Chapter 38

A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? A. Avoid heavy lifting. B. Avoid fiber in the diet. C. Take an antacid frequently. D. Take an herbal form of feverfew.

A. Avoid heavy lifting.

The critical care nurse is giving end-of-shift report on a client. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? A. Comatose B. Somnolence C. Stupor D. Normal

A. Comatose

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop? A. Damage to the nerves that facilitate vision and hearing B. Damage to the vagal nerve C. Damage to the olfactory nerve D. Damage to the facial nerve

A. Damage to the nerves that facilitate vision and hearing

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? A. Elevate the head of the bed. B. Complete a head-to-toe assessment. C. Administer morning dose of anticonvulsant. D. Administer Percocet as ordered.

A. Elevate the head of the bed.

The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client? A. Increased intracranial pressure B. Decreased intracranial pressure C. Hypervolemia D. Hypovolemia

A. Increased intracranial pressure

A Client is diagnosed with blepharitis. What symptoms should a nurse monitor in this A. Patchy flakes clinging to the eyelashes B. A red pustule in the internal tissue of the eyelid C. Redness surrounding the conjunctival sac D. A halo around the pupil

A. Patchy flakes clinging to the eyelashes

The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action? A. Assess client's reaction to new medication schedule. B. Administer medications at exact intervals ordered. C. Document medication given and dose. D. Give client plenty of fluids with medications.

B. Administer medications at exact intervals ordered.

The nurse is collecting the history of a client diagnosed with a cataract and is performing a focused assessment. Which finding should the nurse anticipate? A. A burning sensation and the sensation of an object in the eye B. Blurred or cloudy vision C. Inability to produce sufficient tears D. A swollen lacrimal caruncle

B. Blurred or cloudy vision

The nurse is performing a Weber test on a client. During this test, where should the nurse place the tuning fork? A. On the mastoid process behind the ear B. In the midline of the client's skull or in the center of the forehead C. Near the external meatus of each ear D. Under the bridge of the nose

B. In the midline of the client's skull or in the center of the forehead

A nurse is caring for a client who has just been diagnosed with glaucoma. What teaching should the nurse include with this client? A. How long it will be necessary to wear dark glasses B. The importance of regular bowel habits C. What vegetables to eat D. When it will be possible to read again

B. The importance of regular bowel habits

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the: A. musculoskeletal system. B. sympathetic nervous system. C. parasympathetic nervous system. D. endocrine system.

B. sympathetic nervous system.

The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer? A. Headache and pain in the neck B. Claustrophobia C. Allergic reaction to the imaging material D. Allergic reaction to radioactive rays

C. Allergic reaction to the imaging material

client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate? A. Measure the heart and the pulse rate. B. Provide the client with caffeine-rich drinks. C. Allow the client to wash hair and rest. D. Measure the level of consciousness (LOC) of the client.

C. Allow the client to wash hair and rest.

A client the nurse is caring for experiences a seizure. What would be a priority nursing action? A. Restrain the client during the seizure. B. Insert a tongue blade between the teeth. C. Protect the client from injury. D. Suction the mouth during the convulsion

C. Protect the client from injury.

The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern? A. The HCP maintains aseptic procedure, B. The pressure is noted to be 90 mm H20. C. The cerebrospinal fluid (CSF) is cloudy in nature. D. The HCP administers a drug by intrathecal injection.

C. The cerebrospinal fluid (CSF) is cloudy in nature.

The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve? A. II B. VI C. VIIII D. XI

C. VIIII

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? A. "I sense that you are happy it was not a stroke". B. "People who experience a TIA will develop a stroke". C. "TIA symptoms are short-lived and resolve within 24 hours". D. "TIA is a warning sign. Let's talk about lowering your risks."

D. "TIA is a warning sign. Let's talk about lowering your risks."

An older client complains of a constant headache. A physical examination shows papilledema. Based on these symptoms, what condition would the nurse suspect? A. Epilepsy B. Trigeminal neuralgia C. Hypostatic pneumonia D. Brain tumor

D. Brain tumor

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? A. Ischemic B. Hemorrhagic C. Right-sided D. Left-sided

A. Ischemic

The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate? A. Using the Romberg test B. Observing the reaction of pupils to light C. Observing the client's response to painful stimuli D. Monitoring the client's sensitivity to temperature, touch, and pain

C. Observing the client's response to painful stimuli

A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client? A. Avoid crowas. B. Take drugs only after meals at night. C. Avoid caffeine and alcohol. D. Use caution while driving or performing hazardous activities.

D. Use caution while driving or performing hazardous activities.

The nurse is caring for a client with head trauma. Which assessment finding(s) would indicate an increasing intracranial pressure (ICP) in this client? Select all that apply. A. Stiff neck B. Generalized pain C. Glasgow Coma Scale of 15 D. Elevated systolic blood pressure E. Brisk pupil response F. Wide pulse pressure

D. Elevated systolic blood pressure F. Wide pulse pressure

A nurse is caring for a client with an injury to the central nervous system. When carir for a client with a spinal cord insult that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction? A. Identification of information due to slowed passages of information to brain. B. Cognitive ability to understand relayed information. C. Processing information transferred from the environment. D. Response due to interrupted impulses from the central nervous system

D. Response due to interrupted impulses from the central nervous system

The nurse is caring for a client with open-angle glaucoma. What does the nurse know that this disease causes? Select all that apply. A. Atrophy of nerve fibers in the central area of the retina B. Edema of the lens C. Degeneration of the optic nerve D. Edema of the cornea E. Atrophy of nerve fibers in the peripheral areas of the retina

C. Degeneration of the optic nerve D. Edema of the cornea E. Atrophy of nerve fibers in the

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client? A. Decreased Fluid Volume Risk B. Aspiration Risk C. Impaired Swallowing D. Malnutrition Risk

C. Impaired Swallowing