Neuro PrepU 2

24 to 48 hours after surgery.

The client reports that the nasal packing is uncomfortable and asks when it will be removed. The nurse should tell the client the nasal packing is usually removed:

get another nurse to help logroll the client into position.

The client with a lumbar laminectomy asks to be turned onto the side. The nurse should:

social isolation

The nurse should assess an older adult who has diminished hearing and vision for which condition?

Escape the source of pain.

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the client's first response to pain will be to do what?

"Avoid stimulants and alcohol for 24 to 48 hours before the test."

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?

gastrointestinal

Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which body system?

perform frequent mouth care.

Following nasal surgery, the client has packing in the nose. The nurse should:

Activate the Rapid Response Team (RRT).

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 bpm; and respiratory rate of 30 shallow breaths/min. What should the nurse do first?

comparing equality of hand grasps.

For a neurologically injured client, the nurse should assess motor strength by:

dysphagia

difficulty swallowing An elderly client has suffered a cerebrovascular accident (CVA). The right side of the client's face has visible ptosis. The nurse would be alert to which finding?

Ambenonium

is used as an antimyasthenic.

Carbachol

reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma.

"I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens."

A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction?

dysfunction in the brain stem.

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates

Medicate the client with an antiemetic, as prescribed.

A short time after cataract surgery, the client has nausea. What should the nurse do first?

bradycardia widening pulse pressure

A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temperature 99°F (37°C), pulse 100 bpm, respirations 18 breaths/min, and blood pressure 130/70 mm Hg. The nurse should report which changes, if they occur, to the health care provider (HCP)? Select all that apply.

a 63-year-old with multiple sclerosis who has an oral temperature of 101.8° F (38.8° C) and flank pain

After receiving a change-of-shift report at 0700, the nurse should assess which client first?

sudden bursts of energy

Which is not a typical clinical manifestation of multiple sclerosis (MS)?

Pyridostigmine

serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic.

Edrophonium

temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity.

Risk for injury related to vertigo

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?

The client will typically experience more pain at the donor site than at the fusion site.

The nurse develops a teaching plan for a client scheduled for a spinal fusion. What should the nurse tell the client?

Explain how to overcome a freezing gait by telling the client to march in place.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?

baclofen

The nurse is admitting a client diagnosed with multiple sclerosis (MS). Which medication would the nurse expect to find on the client's record?

Eat a low-purine diet. Limit alcohol intake.

The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply.

the nurse will have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean them from sedation therapy. A nurse needs further assessment data to determine whether

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."

A client preparing to undergo a lumbar puncture states they don't think they will be able to get comfortable with their knees drawn up to the abdomen and the chin touching their chest. The client asks if they can lie on their left side. Which statement is the best response by the nurse?

Monitor the temperature of the bathwater.

The nurse is caring for a client with an injury to the thalamus. What information should the nurse include in the care plan?

Refer to primary healthcare provider Assess sleep routine/hours Have client keep a sleep diary

A client who has apnea during sleep would require which of the following interventions? Select all that apply.

The client uses a mirror to inspect the skin.

A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

increased intraocular pressure (IOP).

A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a corticosteroid ointment, one-half inch in the lower conjunctival sac four times a day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent

regular exercise

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial?

lung auscultation and measurement of vital capacity and tidal volume

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.

A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first?

Notify the physician of the fingerstick glucose level, inquire about insulin therapy, and ask whether the dexamethasone should be administered.

A nurse is administering dexamethasone 4 mg I.V. to a client diagnosed with a brain tumor. The nursing assistant informs the nurse that the client's fingerstick glucose level is 240 mg/dl (13.32 mmol/L). A sliding insulin scale hasn't been ordered. How should the nurse intervene?

Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. The client's level of consciousness is decreased, and they require nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?

Edrophonium.

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?

impaired swallowing

A client continues to improve after a left hemisphere cerebrovascular accident (CVA). The interprofessional team is planning a transfer to a rehabilitation unit for follow-up care. Which nursing diagnosis is the priority?

generalized

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

is a medical emergency that can rapidly lead to blindness.

A client has been diagnosed with an acute episode of angle-closure glaucoma. The client asks the nurse what will be done. What should the nurse tell the client about this health problem? Acute angle-closure glaucoma:

Ensure that oxygen is flowing at 5 liters per minute by nasal cannula. Check the client's pulse oximetry reading every 1 hour.

A client is stabilized in the emergency department and moved to the neurologic intensive care unit with a diagnosis of spinal cord injury at level C4-C5. The nurse is working with an experienced unlicensed assistive personnel (UAP). Which items can the nurse delegate to the UAP? Select all that apply.

increased intracranial pressure

The nurse is assessing a client with a head injury. On admission, the pupils were equal; now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What would this change in neurologic status suggest to the nurse?

Increase the frequency of client observation.

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?

Pupils are equal with sluggish reaction to light.

The nurse is completing a neurologic assessment on a client admitted with a contusion to the brain. Which finding does the nurse prioritize as requiring immediate action?

a stiff, masklike facial expression.

When assessing the client with Parkinson's disease, the nurse should observe the client for:

Notify the health care provider (HCP) if vision changes occur.

Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin?

preparing for mechanical ventilation

Which nursing action addresses the primary concern for a client with Guillain-Barré syndrome?

disorientation, increasing blood pressure, bradycardia, and bradypnea

Which nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma?

slow, irregular respirations

Which respiratory pattern indicates increasing intracranial pressure in the brain stem?

increased gradually; the client can resume usual activities in 5 to 6 weeks.

Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?