MS2 Test 1

The nurse is caring for a client with tetraplegia following a motor vehicle accident. A family member of the client states, "I know there is grief associated with the loss of independence, but how do I help my loved one to move past that?" The nurse is most helpful to say which of the following?

"Grief is a normal process. Let's discuss offering support throughout the process."

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

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

A cervical collar

The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious, stating, "What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain?" The nurse is most correct to turn the teaching to which surgical procedure?

A spinal fusion

A 6-year-old child has come to the emergency department (ED) after falling off a bike. The health care provider diagnoses a concussion and the child's parent asks the nurse what a concussion is. What should the nurse's response be?

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

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 undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate?

Allow the client to wash hair and rest.

The school nurse notes a 6-year-old running across the playground with friends. The child stops in midstride, freezing for a few seconds. Then the child resumes running across the playground. The school nurse suspects what in this child?

An absence seizure

The nurse is performing discharge teaching for a female client who was hospitalized after a spinal cord injury that resulted in motor paralysis. Which of the following prescription classifications, used prior to hospitalization, is most important to review with the client before discharge?

An antihistamine

The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated?

Antihistamine

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?

Avoid heavy lifting.

An older client complains of a constant headache. A physical examination shows papilledema. Based on these symptoms, what condition would the nurse suspect?

Brain tumor

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

Cluster

Which diagnostic procedure would the nurse anticipate performing first if the goal was to obtain a thin "slice" of a muscular body area?

Computed tomography (CT)

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

Computed tomography (CT) scan

The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?

Cranial nerve XII

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate?

Edema to the head with bruising of the mastoid process

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Elevate the head of the bed.

The nurse provides care for a client with a deteriorating neurologic status. The nurse collects data at the beginning of the shift that reveals a falling blood pressure (BP) and heart rate (HR), and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?

Flaccidity

A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client?

Grade V on the Hunt-Hess Scale

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

Halo sign

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.

The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client?

Increased intracranial pressure

A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

Lethargy

The nurse is instructing the paralyzed client on a method to stimulate the relaxation of the urinary sphincter aiding in urinary elimination. Which instruction would be correct?

Lightly massage or tap the skin above the pubic area.

A client presents to the emergency department status postseizure. The health care provider wants to measure CSF pressure. What test might be ordered on this client?

Lumbar puncture

Which neurons transmit impulses from the CNS?

Motor

The nurse 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 toward both sides

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?

Nausea

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?

Neurovascular system

A middle-aged client has scheduled a sick visit to the physician's office, reporting 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 shows potential causes of the pain. Which area of the drawing would the nurse emphasize?

Nucleus pulposus

The nurse is providing teaching to a client who reports tension headaches. Which instruction would be beneficial to prevent onset of symptoms?

Perform stretching exercises and frequent position changes.

The nurse is caring for a client with neurologic deficits who is interested in implementing a bowel training program. Which does the nurse identify as the first step?

Recording bowel movements

A nurse is caring for a client with a neurologic deficit whose condition has stabilized. What phase of the neurologic deficit begins now?

Recovery

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

A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches?

Relaxes muscles

A nurse is caring for a client with an injury to the central nervous system. When caring 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?

Response due to interrupted impulses from the central nervous system

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

Sciatic nerve pain

A nurse is working in an outpatient studies unit administering neurological tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. With what substance does the nurse reply?

Shampoo

Which nursing assessment finding is most indicative of a hemorrhagic stroke?

Sudden onset of breathing alterations

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

Sympathetic nervous system

The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. What should the nurse tell the client?

That the covering is called myelin and that it can be discussed further at the next meeting.

The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern?

The cerebrospinal fluid (CSF) is cloudy in nature.

The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care?

The client with history of seizures

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location should the nurse explain differentiates the two disorders?

The first lumbar vertebrae

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?

Use caution while driving or performing hazardous activities.

The nurse is caring for a client with Bell palsy. Which of the following teaching points is a priority in the management of symptoms for this client?

Use ophthalmic lubricant and protect the eye.

The nurse is instructing the client on how to perform Credé maneuver. In which situation is this maneuver helpful?

When a client is attempting to empty the bladder