ATI NEURO PRACTICE 225 Q'S

A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse take to maintain privacy for the client? A. Close the door to the client's room. B. Pull the curtains around the client's bed. C. Ask family members to leave the room. D. Use sterile drapes to cover the client.

B. Pull the curtains around the client's bed.

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? A. The client states having a severe headache. B. The client's bladder becomes distended. C. The client's blood pressure becomes elevated. D. The client states having nasal congestion.

B. The client's bladder becomes distended.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? A. Pruritus B. Hypertension C. Bradykinesia D. Xerostomia

C. Bradykinesia

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.) A. Massage over erythematous bony prominences. B. Implement turning schedule every 4 hr. C. Use pillows to keep heels off the bed surface. D. Keep the client's skin dry with powder. E. Minimize skin exposure to moisture.

C. Use pillows to keep heels off the bed surface. E. Minimize skin exposure to moisture.

A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings? A. Nuchal rigidity B. Pupils reactive to light C. Widened pulse pressure D. Elevated temperature

C. Widened pulse pressure Rationale: A widened pulse pressure is a manifestation of increased ICP. Other manifestations include bradycardia, vomiting, and decreased level of consciousness.

A client diagnosed with Parkinson's disease is beginning medication therapy. The nurse realizes that the goal of treatment for Parkinson's disease is to: A. improve sleep. B. reduce appetite. C. control tremor and rigidity. D. reduce the need for joint replacement surgery.

C. control tremor and rigidity.

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client A. displays compulsive and ritualistic behaviors. B. reminisces about the past. C. makes up stories when he is unable to remember actual events. D. refuses to leave home to see a provider.

C. makes up stories when he is unable to remember actual events.

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? A. Rotate assignment of daily caregivers. B. Provide an activity schedule that changes from day to day. C. Limit time for the client to perform activities. D. Talk the client through tasks one step at a time.

D. Talk the client through tasks one step at a time.

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? A. To convert atrial fibrillation to sinus rhythm B. To dissolve clots in the bloodstream C. To slow the response of the ventricles to the fast atrial impulses D. To reduce the risk of stroke in clients who have atrial fibrillation

D. To reduce the risk of stroke in clients who have atrial fibrillation

A nurse is planning care for a client who has Alzheimer's disease and is in the terminal phase. Which of the following findings should the nurse expect? A. Needs assistance with finances B. Speech degrades to a few words C. Requires cueing to eat D. Unable to sit up

D. Unable to sit up

138.For each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, or multiple sclerosis. Each finding can support more than 1 disease process.

Orientation status is consistent with Parkinson's disease, stroke, and multiple sclerosis. Cognitive impairment can occur in Parkinson's disease and multiple sclerosis due to degeneration of neural pathways. Cognitive impairment is consistent with a stroke due to an interruption in cerebral perfusion.Ambulation pattern is consistent with Parkinson's disease.The client is experiencing slowed movement and shuffling gait which are consistent with Parkinson's disease due to the progressive loss of the neurotransmitter, dopamine.Muscle movements are consistent with Parkinson's disease. The client is experiencing resting tremors which are consistent with Parkinson's disease due to the progressive loss of the neurotransmitter, dopamine.Speech is consistent with Parkinson's disease, stroke, and multiple sclerosis. The client is experiencing slurred speech which can occur in Parkinson's disease and multiple sclerosis due to degeneration of neural pathways. Slurred speech is also consistent with a stroke due to an interruption in cerebral perfusion.Facial rigidity is consistent with Parkinson's disease.Facial rigidity can occur in Parkinson's disease due to the progressive loss of the neurotransmitter, dopamine.

A client is being seen in the emergency department experiencing symptoms of a stroke. The nurse realizes that the administration of a medication to break clots, such as tPA, should be administered within how many minutes of the client presenting the symptoms? A. 180 minutes B. 30 minutes C. 60 minutes D. 90 minutes

A. 180 minutes

A nurse is providing education to the family of a client who has Alzheimer's disease. Which of the following statements should the nurse make when explaining the role of acetylcholine in this disease process? A. "Acetylcholine plays a central role in findings of Alzheimer's disease." B. "Acetylcholine has minimal impact on sleep and muscle functioning." C. "Acetylcholine is an excitatory neurotransmitter that is responsible for learning and memory." D. "Acetylcholine regulates the release of histamine and glutamate."

A. "Acetylcholine plays a central role in findings of Alzheimer's disease."

A nurse is teaching a client who has multiple sclerosis about a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? A. "Do not take antihistamines with this medication." B. "Take the medication on an empty stomach." C. "Stop taking the medication immediately for a headache." D. "Expect to develop diarrhea initially."

A. "Do not take antihistamines with this medication."

A nurse is teaching a client who has multiple sclerosis and a new prescription for dantrolene. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to apply a sunscreen when I go outside." B. "I can take an over-the-counter antihistamine for allergies when I'm taking this drug." C. "I should take this medication when my spasms are bad." D. "My muscle strength should improve a lot in 2 to 3 days."

A. "I need to apply a sunscreen when I go outside."

A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate? A. "Incorporate nonverbal cues in the conversation." B. "Ask multiple choice questions as part of the conversation." C. "Use a higher-pitched tone of voice when speaking." D. "Use simple, child-like statements when speaking."

A. "Incorporate nonverbal cues in the conversation."

A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following information should the nurse include in the teaching? A. "Syncope episodes may occur when taking this medication." B. "This medication may cause tachycardia." C. "You should administer the medication each morning." D. "You will need to monitor for constipation."

A. "Syncope episodes may occur when taking this medication."

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A. A reddened area over the sacrum B. Stiffness in the lower extremities C. Difficulty moving the upper extremities D. Difficulty hearing some types of sounds

A. A reddened area over the sacrum

A home health nurse is reinforcing coping strategies with the family caregiver of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Actions to reduce stress B. Identification of a social support system C. Referral to available community resources D. Instruction on client medication administration E. Expected physiological changes of the disease

A. Actions to reduce stress B. Identification of a social support system C. Referral to available community resources E. Expected physiological changes of the disease

A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? A. Apply downward pressure while the client shrugs his shoulders upward. B. Apply resistance while the client lifts his legs from the bed. C. Ask the client to grasp an object and form a fist. D. Apply resistance while the client flexes his arms.

A. Apply downward pressure while the client shrugs his shoulders upward.

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take? A. Assist the client to the correct room. B. Place the client in restraints. C. Reorient the client to time and place. D. Move the client to a room at the end of the hall.

A. Assist the client to the correct room.

A nurse is discussing a client's needs at an interdisciplinary team conference. The client had a stroke and requires inpatient rehabilitation incorporated into their plan of care. Which of the nursing competencies is the nurse demonstrating? A. Collaborator B. Advocate C. Nurse manager D. Case manager

A. Collaborator

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? A. Decreased level of consciousness B. Tachypnea C. Bilateral weakness of extremities D. Hypotension

A. Decreased level of consciousness

A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis? A. Developing a respiratory infection B. Taking too much prescribed medication C. Diet high in protein D. Not exercising enough

A. Developing a respiratory infection

A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client? A. Dim lighting installed throughout the house. B. The hot water heater is set at 54ºC (130º F). C. Medications are stored in a clear bag. D. Grab bars are installed in the bathroom. E. Area rugs are placed in the living room.

A. Dim lighting installed throughout the house. B. The hot water heater is set at 54ºC (130º F). C. Medications are stored in a clear bag E. Area rugs are placed in the living room.

A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following interventions should the nurse take? A. Elevate the head of the bed to 30&deg. B. Notify the provider for drainage greater than 80 mL/8hr. C. Place the client in a flat, lateral position. D. Provide passive range-of-motion exercises to the neck.

A. Elevate the head of the bed to 30&deg.

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? A. Establish the ability to communicate effectively. B. Compensate for loss of depth perception. C. Learn to control impulsive behavior. D. Improve left-side motor function.

A. Establish the ability to communicate effectively.

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) A. Headache B. Neck pain and stiffness C. Slurred speech D. Pupillary changes E. Disorientation

A. Headache C. Slurred speech D. Pupillary changes E. Disorientation

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.) A. Hypotension B. Polyuria C. Hyperthermia D. Absence of bowel sounds E. Weakened gag reflex

A. Hypotension D. Absence of bowel sounds E. Weakened gag reflex

A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take? A. Log roll the client every 2 hr. B. Assist the client to sit upright in a chair for 4 hr at a time. C. Expect clear drainage on the spinal dressing. D. Elevate the client's legs when he is sitting in a chair.

A. Log roll the client every 2 hr.

A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include? A. Log roll the client every 2 hr. B. Assist the client to sit upright in a chair for 4 hr at a time. C. Expect clear drainage on the spinal dressing. D. Perform neurological checks every 8 hr.

A. Log roll the client every 2 hr.

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take? A. Speak to the client about one idea at a time. B. Ask the client to multi-task. C. Limit questions to yes and no answers. D. Focus on a single form of communication.

A. Speak to the client about one idea at a time.

A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take? A. Monitor sensory perception of the lower extremities B. Assist the client into a knee-chest position to manage postoperative discomfort. C. Maintain strict bed rest for the first 48 hr postoperative. D. Position the client in a high-Fowler's position if clear drainage is noted on the dressing.

A. Monitor sensory perception of the lower extremities

A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care? A. Monitor the client for an elevated temperature. B. Provide range of motion to the client's neck. C. Remove the vest daily to inspect the client's skin integrity. D. Check that the halo jacket is snug against the client's skin.

A. Monitor the client for an elevated temperature.

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care? A. Obtain IV access. B. Keep the lights on when the client is sleeping. C. Place the client's bed in the high position. D. Keep a padded tongue blade available at the client's bedside.

A. Obtain IV access.

A nurse is caring for a client who recently had a stroke. The client requires assistance with strengthening the affected side. Which of the following referrals should the nurse anticipate the provider to make? A. Physical therapist B. Occupational therapist C. Respiratory therapist D. Social worker

A. Physical therapist

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? A. Poor impulse control B. Unable to discriminate words and letters C. Deficits in the right visual field D. Motor retardation

A. Poor impulse control

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take? A. Prepare the client for mechanical ventilation. B. Administer an anticholinesterase medication. C. Instruct the client to perform the pursed lip breathing. D. Prepare to administer a vasoconstrictor.

A. Prepare the client for mechanical ventilation.

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.) A. Provide a suction setup at the bedside. B. Elevate the side rails near the head when the client is in bed. C. Place the bed in the lowest position. D. Keep an oxygen setup at the bedside. E. Furnish restraints at the bedside

A. Provide a suction setup at the bedside. B. Elevate the side rails near the head when the client is in bed. C. Place the bed in the lowest position. D. Keep an oxygen setup at the bedside.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? A. Provide client supervision. B. Limit client physical activity. C. Speak loudly to the client. D. Leave the television on continuously.

A. Provide client supervision.

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected? A. Pushes the painful stimulus away B. Extends her body toward the painful stimulus C. Shows no reaction to the painful stimulus D. Flexes the upper and extends the lower extremities in response to the painful stimulus

A. Pushes the painful stimulus away

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? A. Reduce edema of the brain. B. Provide fluid hydration. C. Increase cell size in the brain. D. Expand extracellular fluid volume.

A. Reduce edema of the brain.

A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver asks the nurse what type of essential oils should be used when the client receives massage therapy to decrease anxiety. Which of the following oils should the nurse recommend? A. Rosemary B. Eucalyptus C. Cypress D. Frankincense

A. Rosemary

A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? A. Systolic blood pressure is increased B. Cardiac output is reduced C. Apical heart rate is increased D. Urine output is reduced

A. Systolic blood pressure is increased

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score? A. The client needs total nursing care. B. The client is alert and oriented. C. The client is in a deep coma. D. Indicates stable neurologic status

A. The client needs total nursing care.

A nurse is providing dietary teaching to a client who has been diagnosed with Alzheimer's disease about including foods to decrease the progression of the disease. Which of the following foods should the nurse recommend? A. Tuna sandwich B. Hamburgers C. Turkey sandwich D. Cheese pizza

A. Tuna sandwich

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client? A. "Do have a history of chronic alcohol abuse?" B. "Have you had a recent influenza infection?" C. "Have traveled overseas recently?" D. "Are you taking a multivitamin?"

B. "Have you had a recent influenza infection?"

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client? A. "Do have a history of chronic alcohol abuse?" B. "Have you had a recent influenza infection?" C. "Have traveled overseas recently?" D. "Are you taking a multivitamin?"

B. "Have you had a recent influenza infection?"

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting? A. "My wife tries to get me to go to the grocery store, but I don't like to go out much." B. "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." C. "My greatest pleasure each day is having a few beers every day." D. "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."

B. "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better."

A nurse in an acute care facility is assessing a client who had hip surgery and has Alzheimer's disease. The nurse asks the client how therapy went that morning. Which of the following statements by the client should the nurse document as confabulation? A. "This morning, this morning, this morning..." B. "It was good. The Queen of England visited me there." C. "I just don't remember what I did this morning." D. "Snip, snap. Take a nap."

B. "It was good. The Queen of England visited me there."

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? A. "Turn the screws on the device once each day." B. "The purpose of this device is to immobilize the cervical spine." C. "Apply talcum powder under the vest to limit friction." D. "The purpose of this device is to allow for neck movement during the healing process."

B. "The purpose of this device is to immobilize the cervical spine."

A nurse is caring for an unconscious client who has a loss of the corneal reflex. Which of the following actions should the nurse take? A. Keep the room darkened. B. Apply lubricating eye drops. C. Alternate warm saline compresses to the eyes. D. Clean the eyes with a mild soap.

B. Apply lubricating eye drops.

A nurse is caring for a client who had a stroke and has dysphagia. The nurse should monitor the client for which of the following complications? A. Gastroesophageal reflux disease B. Aspiration C. Peptic ulcer disease D. Dumping syndrome

B. Aspiration

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate? A. Fresh fish B. Cheddar cheese C. Cherries D. Chicken

B. Cheddar cheese

A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization? A. Urge incontinence B. Dribbling of urine C. Weight gain D. Rectal distention

B. Dribbling of urine

A nurse is caring for a client who is at 6 weeks of gestation and has pneumonia. While the nurse is obtaining the client's history, the client tells the nurse that she takes the herb feverfew for migraine headaches. Which of the following actions should the nurse take? A. Tell the client that she should take an over-the-counter analgesic instead. B. Explain to the client that she should not take this herb while she is pregnant. C. Ask the client why she would take an herb during pregnancy. D. Suggest that the client ask her herbalist within the next few weeks about taking it while pregnant.

B. Explain to the client that she should not take this herb while she is pregnant.

A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take? A. Provide the client with a fixed showerhead. B. Give the client a long-handled sponge. C. Fill the client's bathtub with water at 48° C (118.4° F). D. Offer the client bar soap.

B. Give the client a long-handled sponge.

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading B. Inability to recognize his family members C. Right hemiparesis D. Aphasia

B. Inability to recognize his family members

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure? A. Brisk pupillary reaction to light. B. Increased sleeping C. Tachycardia D. Depressed fontanels

B. Increased sleeping

A nurse is assessing a client who is receiving a continuous IV infusion of dopamine. Which of the following findings should the nurse recognize as a therapeutic effect? A. Increased pulse B. Increased urine output C. Decreased blood pressure D. Decreased dysrhythmias

B. Increased urine output

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse? A. PaC02 35 mm Hg B. Intracranial pressure (ICP) 18 mm Hg C. Pulse oximetry 96% D. Blood pressure 140/82 mm Hg

B. Intracranial pressure (ICP) 18 mm Hg

A nurse is caring for a client who has experienced a stroke and exhibits parkinsonian effects. The client's cognition fluctuates. Which of the following types of dementia should the nurse expect the client to have? A. Frontotemporal lobar degeneration B. Lewy body disease C. HIV infection D. Prion disease

B. Lewy body disease

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? A. Gradual onset of several hours B. Manifestations preceded by a severe headache C. Maintains consciousness D. History of neurologic deficits lasting less than 1 hr

B. Manifestations preceded by a severe headache

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test? A. A pill-rolling tremor appears. B. Muscle contractions become progressively stronger. C. Electrical charge in a muscle increases in intensity. D. Muscle strength shows no change.

B. Muscle contractions become progressively stronger.

A nurse is assessing a client who had a craniotomy and has develope syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate? A. Hypernatremia B. Oliguria C. Weight loss D. Increased thirst

B. Oliguria

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? A. Insert a padded tongue blade into the client's mouth. B. Place a pillow under the client's head. C. Gently restrain the client's extremities. D. Apply a face mask for oxygen administration.

B. Place a pillow under the client's head.

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? A. Insert a tongue blade in the client's mouth. B. Place the client on his side. C. Hold the client's arms and legs from moving. D. Place the client back in bed.

B. Place the client on his side.

1A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? A. Confusion B. Weakness C. Increased intracranial pressure D. Increased urinary output

B. Weakness

A nurse is caring for a client who has Alzheimer's disease and is obtaining data from their partner who is their full-time caregiver. Which of the following responses by the partner should the nurse identify as a potential concern? A. "I have a family member that comes by twice a week to allow me to run errands." B. "I am able to get rest at night because they often sleep well." C. "I get agitated when they don't eat their food at mealtime." D. "I am able to do my hobbies while taking care of them."

C. "I get agitated when they don't eat their food at mealtime."

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective? A. "My partner should cough while swallowing food." B. "My partner should place their food on the weaker side of their mouth when eating." C. "My partner should tilt their head forward when swallowing." D. "My partner should sit at a 30&deg angle while eating their meals."

C. "My partner should tilt their head forward when swallowing."

A nurse is teaching a client who has a new prescription for sumatriptan tablets to treat migraine headaches. Which of the following instructions should the nurse include? A. "Take daily to prevent headaches." B. "Chew tablet well before swallowing." C. "Report swelling of eyelids after dosage." D. "Repeat dose in 1 hour for unrelieved headache."

C. "Report swelling of eyelids after dosage."

A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse is appropriate? A. "This is where you live now." B. "This is a safer place for you to live." C. "Tell me what you like to cook for dinner." D. "Your family said there is no one to care for you at home."

C. "Tell me what you like to cook for dinner."

A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include? A. "Take this medication daily to prevent headaches." B. "Activate the patch 30 minutes after application." C. "Use contraception while taking this medication." D. "You can bathe with the patch in place."

C. "Use contraception while taking this medication."

A nurse is providing an in-service to a group of nurses on medications used to treat the progression of Alzheimer's disease. Which of the following medications should the nurse include in the teaching? A. Tetrabenazine B. Warfarin C. Aducanumab D. Levodopa

C. Aducanumab

A community health nurse is preparing an educational activity on Alzheimer's disease. Which of the following risk factors should the nurse include as the greatest risk for this disease? A. Genetics B. History of Down syndrome C. Age D. Androgen deprivation therapy

C. Age

A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop? A. Place sandbags to maintain right plantar flexion. B. Position soft pillows against the bottom of the feet. C. Apply a protective boot to the right ankle. D. Splint the right lower extremity to maintain proper alignment.

C. Apply a protective boot to the right ankle.

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication? A. Have the client empty his bladder. B. Put up the side rails on the client's bed. C. Ask the client to take a few sips of water. D. Place the client in low Fowler's position.

C. Ask the client to take a few sips of water.

A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse's priority? A. Recommend that the partner place the client in a long-term care facility. B. Suggest that the partner see a counselor to help him cope with his exhaustion. C. Ask the partner to talk about his difficulties in caring for the client. D. Tell the partner to call a family meeting to get help.

C. Ask the partner to talk about his difficulties in caring for the client.

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take? A. Obtain the telephone number of the client's provider. B. Find a location for the client to sit. C. Call emergency services. D. Drive the client to the nearest emergency department.

C. Call emergency services.

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take? A. Teach controlled coughing and deep breathing. B. Provide a brightly lit environment. C. Elevate the head of the bed. D. Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day.

C. Elevate the head of the bed.

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? A. Cleanse the perineum from back to front. B. Obtain a prescription for an indwelling urinary catheter. C. Encourage fluid intake at and between meals. D. Offer the client the bedpan every 2 hr.

C. Encourage fluid intake at and between meals.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? A. Encourage brief exercise before meals to promote appetite. B. Place food in the affected side of the mouth. C. Encourage the client to take small bites. D. Place the client with the head reclined back to facilitate swallowing.

C. Encourage the client to take small bites.

A nurse is caring for a client who has Alzheimer's disease and is having difficulty with multitasking. Which of the following cognitive deficits is the client experiencing? A. Complex attention B. Learning and memory C. Executive function D. Perceptual-motor

C. Executive function

A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect? A. Negative Babinski reflex B. Increased appetite C. Hyporeflexia D. Tachycardia

C. Hyporeflexia

A nurse is caring for a client who has dementia and observes that the client becomes stressed and requires assistance and monitoring when their family visits. When the family leaves the room, the client returns to baseline and the deficits are gone. Using the Functional Assessment Stage Tool, the nurse should identify that the client is in which of the following stages of Alzheimer's disease? A. Mild B. Moderate C. Incipient D. Severe

C. Incipient

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? A. Hypotension B. Tachycardia C. Irritability D. Tinnitus

C. Irritability

A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take? A. Turn the television on at all times. B. Hang abstract pictures on the walls. C. Keep familiar personal items at the bedside. D. Encourage bright glaring lighting in the room.

C. Keep familiar personal items at the bedside.

A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following action should the nurse take? A. Provide the client with water to test the gag reflex. B. Perform carotid massage. C. Notify emergency management services. D. Drive the client to the nearest medical facility.

C. Notify emergency management services.

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? A. Administer a nitrate antihypertensive. B. Assess the client for bladder distention. C. Place the client in a high-Fowler's position. D. Obtain the client's heart rate.

C. Place the client in a high-Fowler's position.

A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? A. Post a written schedule of daily activities. B. Use an overhead loudspeaker to announce events. C. Provide a consistent daily routine. D. Allow the client to choose free-time activities.

C. Provide a consistent daily routine.

A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence? A. Stress incontinence B. Urge incontinence C. Reflex incontinence D. Overflow incontinence

C. Reflex incontinence

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? A. Provide a nonskid mat to alleviate plate movement. B. Encourage the client to use his right hand when feeding himself. C. Remind the client to look for food on the left side of the tray. D. Encourage the use of the wide grip utensils.

C. Remind the client to look for food on the left side of the tray.

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? A. Perform passive range of motion on each extremity. B. Monitor the client's electrolyte levels. C. Suction saliva from the client's mouth. D. Record the client's intake and output.

C. Suction saliva from the client's mouth.

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? A. The client's ECG tracing shows irregular heart rate without P waves. B. The client has an aPTT of 80 seconds. C. The client experiences sudden weakness of one arm and leg. D. The client's urine output is cloudy and odorous.

C. The client experiences sudden weakness of one arm and leg.

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain? A. The partner has placed locks at the top of the doors leading to the outside. B. The partner has hired a house cleaner. C. The partner has lost 20 lb in the past 2 months. D. The partner redirects the client when the client is frustrated.

C. The partner has lost 20 lb in the past 2 months.

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? A. "Wear an eye patch on the right eye at all times." B. "Plan to relax in a hot tub spa each day." C. "Engage in a vigorous exercise program." D. "Implement a schedule to include periods of rest."

D. "Implement a schedule to include periods of rest."

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching? A. "Insert a padded tongue blade into the client's mouth." B. "Restrain the client." C. "Place the client on his back." D. "Move objects away from the client."

D. "Move objects away from the client."

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? A. Ability to achieve independent transfer from bed to wheelchair B. Independent control of bowel and bladder function C. Use of a wheelchair with a chin or mouth stick D. Ability to self-feed with the use of adaptive equipment

D. Ability to self-feed with the use of adaptive equipment

A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? A. Delay in disease progression B. Improved bladder function C. Relief of depression D. Decreased tremors

D. Decreased tremors

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? A. Inform the client that privileges are related to participation in therapy. B. Limit visiting hours until the client begins to participate in therapy. C. Allow the client to control the timing and frequency of the therapy. D. Establish a plan of care with the client that sets attainable goals.

D. Establish a plan of care with the client that sets attainable goals.

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include? A. History of smoking B. Obesity C. History of hypertension D. Genetics

D. Genetics

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings? A. Impaired sense of humor B. Loss of depth perception C. Poor judgment D. Intellectual impairment

D. Intellectual impairment

A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following? A. Muscle mass B. Muscle strength C. Bone density D. Joint flexibility

D. Joint flexibility

A nurse is preparing to turn a client who is obese following a spinal fusion. The nurse should plan to use which of the following techniques to turn this client? A. Hoyer lift B. Draw sheet C. Sliding board D. Log roll

D. Log roll

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? A. Albumin 25% B. Dextran 70 C. Hydroxyethyl glucose D. Mannitol 25%

D. Mannitol 25%

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer? A. Albumin 25% B. Dextran 70 C. Hydroxyethyl glucose D. Mannitol 25%

D. Mannitol 25%

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? A. Paresthesia B. Hemiplegia C. Quadriplegia D. Paraplegia

D. Paraplegia

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? A. Check the client for a fecal impaction. B. Examine the client for areas of skin breakdown. C. Check the client's bladder for distention. D. Place the client in a sitting position.

D. Place the client in a sitting position.

A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make? A. Hospice care B. Restorative care C. Mental health care D. Respite care

D. Respite care

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe. B. Place the client in a supine position. C. Place a warming blanket on the client. D. Use log rolling to reposition the client.

D. Use log rolling to reposition the client.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? A. pulse and blood pressure findings B. behavioral indicators and effect C. scheduled treatments and client illness D. a self-report pain rating scale

D. a self-report pain rating scale

For each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, and/or multiple sclerosis. Each finding can support more than one disease process.

Facial symmetry is consistent with stroke. Unilateral facial droop can occur in a stroke due to a decrease in cerebral perfusion to one hemisphere of the brain. Rigid facial muscles is consistent with Parkinson's disease. Hypertension is consistent with stroke. Hypertension is a risk factor for the development of a stroke. Orthostatic hypotension can occur in Parkinson's disease due to a decrease in sympathetic nervous system response. Cognitive function is consistent with Parkinson's disease, stroke, and multiple sclerosis. Cognitive impairment can occur in Parkinson's disease and multiple sclerosis due to degeneration of neural pathways. Cognitive impairment is consistent with a stroke due to an interruption in cerebral perfusion.Speech is consistent with Parkinson's disease, stroke, and multiple sclerosis. Slurred speech can occur in Parkinson's disease and multiple sclerosis due to degeneration of neural pathways. Aphasia is consistent with a stroke due to an interruption in cerebral perfusion.Mobility status is consistent with Parkinson's disease, stroke, and multiple sclerosis. Impaired mobility can occur in Parkinson's disease and multiple sclerosis due to degeneration of neural pathways. Impaired mobility is consistent with a stroke due to an interruption in cerebral perfusion.

A client tells the nurse that he sees flashing lights that occur prior to the onset of a seizure. Which of the following phases of a seizure is this client describing to the nurse? A. Aural phase B. Prodromal phase C. Ictal phase D. Postictal phase

A. Aural phase

A nurse is assessing an 11-month-old infant. Which of the following manifestations is associated with a CNS infection? A. Oliguria B. Bulging fontanel C. Negative Brudzinski sign D. Jaundice

B. Bulging fontanel

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III? A. Testing visual acuity B. Observing for facial symmetry C. Eliciting the gag reflex D. Checking the pupillary response to light

D. Checking the pupillary response to light

A nurse is admitting an older adult client who has diabetic neuropathy with painful, burning feet. Which of the following interventions should the nurse anticipate the health care provider to prescribe? A. Place a bed cradle on the client's bed. B. Inspect the client's feet once weekly. C. Apply graduated compression stockings to the client's lower extremities. D. Put a heating pad on the client's feet.

A. Place a bed cradle on the client's bed.

A nurse is teaching a client who is scheduled for a CT scan of the head with contrast. Which of the following statements by the client indicates a need for further teaching? A. "I can take my morning dose of metformin." B. "I will keep my head still during the procedure." C. "I will not eat or drink 4 hr prior to the procedure." D. "I will feel a warm sensation when the dye is injected."

A. "I can take my morning dose of metformin."

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? A. Place suction equipment at the client's bedside. B. Apply an eye patch to the client's right eye C. Avoid the use of warm water to wash the client's face. D. Provide range-of-motion exercises to the client's neck and shoulders.

A. Place suction equipment at the client's bedside.

75.A newly licensed nurse asks the charge nurse about functional neurological symptom disorder. Which of the following responses should the charge nurse make? A. "The manifestations of this disorder are worse during times of increased stress." B. "Clients who have this disorder exhibit more than one personality." C. "Clients who have this disorder consciously control the manifestations." D. "Feeling outside of one's body is a primary manifestation of this disorder."

A. "The manifestations of this disorder are worse during times of increased stress."

A nurse is reviewing treatment options for a client who has functional neurological symptom disorder. Which of the following treatments should the nurse identify as being most effective for this disorder? A. A combination of medication and psychotherapy B. Daily physical therapy C. Daily benzodiazepines to prevent new symptoms. D. Systematic desensitization

A. A combination of medication and psychotherapy

A client is prescribed phenytoin (Dilantin) for a seizure disorder. Which of the following would indicate that the client is adhering to the medication schedule? A. Absence of seizures B. The client is sleepy. C. The client no longer has headaches. D. The client is eating more food.

A. Absence of seizures

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? A. Administer antibiotics when available. B. Reduce environmental stimuli. C. Document intake and output. D. Maintain seizure precautions.

A. Administer antibiotics when available.

A nurse is caring for a client who has a seizure disorder. (Select all that apply.) (NGN) A. Administer supplemental oxygen to the client B. Turn the client to the side C. Time the duration of the seizure D. Place a tongue depressor in the client's mouth E. Restrain the client

A. Administer supplemental oxygen to the client B. Turn the client to the side C. Time the duration of the seizure

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II? A. Ask the client to read a Snellen chart. B. Listen to the client's speech. C. Ask the client to identify scented aromas. D. Ask the client to clench his teeth.

A. Ask the client to read a Snellen chart.

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve XII? A. Ask the client to stick out their tongue and observe if it is midline B. Observe for the ability of the client to turn their head side to side. C. Have the client identify specific smells. D. Whisper in one of the client's ears while occluding the other.

A. Ask the client to stick out their tongue and observe if it is midline

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.) A. Color B. Temperature C. Ecchymosis D. Skin integrity E. Sensation

A. Color B. Temperature E. Sensation

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform? A. Complete a neurological check B. Administer the prescribed PRN antihypertensive medication. C. Increase the client's fluid intake. D. Hold the client's evening dose of digoxin.

A. Complete a neurological check

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first? A. Evaluate the client's neurological status. B. Perform a complete blood count. C. Check the client's temperature. D. Administer an oral analgesic.

A. Evaluate the client's neurological status.

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing early stage of an increase in intracranial pressure (ICP) ? (Select all that apply.) A. Headache B. Neck pain and stiffness C. Purposeless movements D. Pupillary changes E. Disorientation

A. Headache C. Purposeless movements D. Pupillary changes E. Disorientation

A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III? A. Instruct the client to look up and down without moving his head. B. Observe the client's ability to smile and frown C. Have the client stand with eyes his closed and touch his nose. D. Ask the client to shrug his shoulders against passive resistance.

A. Instruct the client to look up and down without moving his head.

A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking? A. Invoking implied consent B. Delaying the surgery until a member of the client's family is reached C. Asking the client to sign the surgical consent form D. Prescribing naloxone to reverse the effects of the morphine

A. Invoking implied consent

A nurse is developing a plan of care for a client following a lumbar puncture. Which of the following actions should the nurse include in the plan? (Select all that apply.) A. Provide oral fluids. B. Monitor for nausea. C. Maintain fetal position. D. Check level of consciousness. E. Check sensation in the toes.

A. Provide oral fluids. B. Monitor for nausea. D. Check level of consciousness. E. Check sensation in the toes.

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? A. Severe headache B. Bradycardia C. Blurred vision D. Oriented to person, place, and year

A. Severe headache

33.A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose? A. Shake the container vigorously. B. Be sure the child has not eaten within the hour. C. Perform mouth care. D. Check the child's blood pressure.

A. Shake the container vigorously.

A patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? A. The patient has new-onset weakness of both legs. B. The patient complains of chronic severe back pain. C. The patient starts to cry and says, "I feel hopeless." D. The patient expresses anxiety about having surgery.

A. The patient has new-onset weakness of both legs.

The nurse will explain to the patient who has a T2 spinal cord transection injury that A. use of the shoulders will be limited. B. function of both arms should be retained. C. total loss of respiratory function may occur. D. tachycardia is common with this type of injury.

B. function of both arms should be retained.

The nurse is instructing a client newly diagnosed with multiple sclerosis (MS). To determine the effectiveness of his teaching, the nurse would expect the client to state: A. "It is best for me to be in a cold environment." B. "I should avoid taking a hot bath." C. "I should eat foods low in salt." D. "I should be better in a week."

B. "I should avoid taking a hot bath."

A nurse is providing education to a group of clients about the process of neurotransmission. Which of the following statements about neurotransmission should the nurse make? A. "Neurotransmitters are chemical components that allow neurons to store energy for future use. B. "Neurotransmitters are found throughout the body." C. "Neurotransmitters function by inhibiting the production of glucose." D. "Neurotransmitters are activated by the enzyme transferase."

B. "Neurotransmitters are found throughout the body."

A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. Which of the following statements should the nurse include in the teaching? A. "Take this medication with an antacid to reduce gastric irritation." B. "You may experience drowsiness while taking this medication." C. "You should take this medication with meals." D. "You may continue to breastfeed while taking this medication."

B. "You may experience drowsiness while taking this medication."

A nurse is reviewing data for a client who is manifesting symptoms related to a neurodevelopmental disorder. Which of the following tools should the nurse use to best screen the data for a neurodevelopmental disorder? A. Medical history form B. ADHD-FX C. Family composition questionnaire D. Neurological assessment scale

B. ADHD-FX

A nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take? A. Administer the medication at 100 mg/min. B. Administer a saline solution after injection. C. Hold the injection if seizure activity is present. D. Dilute the medication with dextrose 5% in water.

B. Administer a saline solution after injection.

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide? A. Phenytoin turns urine blue. B. Alcohol increases the chance of phenytoin toxicity. C. Avoid flossing the teeth to prevent gum irritation. D. Take an antacid with the medication if indigestion occurs.

B. Alcohol increases the chance of phenytoin toxicity.

A nurse is teaching a client who has diabetic neuropathy about foot care. Which of the following instructions should the nurse include? A. Wear open-toed shoes. B. Avoid walking barefoot. C. Wash feet in hot water. D. Apply lotion between the toes.

B. Avoid walking barefoot.

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.) A. Confusion B. Bradycardia C. Hypotension D. Nonreactive dilated pupils E. Slurred speech

B. Bradycardia D. Nonreactive dilated pupils

A nurse is teaching a client who taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects? A. Excess salivation B. Difficulty voiding C. Diarrhea D. Slow pulse

B. Difficulty voiding

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? A. Transient ischemic attack (TIA) B. Hemorrhagic stroke C. Thrombotic stroke D. Embolic stroke

B. Hemorrhagic stroke

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective to decrease incidence in this population? A. Emphasize the importance of hand washing. B. Immunize adolescents and college freshman C. Support serving healthy nutritional options in the college cafeteria. D. Encourage adolescents and young adults to avoid crowds in the winter.

B. Immunize adolescents and college freshman

A nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. Which of the following should the nurse include in the teaching as manifestations seen in the moderate stage of Alzheimer's disease? (Select all that apply.) A. Inability to find commonly used items B. Inability to perform common tasks C. Difficulty with talking or reading D. Difficulty remembering how to swallow E. Inability to recognize family members

B. Inability to perform common tasks C. Difficulty with talking or reading

A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the client's spine. The nurse should expect the provider to document which of the following disorders? A. Scoliosis B. Kyphosis C. Lordosis D. Ankylosis

B. Kyphosis

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII? A. Check the client's visual acuity using a Snellen chart. B. Observe for facial symmetry while the client smiles. C. Have the client identify specific smells. D. Whisper in one of the client's ears while occluding the other.

B. Observe for facial symmetry while the client smiles.

92.A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI? A. Check the client's visual acuity using a Snellen chart. B. Observe for the ability of the client to turn their head side to side. C. Have the client identify specific smells. D. Whisper in one of the client's ears while occluding the other.

B. Observe for the ability of the client to turn their head side to side.

A client is experiencing a grand mal seizure. Which of the following interventions should the nurse do during this seizure? A. Leave the client alone. B. Protect the client's head. C. Give water to the client to avoid dehydration. D. Place a finger in the client's mouth to avoid swallowing the tongue.

B. Protect the client's head.

A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply. (NGN) A. Administer a soapsuds enema B.Place the client in a lateral position with the knees drawn to the abdomen C. Assess for allergies to contrast dyes D. Obtain coagulation studies E. Place client NPO for 4 to 6 hr F. Ensure informed consent is obtained G. Administer IV sedation as prescribed H. Provide education about the procedure

B.Place the client in a lateral position with the knees drawn to the abdomen D. Obtain coagulation studies F. Ensure informed consent is obtained H. Provide education about the procedure

A nurse is caring for an adolescent client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the client's parent is the nurse's priority? A. "He takes a 2-hour nap every day after school." B. "He says he feels sick to his stomach after taking this medication." C. "He has so many new bruises on his body." D. "He says his mouth is always dry."

C. "He has so many new bruises on his body."

A nurse is caring for a child who has influenza. The nurse should identify that which of the following statements by the parent indicates the child has an increased risk for Reye syndrome? A. "I give my child ibuprofen when his muscles are aching." B. "I am encouraging my child to drink grapefruit juice." C. "I give my child aspirin to reduce his fever." D. "I am leaving a humidifier on in my child's room when he naps."

C. "I give my child aspirin to reduce his fever."

A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse? A. "I will call your primary care provider to report your concerns." B. "I will take your baby to the nursery for further examination." C. "This occurs because newborns lack muscle control to regulate eye movement." D. "This is a concern, but strabismus is easily treated with patching."

C. "This occurs because newborns lack muscle control to regulate eye movement."

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? A. Blood pressure B. Oxygen saturation C. Intracranial pressure D. Hemoglobin and hematocrit

C. Intracranial pressure

The nurse is planning care for a client diagnosed with increased intracranial pressure after a head injury. Which of the following interventions can be used to reduce increased intracranial pressure? A. Administer antibiotics as prescribed. B. Keep the head of the bed in the flat position. C. Administer corticosteroids and osmotic diuretics as prescribed. D. Perform range-of-motion exercises every hour.

C. Administer corticosteroids and osmotic diuretics as prescribed.

30.A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? A. Check for a fecal impaction. B. Give the prescribed antiemetic. C. Assess the blood pressure (BP). D. Notify the health care provider.

C. Assess the blood pressure (BP).

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? A. Kernig's sign B. Nuchal rigidity C. Brudzinski's sign D. Bradykinesia

C. Brudzinski's sign

A nurse is assessing a client who has peripheral neuropathy. Which of the following findings should the nurse expect? A. Hyperreflexia B. Increased ability to detect temperature C. Burning sensation in feet D. Loss of sensation to pressure

C. Burning sensation in feet

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve I? A. Check the client's visual acuity using a Snellen chart. B. Observe for facial symmetry while the client smiles. C. Have the client identify specific smells. D. Whisper in one of the client's ears while occluding the other.

C. Have the client identify specific smells.

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache? A. Administer pain medication. B. Darken the client's room and close the door. C. Increase fluid intake. D. Elevate the head of the bed to 30º.

C. Increase fluid intake.

For a client diagnosed with Parkinson's disease, which of the following teaching will the nurse give to caregiver? A. Isolate the patient B. Let patient eat food hard to swallow C. Instituting fall precautions D. Encourage the patient do quick decisions

C. Instituting fall precautions

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client? A. Piperacillin/tazobactam B. Levothyroxine C. Levodopa/carbidopa D. Carbamazepine

C. Levodopa/carbidopa

A nurse is providing discharge instructions for a client who has a traumatic brain injury. Which of the following findings should be included in these instructions? (Select all that apply.) A. There is not restrictions to return to work as soon as possible B. Avoid use of helmets C. Limit the consumption of alcoholic beverages D. Avoid use of illicit drug E. Teach signs and symptoms of complications F. Acquire medical clearance prior to returning to work that uses heavy machinery

C. Limit the consumption of alcoholic beverages D. Avoid use of illicit drug E. Teach signs and symptoms of complications F. Acquire medical clearance prior to returning to work that uses heavy machinery

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care? A. Place the client in a semi-Fowler's position. B. Admit the client to a private room. C. Measure head circumference every shift. D. Implement seizure precautions.

C. Measure head circumference every shift.

An adult female in her 30s complains of numbness and tingling in the hands, fatigue, loss of coordination, incontinence, nystagmus, and ataxia. Which of the following neurological health problems do these symptoms suggest to the nurse? A. Brain tumor B. Myasthenia Gravis C. Multiple sclerosis D. Diabetes

C. Multiple sclerosis

A nurse is caring for a client who has sleep dysregulation, poor memory, and poor concentration. Which of the following neurotransmitters should the nurse identify as being responsible for the client's manifestations? A. Dopamine B. Serotonin C. Norepinephrine D. Histamine

C. Norepinephrine

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? A. Extension of the arms B. Pronation of the hands C. Plantar flexion of the legs D. External rotation of the lower extremities

C. Plantar flexion of the legs

A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care? A. Maintain the infant in the supine position. B. Initiate contact precautions C. Provide a latex-free environment. D. Limit visitors to immediate family members.

C. Provide a latex-free environment.

A nurse is teaching a client who has a new prescription for phenytoin. The nurse should instruct the client to monitor for and report which of the following adverse effects of this medication? A. Metallic taste B. Diarrhea C. Skin rash D. Anxiety

C. Skin rash

A nurse is orienting a newly licensed nurse in the care of an infant who has myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective? A. Performs range of motion on the infant's hips B. Maintains a dry dressing over the sac C. Takes an axillary temperature D. Places the infant in a side-lying position

C. Takes an axillary temperature

A nurse is preparing a presentation on neurotransmission. Which of the following statements about the neurotransmitter histamine should the nurse include? A. "Histamine is responsible for affective and cognitive functioning." B. "Histamine is essential to sleep and muscle functioning." C. "Histamine is an excitatory neurotransmitter that is responsible for learning and memory." D. "Histamine is partially responsible for level of consciousness."

D. "Histamine is partially responsible for level of consciousness."

nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching? A. "I will notify my doctor before taking any other medications." B. "I have made an appointment to see my dentist next week." C. "I know that I cannot switch brands of this medication." D. "I can take the medication at any moment during the day as long as a take it daily."

D. "I can take the medication at any moment during the day as long as a take it daily."

A nurse is providing discharge instructions to a parent and his school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include? A. Encourage the child to take a 45 min nap daily. B. Allow the child to stay at home on days when her joints are painful. C. Apply cool compresses for 20 min every hour. D. Administer prednisone on an alternate-day schedule.

D. Administer prednisone on an alternate-day schedule.

A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign? A. Pinpoint pupils B. Jerking contractions of the head and neck C. Pronation of the arms D. Dorsiflexion of the great toe

D. Dorsiflexion of the great toe

A nurse is caring for a client who reports a severe headache following a lumbar puncture. Which of the following actions should the nurse take? A. Provide a low-sodium diet B. Administer sumatriptan. C. Place in high-Fowler's position. D. Encourage oral fluids.

D. Encourage oral fluids.

A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent neural tube defects in the fetus? A. Calcium B. Iron C. Vitamin C D. Folic acid

D. Folic acid

A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care? A. Keep the infant NPO for 6 hr prior the procedure. B. Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure. C. Place the infant in an infant seat for 2 hr following the procedure. D. Hold the infant's chin to his chest and knees to his abdomen during the procedure.

D. Hold the infant's chin to his chest and knees to his abdomen during the procedure.

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? A. Measure the circumference of the thigh. B. Palpate the femoral pulse. C. Monitor the client's calf for edema. D. Instruct the client to wiggle his toes.

D. Instruct the client to wiggle his toes.

A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care? A. Provide respite services for the parents. B. Improve the client's communication skills. C. Foster self-care activities. D. Modify the environment.

D. Modify the environment.

A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client? A. Trendelenburg B. Semi-Fowler's C. Prone D. On the unoperated side

D. On the unoperated side

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? A. Prepare the child for a lumbar puncture. B. Administer an intravenous antibiotic. C. Obtain blood cultures. D. Place the child in isolation.

D. Place the child in isolation.

A client diagnosed with a brain tumor is going to receive chemotherapy. The nurse realizes that all of the following are part of the Brain CA signs and symptoms EXCEPT: A. Difficulty speaking, thinking or articulating words B. Changes in cognition, mentation or personality C. Headaches that are usually more severe on awakening in the morning D. Pneumonia

D. Pneumonia

A nurse is discussing the plan of care with the guardians of a child recently diagnosed with a neurodevelopmental disorder. The guardians tell the nurse that they are opposed to any medication intervention. Which of the following actions should the nurse take? A. Tell the guardians that medication intervention will be necessary to proceed with the child's care. B. Educate the guardians about the possible effects and tolerability of medication intervention for their child. C. Suggest that the guardians find a new health care provider that will comply with their wishes for treatment. D. Recommend the use of nonpharmacological interventions to the child's provider

D. Recommend the use of nonpharmacological interventions to the child's provider

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. Tachycardia B. Amnesia C. Hypotension D. Restlessness

D. Restlessness

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion? A. Photophobia B. Nuchal rigidity C. Positive Kernig's sign D. Restlessness

D. Restlessness

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? A. Dehydration B. Seizures C. Burns D. Shivering

D. Shivering

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? A. The client can follow simple motor commands. B. The client is unable to make vocal sound. C. The client is unconscious. D. The client opens his eyes when spoken to.

D. The client opens his eyes when spoken to.

The nurse, caring for a client with a traumatic brain injury, realizes that the major cause of these types of injuries is: A. guns B. sports C. falls D. motor vehicle crashes

D. motor vehicle crashes

A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect? A. Vertigo B. Dysphagia C. Diplopia D. Apraxia

A. Vertigo

A client is diagnosed with a headache from a secondary cause. The nurse realizes this type of headache can be caused by A. a tumor. B. tension. C. a migraine. D. cluster

A. a tumor.

While instructing a client on stroke prevention, the nurse mentions medications that are useful in stroke prevention. The following medications are effective in preventing a stroke, EXCEPT: A. antihistamines B. anticoagulants. C. Blood pressure medication D. antiplatelets

A. antihistamines

A nurse is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the nurse place at the client's bedside? A. Bag valve mask device B. Defibrillator machine C. Chest tube equipment D. Central venous catheter tray

A. Bag valve mask device

A nurse is planning care for a client who is to receive a competitive neuromuscular blocking agent. Which of the following items should the nurse plan to have at the client's bedside? A. Bag-valve-mask device B. Temporary pacemaker C. Urinary catheter insertion tray D. Central venous catheterization tray

A. Bag-valve-mask device

A nurse is caring for a client who has chemotherapy- induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms? A. Extremities that turned blue when exposed to cold B. Tingling feeling in the extremities C. Jerking movements of the extremities D. Spasms of the extremities

B. Tingling feeling in the extremities

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.) A. Loosen restrictive clothing. B. Insert a bite stick into the client's mouth. C. Place the client into a supine position. D. Place a pillow under the client's head. E. Apply restraints.

A. Loosen restrictive clothing. D. Place a pillow under the client's head.

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant? A. Maintain the integrity of the sac. B. Promote maternal-infant bonding. C. Educate the parents about the defect. D. Provide age-appropriate stimulation.

A. Maintain the integrity of the sac.

The nurse is instructing a client diagnosed with a brain tumor on symptoms to immediately report to her physician. Which of the following should be included in these instructions? A. New onset of Seizures B. Anemia C. 3.Headache D. GI problems and Loss of appetite

A. New onset of Seizures

A client has been diagnosed with Parkinson's disease. Which of the following will the nurse most likely assess in this client? (Select all that apply.) A. Tremor B. Muscle rigidity C. Akinesia D. Mask-like face E. Dysphagia F. Auditive disorders

A. Tremor B. Muscle rigidity C. Akinesia D. Mask-like face E. Dysphagia

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Turn the client's head to the side. B. Check the client's motor strength. C. Loosen the clothing around the client's waist. D. Document the time the seizure began.

A. Turn the client's head to the side.

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next? A. Complete a vascular assessment. B. Administer an antipyretic. C. Decrease environmental stimuli. D. Assess the cranial nerves.

D. Assess the cranial nerves.

A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? A. "An MRI scan is not distorted by movement, so you do not have to lie still." B. "An MRI scan is a short procedure and should take no longer than 30 minutes." C. "The MRI contrast dye contains iodine and can cause your skin to itch." D. "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."

D. "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."

A nurse is preparing to administer phenytoin 50 mg IV bolus to a client who has a seizure disorder. The medication is supplied as a 50 mg/mL vial. Which of the following actions should the nurse take? A. Slow the injection if the medication crystallizes. B. Dilute the medication with sterile water before injecting. C. Follow the IV injection with sterile water. D. Administer the medication over 1 min.

D. Administer the medication over 1 min.

25.A client is suffering from Alzheimer's disease. All of the following are teaching information the nurse will give to the caregiver Except? A. Allow the patient extra time to answer questions. B. Assign simple tasks to be completed by the client. C. Assist the client with any needs associated with activities of daily living (ADLs). D. Allow the client to have soul food (fat) instead of reach in fiber.

D. Allow the client to have soul food (fat) instead of reach in fiber.

The nurse, caring for a client diagnosed with a brain tumor. The following statements would be appropriate interpretation by the nurse related to the disease EXCEPT: A. Regardless of location tumors can expand and invade, compress and displace normal brain tissue B. Leading to brain tissue inflammation, edema, Increased ICP and neuro deficits C. Malignant tumors require more aggressive treatment (SX, Radiation, Chemotherapy D. Brain tumors are always malignant or metastatic.

D. Brain tumors are always malignant or metastatic.

A nurse is teaching about neural tube defects to a group of females who are pregnant. Which of the following disease processes should the nurse include as an example of a neural tube defect? A. Cerebral palsy B. Hydrocephalus C. Muscular dystrophy D. Spina bifida

D. Spina bifida