nervous

The nurse is reinforcing instructions to an adolescent who has a history of seizures and is taking an anticonvulsant medication. Which statement indicates the client understands the instructions? "I will never be able to drive a car." "If I forget my morning medication, I can take two pills at bedtime." "I should not stop taking my medications even if my seizures go away." "My anticonvulsant medication will clear up my skin."

"I should not stop taking my medications even if my seizures go away."

Phenytoin, 100 mg orally three times daily, has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. Which statement by the client indicates an understanding of the instructions? "I will use a soft toothbrush to brush my teeth." "If my throat becomes sore, it's a normal effect of the medication and it's nothing to be concerned about." "It's all right to break the capsules to make it easier for me to swallow them." "If I forget to take my medication, I can wait until the next dose and eliminate that dose."

"I will use a soft toothbrush to brush my teeth."

The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems? Previous back injury History of hypertension Allergy to pollen History of headaches

Allergy to pollen

The client with myasthenia gravis becomes increasingly weak. The primary health care provider (PHCP) prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which change in condition indicates that the client is in cholinergic crisis? A temporary worsening of the condition Complaints of muscle spasms An improvement of the weakness No change in the condition

An improvement of the weakness

The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? Select all that apply. Bloody or clear drainage from the auditory canal Purulent drainage from the auditory canal Bruising behind ears ("Battle's sign") Bruising around eyes ("raccoon eyes") Periorbital edema Epistaxis

Bloody or clear drainage from the auditory canal Bruising behind ears ("Battle's sign") Bruising around eyes ("raccoon eyes")

The client is receiving meperidine hydrochloride for pain. Which signs/symptoms are side and adverse effects of this medication? Select all that apply. Increased respiratory rate Drowsiness Diarrhea Urinary frequency Hypotension Tremors

Drowsiness Hypotension Tremors

The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity? Isometric exercises Blowing the nose Coughing vigorously Exhaling during repositioning

Exhaling during repositioning

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client? Encouraging the family not to "give in" to their feelings of grief Ensuring adherence to visiting hours to ensure the client's rest Explaining equipment and procedures on an ongoing basis Discouraging the family from touching the client

Explaining equipment and procedures on an ongoing basis

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center which is located in which part of the brain? Hippocampus Cerebellum Cerebrum Hypothalamus

Hypothalamus

Carbidopa-levodopa is prescribed for a client with Parkinson's disease, and the nurse monitors the client for adverse effects of the medication. Which sign/symptom indicates the client is experiencing an adverse effect? Tachycardia Pruritus Hypertension Impaired voluntary movements

Impaired voluntary movements

The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising? Decreasing temperature, increasing pulse, decreasing respirations, increasing BP Increasing temperature, increasing pulse, increasing respirations, decreasing BP Decreasing temperature, decreasing pulse, increasing respirations, decreasing BP Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? Limiting bladder catheterization to once every 12 hours Strictly adhering to a bowel retraining program Avoiding unnecessary pressure on the lower limbs Keeping the linen wrinkle-free under the client

Limiting bladder catheterization to once every 12 hours

A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which findings noted in the client history indicates that the client may be ineligible for this diagnostic procedure? Select all that apply. Permanent pacemaker Prosthetic valve replacement Hypertension Hip replacement Chronic obstructive pulmonary disorder

Permanent pacemaker Prosthetic valve replacement Hip replacement

A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety? Place the client on aspiration precautions. Provide a clear path for ambulation without obstacles. Prohibit intensely smelling foods such as onions and tuna Speak loudly to the client.

Provide a clear path for ambulation without obstacles.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions by the nurse would be contraindicated? Select all that apply. Consider insertion of a padded tongue blade. Position the client to the side, if possible, with head flexed forward. Remove the pillow and raise the padded side rails. Loosen restrictive clothing. Restrain the client's limbs. Consider insertion of a padded tongue blade.

Restrain the client's limbs. Consider insertion of a padded tongue blade.

The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria? Separates into concentric rings and tests positive for glucose Is clear in appearance and tests negative for glucose Clumps together on the dressing and has a pH of 7 Is grossly bloody in appearance and has a pH of 6

Separates into concentric rings and tests positive for glucose

The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure? Suctioning for longer than 30 seconds Keeping a supply of suction catheters at the bedside Hyperoxygenating the client before, during, and after suctioning Auscultating breath sounds to determine the need for suctioning

Suctioning for longer than 30 seconds

Meperidine hydrochloride is prescribed for the client with pain. Which should the nurse monitor as a side effect of this medication? Hypertension Urinary retention Diarrhea Bradycardia

Urinary retention

The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom indicates this crisis is taking place? Ataxia Hypothermia Mouth sores Hypertension

hypertension

Carbamazepine is prescribed for a client with a diagnosis of psychomotor seizures. The nurse reviews the client's health history knowing that this medication is contraindicated if which disorder is present? Headaches Liver disease Hypothyroidism Diabetes mellitus

liver disease

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room? Electrocardiographic monitoring electrodes and intubation tray Nebulizer and pulse oximeter Flashlight and incentive spirometer Blood pressure cuff and flashlight

Electrocardiographic monitoring electrodes and intubation tray

The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which findings are early indications that the level of consciousness (LOC) is deteriorating? Select all that apply. Clear speech Drowsiness Ptosis of the left eyelid Less frequent speech Slight slurring of speech Frequent spontaneous speech

Electrocardiographic monitoring electrodes and intubation tray Slight slurring of speech less frequent speech

A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse should plan which approach as therapeutic in assisting the client to cope with the disease? Encourage and praise perseverance in exercising and performing ADL. Assist the client with activities of daily living (ADL) as much as possible. Plan only a few activities for the client during the day. Cluster activities at the end of the day when the client is most bored.

Encourage and praise perseverance in exercising and performing ADL.

The nurse is caring for a client receiving morphine sulfate intravenously for pain. Because morphine sulfate has been prescribed for this client, which nursing action should be included in the plan of care? Encourage the client to cough and deep breathe. Monitor the client's temperature. Encourage fluid intake. Maintain the client in a supine position.

Encourage the client to cough and deep breathe.

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? Providing sensory cues Giving simple, clear directions Providing a stable environment Encouraging multiple visitors at one time

Encouraging multiple visitors at one time

A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that there is a need for further teaching if the nurse observes which action by the family? Performing active ROM to the affected leg Encouraging the client to stand unassisted on the leg Providing passive range of motion (ROM) to the affected leg Applying a premolded splint

Encouraging the client to stand unassisted on the leg

The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which should the nurse check before the procedure? Allergy to salmon Excessive weight Allergy to iodine or shellfish Claustrophobia

Encouraging the client to stand unassisted on the leg

A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration? Padding the bed with an absorbent cotton pad Using adult diapers Inserting an indwelling urinary catheter Establishing a toileting schedule

Establishing a toileting schedule

The nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item should be included as part of the precautions? Allowing 1 cup of caffeinated coffee per day Allowing out-of-bed activities as tolerated Maintaining the head of the bed at 15 degrees Limiting cigarettes to 3 per day

Maintaining the head of the bed at 15 degrees

The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom? Difficulty speaking Difficulty awakening Minor headache Vomiting

Minor headache

The nurse is caring for a client with severe back pain, and codeine sulfate has been prescribed for the client. Which should the nurse include in the plan of care while the client is taking this medication? Monitor bowel activity. Restrict fluid intake. Monitor peripheral pulses. Monitor for hypertension.

Monitor bowel activity.

The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted? Sudden tachycardia Pallor of the face and neck Severe, throbbing headache Severe and sudden hypotension

Severe, throbbing headache

The nurse is caring for a client who is taking phenytoin for control of seizures. During data collection, the nurse notes that the client is taking birth control pills. Which information should the nurse provide to the client? Pregnancy should be avoided while taking phenytoin. The client may stop taking the phenytoin if it is causing severe gastrointestinal effects. The increased risk of thrombophlebitis exists while taking phenytoin and birth control pills together. The potential for decreased effectiveness of the birth control pills exists while taking phenytoin.

The potential for decreased effectiveness of the birth control pills exists while taking phenytoin.

The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? The client is taken for spinal x-rays. The primary health care provider (PHCP) reviews the x-ray results. The nurse needs to provide physical care. The family comes to visit after surgery.

The primary health care provider (PHCP) reviews the x-ray results.

The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply. Use gestures when talking to enhance words. Phrase what was said differently the second time, if there is a need to repeat it. Give the client directions using short phrases and simple terms. Face the client when talking. Speak slowly and maintain eye contact. Avoid the use of body language when talking to the client.

Use gestures when talking to enhance words. Give the client directions using short phrases and simple terms. Face the client when talking. Speak slowly and maintain eye contact.

The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client? Just out of the client's reach, on the right side Within the client's reach, on the left side Within the client's reach, on the right side Just out of the client's reach, on the left side

Within the client's reach, on the left side

Ibuprofen is prescribed for a client. Which instruction should the nurse give the client about taking this medication? Take with 8 oz of milk. Take 60 minutes before breakfast. Take in the morning after arising. Take at bedtime on an empty stomach.

take with 8oz of milk