headaches. What aspect of the client's health history should the nurse identify as a potential contributor to the client's headaches?

The client takes vasodilators for the treatment of angina.

A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider?

The client will require full assistance for all aspects of elimination.

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event?

The client's urinary catheter became occluded.

An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (ICP) for which of the following actions?

To dehydrate the brain and reduce cerebral edema

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?

To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow

A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following?

Watchful waiting and close monitoring

A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way?

Weakness starting in the muscles supplied by the cranial nerves

A client with suspected Parkinson disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor?

When the client is resting

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

Within 24 hours after exposure

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves?

X

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing?

XII

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply.

Young age Substance abuse Male gender

A client's family is trying to understand the client's diagnosis of an acute subdural hematoma. The nurse would best explain the condition by stating that a subdural hematoma is:

a result of venous bleeding into the space below the dura.

The family nurse practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

moving the head and chin toward the chest