ATI- Neurosensory

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure?

The client has a pacemaker Rationale: An MRI uses strong magnets and radio waves that are evaluated using computer technology to view three-dimensional images of the body. Since and MRI is magnetically generates, it is not indicated for use in the presence of certain medical implants. Clients who has cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators can not undergo an MRI because the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures.

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample?

The client rigidly extends his arms. Rationale: A client who exhibits a decerebrate posture rigidly extends and pronates his four extremities and externally rotates his wrists. Decerebrate posturing indicates severe brain stem injury and late neurologic decline.

A nurse is reinforcing teaching about auras with a client who has a new diagnosis of simple partial seizures. Which of the following statements by the client indicates an understanding of the teaching?

"An aura is a sensory warning that is a seizure is imminent." Rationale: An aura is a sensory warning that is a seizure is imminent. The aura can be similar to a hallucination and involve and of these senses. The client can report hearing bells, seeing lights, or smelling an odor.

A nurse is reinforcing teaching with a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching?

"Darken the lights." Rationale: The nurse should instruct the client to lie down in a dark room to reduce migraine pain.

A nurse is reinforcing teaching with a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the teaching?

"I will avoid bending over." Rationale: The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valhalla maneuver. An increase in intraocular pressure can result in intraocular hemorrhage.

A nurse is reinforcing teaching with a client who has a new diagnosis of Ménière's disease. Which of the following instructions should the nurse include in the teaching?

Avoid sudden movements Rationale: Meniere's disease is a disorder of the inner ear affecting balance and hearing, characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations.

A nurse is collecting data from a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia?

Report of a headache Rationale: Autonomic dysreflexia is a neurologic emergency that can occur in clients who have a cervical to thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.

A nurse is collecting data from a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect?

Swelling behind the affected ear Rationale: Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include swelling and pain behind the ear.

A nurse is reinforcing discharge teaching with a client who is postoperative following sclera buckling to repaid a detached retina. Which of the following instructions should the nurse include in the teaching?

"You should expect to see flashing lights in front of the affected eye after the procedure." Rationale: The client should expect to see flashing lights in front of the affected eye for several weeks following the procedure.

A nurse is collecting data from a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations?

Cheyne-Stokes Rationale: Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths, followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose of increased intracranial pressure and can precede death.

A nurse in a rehabilitation center is collecting data from a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect?

Difficulty with speech Rationale: The left hemisphere of the brain is usually the dominant side and is responsible for language. This is always true for right-handed clients and for the majority of left-handed clients. Since this client is recovering from a left-hemisphere stroke, the nurse should anticipate that the client will have aphasia and require speech therapy to establish communication.

A nurse is reinforcing teaching with a new client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following information should the nurse include in the teaching? SATA

Driving can be dangerous dude to the loss of peripheral vision - damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can cause complete vision loss if not treated. Laser surgery can help reestablish the flow of aqueous humor - laser surgery can reopen the trabecular mesh work and widen the Canal of Schlemm

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside?

Oral-nasal suction equipment Rationale: The client who has myasthenia gravis is at risk for aspiration because of progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcysteine receptors. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.

A nurse is reinforcing teaching with the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestation of ALS?

Weakness of the distal extremities Rationale: ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain and the spinal cord causing muscle wasting spasticity, and eventually paralysis. Early manifestations of ALS include increasing muscle weakness, especially involving the distal arms and legs (hands and feet), speech, swallowing, and breathing.

A nurse is reinforcing teaching with a group of clients about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching?

A TIA can precede an ischemic stroke Rationale: TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stoke. Manifestations of a TIA include loss of vision in one eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness.

A nurse is reinforcing teaching with a partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is the priority?

Dysphagia Rationale: Dysphagia is the priority manifestation for this client because it can lead to aspiration.

A nurse is collecting data from a client who has a brain tumor. Which of the following findings indicates cranial nerve involvement?

Dysphagia Rationale: Dysphagia, or difficulty swallowing, can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus).

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. The nurse should recognize which of the following findings is consistent with the diagnosis?

Elevated protein Rationale: An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include an increase in protein in the cerebrospinal fluid.

A nurse is reinforcing teaching with a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?

Feeling of fullness in the ear Rationale: A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations can include ear pain, a cracking sound when yawning or swallowing, and mild dizziness.

A nurse is reinforcing teaching with an adolescent client who has a recurrent external otitis. Which of the following instructions should the nurse include in the teaching?

Instill a diluted alcohol solution into the ear after swimming Rationale: External otitis is an inflammation of the external auditory canal often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops to decrease bacteria and dry the external ear canal.

A nurse is reinforcing teaching with a client who is preoperative for cataract surgery. The nurse should include in the teaching that which of the following is an adverse effect of cataract surgery?

Intraocular hemorrhage Rationale: Intraocular hemorrhage is an adverse effect of cataract surgery. The client should immediately report manifestations of intraocular hemorrhage, such as eye pain, brow pain, and decreased vision, to the provider.

A nurse is collecting data from a client who is admitted to the facility for observation following a closed head injury. Which of the following data is the priority for the nurse to collect to detect a change in the client's neurologic status?

Level of consciousness Rationale: A change in the client's level of consciousness can be the first indication of a change in neurologic status.

A nurse is reinforcing teaching with the family of a client who has stage II Alzheimer's disease (AD). Which of the following information should the nurse include in the teaching?

Limit choices offered to the client Rationale: Choices should be limited for the client who has stage II AD to reduce confusion and frustration.

A nurse is reinforcing discharge teaching with the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct client's family to take which of the following actions first in the event of a seizure?

Protect the client's head Rationale: The client is at greatest risk for injury from hitting his head; therefore, the first action the nurse should take is to protect the client's head from injury.

A nurse is caring for a client who has had a closed head injury. The nurse should place the client in which of the following positions?

Semi-Fowler's Rationale: To prevent an increase intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30 degrees. Thus positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure.

A nurse is collecting data from a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations?

Severe eye pain Rationale: Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headache, brow pain, and nausea and vomiting.

A nurse is collecting data from a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect?

Weakness of the lower extremities Rationale: Gillian-barre syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized bu the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities.

A nurse is collecting data from a client following a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?

Widened pulse pressure Rationale: A widening of the pulse pressure, the difference between the systolic and diastolic pressure, is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting.

A nurse is collecting data from a client who has a closed head injury and is receiving mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates to the nurse that the medication is having a therapeutic effect?

The client's urine output is 250 mL/hr Rationale: Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. An increase in urine output is desired. A decrease in cerebral edema should result in a decrease in ICP.

A nurse is collecting data from a client who has a recent head trauma and a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to monitor for DI?

Specific gravity Rationale: Diabetes insipidus is caused by damage to the hypothalamus, or the pituitary gland, as a result of cranial surgery, infection, or a tumor. It is a condition in which an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus.