Exam #2 Review

_________ ________ allow cerebrospinal fluid to leak fom the nose and ears.

Basilar fractures

A patient who has been severely beaten is admitted to teh emergency department. The nurse suspects a basilar skull fracture after assessing:

Raccoon's eyes and Battle sign

The nurse initiates a teaching plan for the family and client with neurologic deficitss because of Parkinson's disease. What nursing instruction is the highest priority?

Reduce home safety hazards.

A client is prescribed phenytoin for a recurrent convulsive disorder. The nurse teaches the client that the most common adverse reactions are?

Related to the GI system

When caring for a client with a neurologic deficit, what nursing intervention is most important for preventing the formation of a pressure ulcer?

Relieve pressure over bony prominences.

A client with Parkinson disease is prescribed carbidopa/levodopa. The nurse will exercise caution when administering this drug if which disorder is noted in the client's medical history? Select all that apply.

Renal disease Asthma Peptic ulcer disease

A client with a neurologic deficit has been admitted to the nursing unit. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Which of the following action should the nurse perform immediately?

Report the change to the physician.

The nurse is caring for a client postoperatively from a spinal tumor resection. The nurse assesses that the client has partial paralysis. What anticipated problems should the nurse include in the client's care plan? Select all that apply.

Risk for impaired physical mobility Risk for injury Risk for powerlessness Risk for knowledge deficit

A _________ may be defined as periodic disturbances of the brain's electrical activity.

Seizure

________ and _______ are terms often used interchangeably to describe a convulsion.

Seizures, convulsions

The nurse is educating the client who had been started on Dilantin and its side effects. Which symptom would indicate a life-threatening condition and should be reported to the healthcare provider immediately?

Shortness off breath

Which nursing technique best allows the client with slight expressive aphasia to communicate his feelings about using adaptive equipment in public?

Sit beside client and patiently assist in interpreting communication.

When caring for a client taking a succinimide for seizure control, the nurse monitors the client for blood dyscrasias. Which of the following symptoms would indicate that the client may be developing a blood dyscrasia?

Sore throat, general malaise

_______ ________ is a loss of sympathetic reflex activity below the level of injury 30 to 60 minutes of a spinal injury.

Spinal shock

The recovery phase begins when the patient is...

Stable

Serious skin reactions, such as _______ _______ ________, has been associated with the use of Lamictal.

Steven-Johnson's disease

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the spae below the dura?

Subdural

A(n) _____________ results from venous bleeding, with blood gradually accumulating in the space below the dura.

Subdural hematoma

Which of the following best describes convulsions?

Sudden, involuntary contractions

A(n) ________ incision is made behind the hairline on the side of pathology.

Supratentorial

A nurse is prviding care to a client recently diagnosed with a brain tumor. When planning this client's care, the nurse anticipates which therapy as providing the best outcome for the client?

Surgery

The nurse is caring for a patient experiencing autonomic dysreflexia. Which of the following does the nurse recognize as a source of symptoms?

Sympathetic nervous system

A family member asks the nurse which exercise is best to help a client with Parkinson disease maintain balance. Which is the best response?

Tai Chi

Identify the interventions to use to help promote sleep for the client with RLS. Select all that apply.

Take a hot bath Do a crossword puzzle

A patient has sustained a head injury and is unconscious in the emergency room. A family member of the patient arrives and is providing details of the patient's medical history. Which information is of most concern to the nurse?

The patient's medications include warfarin (Coumadin).

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following health care provider prescriptions: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?

To avoid impeding venous outflow

Achalasia refers to the failure of the muscles of the lower esophagus to relax, causing difficulty in swallowing.

True

Antiepileptics drugs are used to manage seizure disorders.

True

To decrease the risk of developing a pressure ulcer, the patient should be placed on a turning mattress.

True

Use of the joint can be permanently lost if not exercised regularly.

True

A 70-year-old client with Parkinson's disease is receiving pramipexole. Which potential adverse reaction should the nurse monitor the client for?

Visual hallucinations

A client has been prescribed an anticholinergic agent for treatment of Parkinson-related symptoms. What client education should be provided?

Void before taking the medication.

Which statement would be included when educating the client taking trimethadione for seizures?

Wear a sunscreen and protective clothing when exposed to sunlight.

Which of the following is a sign of increasing ICP?

Widening pulse pressure

The client is newly diagnosed with epilepsy. What factors should the healthcare team consider when determining the drug of choice for the client? Select all that apply.

age type of epilepsy culture and ethnicity

The three categories of seizures disorders are ________, ________, and _______.

ideopathic, hereditary, acquired

The nurse is preparing to administer carbidopa/levodopa to a client recently diagnosed with Parkinson disease. The nurse should question this order if which disorder is noted in the client's record? Select all that apply.

narrow-angle glaucoma use of MAOI antidepressants

A mother brings her 6-year-old to the emergency department after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?

"A concussion is a blow to the headd that jars the brain, resulting in diffuse and microscopic injury to the brain."

A client with a history of tremors and gait changes has been diagnosed with Parkinson's disease and the client's provider has prescribed carbidopa-levodopa 25/100 mg PO t.i.d. What should the nurse teach the client about the safe and effective use of this medication?

"It's best to avoid taking any over-the-counter vitamin supplements during treatment." "You can take this medication with food or on an empty stomach, whichever you prefer."

The ________ phase follows sudden neurologic event, such as a cerebrovascular accident (CVA) or a head or spinal cord injury.

Acute

Neurologic deficits are divided into three phases...

Acute, Recovery, Chronic

A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply.

Administer antipyretics as prescribed Perform frequent neurologic assessments Monitor pain levels and administer analgesics

Drugs that work to stimulate the dopamine receptors are called __________.

Agonist

In which of the following disease processes is the nurse most likely to care for a client in the chronic phase of a neurologic disease?

Alzheimer's disease

An older adult patient exhibiting clinical manifestations of a brain tumor is admitted to the hospital for testing. What tumor types does the nurse know are commonly seen in the older adult?

Anaplastic astrocytoma Cerebral metastasis from other sites Glioblastoma

The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a patient with head injuries, which type of medications are frequently administered? Select all that apply.

Anticonvulsants Analgesics Antibiotics

The client who has Parkinson's disease is experiencing dysphagia. Which drug should the nurse have available for parenteral administration?

Apomorphine

The drug ________ is used for "on-off" hypomobility episodes.

Apomorphine

A home care nurse is helping a client and family cope with a recent neurologic deficit. What intervention is most important for the nurse to perform first?

Assist the client and family to identify possible needs and solutions.

When caring for a patient who is post-intracranial surgery what is the most important parameter to monitor?

Body temperature

The nurse is caring for a patient with a spinal cord injury leaving paralysis. When planning care related to the musculoskeletal system, which considerations are important? Check all that apply.

Bone demineralization Contractures Spasticity Limited range of motion

Neurosurgical procedures may reqire the use of ________ _______ to make a bone flap in the skull, aspirate a brain abscess, or evacuate a hematoma.

Burr holes

A patient with a spinal cord injury has full head and neck control when the injury is at which level?

C5

The nurse understands that a client receiving which anticonvulsant will need close observation for possible toxicity after the initiation of a protease inhibitor such as lopinavir/ritonavir (Kaletra) for the treatment of HIV?

Carbamazepine

Injuries that occur when the brain rebounds and hits the opposite side of the skull is called ______________.

Contrecoup injury

A client has been prescribed benztropine as drug therapy for Parkinson's disease. What assessment finding would suggest a therapeutic effect to the nurse?

Decreased rigidity and tremors

Parkinsons disease is a _______ disorder of the central nervous system.

Degenerative

A client with a brain tumor is exhibiting papilledema. When reviewing the client's history, which information would the nurse correlate with this finding? Select all that apply.

Double vision Visual field deficit

Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field?

Ensure a clutter-free walkway.

Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery?

Epidural

A nurse is caring for a patient with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?

Establishing an intermittent catheterization routine every 4 hours

_________ _________ is the compromised ability to put words together meaningfully when trying to communicate.

Expressive disphagia

An emergency department nurse is admitting a client brought in by the paramedics after falling from a tree stand. The client has fractured vertebrae at T3 and T4. The nurse knows the client is in the acute phase of neurologic deficit. What should the nurse know about the medical management of this client?

Goal is to stabilize the client and prevent further neurologic damage.

When administering diazepam to an older client, the nurse should monitor the client for unusual effects of the drug such as?

Heart arrhythmias

Ethotoin is contraindicated in patients with ________ abnormalities

Hepatic

The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?

Herniation occurs through the foramen magnum

______ should be avoided in head injuries unless prescribed by a physician.

Ibuprofen

Rehabilitation is designed to meet the client's ________ and long-term needs.

Immediate

A(n) _________ incision is a horseshoe0shaped incision around the occipital lobe.

Infratentorial

_______ is used cautiously in patients with cardiovascular or pulmonary diseases, peptic ulcer disease, renal or hepatic disease, and psychosis.

Levodopa

The nurse is explaining the therapeutic effects of medication to a client with Parkinson's disease. What characteristics of levodopa and dopamine should the nurse describe? Select all that apply.

Levodopa is a precursor of dopamine Levodopa crosses the blood-brain barrier Levodopa is converted to dopamine

The client taking Tolcapone for Parkinson disease is monitored closely for which of the following?

Liver dysfunction

A patient with a concussion is discharged after the assessment. Which instruction should the nurse give the patient's family?

Look for signs of increased intracranial pressure

A nurse is reading a jurnal article about spinal cord tumors and metastasis from other primary sites. The nurse demonstrates understanding of the article when identifying which primary sites as commonly metastasizing to the spinal cord? Select all that apply.

Lung Breast Gastrointestinal tract

The client has been diagnosed with Parkinson's disease and has been prescribed levodopa. What should the nurse include in the care plan? Select all that apply.

Monitor the client's vital signs each shift Monitor the client's urine output each shift Auscultate the client's bowel sounds once per shift Monitor the client's creatinine clearance whenever available

Which is the most common cause of spinal cord injury?

Motor vehicle crashes

A patient with a herniated lumbar disc has asked about nonsurgical strategies to help with mobility. What strategies will the nurse teach the patient? Check all that apply.

Muscle relaxants Weight reduction Physical therapy Nonsteroidal anti-inflammatory medications

_______ seizures involve sudden, forceful contractions involving single or mltiple groups of muscles.

Myoclonic

A condition in which one or more functions of the central and peripheral nervous systems are decreased, impaired, or absent is known as a _______ ________.

Neurological deficit

A(n) _______ _______ is a condition in which one or more functions of the central and peripheral nervous systems are decreased, impaired, or absent.

Neurological deficit

A middle-aged patient has scheduled a sick visit to the physician's office, stating symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and identified potential causes of the pain. Which area of the drawing would the nurse emphasize?

Nucleus pulposus

A patient with a spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in the patient? Check all that apply.

Orthostatic hypotension Autonomic dysreflexia DVT

A patient reports beginning to experience lower back pain after lifting a heavy box. Which symptoms would lead the provider to suspect lumbar nerve compression? Select all that apply.

Pain in the buttocks that extends down the leg Weakeness in the muscles of the left leg

The nurse caring for a client diagnosed with Parkinson disease has prepared a plan of care that would include what goal?

Promoting effective communication

A physician orders oral levodopa 0.75g to be given. The only dosage available on hand is 100mg, 250mg, nd 500mg tablets. What would the nurse administer to this patient? Only one correct answer.

1 250mg tablet and 1 500mg tablet

The most serious adverse reactions seen with levodopa include which of the following?

Choreiform and dystonic movements.

Which activities would the patient with a T4 spinal cord injury be able to perform independently? Select all that apply.

Eating Breathing Transferring to a wheelchair Writing

Drugs with cholinergic blocking activity are used as antiemetic therapy in all forms of Parkinsonism.

False

The focus of client management during the recovery phase is to stabilize the client and prevent further neurologic damage.

False

The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of, or leaking of, cerebral spinal fluid?

Halo sign

Cervical traction is done with either a _______ _______ device or ________ _______.

Halo vest, cervical tongs

An 68-year-old client was diagnosed with Parkinson's disease two years ago and symptoms have grafually worsened. What nursing diagnoses are likely to be applicable to this client? Select all that apply.

Impaired Physical Mobility related to extrapyramidal symptoms Self-care Deficit: Dressing/Grooming related to ataxia

Simple seizures, motor seizures, and somatosensory seizures are classified as what type of seizure?

Partial seizures

The barbiturate ________ is commonly used to treat convulsive disorders.

Phenobarbital

Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident?

Prevention of joint contractures

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?

Pulse and blood pressure

The nurse is caring for clients on a neurologic floor. Which client goal is most appropriate for the acute phase of a neurologic injury?

The client's vital signs will stabilize returning to baseline.

Clients are taught to use a clean technique for irrigating, changing, or inserting catheters at home.

True

Generalized seizures involve a loss of consciousness.

True

Levodopa crosses the blood brain barrier.

True

Levodopa is a chemical formulation found in plants and animals that is converted into dopamine by the body.

True

Many clients with neurologic deficits have difficulty coping with their disability.

True

Parkinsonism refers to a group of symptoms involving motor movement.

True

Patients with spinal cord injuries are at increased risk for developing pressure ulcers.

True

Supplementing dopamine is difficult because of the blood-brain barrier.

True

The nurse caring for a client with a neurologic deficit must begin client and family teaching long before discharge.

True

The nurse is teaching a client and caregivers about the prescribed phenytoin. The nurse determines the session is successful when they correctly choose which adverse reaction to report to the health care provider immediately? Select all that apply.

Ataxia Slurred speech Lethargy

________ _______ is a condition in which your involuntary nervous system overreacts to external or bodily stimuli.

Autonomic dysreflexia

Some antiepileptic medication may cause birth defects. The nurse should instruct the female client regarding?

Birth control methods

A patient who has sustained a basal skull fracture is admitted to the neurological unit. The nurse should know that the patient should be observed for:

Bleeding from the ears

A 25-year-old client takes ethosuximide for the treatment of absence seizures calls the clinic to report that she has developed a sore throat and a slight fever. The nurse will explain that she should come to the clinic to have what checked?

Blood cell count

A nurse is caring for a client diagnosed with Guillain-Barre syndrome. The client states, "It's getting harder t take a deep breath." Which action by the nurse is most appropriate?

Call the physician and prepare for intubation

The nurse working on the neurological unit is caring for a patient with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?

Ecchymosis over the mastoid

The level of carbamazepine is increased when an anticonvulsant is administered with theophylline.

False

Trimethadione is easily absorbed in the GI tract and is effective in controlling partial seizures.

False

Valproic acid is used with caution in patients with pulmonary disease and in hyperactive children.

False

A gymnast sustained a blow to the head after falling off the balance beam. The patient has had surgery to repair an epidural hematoma. Once regaining consciousness, the patient asks for somehting to drink. The nurse advises that the patient is under fluid restriction to:

Increase cerebral perfusion

The nurse practitioner prescribes the medication of choice for an MS patient who is experiencing disabling episodes of muscles spasms, especially at night. Which of the following is the drug most likely prescribed in this scenario?

Lioresal

A nurse is reviewing CT scan of the brain, which states that the patient has arterial bleeding with bloof accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Monitoring is needed as rapid neurologic deterioration may occur

Which of the following occupations are anticipated to improve the functioning of a client with a neurologic deficit? Select all that apply.

Occupational therapist Speech therapist Neurologist Physical therapist

A patient with a T4 level spinal cord injury reports severe headache. The nurse notes profuse diaphoresis of the patient's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?

Place the atient in a sitting position

Which stimulus is known to trigger an episode of autonomic dysreflexia in the patient who has suffered a spinal cord injury?

Placing a blanket over the client

A client with a history of a brain tumor is undergoing diagnostic testing to evaluate whether current symptoms are the result of the tumor or scar tissue. The nurse would prepare the client for which test?

Positron emission tomography (PET)

Which of the following are the immediate complications of spinal cord injury? Check all that apply.

Respiratory arrest Spinal shock

A patient has been diagnosed with a consussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the patient to contact the physician or return to the ED if the patient demonstrates which complications? Select all that apply.

Slurred speech Vomiting Weakness on one side of the body

________ depresses the motor cortex, creating a higher threshold before nerves react to the convulsive stimuli.

Succinamide

Basilar skull fractures are more serious than simple skull fractures.

True

Coup injuries occur at the point of contact.

True

Cummulative and sustained concussions, such as those that are sports related, can result in long-term effects.

True

While administering phenytoin, the nurse should observe the client what adverse reaction? Select all that apply.

ataxia nausea lethargy gingival hyperplasia

A nurse is conducting an assessment on a client who is admitted with Parkinson disease. Which potential findings will the nurse anticipate noting on the physical assessment? Select all that apply.

slurred speech tremors

Clients should be monitored closely for EPS when taking antiparkinson drugs with which class of drugs?

Antidepressants

Paralyzed clients with reflex incontinence can lightly massage or tap the skin above the pubic area, a method known as ________ ________ that stimulates relaxation of the urinary sphincter.

Cutaneous triggering

Status epilepticus is an emergency.

True

A client with a malignant brain tumor comes to the clinic for a folow up. During the visit, the client asks the nurse, "Why am I so tired all the time?" When responding to the client, which information would the nurse include as possible causes? Select all that apply.

Tumor Treatment being used Stress

A patient with Parkinson's disease asks the nurse what can be done to prevent problems with bowel elimination. What would be an intervention that would assist this patient with a regular stool pattern?

Adopt a diet with moderate fiber intake

Which of the following adverse reactions, if observed in a client prescribed phenytoin, would indicate that the patient may be developing phenytoin toxicity?

Ataxia

A patient with a T4 level spinal cord injury is complaining of a severe headache. The nurse notes profuse diaphoresis of the patient's forehead and scalp. Which of the following does the nurse suspect?

Autonomic dysreflexia

The ICU has four clients from a violent motor vehicle accident. When assessing the patients, which patient would the nurse assess first?

Basilar fracture

_________ movements refer to the involuntary muscular twitching of the limbs or facial muscles.

Choreiform

A(n) ___________ is a surgical opening of the skull to gain access to structures beneath the cranial bones.

Craniotomy

Parkinson disease occurs because of the lack of which neurotransmiter?

Dopamine

When planning strategies for managing bowel elimination for the client with a neurologic deficit, what nursing intervention is most appropriate to include?

Encourage a high fiber diet to increase stool bulk.

A concussion is more serious than a contusion and leads to gross structural injury to the brain.

False

Contractures can occur when a joint is exercised regularly.

False

Dopaminergics are drugs that do not affect the dopamine content of the brain.

False

Neurologic deficits usually affect only one body system.

False

______ is the removal of the posterior arch of a vertebra to expose the spinal cord.

Lamnectomy

________ is weakness or paralysis and compromised sensory functions of both legs and lower pelvis, which occurs with spinal injuries below the T1 level.

Peraplegia

The nurse is preparing to administer a new drug to a client currently prescribed carbidopa/levodopa which can decrease its effects. Which medication will require the nurse to monitor for decreased carbidopa/levodopa effectiveness? Select all that apply.

Phenytoin Zonisamide

A patient involved in an MVA is brought to the ED. After examination and diagnostics, the neurosurgeon diagnoses an epidural hematoma and orders the client prepared for surgery. Postoperatively, the patient arrives in ICU with report of an excellent surgical outcome. What interventions would be performed as part of nursing management? Select ALL that apply.

Place the patient lying on the unaffected side Remove and reapply anti-embolism stocking every 8 hours

The nurse is preparing to administer phenytoin to a client. The nurse should question this order if which disorder is noted in the client's past history? Select all that apply.

Pregnancy Sinus bradycardia

The nurse caring for a client in the chronic phase of a neurologic deficit knows that nursing management focuses on what?

Preventing physical and psychological complications

The nurse is caring for an 82-year-old client who needs bladder training. The nurse knows that bladder training is difficult for older adult clients with neurologic deficit because of what?

Relaxation of the internal bladder sphincter

An older adult client experiencing seizures is prescribed diazepam. Which assessment should the nurse prioritize?

Respiratory rate and depth

The nurse is caring for a client diagnosed with generalized seizures. What classifications of medications will the nurse administer to this client? Select all that apply.

Succinimides Hydantoins Benzodiazepines

Focal seizures make up what percentage of total seizures?

60%

When taking a cholinergic blocking drug for Parkinson like symptoms, the client most likely would experience which of the following adverse reaction?

Dry mouth, dizziness

Anurse is caring for a patient who has been prescribed miscellaneous anticonvulsants containing valproic acid. What method of drug administration should the nurse inform the patient about?

Do not chew but swallow the whole tablet to avoid irritation

Benzodiazepines and barbiturates inhibit the uptake of gamma-aminobutyric acid at receptors.

True

Which type of brain injury is characterized by loss of consciousness associated with stupor and confusion?

Contusion

Which types of brain injury has occurred in the patient that can be aroused with effort but soon slips back into unconsciousness?

Contussion

The nurse is caring for a patient with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used?

A cervical collar

The nurse is volunteering for a Red Cross blood drive and is taking the history of potential donors. Which volunteer would the nurse know will not be allowed to donate blood?

A donor who was in college in England for 1 year

A college student goes to the infirmary with a fever, headache, and a stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? Select all that apply.

Administration of rifampin (Rifadin) Administration of ciprofloxacin hydrochloride (Cipro) Administration of ceftriaxone sodium (Rocephin)

The nurse has administered carbidopa/levodopa to a client. Which findings should the nurse prioritize on the ongoing assessment? Select all that apply.

Choreiform movements Dry mouth Anorexia

Lou Gehrig's disease is an example of ______ _______ of a neurologic deficit.

Chronic phase

A client with a brain tumor is experiencing changes in cognition that require the nurse to reorient the client frequently. When performing this task, which devices would be appropriate for the nurse to use? Select all that apply.

Client's clothing Picture of the client's family Clock Calendar

A patient brought to the hospital after a skiing accident was unconsious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of traumatic brain injury (TBI) is suspected in this situation?

Epidural hematoma

Foods high in pyridoxine (Vit B6) reduce the effect of carbidopa.

False

_______ _______ _______ facilitates the movement of paralyzed muscles to peal a modified bicycle.

Functional electrical stimulation

Older clients prescribed one of the dopamine receptor agonists are monitored closely for which of the following adverse reactions?

Hallucinations

The nurse is conducting a preadministration assessment of a client prescribed entacapone. The nurse determines caution is warranted after discovering which disorders listed in the client's past history? Select all that apply.

Hypotension Renal dysfunction Hepatic dysfunction Hypertension

The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority?

Include client in planning of care and settling of goals.

The nurse is caring for a client with a brain tumor who is experiencing symptoms due to compression and infiltration of normal tissue. The pathophysiologic changes that result can cause what manifestations? Select all that apply.

Increased ICP Focal neurologic signs Altered pituitary function

The nurse tests the patient's motor repsonse by assessing a reaction to a _______ stimulus.

Painful

A client is in the skilled rehabilitation setting during the chronic phase of care. When developing the client's nursing pln of care, what long-term goal is most appropriate?

The client will be free of skin breakdown or contractures.

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?

The client will remain free of injury if a seizure does occur.

Cerebral heatomas can lead to increased intracranial pressure.

True

Cervical spine injuries are managed with immediate immobilization.

True

A client is diagnosed with a tumor of the temporal lobe. When developing the client's plan of care the nurse would plan interventions to address problems with which areas of functioning? Select all that apply.

Understanding language Emotions Memory

The nurse reports which of the following as a diminished response to antiparkinson drug treatment rather than an adverse reaction?

Increased hand tremor

A patient has sustainted a traumatic brain injury. Which of the following is the priority nursing diagnosis for this patient?

Ineffective airway clearance related to brain injury

The statements presented here match nursing interventions with nursing diagnoses. Which statements are appropriate for a patient who has suffered a head injury? Select all that apply.

Ineffective airway clearance: Apply suction as indicated. Disturbed sleep pattern: Provide back rubs to the client. Interrupted family process: Encourage the family to join a support group.

A client diagnosed with Bell palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles?

Whistling