MS Ch 36 37 38

What is the therapeutic range for Coumadin?

2.0-3.0

Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA?

A client with a TIA may experience impaired muscle coordination or paralysis on one side. Respiratory distress and severe headache are not associated with TIA. Nausea and vomiting is not a usual symptom of TIA.

A female client undergoes a scheduled electroencephalogram (EEG). Which of the following postprocedure activities should the nurse carry out for the client?

After an EEG, the nurse should ensure rest for the sleep-deprived client and shampoo the client's hair to remove the glue used to affix electrodes to the scalp. The client is advised not to take sedative drugs and caffeine-related drinks before the EEG, and there is no reason to provide the client with them after the test. The nurse should not measure the LOC, the heart rate, or the pulse rate of the client unless advised by the physician.

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?

Document the length and progression of the seizure.

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate and adventitious breath sounds

You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should you keep always ready at the bedside?

Intubation tray and suction apparatus

You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?

Ischemic

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?

Left-sided CVA

The physician wants to know what the pressure is in the client's head. What test might be ordered on this client?

Lumbar puncture

Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease?

Maintain a safe environment.

What neurons transmit impulses from the CNS?

Motor

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?

Place client in side-lying position

The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Position the client flat at least 3 hours

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?

Suicidal ideations

Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm?

The stimulation can increase ICP or trigger a seizure.

A client presents to the walk-in clinic complaining of a migraine. The client is prescribed a neuronal stabilizer. What should the nurse suggest to the client?

Use caution while driving

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 client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because these activities increase intracranial pressure and thereby headaches and potential rupture of aneurysm. Avoidance of fiber may lead to constipation and straining with stools and would not be recommended. There would not be a recommendation for antacids or feverfew in the discharge teaching.

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?

Allergic reaction to the imaging material

A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy?

Anticipate need for endotracheal intubation

While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind his right eye, which is red and tearing. What type of headache would you suspect this client of having?

Cluster

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Drooping eyelids

A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?

Flaccidity

A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client?

Hopelessness

The family nurse practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

Moving the head and chin toward the chest

A client is receiving baclofen (Lioresal) for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following?

Muscle spasms

The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response?

Observing the client's response to painful stimulus

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse is correct to instruct on the action of which system?

Sympathetic

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?

TIA is warning sign of stroke

How does a nurse use the Glasgow Coma Scale to assess LOC?

The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC.

What should a nurse instruct a pt with Bell's Pasly to do?

The VII cranial nerve supplies muscles to the face. In Bell's palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux (cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsy because it is thought to be caused by a virus.

A critical care nurse is documenting her assessment of a client she is caring for. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean?

The client is not responding to stimuli

A client, with a recent closed head injury, began experiencing partial (focal) seizures and asks the nurse to explain why this is happening.

The client wants a simple explanation to help alleviate fears and concerns. Explaining that seizures are common (or even normal) after head trauma can assist the client by decreasing fears and open the door for further teaching about the disruption of impulses and irritation in the brain due to the injury. Partial seizures involve a part of the brain that is irritated; this is factual but does not answer the question asked. Generalized seizures involve the entire brain from the onset and the electrical impulses are chaotic, but this information is not significant to the question asked by the client.

What is the priority nursing intervention(s) for a pt who is seizing?

The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure.