EAQ

A client with Parkinsonism takes an anticholinergic medication for morning stiffness and tremors in the R arm. During a visit to the clinic, the client complained of some numbness in the L hand. Which intervention, would the nurse implement for this client?

Make arrangements immediately for further medical evaluation by the client's primary health care provider

which hearing disorder is more common in women than in men?

Ostosclerosis *sex of the client may also influence the conditions associated with hearing loss

Which assessment finding for a client who is anxious indicates SNS stimulation?

Skin pallor *sns constricts the smooth m. of blood vessels in skins when person is under stress causing pallor skin

Which action puts a client at risk for low back injury and pain?

Smoking tobacco *causes constriction of blood flow

which physiological process can be corrected with a rx'd convex lens?

convergence of images behind the retina

Recently hospitalized client w/multiple sclerosis voices a concern about generalized weakness & fluctuating physical status? What is the priority for this client?

space activities thru the day

What action eleicits the brachioradialis reflex?

striking the radius 3 to 5 cm above the wrist

Which muscle helps in moving the eye diagonally downward toward the middle of the head?

-medial rectus muscle -inferior rectus muscle

Tonic-clonic seizure, what action would nurse take for a client?

-taking measure to prevent injury -or turn client to the side to allow secretions to drain while maintaining airway

which clinical indicators would the nurse consider evidence of increasing intracranial pressure?

-vomting -irritability -decreased level of consciousness

Which action would the nurse take when caring for an older adult with a history of recent memory loss?

Employ electronic devices that provide alerts

a client is admitted to the hospital after having a tonic clonic seizure and is diagnosed w/a seizure disorder. Which is most important for the nurse to include in teaching program?

Explain ways to prevent physical trauma from occurring during a seizure.

A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reports back pain and an inability to move the legs. Which action should the nurse take first?

Leave the individual lying on the back with instructions not to move, and leave to seek additional help.

which color of cerebrospinal fluid may indicate subarachnoid hemorrhage in the client?

Yellow - due to hemolysis of the rbc, which leads to increased production of bilirubin

which action is essential for the nurse to take after a client returns from spinal injury?

assess the clients feet for sensation

Which assessment finding alerts the nurse to increasing intracranial pressure?

widening pulse pressure

During an annual physical exam, client report not able to smell coffee and most foods, which CN would the nurse assess?

Cranial Nerve I (olfactory nerve)

Damage to which cranial nerve may lead to decreased olfactory acuity?

Cranial Nerve I - originates at the olfactory bulb and assists w/perception of smell.

which factors in client's history increase the risk of hearing loss?

-diabetes -noisy environment -ear infections -loud music

Which sleep disorders are examples of dyssomnias?

-insomnia -restless leg syndrome -obstructive sleep apnea

which diagnostic test report will the nurse review for confirmation of a clients suspected brain tumor?

CT

Finding for clinical manifestation of a cluster headache?

Ipsilateral tearing of the eye

Which structure helps bend light rays and allows them to fall into the retina?

Lens - is a bioconvex structure located behind the iris - prime function to bend light rays, allowing them to fall onto the retina

Paraplegia

lower extremities are paralyzed

the superior oblique muscle controls which eye movement?

pulls the eye downward

which group has the highest rate of meningococcal infection?

young adults

Which glasgow coma scale indicates that the client is in a coma?

6 - a score of 8 or below indicates coma.

a health care provider prescribed a diagnostic workup for a client who may have myasthenia gravis. Which initial objective would the nurse establish with the client?

The client will maintain present muscle strength *maintain appropriate activity and prevent muscle atrophy

While conducting an eye examination the ophthamologist shines a light into the clients pupil and observes that there is a slow recovery of pupil size. Which muscular atrophy is responsible for this condition?

The iris dilator muscle

Which finding for a client with a head injury indicates increasing Intracranial pressure?

increased restlessness *indicates lack of 02 to brainstem

Which nursing action would be implemented after a client has a lumbar puncture?

maintaining the client in the supine position for several hours

which action would the nurse take when caring for a client who has a possible skull fracture as a result of trauma?

monitor the client for signs of brain injury

a family member who visits an 80 year old client in a nursing home remarks how thin and wrinkled the client looks. Which response by the nurse will help the family member understand the normal aging process?

older adults have lost the tissue that helps puff out the skin

a client newly diagnosed with multiple sclerosis asks the nurse. Will I experience pain, which response would the nurse give?

pain is not a characteristic symptom of this condition

which finding would the nurse expect to identify when assessing a client with a herniated lumbar disk?

pain radiating to the hip and leg

which clinical indicator would the nurse expect to find when assessing a client with hemiplegia?

paralysis of one side of the body

Which type of nerve helps the client's pupil constrict?

parasympathetic-motor the motor nerves help in eye movement

What goal would be addressed in a care plan for a client with Bell palsy?

preventing corneal damage

A client with myasthenia gravis experienced generalized weakness. Which nursing intervention would the nurse integrate into the clients plan of care?

provide the client freuent rest periods

how would the nurse describe the characteristic gait associated with Parkinsons disease when documenting it on the clients health record?

shuffling

which term would the nurse use to document observing the characteristic gait associated with Parkinson's disease?

shuffling - seen with basal ganglia defects

which information would the nurse include in the discharge teaching plan for a client who sustained a CVA with residual hemiparesis & hemianopsia?

signficance of a safe environment

which type of impairment does the nurse expect the client who has expressive aphasia to exhibit?

speaking or writing posterior frontal region of the dominant hemisphere

Which function would the nurse consider in the plan of care when a client has dysphagia?

swallowing

which principles of body mechanics would the nurse use when providing care for an immobilized client?

Placing feet apart to increase stability of the body

Which is the middle layer of the eyeball?

Uveal tract *consists of the iris, choroid, and ciliary body

Which test helps a primary health care provider distinguish b/t conductive and sensorineural hearing loss?

Weber test *tuning fork tests help in differentiating conductive and sensorineural

a client falls from a two story building and is taken to the hospital unconscious. Which finding during the initial nursing assessment would be of concern to the nurse?

bleeding from the ears

Postanesthesia care unit nurse providing care for a client who had a craniotomy for a meningioma would monitor for which specific clinical manifestation in this client?

blurred vision

upon assessment the nurse finds the following, the nurse will prepare the client for which type of surgery?

Cataract removal

which reflex is the nurse testing when using a dull object to stroke from the lateral sole of a clients food upward to the great toe?

Babinski

which medication used in the treatment of clients with glaucoma is a prostaglandin agonist?

Bimatoprost

which part of the brain contains the central switchboard of the CNS

Diencephalon *the thalamus along with the hypothalamus and epithalamus are located in the diencephalon of the brain

Which cranial nerve damages from the clients medulla?

Hypoglossal *medulla is part of the brainstem, thehypoglossal n. XII emerges from the medulla

65 year old client tells the nurse, I see some particles that float within my field of vision. Which condition may be the cause of this?

Liquefaction and detachment of the vitreous membrane

CVA - brain attack - client not able to differentiate between heat or cold and dull sensory stimulation. The nurse would conclude the CVA affected which lobe of the brain?

Parietal

The nurse observes dorsiflexion of the big toe & fanning of other toes when the lateral side of a clients foot is stroked. Which finding would the nurse document?

exhibits positive Babinski sign *suggests upper motor neuron disease of the pyramidal tract in adults

which factor is the nurse assessing when checking the cardinal positions from the image?

extraocular muscle function

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open angle glaucoma?

impariment of peripheral vision

The nurse is teaching the client about cerumen when irrigating the ear. Which area will the nurse indicate to the client in the given image that is an example of cerumen?

2 option 2 indicates cerumen

The nurse teaches the staff about the nasolacrimal duct. Which choice on the image below would the staff choose that indicates successful learning?

4

which part of the brain is primarily assoc w/life support and basic functions of the body?

brainstem - connects the brain to the CNS

Which condition is due to decreased elasticity of the ocular lens?

Presbyopia *age related problem in which the lens loses its elasticity & is less able to change its shape to focus the eye for close work

A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)?

Pulse 50 bpm & bp 140/60 mm Hg

Optimum nurtrition which intervention would nurse implement when determine a client, who sustained a brain attack needs assistance with eating

clients should be encourage to participate in their own care (in feeding process)

Which cerebral lobe includes the speech area that allows the client to process words into coherent thoughts?

temportal lobe

a client who is newly diagnosed with multiple sclerosis is obviously upset and asks, am I going to die, which response would the nurse make?

the prognosis is varies as most individuals have remissions and exacerbations

which cranial nerve is responsible for the clients euilibrium?

the vestibulocohlear

which clinical indicator would the nurse expect to identify when assessing a client who has brain tumor in the occiptal lobe?

visual hallucinations

a young adult is unconscious after an accident. As part of the assessment nurse applies a painful stimulus to the clients left lower leg.

withdrawing the leg

After assessing a clients vision, the nurse observes the client has difficulty seeing objects that are far away. Which condition would the nurse suspect the client is experiencing?

Myopia

Which gerontologic assessment findings of the auditory system are related to the inner ear?

1. Hair cell degeneration 2. Reduced blood supply to the cochlea 5. Less effective vestibular apparatus in the semicircular canals

Which nursing action would be included in the plan of care for a client scheduled to have a CT scan of the brain?

Telling client what to expect during the test

which region of the brain regulates verbal expression?

Broca area

Which area of the cerebral lobe is linked to Wernicke's area of speech?

Temporal lobe, helps in processing of words into coherent thought and understanding of written or spoken words.

a client reports buzzing in the ear for the past 5 days and a decreased ability to hear sounds. After interacting with the client, the nurse finds that the client is receiving long term aminoglycoside therapy. Which cranial n. would the nurse suspect to be affected?

CN VIII *is the vestibulocochlear nerve, a part of central auditory system.

Which test is used to diagnose diseases of the vestibular system?

Caloric reflex test *is a test of the vestibulo-ocular reflex that involves irrigating cold or warm water into external auditory canal

Which radiologic test is used to obtain 3 dimensional brain images?

Computed tomography CT

Which action would the nurse test when assessing a clients eyes to ensure formation of a single image of close objects?

Convergence action of the eyes ensures that only a single image of close objects is seen. Mydriasis is pupil dilation when exposed to reduced light or looking at a distance.

Which lobe of the cerebrum incldues the Broca speech center?

Frontal lobe and is responsible for formation of words into speech

which position will a client maintain immediately after having a supratentorial craniotomy for a tumor of the right frontal lobe of the cerebral cortex?

Head of the bed elevated 30 to 45 degrees with the neck in neutral alignment

An adult client is brought to the emergency department by a friend who states, "We were all partying at a club, and all of a sudden my friend collapsed." Vital signs revealed a temperature of 99.2° F, pulse of 152, respiratory rate of 32, blood pressure of 163/92. After performing a physical assessment and collecting a health history from the client, what action should the nurse take next?

Inform the healthcare provider of the client's status and prepare to start an intravenous (IV) line.

which explanation would the nurse provide to a client about TIAs

Temporary episodes of neurological dysfunction

which condition is associated with involuntary and rapid twitching of the eyeball?

Nystagmus involuntary and rapid twitching of the eyeball.

Which visual system assessment technique provides a magnified view of the retina and optic nerve head?

Ophthalmoscopy *provides a magnified view of the retina and optic nerve head.

Which type of reflex is the nurse performing in the figure?

Patellar reflex

Which goals is the nurse trying to achieve by reinforcing to the client that its important to seek treatment for primary open angle glaucoma (POAG)

Prevent blindness

client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Spacing activities will encourage maximum functioning within the limits of strength and fatigue

Which medication is a beta-adrenergic blocker used to reduce intraocular pressure?

Timolol used for treatment of glaucoma

Which health problem hx would increase an older adults risk for experiencing a CVA?

Transient ischemic attacks TIAs

when assessing a clients pupils the nurse identifies a noticeable difference in the pupil sizes which term would the nurse use to describe this condition?

anisocoria

a client reports a severe unilateral throbbing headache, nausea, intolerance to light and sound, double vision. Which phase of this headache involved double vision?

aura phase

which statement indicates the nurse has correct understanding about trigeminal autonomic cephalagia (cluster headaches)

caused by overactive hypothalamus

a client who has experienced a subarachnoid hemorrhage would be maintained in which position?

in bed with head of bed elevated

which clinical manifestation would the nurse expect the client who has a tumor of the cerebellum to exhibit?

inability to coordinate movement

Which assessment finding would the nurse document in clients health record as positive Romberg test?

inability to stand with feet together when eyes are closed *evaluates proprioception-client asked to close eyes when standing, if balance lost after eyes are closed a positive romberg test suggest theres sensory cause.