chapter 38

A nurse is teaching a client with cerebellar function impairment. Which statement would the nurse include in this client's discharge teaching?

"Ask a friend to drive you to your follow-up appointments."

A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, "I am worried I will not be able to care for my young children." How would the nurse respond?

"Can you tell me more about what worries you, so we can see if we can do something to make adjustments?"

A nurse asks a client to take deep breaths during an electroencephalography. The client asks, "Why are you asking me to do this?" How would the nurse respond?

"Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity."

The nurse assesses a client's recent memory. Which statement by the client confirms that recent memory is intact?

"I ate oatmeal with wheat toast and orange juice for breakfast."

After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the client's understanding. Which statement indicates client understanding of the teaching?

"I can return to myusual activities immediately after the MRI."

How would the nurse document this finding? (Hands near chest)

Decorticate posturing

A nurse assesses a client with an injury to the medulla. Which clinical manifestations would the nurse expect to find? (Select all that apply.)

Decreased respiratory rate Impaired swallowing Inability to shrug shoulders Loss of gag reflex

A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment finding would be the priority for the nurse to report to the primary health care provider?

Decreasing level of consciousness

A nurse plans care for a 77-year-old client who is experiencingage-relatedperipheral sensory perception changes. Which intervention would the nurse include in this client's plan of care?

Ensure that the path to the bathroom is free from clutter.

A nurse assesses a client with a brain tumor. Which newly identified assessment findings would alert the nurse to urgently communicate with the primary health care provider? (Select all that apply.)

Glasgow Coma Scale score of 8 Decerebrate posturing Decreasing level of consciousness

An 84-year-old client who is usually alert and oriented experiences an acute cognitive decline. Which of the following factors would the nurse anticipate as contributing to this neurologic change? (Select all that apply.)

Infection Drug toxicity Hypoxia

When assessing a client who had a traumatic brain injury, the nurse notes that the client is drowsy but easily aroused. What level of consciousness will the nurse document to describe this client's current level of consciousness?

Lethargic

A nurse assesses a patient who is recovering from a lumbar puncture (LP). Which complication of this procedure would alert the nurse to urgently contact the primary health care provider?

Nausea and vomiting

A nurse assesses a client recovering from a cerebral angiography via the right femoral artery. Which assessment would the nurse complete?

Palpate bilateral lower extremity pulses.

The nurse is performing an assessment of cranial nerve III. Which testing isappropriate?

Pupil constriction

The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V. What assessment findings will the nurse expect for this client?

Severe facial pain

A nurse prepares a client for lumbar puncture (LP). Which assessment finding would alert the nurse to contact the primary health care provider?

Shingles infection on the client's back

A nurse assesses an older client. Which assessment findings would the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)

Slower processing time Change in sleep patterns

A nurse performs an assessment of pain discrimination on an older adult. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action would the nurse take next?

Touch the pin on the same area of the left hand.

The nurse teaches an 80-year-old client with diminished peripheral sensation. Which statement would the nurse include in this client's teaching?

"Look at the placement of your feet when walking."

Which statement would the nurse include when teaching the assistive personnel (AP) about how to care for a client with cranial nerve II impairment?

"Tell the client where food items are on the breakfast tray."

A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How would the nurse document this client's assessment using the Glasgow Coma Scale shown below?

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