Neuro ATI Med-Surg book application questions

A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to assess for this finding? A. Stroke the lateral aspect of the sole of the foot. B. Ask the client to blink both eyes. C. Observe for facial drooping. D. Have the client stand erect with eves closed.

A. A Babinski sign is elicited by stroking the lateral aspect of the sole of the foot. B. Asking the client to blink his eyes assesses cranial nerve function and is not part of the Romberg test. C. Observing for facial drooping assesses cranial nerve function and is not part of the Romberg test. D. CORRECT: A positive Romberg sign is indicated when a client loses their balance while attempting to stand erect with their eyes closed.

A nurse is caring for a client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? A. Cataracts B. Open-angle glaucoma C. Macular degeneration D. Angle-closure glaucoma

A. A client who has cataracts experiences a decrease in peripheral and central vision due to opacity of the lens B. CORRECT: This is a manifestation of open-angle glaucoma. A gradual loss of peripheral vision is a manifestation associated with this diagnosis. C. A client who has macular degeneration experiences a loss of central vision. D. A client who has angle-closure glaucoma experiences sudden nausea, severe pain, and halos around lights.

A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left-hemispheric stroke? A. Impulse control difficulty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception

A. A client who has experienced a right-hemispheric stroke will experience difficulty with impulse control. B. A client who has experienced a right hemispheric stroke will experience poor judgment. C. CORRECT: A client who experienced a left-hemispheric stroke will demonstrate the inability to recognize familiar objects, known as agnosia. D. A client who experienced a right-hemispheric stroke will experience a loss of depth perception.

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of the body. B. Place the bedside table on the right side of the bed. C. Orient the client to the food on the plate using the clock method. D. Place the wheelchair on the client's left side.

A. A client who has left homonymous hemianopsia has lost the left visual field of both eyes. The client should be taught to turn the head to the left to visualize the entire field of vision. B. CORRECT: The client is unable to visualize to the left midline of their body. Placing the bedside table on the right side of the client's bed will permit visualization of items on the table. C. Using the clock method of food placement will be ineffective because only half of the plate can be seen. D. The wheelchair should be placed to the client's right or unaffected side.

A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? A. Most clients exaggerate their level of pain. B. Pain must have an identifiable source to justify the use of opioids. C. Objective data are essential in assessing pain. D. Pain is whatever the client says it is.

A. A misconception about pain is that clients exaggerate their pain level. B. Clients can have pain without being able to identity the source. C. Objective data are not always present when clients have pain. D. CORRECT: The nurse should identify that pain is a subjective experience, and the client is the best source of information about it.

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? A. Pearly gray tympanic membrane (TM) B. Malleus visible behind the TM C. Presence of soft cerumen in the external canal D. Fluid or bubbles seen behind the TM

A. A pearly gray TM is an expected finding during an otoscopic examination. B. Visualization of the malleus behind the TM is an expected finding during an otoscopic examination. C. Cerumen of various colors, depending on the client's skin color or ethnic background, is an expected finding in the external ear canal. D. CORRECT: Fluid behind the TM indicates the possibility of otitis media and is not an expected finding

A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? A. Use music therapy for relaxation with the onset of the headache. B. Increase physical activity when a headache is present. C. Drink beverages that contain artificial sweeteners to prevent headaches. D. Apply a cool cloth to the face during a headache.

A. A quiet, dark environment can provide comfort during a migraine headache. B. Increasing physical activity during a migraine headache can worsen the pain. C. Artificial sweeteners contain tyramine, which can trigger a migraine headache. D. CORRECT: A cool cloth placed over the client's eyes can provide comfort and relieve pain.

A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following prescriptions should the nurse clarify with the provider? A. Anticoagulant B. Plasma expanders C. H2 antagonists D. Muscle relaxants

A. Administer an anticoagulant to decrease the risk of developing a VTE. B. Administer plasma expanders to treat hypotension caused by the SCI. C. Administer H2 antagonists to decrease the complication of developing a gastric ulcer from stress. D. CORRECT: Clarity with the provider the need for the client to receive muscle relaxants. The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

A nurse working in a long-term care facility is planning care for a client who has moderate Alzheimer's (mild or moderate stage). Which of the following interventions should be included in the plan of care? A. Use a gait belt for ambulation. B. Thicken all liquids. C. Provide protective undergarments. D. Reorient the client to self and current events.

A. Ambulation is affected as the client advances into severe Alzheimer's (late stage). B. Impaired swallowing is a finding as the client advances into severe Alzheimer's (late stage). C. The client in severe Alzheimer's (late stage) experiences episodes of urinary and fecal incontinence. D. CORRECT: A client who has moderate Alzheimer's (middle or moderate stage) can require reorientation to self and current events as cognitive function declines.

A nurse is caring for a client who has experienced a right-hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (Select all that apply.) A. Impulse control B. Moving the left side C. Depth perception D. Speaking E. Situational awareness

A. CORRECT: A client who has experienced a right-hemispheric stroke can exhibit impulse control difficulty, such as the urgency to use the restroom B. CORRECT: A client who has experienced a right-hemispheric stroke can exhibit left-sided hemiplegia C. CORRECT: A client who has experienced a right-hemispheric stroke can experience a loss in depth perception. D. A client who has experienced a left-hemispheric stroke can experience aphasia. E. CORRECT: A client who has experienced a right-hemispheric stroke can demonstrate a lack of awareness of surroundings.

A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively? (SATA) A. Increased intracranial pressure B. Hemorrhagic shock C. Hydrocephalus D. Hypoglycemia E. Seizures

A. CORRECT: A client who has had a craniotomy should be monitored postoperatively for increased ICP. B. Although hypovolemic shock can occur secondary to SIADH, hemorrhagic shock is not a concern C. CORRECT: Following a craniotomy, the client should be monitored for the development of hydrocephalus. D. An alteration in glucose metabolism is not usually a postoperative concern after this surgery. E. CORRECT: Seizures are a postoperative complication that should be monitored following a craniotomy.

A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (SATA) A. Areas of paresthesia B. Involuntary eye movements C. Alopecia D. Increased salivation E. Ataxia

A. CORRECT: Areas of loss of skin sensation are a finding in a client who has MS. B. CORRECT: Nystagmus is a finding in a client who has MS. C. Hair loss is not a finding in a client who has MS. D. Dysphagia, swallowing difficulty, is a finding in a client who has amyotrophic lateral sclerosis. E. CORRECT: Ataxia occurs in the client who has MS as muscle weakness develops and there is loss of coordination.

A nurse is completing an assessment of a client who has increased intracranial pressure (ICP). Which of the following are expected findings? (SATA) A. Disoriented to time and place B. Restlessness and irritability C. Unequal pupils D. ICP 15 mm Hg E. Headache

A. CORRECT: Changes in level of consciousness are an early indicator of increased ICP. B. CORRECT: Increased ICP can cause behavior changes, such as restlessness and irritabilitv. C. CORRECT: Unequal pupils indicates pressure on the oculomotor nerve secondary to increased ICP. D. An ICP of 15 mm Hg is within the expected reference range. CORRECT: A headache is a manifestation of increased ICP.

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (SATA) A. Speak to the client at a slower rate. B. Assist the client to use cards with pictures. C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time.

A. CORRECT: Clients who have global aphasia have difficulty with speaking and understanding speech. One strategy that can enhance client understanding is speaking to the client at a slower rate. B. CORRECT: One strategy that can enhance understanding is the use of alternative forms of communication, such as cards with pictures or a computer. C. For the client who has aphasia, speaking in a loud voice is unnecessary and can be interpreted as patronizing. D. Allow the client adequate time to finish sentences and not complete the sentences for them. E. CORRECT: One strategy that can enhance understanding is giving instructions one step at a time.

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? (SATA) A. "It is given to reduce swelling of the brain." B. "You will need to monitor for low blood sugar." C. "You might notice weight gain." D. "Tumor growth will be delayed." E. "It can cause you to retain fluids."

A. CORRECT: Dexamethasone is a common steroid prescribed to reduce cerebral edema. B. The client can experience hyperglycemia as an adverse effect of dexamethasone. C. CORRECT: Weight gain is an adverse effect of dexamethasone D. Dexamethasone does not affect tumor growth.It is given to prevent cerebral edema. E. CORRECT: Fluid retention is an adverse effect of dexamethasone.

A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? (SATA) A. Enlarged adenoids B. Report of recent colds C. Client prescription for daily furosemide D. Light reflex visible on otoscopic exam in the affected ear E. Ear pain relieved by meclizine

A. CORRECT: Enlarged tonsils and adenoids are a finding associated with a middle ear infection. B. CORRECT: Frequent colds are findings associated with a middle ear infection. C. Furosemide is an ototoxic medication and can cause sensorineural hearing loss, but taking furosemide does not cause a middle ear disorder. D. Light reflexes are absent or in altered positions in a client who has a middle ear disorder. E. Meclizine is prescribed to relieve vertigo for inner ear disorders, but does not relieve the pain of a middle ear infection.

A nurse is caring for a client who has Alzheimer's disease.A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurse's response? (Select all that apply) A. Exposure to metal waste products B. Long-term estrogen therapy C. Sustained use of vitamin E D. Previous head injury E. History of herpes infection

A. CORRECT: Exposure to metal and toxic waste is a risk factor for Alzheimer's disease. B. Long-term estrogen therapy can prevent Alzheimer's disease. C. Long-term use of vitamin E is not a risk factor for Alzheimer's disease. D. CORRECT: A previous head injury is a risk factor for Alzheimer's disease. E. CORRECT: A history of herpes infection is a risk factor for Alzheimer's disease.

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A. CORRECT: Headache is a finding associated with increased ICP. B. CORRECT: Dilated pupils is a finding associated with increased ICP. C. Bradycardia, not tachycardia, is a finding associated with increased ICP. D. CORRECT: Decorticate or decerebrate posturing is a finding associated with increased ICP. E. Hypertension, not hypotension, is a finding associated with increased ICP

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter

A. CORRECT: Implement the noninvasive use of a condom catheter, because the bladder will empty on its own due to the client having an upper motor neuron injury, which is manifested b a spastic bladder. B. Implement the intermittent urinary catheterization method for a client who has a flaccid bladder. C. Implement the Credé's method for a client who has a flaccid bladder. D. An indwelling urinard carioter is an invasive procedure. Do not implement this bladder management method for the client.

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? A. Increase intake of deep yellow and orange vegetables. B. Administer eye drops twice daily. C. Avoid bending at the waist. D. Wear an eye patch at night.

A. CORRECT: Instruct the client to increase dietary intake of carotenoids and antioxidants to slow the progression of the macular degeneration. B. A client who has primary open-angle glaucoma should administer eye drops twice daily. C. A client who is at risk for increased intraocular pressure, such as following cataract surgery, should avoid bending at the waist. D. A client who has had eye surgery, such as cataract surgery, should wear an eye patch at night to protect the eye from injury.

A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse expect to administer? A. Ketorolac B. Ketamine C. Meperidine D. Methadone

A. CORRECT: Ketorolac is in the NSAID category and is useful for anti-inflammatory effects in managing minor pain following a sprain. B. Ketamine is an anesthetic agent that is often used as an adjuvant medication for treating neuropathic pain. C. Meperidine is not recommended for regular use due to adverse effects of the medication. D. Methadone is effective for treating severe pain.

A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? A. "I should restrict rapid movements and avoid bending from the waist for several weeks." B. "I should wait until the day after surgery to wash my hair." C. "I will remove the dressing behind my ear in 7 days." D. "My hearing should be back to normal right after my surgery."

A. CORRECT: Rapid movements and bending from the waist should be avoided for 3 weeks following ear surgery. B. Avoid showering and washing hair for at least several days up to 1 week following ear surgery.The ear must remain dry during this time. C. Middle ear surgery is performed through the tympanic membrane, and the client will have a dry dressing within the ear canal. There is no external excision. D. Decreased hearing is expected following middle ear surgery due to presence of a dressing within the ear canal and possible drainage.

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (SATA) A. Reduce exposure to bright lighting. B. Move head slowly when changing positions. C. Do not eat fruit high in potassium. D. Plan evenly-spaced daily fluid intake. E. Avoid fluids containing caffeine.

A. CORRECT: Remaining in a darkened, quiet environment can reduce vertigo, particularly when it is severe. B. CORRECT: Moving slowly when standing or changing positions can reduce vertigo. C. The client who has vertigo should be instructed to avoid foods containing high levels of sodium to reduce fluid retention, which can cause vertigo. D. CORRECT: Fluid intake should be planned so that it is evenly spaced throughout the day to prevent excess fluid accumulation in the semicircular canals E. The client should avoid fluids containing caffeine or alcohol to minimize vertigo.

A nurse is making a home visit to a client who has AD. The client's partner states that the client is often disoriented to time and place, is unsteady, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? (SATA) A. Remove floor rugs. B. Have door locks that can be easily opened. C Provide increased lighting in stairwells. D. Install handrails in the bathroom. E. Place the mattress on the floor.

A. CORRECT: Removing floor rugs can decrease the risk of falling. B. Easy-to-open door locks increase the risk for a client who wanders to get out of his home and get lost. C. CORRECT: Good lighting can decrease the risk for falling in dark areas, such as stairways. D. CORRECT: Installing handrails in the bathroom can be useful for the client to hold on to when his gait is unsteady. E. CORRECT: By placing the client's mattress on the floor, the risk of falling or tripping is decreased.

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (SATA) A. Have suction equipment available for use. B. Feed the client thickened liquids. C. Place food on the unaffected side of the client's mouth. D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with the neck flexed.

A. CORRECT: Suction equipment should be available in case of choking and aspiration. B. CORRECT: The client should be given liquids that are thicker than water to prevent aspiration. C. CORRECT: Placing food on the unaffected side of the client's mouth will allow them to have better control of the food and reduce the risk of aspiration D. Due to the risk of aspiration, assistive personnel should not be assigned to feed the client because the client's swallowing ability should be assessed, and suctioning can be needed if choking occurs. E. CORRECT: The client should be taught to flex the neck, tucking the chin down and under to close the epiglottis during swallowing

A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? (SATA) A. implement seizure precautions B. perform neurologic checks four times a day C. administer morphine for the report of neck and generalized pain D. turn off room lights and television E. monitor for impaired extraocular movements F. encourage the client to cough frequently

A. CORRECT: The client is at risk for seizures due to possible increased ICP. Therefore, the nurse should implement seizures precautions to reduce the client's risk for injury. B. The nurse should perform neurologic checks at least every 2 hours for a client who is at risk for increased ICP. C. The nurse should avoid administering opioids to a client who is at risk for increased ICP. Opioids can mask changes in the client's level of consciousness. D. CORRECT: The nurse should turn off room lights and the television because they can increase neuron stimulation and cause a seizure when a client is at risk for increased ICP. E. CORRECT: The nurse should monitor for impaired extraocular movements because this finding can indicate increased ICP. F. The nurse should instruct the client to avoid coughing because this action can cause increased ICP.

A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

A. CORRECT: The greatest risk to the client during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention to take is to prevent further damage to the spinal cord by minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation oF the client to decrease ischemia of the spinal cord. B. Implement ROM exercise to prevent contractures.However, another action is the priority. C. Implement a turning schedule to prevent skin breakdown. However, another action is the priority. D. Slowly move the client to an upright position to prevent postural hypotension. However, another action is the priority.

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. keep the client in a side-lying position B. document the duration of the seizure C. reorient the client to the environment D. provide client hygiene

A. CORRECT: The greatest risk to the client is aspiration during the postictal phase. Therefore, the priority intervention is to keep the client in a side-lying position so secretions can drain from the mouth keeping the airway patent. B. The nurse should document the duration of the seizure in the client's medical record, but there is another action that the nurse should take first. C. The nurse should reorient the client to the environment because the client can feel confused, but there is another action that the nurse should take first. D. The nurse should provide client hygiene if the client experienced incontinence during the seizure, but there is another action that the nurse should take first.

A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement.

A. CORRECT: The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out B. Insertion of a nasogastric tube is not the priority nursing action at this time. C. Frequent monitoring of pulse and blood pressure is important but not the priority nursing action at this time D. Establishing IV access for fluid replacement is important but not the priority nursing action at this time.

A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "I am about to have a seizure". Which of the following actions should the nurse implement? (SATA) A. Provide privacy B. Ease the client to the floor if standing C. Move furniture away from the client D. Loosen the client's clothing E. Protect the client's head with padding F. Restrain the client

A. CORRECT: The nurse should implement privacy to minimize the client's embarrassment B. CORRECT: The nurse should ease the client to the floor to prevent falling and injury C. CORRECT: The nurse should move the furniture away from the client to prevent injury D. CORRECT: The nurse should loosen the client's clothing to minimize restriction of movement E. CORRECT: The nurse should protect the client's head from injury by placing the client' head in her lap or using a pillow or blanket under the head during a seizure F. The nurse should not restrain the client. Restraint can increase the client's risk for injury or more seizure activity

A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (SATA) A. Avoid overwhelming fatigue B. Remove caffeinated products from the diet C. Limit looking at flashing lights D. Perform aerobic exercise E. Limit episodes of hypoventilation F. Use of aerosol hairspray is recommended

A. CORRECT: The nurse should instruct the client to avoid overwhelming fatigue, which can trigger a seizure by stimulating abnormal electrical neuron activity. B. CORRECT: The nurse should instruct the client to remove caffeinated products from the diet, which can trigger a seizure by stimulating abnormal electrical neuron activity. C. CORRECT: The nurse should instruct the client to refrain from looking at flashing lights, which can trigger a seizure by stimulating abnormal electrical neuron activity. D. The nurse should instruct the client to avoid vigorous physical activity, which can help to avoid triggering a seizure. E. The nurse should instruct the client to limit excess hyperventilation, which can trigger a seizure by stimulating abnormal electrical neuron activity. F. The nurse should instruct the client to avoid using aerosol hairspray, which can trigger a seizure by stimulating abnormal electrical neuron activity.

A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? (SATA) A. "I think I might be pregnant" B. "I take warfarin" C. "I take antihypertensive medication" D. "I am allergic to shrimp" E. "I ate a light breakfast this morning"

A. CORRECT: The nurse should report the client's statement of possible pregnancy to the provider because contrast media can place the fetus at risk. B. CORRECT: The nurse should report that the client is taking warfarin to the provider due to the potential for bleeding following angiography. C. There is no contraindication related to cerebral angiography for a client who is taking antihypertensive medication. D. CORRECT: The nurse should report a client's report allergy to shrimp, which is a shellfish, to the provider due to a potential allergic reaction to the contrast media. E. CORRECT: The nurse should report a client's intake of food to the provider since the client should remain NPO for 4 to 6 hr prior to the procedure.

A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (SATA) A. place client in supine position B. flex client's hip and knee C. place hands behind clients neck D. bend client's head toward chest E. straighten the client's flexed leg at the knee

A. CORRECT: Thee nurse should place the client in supine position when assessing for Brudzinski's sign. B. The nurse should flex the client's hip and knee when assessing for Kernig's sign. C. CORRECT: The nurse should place her hands behind the client's neck when assessing for Brudzinskis sign, in order to flex the client's neck. D. CORRECT: The nurse should bend the client's head toward the chest when assessing for Brudzinski's sign. E. The nurse would straighten the client's flexed leg at the knee when assessing for Kernig's sign.

A nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescription for bromocriptine. Which of the following should the nurse include? A. rise slowly when standing B. expect urine to become dark-colored C. avoid foods containing tyramine D. report any skin discoloration

A. CORRECT: orthostatic hypotension is a common adverse effect of bromocriptine, a dopamine receptor agonist. therefore, rising slowly when standing up will decreased the risk of dizziness and lightheadedness. B. the client should expect urine to turn dark when taking entacapone, a COMT inhibitor. Dark urine is not an expected finding when taking bromocriptine. C. The client should avoid tyramine in the diet when taking selegiline, a monoamine type B inhibitor. However, bromocriptine does not interact with foods that contain tyramine. D. Skin discoloration is an adverse effect of amantadine, N anti-viral medication. However, ti is not an adverse effect of bromocriptine.

A nurse in a provider's office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? (SATA) A. Pain is bilateral across the posterior occipital area. B. Client experiences altered sleep-wake cycle. C. Headache occurs approximately 1 to 8 times daily. D. Client describes headache pain as dull and throbbing. E. Nasal congestion and drainage occur

A. Cluster headaches typically cause pain on one side of the head and radiate to the forehead, temple, or cheek. B. CORRECT: Cluster headaches can be due to a lack of continuity in the sleep-wake cycle. C. CORRECT: Cluster headaches occur approximately 1 to 8 times daily. D. Cluster headaches are described as unilateral, intense, and nonthrobbing. E. CORRECT: A client can have a runny nose and nasal congestion with a cluster headache.

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches.Which of the following questions should the nurse ask to identify the aura type of migraine headaches? A. "Do the headaches occur multiple times each day?" B. "Is your headache accompanied by profuse facial sweating?" C. "Does your headache occur on one side of your head?" D. "Do you have the same manifestations each time the headache occurs?"

A. Cluster headaches typically occur 1 to 8 times each day. B. Profuse facial sweating is typical in the presence of cluster headaches. C. Unilateral headaches are associated with cluster headaches and common migraines. D. CORRECT: Clients who have aura type migraines typically have the same manifestations each time the headache occurs.

A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? (SATA) A. decreased vision B. pill-rolling tremor of fingers C. shuffling gait D. drooling E. bilateral ankle edema F. lack of facial expression

A. Decreased vision is not an expected finding in a client who has PD. B. CORRECT: The client who has PD can manifest pill-rolling tremors of the fingers due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult. C. CORRECT: The client who has PD can manifest shuffling gait because of overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult. D. CORRECT: The client who has PD can manifest drooling because of overstimulation of the basal ganglia by acetylcholine, making the controlled movement of swallowing secretions difficult. E. Bilateral ankle edema is not an expected finding in a client who has PD, but can be an adverse effect of certain medications used for treatment. F. CORRECT: The client who has PD can manifest a lack of facial expressions due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.

A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor and has a respiratory rate of 12. Which of the following postoperative prescriptions should the nurse clarify with the provider? A. Dexamethasone 30 mg IV bolus BID B. Morphine sulfate 2 mg IV bolusPRN every 2 hr for pain C. Ondansetron 4 mg IV bolus PRN every 4 to 6 hr for nausea D. Phenytoin 100 mg IV bolus TID

A. Dexamethasone is given to prevent cerebral edema and has no CNS depressant effects B. CORRECT: Identify that if a client following a craniotomy has a respiratory rate of 12, the provider should be notified prior to administering morphine. Morphine is a narcotic analgesic, which can cause CNS depressant effects such as respiratory depression C. Ondansetron is prescribed to manage nausea and has no CNS depressant effects. D. Phenytoin is prescribed to prevent seizures and has no CNS depressant effects.

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? A. "You can resume playing golf in 2 days." B. "You need to tilt your head back when washing your hair." C. "You can get water in your eyes in 1 day." D. "You need to limit your housekeeping activities."

A. Do not instruct the client to resume playing golf for several weeks. This could cause a rise in intraocular pressure (IOP) or possible injury to the eye. B. Do not instruct the client to tilt the head back when washing their hair. This could cause a rise in IOP or possible injury to the eye. C. The client should not get water in their eyes for 3 to 7 days following cataract surgery to reduce the risk for infection and promote healing. D. CORRECT: Instruct the client to limit housekeeping activities following cataract surgery. This activity could cause a rise in IOP or injury to the eye.

A nurse is providing teaching to the partner of a client who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective? A. "This medication should increase my husband's appetite. B. "This medication should help my husband sleep better." C. "This medication should help my husband's daily function. D. "This medication should increase my husband's energy level."

A. Donepezil does not affect appetite B. Donepezil does not affect sleep or sleep patterns. C. CORRECT: Donepezil helps slow the progression of AD and can help improve behavior and daily functions. D. Donepezil does not affect energy levels.

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? A. Examine skin for irritation or pressure. B. Sit the client upright in bed. C. Check the urinary catheter for blockage. D. Administer antihypertensive medication.

A. Examine the client's skin for areas of irritation, pressure, or broken skin to alleviate a triggering stimulus.However, another action is the priority. B. CORRECT: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated blood pressure caused by autonomic dysreflexia. The first action to take is to elevate the head of the bed until the client is in an upright position, which should lower the blood pressure secondary to postural hypotension. C. Check the client's catheter for blockage.However, another action is the priority. D. Administer an antihypertensive medication if indicated.However, another action is the priority.

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Eye pain B. Floating spots C. Blurred vision D. White pupils E. Bilateral red reflexes

A. Eye pain is a manifestation associated with primary angle-closure glaucoma. B. Floating spots are a manifestation associated with retinal detachment. C. CORRECT: Blurred vision is a manifestation associated with cataracts. D. CORRECT: White pupils are a manifestation associated with cataracts. E. Bilateral red reflexes are absent in a client who has cataracts.

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids

A. Fluctuations in blood pressure is a manifestation associated with amyotrophic lateral sclerosis. B. CORRECT: Loss of cognitive function is a manifestation associated with MS. C. Ineffective cough is a manifestation associated with amyotrophic lateral sclerosis. D. Drooping eyelids is a manifestation associated with myasthenia gravis.

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

A. Hyperglycemia is not an adverse effect of mannitol. B. CORRECT: Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia. C. Hypovolemia is an adverse effect of mannitol and should be monitored. D. Polyuria is an adverse of mannitol and should be monitored.

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (SATA) A. use the Glasgow Come Scale when assessing the client B. assist the client to a supine position C. administer an opioid medication D. encourage the client to increase fluid intake. E. instruct the client to perform deep breathing and coughing exercises.

A. INCORRECT: The Glasgow Coma Scale is used to assess a client's level of consciousness and is not necessary following a lumbar puncture. B. CORRECT: The nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture. C. CORRECT: The nurse should administer an opioid medication for a client's report of headache pain. D. CORRECT: The nurse should encourage an increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture. E. INCORRECT: Coughing can increase. ICP, which can result in an increase in the client's headache.

A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe? A. Keep the call light near the client. B. Place the client in a room close to the nurses' station. C. Encourage the client to ask for assistance. D. Remind the client to walk with someone for support.

A. Keeping the call light within the client's reach is an appropriate action, but not the first action because the client might not remember to use it. B. CORRECT: Using the safety and risk reduction priority-setting framework, placing the client in close proximity to the nurses' station for close observation is the first action the nurse should take. C. Encouraging the client to ask for assistance is an appropriate action, but not the first action because the client might not remember to ask for assistance. D. Reminding the client to walk with someone is an appropriate action, but not the first action because the client might not remember to call for assistance.

A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if this same type of tumor can occur in other areas of the body. Which of the following responses should the nurse make? A. "It can spread to breasts and kidneys." B. "It can develop in your gastrointestinal tract." C "It is limited to brain tissue." D. "It probably started in another area of your body and spread to your brain."

A. Metastases of a benign brain tumor do not occur. B. Metastases of a benign brain tumor do not occur. C. CORRECT: Benign brain tumors develop from the meninges or cranial nerves and do not metastasize. D. Benign brain tumors develop from the meninges or cranial nerves and are not secondary to other types of tumors.

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

A. Monitor for neurogenic shock, which is a response of the sympathetic nervous system of a client who has a SCI.However, another complication is the priority. B. Monitor for a paralytic ileus, which is a complication immediately following a SCI. However, another complication is the priority. C. Monitor for a stress ulcer, which is a response to changes caused from the SCI. However, another complication is the priority D. CORRECT: When using the airway, breathing, and circulation (ABC) approach to client care, the priority complication is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention.

A nurse is caring for a client who has suspected Ménière's disease. Which of the following is an expected finding? A. Presence of a purulent lesion in the external ear canal B. Feeling of pressure in the ear C. Bulging, red bilateral tympanic membranes D. Unilateral hearing loss

A. Ménière's disease is an inner ear disorder. A purulent lesion in the external ear canal is not an expected finding. B. A feeling of pressure in the ear can occur with otitis media, but is not an expected finding in Ménière's. C. Ménière's disease is an inner ear disorder. Bulging, red bilateral tympanic membranes is a finding associated with a middle ear infection. D. CORRECT: Unilateral sensorineural hearing loss is an expected finding in Ménière's disease.

A nurse at a clinic is talking with a client who has cancer and takes extended-release opioids twice daily. The client reports an increased in localized, achy pain over the last few days. How should the nurse document this increase in pain? A. phantom limb pain B. mixed pain C. breakthrough pain D. neuropathic pain

A. Phantom limp pain is pain that is perceived to be initiated from a part of the body that is no longer present. B. Mixed pain is pain that is difficult to define, for conditions such as fibromyalgia. C. CORRECT: Breakthrough pain is an acute exacerbation of pain beyond the level the client typically experiences. D. Neuropathic pain sensations are described as burning, shooting, or pins and needles.

A nurse is teaching a client who has multiple sclerosis and a new prescription for bacloten. Which of the following statements should the nurse include in the teaching? A. "This medication will help you with your tremors. B. "This medication will help you with your bladder function." C. "This medication can cause your skin to bruise easily." D. "This medication can cause you to experience dizziness."

A. Propranolol is a beta blocker and clonazepar is a benzodiazepine given to clients who have MS to treat tremors. B. Propantheline is an anticholinergic medication that is given to clients who have MS to treat bladder dysfunction. C. Prednisone is a corticosteroid medication that is given to clients who have MS to treat inflammation. An adverse effect of this medication is bruising of the skin. D. CORRECT: Baclofen is an antispasmodic medication that is given to clients who have MS to treat muscle spasms. An adverse effect of this medication is drowsiness, as well as dizziness. Instruct the client to monitor for these findings, as they can lead to impaired safety. The client should be instructed not to discontinue baclofen abruptly.

A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (SATA) A. Sex B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus

A. Sex is not a risk factor associated with glaucoma. B. CORRECT: Genetic predisposition is a risk factor associated with glaucoma C. CORRECT: Hypertension is a risk factor associated with glaucoma D. CORRECT: Age is a risk factor associated with glaucoma. E. CORRECT: Diabetes mellitus is a risk factor associated with glaucoma.

Anurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

A. The Glasgow Coma Scale is important. However, another assessment is the priority. B. Assessment of cranial nerve function is important.However, another assessment is the priority. C. CORRECT: Using the airway, breathing, and circulation (ABC) priority-setting framework, assessment of oxygen saturation is the priority action. Brain tissue can only survive for 3 min before permanent damage occurs. D. Assessment of pupillary response is important.However, another assessment is the priority.

A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8

A. The calculation is incorrect. E3 represents eyes opening secondary to pain, V3 represents verbal response with words spoken inappropriately, and M5 represents motor response to pain with a local reaction. B. CORRECT: The client's score is calculated correctly. indication moderate head injury. E3 represents opening eyes secondary to voice stimulation, V4 represents verbal conversation that is incoherent and disoriented, and the M4 represents motor response as a general withdrawal from pain. C. The client's score is calculated incorrectly. E4 represents eyes opening spontaneously, V5 represents verbal conversation as coherent and oriented, and M6 indicates a client is able to follow commands. D. The client's score is calculated incorrectly. E2 represents eyes opening secondary to pain, V2 represents verbal response by the client making sounds but speaking no words, and M4 is a motor response with a general withdrawal to pain.

The nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device? A. "I'll wait to use the device until it's absolutely necessary" B. "I'll be careful about pushing the button so I don't get an overdose" C. "I should tell the nurse is the pain doesn't stop after I use this device" D. "I will ask my son to push the dose button when I am sleeping"

A. The client may use the device when he beings to feel pain. It will help prevent unnecessary worsening of the pain and more doses of analgesia to provide relief. B. A feature of PCA devices is the timing control or lockout mechanism, which enforces a present minimum interval between medication doses. This safety feature is one means of preventing an overdose because the client cannot self-administer another dose of medication until that time interval has passed. C. CORRECT: The nurse should identify that PCA is a method of delivering pain medication through an electronic infusion device that allows the client to self-administer pain medication on an as-needed basis. If the client is not achieving adequate pain control he should let the nurse know so that she can initiate a reevaluation of the client's pain management plan. D. The client is the only one who should operate the PCA pump. In situations where the client is not able to do so, the provider may authorize a nurse or a family member to operate the pump.

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods? A. Baked salmon B. Salted cashews C. Frozen strawberries D. Fresh asparagus

A. The client should avoid fish that is smoked because it contains tyramine. Baked salmon does not contain tyramine and is not a trigger for migraine headaches. B. CORRECT: Nuts contain tyramine, which can trigger migraine headaches. C. Fruits are not a source of tyramine. D. Vegetables are not a source of tyramine.

A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse? A. teach the client to walk more quickly when ambulating B. complete passive range-of-motion exercises daily C. place the client on a low-protein, low-calorie diet D. give the client extra time to perform activities

A. The client who has PD develops a propulsive gait and tends to walk increasingly rapidly. The client should be reminded to stop occasionally when walking to prevent a propulsive gait and decrease the risk for falls. B. Encourage active, not passive, range-of-motion exercises to promote mobility in the client who has PD and is displaying bradykinesia. C. The client who has PD often requires high-calorie, high-protein supplements between meals in order to maintain adequate weight. D. CORRECT: Bradykinesia is abnormally slowed movement and is seen in clients who have PD. The client should be given extra time to perform activities and should be encouraged to remain active.

A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include? A. consider taking an antacid when on this medication B. water for receding gums when taking this medication C. take the medication at the same time every day D. provide a urine sample to determine therapeutic levels of the medication

A. The nurse does not need to instruct the client to consider taking an antacid, because phenytoin does not cause any gastrointestinal adverse effects. B. The nurse should instruct the client that phenytoin causes overgrowth of the gums. C. CORRECT: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness. D. The nurse should instruct the client to have periodic blood tests to determine the therapeutic level of phenytoin.

A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics B. Implement droplet precautions C. initiate IV access D. decrease bright lights

A. The nurse should administer antibiotics to stop the micro-organisms from multiplying but this is not the priority action B. CORRECT: When using the urgent vs nonurgent approach to care, the nurse determines that priority action is to initiate droplet precautions when meningitis is suspected to prevent the spread of the disease to others. C. The nurse should initiate IV access to allow IV medication and fluid administration, but this is not the priority action. D. The nurse should decreased bright lights because of the client's sensitivity to light, but this is not the priority action.

A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? A. "It is safe to use microwaves that are 1,200 watts or less" B. "You should avoid the use of CT scans without contrast" C. "You should place a magnet over the implantable device when you feel an aura occurring" D. "It is recommended that you use ultrasound diathermy for pain management"

A. The nurse should instruct the client to avoid using a microwave, regardless of wattage, which can affect the function of the stimulator. B. The nurse should instruct the client to avoid MRI's, which can affect the function of the stimulator. C. CORRECT: The nurse should instruct the client to hold a magnet over the implantable device when an aura occurs so as to decrease seizure activity. D. The nurse should instruct the client to avoid the use of ultrasound diathermy for pain management because of its effect on the function of the stimulator.

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. headache B. infection C. aphasia D. hypertension

A. The nurse should monitor a client who has increased ICP for a headache, but a headache does not indicate a complication directly related to the ventriculostomy. B. CORRECT: The nurse should monitor a client who has a ventriculostomy for infection, which is a complication. The nurse should use strict asepsis to avoid this life-threatening condition, which can result in meningitis. C. The nurse should monitor a client who has increased 1CP for aphasia related to the head injury, but this not a complication directly related to the ventriculostomy. D. The nurse should monitor a client who has increased ICP for hypertension, but this is not a complication directly related to the ventriculostomy.

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (SATA) A. Monitor for bradycardia. B. Provide an emesis basin at the bedside C. Administer antipyretic medication D. Perform a skin assessment E. Keep the head of the bed flat

A. The nurse should plan to monitor for tachycardia when a client has meningitis. B. CORRECT: The nurse should provide an emesis basin at the bedside because the client who has meningitis can have nausea and vomiting. C. CORRECT: The nurse should plan to administer antipyretic medication for fever to a client who has meningitis. D. CORRECT: The nurse should perform a skin assessment to determine whether the client has a red macular rash associated with meningococcal meningitis. E. The nurse should elevate the head of the client's bed 30 degrees to promote venous drainage from the head and prevent increased ICP.

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure" B. "Try to stay awake most of the night prior to the procedure" C. "The procedure will take approximately 15 minutes" D. "You will need to lie flat for 4 hours after the procedure"

A. The nurse should teach the client to wash her hair on the morning of the procedure to remove oils, ,gels and sprays, which can affect the EEG readings. B. CORRECT: The nurse should teach the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity. C. The nurse should teach the client that the procedure will take approximately 1 hr. D. The nurse should teach the client that normal activity can resume immediately following the procedure.

A nurse is reviewing the use for the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A. the vaccine is indicated to reduce the risk of respiratory infection B. the vaccine is administered in a series of four doses C. the vaccine is recommended for adolescents before starting college D. the vaccine is initially given at 2 months of age

A. The pneumococcal vaccine is primarily indicated to reduce the risk of respiratory infection. However, it also reduces the risk of CNS infection B. The HIB vaccine is administered to infants in a series of four doses. C. CORRECT: The nurse should identify that the meningococcal vaccine is recommended for adolescents prior to starting college due to the increased risk for infection in communal living facilities. D. The initial dose of the HIB vaccine is recommended for infants at 2 months of age.

A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (SATA) A Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

A. Urinary retention, not urinary incontinence, is a common adverse effect of opioid analgesia. B. Constipation, not diarrhea, is a common adverse effect of opioid analgesia. C. CORRECT: Respiratory depression, which causes respiratory rates to drop to dangerously low levels, is a common adverse effect of opioid analgesia. D. CORRECT: Dizziness or lightheadedness when changing positions is a common adverse effect of opioid analgesia. E. CORRECT: Nausea and vomiting are common adverse effects of opioid analgesia.

A nurse in a clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching? A. "This medication will relieve my symptoms by causing my blood vessels to dilate." B. "I should take this medication daily to prevent the headache from occurring." C. "I should expect facial flushing when I take this medication." D. "This medication will lower my sensitivity to food triggers."

A. Zolmitriptan causes cranial arteries, the basilar arteries, and blood vessels in the dura mater to constrict. B. Zolmitriptan is used for abortive therapy in treating migraine headaches. It is not used for headache prevention. C. CORRECT: Zolmitriptan can cause facial flushing, tingling, and warmth. D. Zolmitriptan is used as a component of abortive therapy for treatment of migraine headaches and does not affect a client's sensitivity to food triggers.

A nurse is developing a care plan for the nutritional needs of a client who has stage IV Parkinson's disease. Which of the following actions should the nurse include? (SATA) A. provide three large balanced meals daily B. record diet and fluid intake daily C. document weight every other week D. offer cold fluids such as milkshakes E. offer nutritional supplements between meals

A. plan to provide small, frequent meals during the day to maintain adequate nutrition B. CORRECT: record the client's diet and fluid intake daily to assess for dietary needs and to maintain adequate nutrition and hydration. C. document the client's weight weekly to identify weight loss and intervene to maintain the client's weight D. CORRECT: provide cold fluids such as milkshakes. Thick and cold fluids are tolerated easier by the client E. CORRECT offer nutritional supplements between meals to maintain the client's weight.

A nurse is caring for a client who displays manifestations of stage III Parkinson's disease. Which of the following actions should the nurse include? A. Recommend a community support group B. Integrate a daily exercise routine C. Provide a walker for ambulation D. Perform ADL's for the client

A. the client/family should be involved in a community support group at the onset of the disease process to enhance coping mechanisms. B. the client should perform daily exercises with the onset of the disease process to promote mobility and independence for as long as possible. C. CORRECT: the client should use a walker for ambulation in stage III Parkinson's disease because movement slows down significantly and gait disturbances occur. D. the client loses ability to perform ADLs during stage V of Parkinson's disease and is dependent on others for care at that time. During earlier stages, the client should be encouraged to remain as independent as possible.

A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube frequently. B. Decrease the noise level in the client's room. C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.

fA. Suctioning increases ICP and should be peformed only when indicated B. CORRECT: Decreasing the noise level and restricting the number of people in the client's room can help prevent increases in ICP. C. Hyperflexion of the client's neck with pillows carries the risk of increasing ICP and should be avoided. The head of the bed should be raised to at least 30°, but the head should be maintained in an upright, neutral position. D. CORRECT: Administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increase ICP. E. Overhydration carries the risk of increasing ICP and should be avoided. Monitor fluid and electrolyte levels closely for the client who has increased ICP.