neuro quiz 1

a nurse is reinforcing teaching w/ a group of clients about TIAs which of the following info should the nurse include in the teaching

a TIA can precede an ischemic stroke

a pt is admitted to the hospital with a dx of TIA. the pt asks the nurse to explain to him what a tia is. which statement by the nurse is expected

a TIA is often a precursor to a stroke

a nurse in an urgent care center is collecting data from a group of clients who all have an odor of alcohol on their breath & multiple injuries to the head & extremities which of the following clients should the nurse report first to the charge nurse

a client who is difficult to arouse & is unable to respond to questions

a nurse is reinforcing teaching w/ a client who has a new dx for MS. the client asks the nurse about the usual course of MS. which of the following responses should the nurse provide?

acute episodes are usually followed by remissions which can last varying lengths of time

a nurse is caring for a client who has moderate alzheimers disease. which of the following actions should the nurse take

add gestures when speaking w/ the client

a nurse is assisting w/ preparing a client for an EEG. when the client asks the nurse what this test does which pf the following responses should the nurse make

an EEG records the electrical activity of your brain cells

a nurse is reinforcing teaching about auras w/ a client who has a new dx of simple partial seizures. which of the following statements by the client indicates an understanding of the teaching

an aura is a sensory warning that a seizure is imminent

a nurse is caring for a client who has received sedation when the nurse applies nailbed pressure, the client withdraws his hand. the nurse should document this response as indicating which of the following

arousal

a nurse is reinforcing teaching w/ a client who has a new dx of menieres disease. which of the follwowing instructions should the nurse include in the teaching

avoid sudden movements

a nurse is assisting w/ triaging clients during a mass casualty event which of the following labels should the nurse assign to a client who has a head injury w/ fixed dilated pupils

black tag

a nurse is reinforcing d/c teaching w/ a client who had a TIA the nurse should instruct the client to monitor which of the following parameters at home

blood pressure

a 76 yo who has parkisnons for the past 6 years has now been admitted to a long term SNF the nurse doing the admission interview and assessment notices which charteristics sign of disease SATA

bradyskineasa tremors rigidity

a nurse asks a client to stand w/ her feet together and her eyes open. after a few seconds the nurse asks the client to close her eyes if the client begins to fall the nurse should interpret this finding as a positive romberg test indicating which of the following alterations

cerebellar dysfunction

a nurse responds to a call from an assistive personnel that a client has had a seizure and is unconscious which of the following data should the nurse collect first

check airway patency

a nurse is collecting data from a client who is unconscious and & has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations alternating w/ periods of apnea. theis client is experiencing which of the following types of respirations

cheyne strokes

a nurse in an urgent care clinic is collecting data from a client who sustained a fall. which of the following findings should the nurse identify as an indication of a skull fx

clear fluid coming from the nares

a nurse is caring for a client who has menieres disease. the nurse should identify that menieres disease affects which structure of the ear

cochlea

a nurse is reinforcing teaching w/ a client who has a new dx of migraine headaches about interventions to reduce pain at the onset of a migraine. which of the following instructions should the nurese include in the teaching

darken the lights

a nurse is collecting data from an older adult client for physiological changes that can occur w/ aging. which of the following findings should the nurse expect

decreased sense of taste

a pt was involved in a snowmobile accident on admission he recieved 02 and intubation his glasgow come score is 6 about 10 min after arrival he is noted to have widened pulse pressure increased BP and bradycardia which finding indicates to the nurse that late stage ICP is present

deepening respirations cushings syndrome

a nurse is preparing a client who has a brain tumor for CT which of the following factors affect the manner in which the nurse will prepare the client for the scan

developed hives when eating shrimp

a nurse in a rehab center is collecting data from a client who is recovering from a left hemisphere stroke. which of the following findings should the nurse expect

difficulty w/ speech

a nurse is caring for a client who experienced a traumatic brain injury. which of the following findings is an indication the client is experiencing increased intracranial pressure

dilated pupils

a nurse is collecting data froma. client who has a head injury w/ a possible skull fx. which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve

dizziness and hearing loss

a nurse is reinforcing teaching w/ a client who has a new dx of primary open angle glaucoma. which of the following pieces of info should the nurse include in the teaching (SATA)

driving can be dangerous due to the loss of peripheral vision laser surgery can help reestablish the flow of aqueous humor

a nurse is collecting data from a client who has a brain tumor. which of the following findings indicates cranial nerve involvement

dysphagia

a nurse is reinforcing teaching about degenerative complications w/ the partner of a client who has a new dx of parkinons disesae. which of the following manifestions is priority

dysphagia

a nurse is assisting w/ the care of a client during the first 72 hrs following a CVA. which of the following actions should the nurse take

elevate the head of the bed by 25 to 30 w/ the client in a neurtral midline position

a nurse is reviewing the lab results of a lumbar puncture for a client who has manifestations of bacterial meningitis. which of the following findings is consistent w/ this dx

elevated protein

a nurse is caring for a client w/ a hx of repeated middle ear infections. the client says "my dr told me these infections are due to an obstruction of the structure that connects the middle ear to the throat" the nurse should identify that the provider is referring to which of the following structures

eustachian tube

a nurse is caring for a client who had a CVA the client appears alert & engaged during the visit but does not respond verbally to questions. the nurse should document this finding as which of the following alterations

expressive aphasia

a nurse is caring for a client who has a hearing impairment which of the following actions should the nurse take when communicating w/ the client

face the client when speaking

a nurse is reinforcing teaching w/ a class of new parents about otitis media. which of the following manifestions should the nurse include in the teaching

feeling of fullness in the ear

a nurse is caring for a client who had a stroke & has expressive aphasia the nurse should identify that the stroke affected which of the following lobes of the clients brain

frontal

a nurse is preparing to test the function of cranial nerve x for a client. which of the following assessment should the nurse use

have the client open his mouth and say "aah"

a nurse is assisting w/ the care of a client who has a cerebral lesion and develops hyperthermia. the nurse should identify that which of the brain is affected

hypothalamus

a nurse is reinforcing teaching w/ a client who is postoperative following cataract surgery & has an intraocular lens implant. which of the following staements by the client indicates an understanding

i will avoid bending over

when teaching a pt about parkinsons which response would indicate the need for further teaching

if i miss an occasional dose of the medication it doesnt matter much

a nurse names 3 objects for the client to remember asks the client to repeat them & tells the client he will have to repeat them again in a few min. after 5 min the nurse asks the client to name the objects. the nurse is using this strategy to test which type of memory

immediate

a nurse is assisting w/ caring for a client who has experienced a head injury from a fall at work. after checking the clients airway breathing and cirrculation (ABC) which of the following actions is the priority for the nurse to perfom

immobilize the clients cervical spine

a nurse is collecting data from a client who recently experienced a head injury. which of the following findings should the nurse identify as an indication of short term memory impairment

inability to locate eyeglasses

a nurse is collecting data from a. client who has increased intracranial pressure and has received intravenous mannitol. the nurse should identify that which of the following findings indicates a therapeutic effect of this medication

increased UA output

which S&S or late stage increased should the LVN be aware of SATA

increased systolic BP widening of the pulse pressure bradycardia

a nurse is reinforcing teaching w/ an adolescent client who has recurrent external otitis. which of the following instructions should the nurse include in the teaching

instill a diluted alcohol solution into the ear after swimming

a nurse is reinforcing teaching w/ a client who is preoperative for cataract surgery. the nurse should include in the teaching that which of the following is an adverse effect of cataract surgery

intraocular hemorrhage

a 12 y/o has a hx of tonic clonic seizures the nurse educates the pt and his family by including which teaching pts

it is uncommon to lose consciousness during this type of seizure

the nursing care plan for a pt w/ ICP will include what as the most therapeutic position for the pt

keep the head of the bed flat

a 13 yo student is admitted to the peiatric unit w/ possible meningitis. the nurse finds that the pt cannot extend her legs completely w/o experiencing extreme pain. the nurse corretly documents this as which sign

kernigs sign

a right handed pt has right sided hemiplegia and aphasia from a stroke what is the location of the lesion

left frontal lobe

a nurse is collecting data from a client who is admitted to the facility for observation following a closed head injury. which of the following data is the priority for the nurse to collect to detect a chnage in the clients neurological status

level of consciousness

a nurse is reinforcing teaching w/ the family of a client who has stage II alzheimers disease. which of the following pieces if info should the nurse include in the teaching

limit choices offered to the client

a nurse is assisting w/ the plan of care for client following a stroke which of the following interventions should the nurse identify as the priority in the plan of care

monitor the client for increased intracranial pressure

a nurse is collecting data from a client who has cataracts. which of the following findings should the nurse expect

opacity visible behind the pupil

a nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. which of the following supplies should the nurse place at the clients bedside

oral nasal suction equipment

during assessment of a pt w/ severe head injury to the ER what is the highest priority assessment for the nurse

patency of airway

a nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. after checking the clients vital signs which of the following actions should the nurse take next

place the clients in a high fowlers position

when caring for a pt who has gone a craniotomy what is the primary nursing intrevention

preventing ICP

a nurse is reinforcing d/c teaching w/ the family of a client who has a new dx of a seizure disorder. the nurse should instruct the clients family to take which of the following actions first if a seizure occurs

protect the clients head

a nurse is caring for a client who has an impairment of cranial nerve II. the nurse should do which of the following to ensure the clients safety

provide an obstacle free path for ambulation

a nurse is reviewing the medical hx of a client who has presbyopia. w/ shich of the following activities should the nurse expect the client to have difficulty

reading the newspaper

during a neurological eval a nurse asks how the client arrived at the appt & w/ whom. which of the following types of memory is the nurse testing

recall

a nurse is caring for a client who has dementia and is experiencing anxiety which of the following actions should the nurse take

redirect the client to a different activity w/ a small group of people

a nurse is reinforcing d/c teaching w/ a client who had a TIA which of the following instructions should the nurse include

reduce dietary sodium

during a neurological eval a nurse asks a client to name all of his children and state their ages & their birth dates. which of the following types of memory is the nurse testing

remote

a nurse is collecting data from a client who has a high thoracic spinal cord injury the nurse should identify which of the following findings as a manifestation of autonomic dysreflexia

report headache

a nurse is assisting w/ the care of a client who has a brainstem injury which of the following physiological functions should the nurse monitor

respiratory effort

a home health nurse is interviewing the adult child of a client who has alzheimers disease. the child is the clients stole caregiver and reports feeling fatigued and overwhelmed which of the following referrals should the nurse make for the caregiver

respite care

a nurse is collecting data from a client who has an acute visual disturbance. decribing a curtain pulled over his visual field of light. the nurse should notify the provider that this client might have which of the following disorders

retinal detachment

a nurse is collecting data from a client who reports vision loss that began w/ a "flash" of light followed by a "curtain" across the field of vision. the nurse should identify that these manifestations indicate which of the following eye disorders

retinal detachment

a nurse is caring for a client who has a left intracranial hemorrhage from a stroke. which of the following findings should the nurse expect

right sided hemiplegia

a nurse is caring for a client who has a losed traumatic brain injury and is experiencing increased intracranial pressure. the nurse should indentify that this elevated ICP is due to which of the following

rigid skull containing cranial contents

a nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. which of the following items in the clients medical record should the nurse identify as a risk factor for tinnitus

sclerosis of the ossicles

a nurse is caring for a client who has a closed head injury the nurse should place the client in which of the followig positions

semi fowlers

a nurse is reinforcing teaching for a client who has a new dx of myasthenia gravis which of the following pieces of information should the nurse provide

set an alarm to ensure medication dosages are taken on time

a nurse is collecting data from a client who has a new dx of acute angle closure glaucoma. the nurse should anticipate the client to report which of the following manifestations

severe eye pain

a nurse is reinforcing teaching w/ a client who is going to have an EGG in the morning. which of the following info should the nurse provide the client

shampoo your hair before the procedure and dont use styling products afterward

the nurse is caring for a pt w/ spinal cord injury who displays symptoms of autonomic dysreflexia what interventions should the nurse implement first

sit the pt upright if permitted

a nurse is collecting data from a client w/ recent head trauma who has a UA output of 600 ml/hr. the nurse suspects the client has manifestations of diabetes insipidus which of the following lab values should the nurse plan to obtain to monitor DI

specific gravity

a nurse is collecting data from a client who has encephalitis due to west nile virus. which of the following findings should the nurse expect (SATA)

stiff neck photophobia lethargy

a nurse is collecting data from a client who has a new dx of mastoiditis which of the following manifestations should the nurse expect

swelling behind the affected ear

the nurse is a caring for a pt who suffered a cervical spine injury what injury can most likely be anticipated

tetraplegia

a nursse is reviewing the medical hx of a client who is scheduled for a MRI exam of the vertebra. which of the following items in the clients hx is a contraindication to the procedure

the client has a pacemaker

a nurse is caring for a client who has receptive aphasia which of the following communication problems should the nurse expect to find when collecting data from this client

the client is unable to understand words or sentences he hears

a nurse is caring for a client who has a TBI & assumes a decerebrate posture in response to noxious stimuli. which of the following reactions should the nurse anticipate when drawing a blood sample

the client rigidly extends his arms

a nurse is collecting data from a client who has a closed head injury and is receiving mannitol for manifestations of increased intracranial pressure which of the following findings indicates the medication is having a therapeutic effect

the clients UA output is 250 ml/hr

a nurse is collecting data from a client who is recovering from a recent stroke. which of the following data is the nurses priority to collect

the clients ability to clear oral secretions

a pt is dx w/ bells palsy as indicated by a feeling of stifffness and drawing sensation of the face. what is important to teach her about the disease

the eye is susceptile to injury if the eyelid does not close

a pt experiencing TIA is scheduled for a carotid endarterectomy the pt asks the nurse what this procedure is the nurse correctly responds w/

this procedure helps prevent a stroke by removing stheroscloric plaques obstructing cerebral blood flow

a nurse is reinforcing teaching w/ a client who has a hx of tonic-clonic seizures & is scheduled for a standard EEG which of the following instructions should the nurse include in the teaching

throughly shampoo the hair prior to the EEG

a nurse is reinforcing teaching w/ a client about treatment options for a profound sensorineural hearing loss. the nurse should include which of the following peices of info about the function of cochlear implants

transmits impulses directly to auditory nerve endings

the nursing assessment of an 80 y/o who has had a stroke found that she had difficulty swallowing. A videofluorsopy with barium was performed to rule out aspiration. the rehab team in the SNF determined that she can eat a soft diet with supervision. which action is important to prevent aspiration

tripping the head toward the unaffected side while swallowing

a nurse is caring for a client who begins to have a generalized tonic clonic seizure while lying in bed. which of the following actions should the nurse take?

turn the client onto the side

a nurse is caring for a client who is experiencing a seizure while in bed. which of the following actions should the nurse take

turn the clients head to the side

a nurse is collecting data from a client who has guillain barre syndrome. which of the following findings should the nurse expect

weakness of lower extremities

a nurse is reinforcing teaching w/ the family of a client who has a new dx of amyotrophic lateral sclerosis. which of the following findings is an early maniestions of ALS

weakness of the distal extremities

a nurse is collecting data from a client following a recent head injury. which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure

widened pulse pressure

a nurse is reinforcing d/c teaching w/ a client who is postop following scleral buckling to repair a detached retina. which of the following instructions should the nurse include in the teaching

you should expect to see flashing in front of the affected eye after the procedure

a nurse is assisting w/ preparing a client for an EEG which of the following directions should the nurse provide to the client

youll begin by lying still w/ your eyes closed

a nurse is reinforcing teaching w/ a client about CT scans of the brain which of the following pieces of info should the nurse include

youll have to lie very still on a long narrow table during the test

a nurse is reinforcing teaching w/ a client who is scheduled for laser assisted in situ keratomileusis surgery. which of the following pieces of info should the nurse include

your procedure will only take 10 or 15 min for each eye