Neuro

A client is receiving phenobarbital orally for the treatment of a seizure disorder. The nurse should assess the client for which common side effect of this medication? 1. Drowsiness 2. Hypocalcemia 3. Blurred vision 4. Seizure activit

1. Drowsiness

The registered nurse is conducting a teaching session on health problems associated with amphetamine use. Which problems should be included in the teaching session? Select all that apply. 1. Renal disease 2. Brain cell death 3. Myocardial infarction 4. Urinary tract infection 5. Syndrome of uncontrollable tremors

2. Brain cell death 3. Myocardial infarction 5. Syndrome of uncontrollable tremors

The nurse is caring for a hospitalized client who has a prescription for dextroamphetamine sulfate 25 mg orally daily. The nurse collaborates with the dietitian to limit the amount of which food item on the client's dietary trays? 1. Bagel 2. Coffee 3. French fries 4. Cheeseburger

2. Coffee

A client who has been prescribed carbamazepine is instructed to report to the clinic for laboratory studies related to serum levels of the medication. Which result value should indicate to the nurse that a therapeutic serum level is achieved with the use of this medication? 1. 2 mcg/mL (8.46 mcmol/L) 2. 4 mcg/mL (16.9 mcmol/L) 3. 8 mcg/mL (33.8 mcmol/L) 4. 15 mcg/mL (63.48 mcmol/L)

3. 8 mcg/mL (33.8 mcmol/L)

The nurse provides home care instructions to a client diagnosed with multiple sclerosis (MS). Which action should the nurse teach the client to take to manage the minimize signs/symptoms of MS? 1. Maintain a low-fiber diet. 2. Avoid becoming pregnant. 3. Avoid taking hot baths or showers. 4. Restrict fluid intake to 1000 mL daily

3. Avoid taking hot baths or showers.

The nurse managing a client's post-supratentorial craniotomy care should assure that the client is maintained in which position? 1. Prone 2. Supine 3. Semi-Fowler's 4. Dorsal recumbent

3. Semi-Fowler's

The nurse is caring for a client with a diagnosis of a mild cerebral bleed resulting from a small cerebral aneurysm rupture. The client reports feeling anxious and restless about family visiting soon. Which comment by the client should assist the nurse in identifying the reason for the anxiety? 1. "My son came to visit me yesterday." 2. "At least I can speak and answer questions." 3. "I have a problem turning my neck to the side." 4. "Look at me, I can no longer be the head of my family."

4. "Look at me, I can no longer be the head of my family."

The home care nurse is evaluating a client's understanding of the self-management of trigeminal neuralgia. Which client statement indicates that there is a need for further teaching? 1. "I should chew on my good side." 2. "An analgesic will relieve my pain." 3. "I should use warm mouthwash for oral hygiene." 4. "Taking my carbamazepine will help control my pain."

2. "An analgesic will relieve my pain."

The nurse is caring for a client diagnosed with a seizure disorder who is taking valproic acid 250 mg orally daily. Which findings indicate that the client is experiencing adverse effects of this medication? Select all that apply. 1. Nausea 2. Vomiting 3. Lethargy 4. Increased appetite 5. Frequent urination

2. Vomiting 3. Lethargy

The nurse is caring for a client diagnosed with left-sided Bell's palsy. Which statement by the client shows a need for further teaching by the nurse? 1. "My left eye is tearing a lot." 2. "I have trouble closing my left eyelid." 3. "I don't know how I'll live with this stroke." 4. "I can't feel anything on the left side of my face."

3. "I don't know how I'll live with this stroke."

A client prescribed benztropine mesylate is provided medication instructions by the nurse. Which statement by the client indicates the need for further teaching? 1. "I need to avoid driving if drowsiness or dizziness occurs." 2. "I should monitor my urinary output and watch for signs of constipation." 3. "I need to call the primary health care provider if I have difficulty swallowing or vomiting occurs." 4. "I should spend 1 hour a day sitting in the sun to enhance the effectiveness of the medication."

4. "I should spend 1 hour a day sitting in the sun to enhance the effectiveness of the medication."

The registered nurse is conducting a teaching session on health problems associated with caffeine use. Which problems should be included in the teaching session? Select all that apply. 1. Anxiety 2. Sleep disruption 3. Peptic ulcer disease 4. Decreased blood pressure 5. Gastroesophageal reflux disease

1. Anxiety 2. Sleep disruption 3. Peptic ulcer disease 5. Gastroesophageal reflux disease

The medication nurse is supervising a newly hired licensed practical nurse (LPN) during the administration of prescribed oral pyridostigmine bromide to a client with a diagnosis of myasthenia gravis. Which observation by the medication nurse indicates safe practice by the LPN? 1. Asking the client to take sips of water 2. Asking the client to lie down on his right side 3. Asking the client to look up at the ceiling for 30 seconds 4. Instructing the client to void before taking the medication

1. Asking the client to take sips of water

A client diagnosed with a closed head injury is receiving phenytoin, an anticonvulsant medication. What signs/symptoms indicate that the client is experiencing side/adverse effects related to this medication? Select all that apply. 1. Ataxia 2. Sedation 3. Constipation 4. Bleeding gums 5. Hyperglycemia 6. Decreased platelet count

1. Ataxia 3. Constipation 4. Bleeding gums 5. Hyperglycemia 6. Decreased platelet count

A medication nurse is supervising a newly hired nurse who is administering pyridostigmine orally to a client diagnosed with myasthenia gravis. Which instruction provided to the client indicates safe practice by the newly hired nurse regarding the administration of this medication? 1. Take the medication with sips of water. 2. Lie on the right side after taking the medication. 3. Hyperextend the neck for 30 seconds before swallowing. 4. Void within at least 10 minutes before taking the medication

1. Take the medication with sips of water.

The nurse is obtaining a history from a client who was admitted to the hospital with a thrombotic stroke. What are the most likely signs/symptoms the client experienced before the stroke occurred? Select all that apply. 1. Temporary aphasia 2. Throbbing headaches 3. Transient hemiplegia 4. Paresthesias of the hands and feet 5. Unexplained loss of consciousnes

1. Temporary aphasia 3. Transient hemiplegia 4. Paresthesias of the hands and feet

The nurse is caring for a client who is receiving selegiline hydrochloride. Which finding indicates that the client is experiencing an adverse effect of the medication? 1. Tremors 2. Confusion 3. Lightheadedness 4. Abdominal discomfort

1. Tremors

The nurse makes a home care visit to a client diagnosed with Bell's palsy. Which statement by the client indicates a need for further teaching? 1. "I wear an eye patch at night." 2. "I am staying on a liquid diet." 3. "I wear dark glasses when I go out." 4. "I have been gently massaging my face."

2. "I am staying on a liquid diet."

hich statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety? 1. "I'm so angry that this happened to me." 2. "I really don't want to live my life like this." 3. "I'm definitely not looking forward to going home." 4. "I don't know if I can make all these major adjustments to my life."

2. "I really don't want to live my life like this."

The nurse has provided instructions to a client diagnosed with Parkinson's disease who is taking carbidopa/levodopa. Which statement by the client indicates the need for further teaching? 1. "I will get up slowly to prevent dizziness." 2. "I will eat lots of foods high in vitamin B6." 3. "I may need to take this medication for the rest of my life." 4. "I will take the medication just before meals to avoid nausea."

2. "I will eat lots of foods high in vitamin B6."

While assisting with bathing, the client who has sustained a spinal cord injury states, "I can't do this. I wish I were dead." Which therapeutic response should the nurse make to encourage communication? 1. "Why do you say that?" 2. "You wish you were dead?" 3. "Would you prefer a shower instead?" 4. "Are you frustrated with your limitations?"

2. "You wish you were dead?"

A client prescribed carbidopa/levodopa tells the home care nurse that his urine has turned a darker color since he began to take this medication. When he expresses a wish to discontinue the treatment, the nurse explains that the darker color of the urine is a result of what occurrence? 1. A developing toxicity 2. A harmless side effect 3. Taking the medication with milk 4. An interaction with another medication

2. A harmless side effect

The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury? 1. Abnormal involuntary flexion of the extremities 2. Abnormal involuntary extension of the extremities 3. Upper extremity extension with lower extremity flexion 4. Upper extremity flexion with lower extremity extension

2. Abnormal involuntary extension of the extremities

`The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left-sided deficits. The nurse plans care with the understanding that which action would be least helpful? 1. Place bedside articles on the left side. 2. Approach the client from the right side. 3. Teach the client to scan the environment. 4. Move the commode and chair to the left side.

2. Approach the client from the right side.

Which instruction should the nurse provide to the client prescribed the medication benztropine mesylate? 1. Sit in the sun for 30 minutes daily. 2. Avoid driving if drowsiness or dizziness occurs. 3. Expect difficulty swallowing while taking this medication. 4. Expect episodes of vomiting and constipation while taking this medication.

2. Avoid driving if drowsiness or dizziness occurs.

While providing care to a client with a head injury, the nurse notes that a client exhibits this posture (refer to figure). What should the nurse document that the client is exhibiting? View Figure 1. Flaccidity 2. Decorticate posturing 3. Decerebrate posturing 4. Rigidity in the upper extremities

2. Decorticate posturing

The nurse should question which medication if prescribed for a client diagnosed with an inoperable ruptured intracranial aneurysm? 1. Nicardipine 2. Heparin sodium 3. Docusate sodium 4. Aminocaproic acid

2. Heparin sodium

When caring for a client diagnosed with myasthenia gravis, the nurse should be alert for which manifestations of myasthenic crisis? Select all that apply. 1. Bradycardia 2. Increased diaphoresis 3. Decreased lacrimation 4. Bowel and bladder incontinence 5. Absent cough and swallow reflex 6. Sudden marked rise in blood pressure

2. Increased diaphoresis 4. Bowel and bladder incontinence 5. Absent cough and swallow reflex 6. Sudden marked rise in blood pressure

The nurse is caring for a client diagnosed with Parkinson's disease who is prescribed benztropine mesylate orally daily. Which action should the nurse take to assess for a side effect of the medication? 1. Check pupillary response. 2. Monitor intake and output. 3. Monitor the prothrombin time (PT). 4. Check the partial thromboplastin time (PTT)

2. Monitor intake and output.

A client is admitted to the hospital in myasthenic crisis. The nurse should ask the client about which precipitating factor for this event? 1. Getting more sleep than usual 2. Not taking prescribed medication 3. A decrease in food intake recently 4. Taking excess prescribed medication

2. Not taking prescribed medication

A client with a spinal cord injury is at risk of developing footdrop. What intervention should the nurse use as a preventive measure? 1. Mole skin-lined heel protectors 2. Regular use of posterior splints 3. Application of pneumatic boots 4. Avoiding dorsal flexion of the foot

2. Regular use of posterior splints

A client diagnosed with myasthenia gravis reports the occurrence of difficulty chewing. The primary health care provider prescribes pyridostigmine bromide to increase muscle strength for this activity. The nurse should instruct the client to take the medication at what time, in relation to meals? 1. Before breakfast daily 2. Thirty minutes before each meal 3. As soon as arising in the morning 4. After dinner daily when most fatigued

2. Thirty minutes before each meal

A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client? 1. Hot cocoa with honey and toast 2. Vanilla pudding and lukewarm milk 3. Hot herbal tea with graham crackers 4. Iced coffee and peanut butter and crackers

2. Vanilla pudding and lukewarm milk

A client with the diagnosis of Bell's palsy is distressed about the change in facial appearance. Which characteristic of Bell's palsy should the nurse tell the client about to help the client cope with the disorder? 1. It usually resolves when treated with vasodilator medications. 2. It is similar to stroke, but all symptoms will go away eventually. 3. It is not caused by stroke, and many clients recover in 3 to 5 weeks. 4. The symptoms will completely go away once the tumor is removed

3. It is not caused by stroke, and many clients recover in 3 to 5 weeks.

Benztropine mesylate is prescribed to treat extrapyramidal symptoms. Which action produced by this medication should lead the nurse to determine that this medication is appropriate? 1. Causes a cholinergic effect 2. Delays the activity of dopamine 3. Minimizes involuntary movements 4. Causes neurotransmitter imbalances

3. Minimizes involuntary movements

The nurse is assigned to care for a client diagnosed with Parkinson's disease who has recently been prescribed levodopa. What is most important to assess before ambulating the client? 1. The client's history of falls 2. Assistive devices used by the client 3. The client's postural (orthostatic) vital signs 4. The degree of intention tremors exhibited by the client

3. The client's postural (orthostatic) vital signs

The nurse observes a client during a seizure and notes that the client's entire body became rigid, and the muscles in all four extremities alternated between relaxation and contraction. Which type of seizure should the nurse document that the client had experienced? 1. Partial seizure 2. Absence seizure 3. Tonic-clonic seizure 4. Complex partial seizure

3. Tonic-clonic seizure

Amantadine hydrochloride 100 mg orally twice daily has been prescribed for a client diagnosed with Parkinson's disease. After the home care nurse provides medication instructions, which statement by the client indicates that further teaching is necessary? 1. "I should see improvement in my condition in about 7 days." 2. "I can get this medication in syrup form if I have difficulty swallowing." 3. "I can empty the capsules into food or fluid to make swallowing easier." 4. "I'll take this medication early in the morning and just before I go to bed."

4. "I'll take this medication early in the morning and just before I go to bed."

The nurse should place a client who sustained a head injury in which position to prevent increased intracranial pressure (ICP)? 1. In left Sims' position 2. In reverse Trendelenburg 3. With the head elevated on a small, flat pillow 4. With the head of the bed elevated at least 30 degrees

4. With the head of the bed elevated at least 30 degree

The nurse caring for a client with an acute head injury should carefully assess which function as the primary indicator of neurological status? 1. Vital signs 2. Motor function 3. Sensory function 4. Level of consciousness

4. Level of consciousness

A client with a history of seizure disorder is taking phenytoin. The clinic nurse reviews the laboratory results of the phenytoin level and determines that the client has been noncompliant with medication therapy if which laboratory result is noted? 1. 5 mcg/mL (19.84 mcmol/L) 2. 10 mcg/mL (39.68 mcmol/L) 3. 16 mcg/mL (63.48 mcmol/L) 4. 19 mcg/mL (75.39 mcmol/L)

1. 5 mcg/mL (19.84 mcmol/L)

Which medication should the nurse expect to be initially prescribed for a client who has experienced an ischemic stroke? 1. A beta blocker 2. A thrombolytic 3. An antiplatelet 4. An oral anticoagulant

2. A thrombolytic

A client diagnosed with myasthenia gravis is ready to return home. The client confides that she is concerned that her significant other will no longer find her physically attractive. Which client-focused action should the nurse encourage in the plan of care? 1. Attend a support group. 2. Cease dwelling on the negative. 3. Reach out for help to face this fear. 4. Share her feelings with her partner.

4. Share her feelings with her partner.

A client recovering from a diagnosed head injury becomes agitated at times. Which nursing action is most appropriate when attempting to calm this client? 1. Assign the client a new task to master. 2. Turn on the television to a musical program. 3. Make the client aware that the behavior is undesirable. 4. Talk about the family pictures on display in the client's room

4. Talk about the family pictures on display in the client's room

A client diagnosed with trigeminal neuralgia asks the nurse what can be done to minimize the episodes of pain. The nurse's response is based on an understanding that what can trigger the pain? 1. Infection or stress 2. Hypoglycemia and fatigue 3. Facial pressure or extreme temperature 4. Excessive watering of the eyes or nasal stuffiness

3. Facial pressure or extreme temperature

A client currently receiving haloperidol at bedtime is now prescribed benztropine mesylate at the same time. The nurse explains to the client that the benztropine mesylate is given for which action? 1. Enhance sleep. 2. Enhance the effects of haloperidol. 3. Enhance the anticholinergic effects of the haloperidol. 4. Help manage any existing extrapyramidal syndrome (EPS).

4. Help manage any existing extrapyramidal syndrome (EPS).

client diagnosed with a cerebral aneurysm is prescribed intravenous medications to produce vasodilation and prevent vasospasms. The nurse monitors the client, knowing that which would indicate a positive client response to the medications? 1. Diarrhea 2. Hypotension 3. Occasional tremors 4. Increased level of consciousness

4. Increased level of consciousness

A client newly diagnosed with Parkinson's disease is prescribed entacapone. The nurse is reviewing the client's medical record. What data warrants primary health care provider notification immediately? 1. The client is experiencing hallucinations. 2. The client is experiencing an increase in tremors. 3. The client is currently taking levodopa/carbidopa. 4. The client is currently taking a monoamine oxidase inhibitor

4. The client is currently taking a monoamine oxidase inhibitor

A family member of a client diagnosed with a brain tumor states that he is feeling distraught and guilty for not encouraging the client to seek medical evaluation earlier. Which information should the nurse incorporate when formulating a response to the family member's statement? 1. A brain tumor presents with few sights/symptoms. 2. It is true that brain tumors are easily recognizable. 3. Brain tumors are never detected until very late in their course. 4. The signs/symptoms of a brain tumor may be easily attributed to another cause

4. The signs/symptoms of a brain tumor may be easily attributed to another cause

A client admitted to the hospital with a diagnosis of a leaking cerebral aneurysm is scheduled for surgery. Which intervention should the nurse implement during the preoperative period? 1. Place the client on bed rest. 2. Allow the client to ambulate only in the room. 3. Obtain a bedside commode for the client's use. 4. Encourage the client to be up at least twice per day

1. Place the client on bed rest.

The nurse has given medication instructions to the client who has been prescribed anticonvulsant therapy with carbamazepine. The nurse determines that the client understands the use of the medication when the client makes which statement? 1. "I can drive as long as it is not at night." 2. "I will use sunscreen when out of doors." 3. "I will keep tissues handy because of excess salivation." 4. "I will discontinue the medication if fever or a sore throat occurs."

2. "I will use sunscreen when out of doors."

A client states, "I'm sure I have restless leg syndrome." The nurse determines that the client is in need of further teaching on the condition when the client identifies the presence of which characteristics? Select all that apply. 1. A heavy feeling in the legs 2. Burning sensations in the limbs 3. Symptom relief when lying down 4. Decreased ability to move the legs 5. Symptoms that are worse in the morning 6. Feeling the need to move the limbs repeatedly

1. A heavy feeling in the legs 3. Symptom relief when lying down 4. Decreased ability to move the legs 5. Symptoms that are worse in the morning

The home care nurse visits a client who had a stroke (brain attack) with resultant unilateral neglect who was recently discharged from the hospital. Which instruction should the nurse provide to the family regarding care? 1. Assist the client from the affected side. 2. Place personal items directly in front of the client. 3. Discourage the client from scanning the environment. 4. Assist the client with grooming the unaffected side first

1. Assist the client from the affected side.

The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)? 1. Assist the client to develop a daily bowel routine to prevent constipation. 2. Teach the client to manage emotional stressors by using mental imaging. 3. Assess vital signs and observe for hypotension, tachycardia, and tachypnea. 4. Administer dexamethasone orally per the primary health care provider's prescription

1. Assist the client to develop a daily bowel routine to prevent constipation.

A client admitted to the hospital is suspected of having Guillain-Barré syndrome. Which assessment findings should the nurse identify as manifestations of this disorder? Select all that apply. 1. Dysphagia 2. Paresthesia 3. Facial weakness 4. Difficulty speaking 5. Hyperactive deep tendon reflexes 6. Descending symmetrical muscle weakness

1. Dysphagia 2. Paresthesia 3. Facial weakness 4. Difficulty speaking

Mannitol is administered intravenously to a client admitted to the hospital with loss of consciousness and a closed head injury. The nurse determines that the medication achieved its priority effect if which outcome was noted? 1. Improved level of consciousness and normal intracranial pressure 2. Weight loss of 1 kg and a serum creatinine of 0.8 mg/dL (70.66 mcmol/L) 3. Serum creatinine of 1.2 mg/dL (106 mcmol/L) and normal intracranial pressure 4. Diuresis of 500 mL in 2 hours and a blood urea nitrogen of 15 mg/dL (5.4 mmol/L)

1. Improved level of consciousness and normal intracranial pressure

A client who has experienced a stroke has episodes of coughing while swallowing liquids. The client has developed a temperature of 101° F (38.3° C) and an oxygen saturation of 91% (down from 98% previously), is slightly confused, and has noticeable dyspnea. Which action should the nurse take? 1. Notify the primary health care provider. 2. Administer an acetaminophen suppository. 3. Encourage the client to cough and deep breathe. 4. Administer a bronchodilator prescribed on an as-needed basis.

1. Notify the primary health care provider.

The nurse is discharging a female client from the hospital who has a diagnosis of a thoracic 11 (T11) fracture with cord transection. The nurse has provided home care instructions to the client. Which action indicates the need for further teaching before discharge? 1. The client jokes about no longer needing to worry about birth control. 2. The client states that she will be careful to not eat as many dairy products. 3. The client verbalizes the need to eat her meals at the same time every day. 4. The client states that she will wash her hands, her perineum, and the catheter with soap and water before performing self-catheterization

1. The client jokes about no longer needing to worry about birth control.

The nurse creates a discharge plan for a client diagnosed with peripheral neuropathy of the lower extremities. Which instructions should the nurse include in the plan? Select all that apply. 1. Wear support or elastic stockings. 2. Wear well-fitted shoes and walk barefoot when at home. 3. Wear dark-colored stockings or socks and change them daily. 4. Use a heating pad set at low setting on the feet if they feel cold. 5. Apply lanolin or lubricating lotion to the legs and feet once or twice daily. 6. Wash the feet and legs with mild soap and water and rinse and dry them well.

1. Wear support or elastic stockings. 5. Apply lanolin or lubricating lotion to the legs and feet once or twice daily. 6. Wash the feet and legs with mild soap and water and rinse and dry them well.

A client with myasthenia gravis is being discharged taking pyridostigmine bromide. The nurse provides the client with medication instructions and makes which statement to the client? 1. "Take the medication on an empty stomach." 2. "Take the medication before activities such as eating or work." 3. "Tonic water with quinine and the use of antacids improve the effect of the medication." 4. "It is not important when you take the medication, as long as you take the exact amount prescribed."

2. "Take the medication before activities such as eating or work."

The nurse is caring for a client diagnosed with a seizure disorder who is receiving phenytoin 100 mg three times daily. Which finding should indicate to the nurse that the client is experiencing a side effect of the medication? 1. Constipation 2. Bleeding gums 3. Difficulty swallowing 4. Brown-appearing urine

2. Bleeding gums

A client diagnosed with myasthenia gravis is reporting vomiting, abdominal cramps, and diarrhea. The nurse notes that the client is hypotensive and experiencing facial muscle twitching. Which possible situation does this assessment data support? 1. Myasthenic crisis 2. Cholinergic crisis 3. Systemic infection 4. Reaction to plasmapheresis

2. Cholinergic crisis Rationale: Signs and symptoms of cholinergic crisis include nausea, vomiting, abdominal cramping, diarrhea, blurred vision, pallor, facial muscle twitching, pupillary miosis, and hypotension. It is caused by overmedication with cholinergic (anticholinesterase) medications, and it is treated by withholding medications. Myasthenic crisis is an exacerbation of myasthenic symptoms caused by undermedication with anticholinesterase medications. There are no data in the question to support the remaining options.

The nurse is planning a discharge teaching plan for a client who sustained a spinal cord injury. To provide for a safe environment regarding home care, which option should be the priority in the discharge teaching plan? 1. Assisting the client to deal with long-term care placement 2. Including the client's significant others in the teaching session 3. Following up on laboratory and diagnostic tests that were prescribed 4. Including information the primary health care provider has indicated

2. Including the client's significant others in the teaching session

A client admitted to the hospital has been prescribed pyridostigmine. When assessing the client for side effects of the medication, the nurse should ask the client about the presence of which occurrence? 1. Mouth ulcers 2. Muscle cramps 3. Feelings of depression 4. Unexplained weight gain

2. Muscle cramps

A client diagnosed with acute respiratory distress syndrome (ARDS) and being mechanically ventilated has received a dose of vecuronium bromide. The nurse determines that the medication has had the intended effect if the client experiences which reaction? 1. Falls asleep 2. Stops fighting the ventilator 3. Produces thinner respiratory secretions 4. Gives weak but equal hand grasps on command

2. Stops fighting the ventilator

A client begins to experience a tonic-clonic seizure. Which actions should the nurse take to assure client safety? Select all that apply. 1. Restrict the client's movements. 2. Turn the supine client to the side. 3. Open the unconscious client's airway. 4. Gently guide the standing client to the floor. 5. Place a padded tongue blade into the client's mouth. 6. Loosen any restrictive clothing that the client is wearing

2. Turn the supine client to the side. 3. Open the unconscious client's airway. 4. Gently guide the standing client to the floor. 6. Loosen any restrictive clothing that the client is wearing

A 13-year-old child has been prescribed valproic acid for the treatment of generalized seizures, and the nurse teaches the child about the potential side effects of the medication. Which statement by the child would indicate the need for further teaching? 1. "I need to take the pills whole and not crush them." 2. "I need to take the medication with food so that I won't get an upset stomach." 3. "I am so glad that I won't lose any of my hair. I was worried what my friends would think." 4. "I know that I might gain weight with the medication, so I need to be careful to not eat a lot of sweets and eat more fruits and vegetables."

3. "I am so glad that I won't lose any of my hair. I was worried what my friends would think."

The nurse teaches a client diagnosed with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client indicates the need for additional teaching? 1. "It is best if I avoid tight clothing and lumpy bedclothes." 2. "I should watch for headache, congestion, and flushed skin." 3. "Signs/symptoms I should watch for include fever and chest pain." 4. "I need to pay close attention to how frequently my bowels move."

3. "Signs/symptoms I should watch for include fever and chest pain."

A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, "I'm no good to anyone. I might as well be dead." Which most therapeutic response should the nurse make to the client? 1. "You're not a useless person at all." 2. "I'll ask the psychologist to see you about this." 3. "You appear to be feeling pretty bad about things." 4. "It makes me uncomfortable when you talk this way."

3. "You appear to be feeling pretty bad about things."

The nurse is reviewing the results of a client's phenytoin level that was drawn that morning. The nurse is preparing to discharge once the level is therapeutic. Which result indicates that this goal has been met? 1. 3 mcg/mL (11.9 mcmol/L) 2. 8 mcg/mL (31.7 mcmol/L) 3. 15 mcg/mL (59.5 mcmol/L) 4. 24 mcg/mL (95.2 mcmol/L)

3. 15 mcg/mL (59.5 mcmol/L)

The nurse in the health care clinic is reviewing the phenytoin level of an adult client who has been taking phenytoin by mouth to control seizures. The nurse determines that the client's level is within the therapeutic range if which result is noted? 1. 3 mcg/mL 2. 8 mcg/mL 3. 16 mcg/mL 4. 24 mcg/mL

3. 16 mcg/mL

The nurse is preparing to assess a client admitted with a diagnosis of trigeminal neuralgia (tic douloureux). On review of the client's record, which symptom should the nurse expect the client is experiencing? 1. Bilateral pain in the area of the sixth cranial nerve 2. Unilateral pain in the area of the sixth cranial nerve 3. Abrupt onset of pain in the area of the fifth cranial nerve 4. Chronic, intermittent pain in the area of the seventh cranial nerve

3. Abrupt onset of pain in the area of the fifth cranial nerve

The nurse performs the Glasgow Coma Scale while assessing a client with a brainstem injury. Which additional interventions should the nurse be prepared to implement? Select all that apply. 1. Assisting with arterial blood gases 2. Assisting with a lumbar puncture 3. Assessing cranial nerve functioning 4. Assessing respiratory rate and rhythm 5. Assessing pulmonary wedge pressure 6. Assessing cognitive abilities, including memory

3. Assessing cranial nerve functioning 4. Assessing respiratory rate and rhythm

The nurse is providing discharge instructions to a client who has been prescribed rasagiline. The client indicates an understanding of the instructions provided when confirming that it is appropriate to eat which food? 1. Raisins 2. Yogurt 3. Chicken 4. Sour cream

3. Chicken

A client diagnosed with a recent complete T4 spinal cord transection tells the nurse that he will walk again as soon as the spinal shock resolves. Which statement provides the most accurate basis for planning a response to the client? 1. The client is projecting by insisting that walking is the rehabilitation goal. 2. To speed acceptance, the client needs reinforcement that he will not walk again. 3. Denial can be protective while the client deals with the anxiety created by the new disability. 4. The client needs to move through the grieving process rapidly to benefit from rehabilitation

3. Denial can be protective while the client deals with the anxiety created by the new disability.

A 16-year-old child, being treated for a seizure disorder, is brought to the emergency department after having just experienced a generalized seizure. Which medications are prescribed long-term to treat a generalized seizure disorder? Select all that apply. 1. Diazepam 2. Alprazolam 3. Gabapentin 4. Ethosuximide 5. Carbamazepine 6. Methylphenidate

3. Gabapentin 4. Ethosuximide 5. Carbamazepine

A client with a history of simple partial seizures is prescribed clorazepate. The client asks the nurse if there is a risk for addiction. The nurse's response is based on the understanding of which information about clorazepate? 1. It is not habit forming either physically or psychologically. 2. It leads to physical tolerance, but only after 10 or more years of therapy. 3. It leads to physical and psychological dependence with prolonged high-dose therapy. 4. It can result in psychological dependence only because of the classification of the medication.

3. It leads to physical and psychological dependence with prolonged high-dose therapy.

A client is admitted to the hospital reporting vomiting and abdominal pain. During the admission assessment, the nurse notes that the client is taking entacapone. Based on this finding, the nurse further assesses the client regarding the presence of which condition? 1. Hypertension 2. Hyperlipidemia 3. Parkinson's disease 4. Peripheral vascular disease

3. Parkinson's disease

The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving? Select all that apply. 1. Flaccidity 2. Presence of a gag reflex 3. Positive Babinski's reflex 4. Development of hyperreflexia 5. Return of the bulbocavernous reflex 6. Return of reflex emptying of the bladder

3. Positive Babinski's reflex 4. Development of hyperreflexia 5. Return of the bulbocavernous reflex 6. Return of reflex emptying of the bladder

The client with myasthenia gravis who has a history of hyperthyroidism asks the nurse about two prescribed drugs, pyridostigmine bromide and prednisone. Which information regarding these medications is appropriate for the nurse to share? 1. Prednisone causes severe weakness. 2. Prednisone is to be taken on an empty stomach only. 3. Pyridostigmine bromide is intended to restore muscle strength and the dose is highly individualized. 4. Pyridostigmine bromide is intended to improve endurance, but fatigue will occur and is nothing to be concerned about

3. Pyridostigmine bromide is intended to restore muscle strength and the dose is highly individualized.

The nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, which information should the nurse provide to the client to minimize the risk for surgery-related injury? 1. Cough and deep breathe hourly. 2. Nasal packing will be removed after 48 hours. 3. Report frequent swallowing or postnasal drip. 4. Acetaminophen is prescribed for severe postsurgical headache

3. Report frequent swallowing or postnasal drip.

The nurse is caring for a client recently prescribed an anticholinesterase agent. As part of the medication teaching plan, the nurse educates the client concerning which common side/adverse effect? 1. Cardiovascular effects such as tachycardia 2. Urinary effects such as urinary hesitation and retention 3. Respiratory effects such as increased bronchial secretions 4. Digestive effects such as decreased motility and tone in the gu

3. Respiratory effects such as increased bronchial secretions

client began taking amantadine hydrochloride approximately 2 weeks ago. The nurse determines that the medication is having a therapeutic effect when the client exhibits a decrease in which manifestation? 1. Voiding 2. Blood pressure 3. Rigidity and akinesia 4. White blood cell count

3. Rigidity and akinesia

Carbamazepine is prescribed for the management of generalized tonic-clonic seizures. The nurse instructs the client to inform the primary health care provider if which sign/symptom occurs? 1. Nausea 2. Dizziness 3. Sore throat 4. Drowsiness

3. Sore throat

A client who sustained a thoracic cord injury a year ago returns to the clinic for a follow-up visit, and the nurse notes a small reddened area on the coccyx. The client is not aware of the reddened area. After counseling the client to relieve pressure on the area by adhering to a turning schedule, which action by the nurse is most appropriate? 1. Teaching the client to feel for reddened areas 2. Asking a family member to assess the skin daily 3. Teaching the client to use a mirror for skin assessment 4. Scheduling the client to return to the clinic daily for a skin check

3. Teaching the client to use a mirror for skin assessment

The nurse is preparing to ambulate a client with a diagnosis of Parkinson's disease who has recently been prescribed levodopa. Which information is most important for the nurse to assess before ambulating the client? 1. The client's history of falls 2. Assistive devices used by the client 3. The client's postural (orthostatic) vital signs 4. The degree of intention tremors exhibited by the client

3. The client's postural (orthostatic) vital signs

A client recovering from a brain attack (stroke) has become irritable and angry regarding self- limitations. Which is the best nursing approach to help the client regain motivation to keep trying to succeed as capable? 1. Ignore the behavior, knowing that the client is grieving. 2. Allow longer and more frequent visitation by the spouse. 3. Use supportive statements to correct the client's behavior. 4. Stress that the nurses are experienced and know how the client feels.

3. Use supportive statements to correct the client's behavior.

A client prescribed dextroamphetamine reports to the nurse difficulty falling asleep at night. The nurse instructs the client on how to minimize sleep disorders. Which statement by the client indicates that teaching has been effective? 1. "I'll take the medication with a bedtime snack." 2. "I'll take the medication upon awaking in the morning." 3. "I'll take the medication two hours before going to bed." 4. "I'll take the medication at least 6 hours before bedtime."

4. "I'll take the medication at least 6 hours before bedtime."

A client diagnosed with Parkinson's disease is having difficulty adjusting to the disorder. The nurse provides education to the family that focuses on addressing the client's activities of daily living. Which statement indicates that the teaching has been effective? 1. "We should plan for only a few activities during the day." 2. "We should assist with activities of daily living as much as possible." 3. "We should cluster activities at the end of the day, to help conserve energy." 4. "We should encourage and praise efforts to exercise and perform activities of daily living.

4. "We should encourage and praise efforts to exercise and perform activities of daily living.

A client diagnosed with Parkinson's disease has begun therapy with levodopa. The nurse determines that the client understands the action of the medication when verbalizing that results may take how long to be apparent? 1. 1 day 2. 3 days 3. 1 week 4. 2 to 3 weeks

4. 2 to 3 weeks

The nurse is admitting a client with a diagnosis of Guillain-Barré syndrome. During the history taking, the nurse should ask if the client has recently experienced which physical problem? 1. Meningitis 2. Seizures or head trauma 3. A back injury or spinal cord trauma 4. A respiratory or gastrointestinal (GI) infection

4. A respiratory or gastrointestinal (GI) infection

The nurse is admitting a client with a history of cardiac disease who has experienced a cerebral stroke. The nurse should perform a neurological assessment and obtain which additional data regarding the client's state of health? 1. Bowel sounds 2. Body temperature 3. Peripheral pulse rate 4. Apical heart rate and rhythm

4. Apical heart rate and rhythm

A client diagnosed with Parkinson's disease is experiencing tremors, rigidity, and bradykinesia. The nurse anticipates that the primary health care provider will prescribe which medication to control these symptoms? 1. Warfarin 2. Phenytoin 3. Pyridostigmine 4. Carbidopa-levodopa

4. Carbidopa-levodopa

A client with a diagnosis of subarachnoid hemorrhage secondary to ruptured cerebral aneurysm has been placed on aneurysm precautions. To promote safety, the nurse should ensure that which intervention is provided to the client? 1. Liquid diet 2. Enemas as needed 3. Help with ambulation 4. Daily stool softeners

4. Daily stool softeners

Entacapone is prescribed for a client with a diagnosis of Parkinson's disease. The nurse provides medication instructions and informs the client of the possibility of which frequent side effect? 1. Pruritus 2. Joint pains 3. A rise in blood pressure 4. Dark yellow or orange urine

4. Dark yellow or orange urine

The nurse is evaluating the status of a client with the diagnosis of myasthenia gravis. The nurse interprets that the client's medication regimen may not be optimal if the client continues to experience fatigue occurring at which time? 1. Early in the morning and before lunch 2. Before meals and at the end of the day 3. Early in the morning and late in the day 4. Following exertion and at the end of the day

4. Following exertion and at the end of the day

The nurse is performing a neurological assessment on a client with a diagnosis of dementia and assessing the function of the frontal lobe of the brain. Which should the nurse assess to yield the best information about this area of functioning? 1. Eye movements 2. Feelings or emotions 3. Level of consciousness 4. Insight, judgment, and planning

4. Insight, judgment, and planning

The nurse is caring for a client with a diagnosis of Parkinson's disease who is taking benztropine mesylate daily. When assessing the client, what should the nurse specifically monitor for to determine if the client is experiencing a side effect of this medication? 1. Pupil response 2. Prothrombin time 3. Skin temperature 4. Intake and output

4. Intake and output

The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention should the nurse include in the plan of care to minimize the client's long-term risk for injury? 1. Change the client's positions slowly. 2. Assess the client for decreased sensation to touch. 3. Assess the client for decreased sensation to vibration. 4. Teach the client about loss of motor function and decreased pain sensation.

4. Teach the client about loss of motor function and decreased pain sensation.

A cooperative, compliant adult client taking 600 mg of carbamazepine twice daily experienced two seizures at home during the past 2 weeks. The nurse should make which interpretation? 1. This is not unusual. 2. This is a possible hysterical response. 3. There is a need to increase the dose of the medication. 4. There is a need for a second anticonvulsant medication to be added to the treatment plan

4. There is a need for a second anticonvulsant medication to be added to the treatment plan