Neuro Saunders Nclex questions

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate?

Contact the health care provider (HCP). Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP, because this finding requires immediate intervention.

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The client asks for a snack and something to drink. The nurse should offer which best snack to the client?

Vanilla wafers and room-temperature water Because mild tactile stimulation of the face can trigger pain in trigeminal neuralgia, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal nerve pain.

A client has suffered a head injury affecting the occipital lobe of the brain. The nurse anticipates that the client may experience difficulty with which sense?

Vision The occipital lobe is responsible for reception of vision and contains visual association areas. This area of the brain helps the individual to visually recognize and understand the surroundings. The other senses listed are not a function of the occipital lobe.

A client has a cerebellar lesion. The nurse would plan to obtain which item for use by this client?

Walker The cerebellum is responsible for balance and coordination. A walker provides stability for the client during ambulation. A raised toilet seat is useful if the client has sufficient mobility or ability to flex the hips. A slider board is used in transferring a client with weak or paralyzed legs from a bed to stretcher or wheelchair. Adaptive eating utensils are beneficial if the client has partial paralysis of the hand.

A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item?

Walker The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. Adaptive eating utensils may be beneficial if the client has partial paralysis of the hand. A raised toilet seat is useful if the client does not have the mobility or ability to flex the hips. A slider board is used in transferring a client from a bed to a stretcher or wheelchair.

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further instruction?

"I can change the time of my medication on the mornings when I feel strong." The client with myasthenia gravis and his or her family should be taught information about the disease and its treatment. They should be aware of the side and adverse effects of anticholinesterase medications and corticosteroids and should be taught that timing of anticholinesterase medication is critical. It is important to instruct the client to administer the medication on time to maintain a chemical balance at the neuromuscular junction. If it is not given on time, the client may become too weak to even swallow. Resting after a walk, coughing and deep breathing many times over the day, and calling the health care provider when experiencing abdominal cramps and diarrhea indicate correct understanding of home care instructions to maintain health with this neurological degenerative disease.

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client?

Encouraging multiple visitors at one time Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in amount and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion can be minimized by reducing environmental stimuli (such as television or multiple visitors) and by keeping familiar personal articles (such as family pictures) at the bedside.

A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care?

Interruption in physical mobility Multiple sclerosis is a chronic, nonprogressive, noncontagious degenerative disease of the central nervous system characterized by demyelinization of the neurons. Interruption in physical mobility is most appropriate for the client with multiple sclerosis experiencing muscle weakness, spasticity, and ataxic gait.

The nurse is assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client's peripheral response to pain?

Nail bed pressure Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

The nurse caring for a client with a head injury is monitoring for signs of increased intracranial pressure. The nurse reviews the record and notes that the intracranial pressure (cerebrospinal fluid) is averaging 8 mm Hg. The nurse plans care, knowing that these results are indicative of which condition?

Normal condition The normal intracranial pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal range.

A client with a history of myasthenic gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenia crisis is suspected. The nurse assesses the client for which precipitating factor?

Omitting doses of medication Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and excessive fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.

The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin (Ditropan XL). The nurse evaluates the effectiveness of the medication by asking the client which assessment question?

"Are you getting up at night to urinate?" Oxybutynin is an antispasmodic used to relieve symptoms of urinary urgency, frequency, nocturia, and incontinence in clients with uninhibited or reflex neurogenic bladder. Expected effects include improved urinary control and decreased urinary frequency, incontinence, and nocturia.

A client is somewhat nervous about undergoing magnetic resonance imaging (MRI). Which statement by the nurse would provide the most reassurance to the client about the procedure?

"Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure." The MRI scanner is a hollow tube that gives some clients a feeling of claustrophobia. Metal objects must be removed before the procedure so that they are not drawn into the magnetic field. The client may eat and may take all prescribed medications before the procedure. If a contrast medium is used, the client may wish to eat lightly if he or she has a tendency to become nauseated easily. The client lies supine on a padded table that moves into the imager. The client must lie still during the procedure. The imager makes tapping noises during the scanning. The client is alone in the imager, but the nurse can reassure the client that the technologist will be in voice communication with the client at all times during the procedure.

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for more information if the client makes which statement?

"Going to the beach will be a nice, relaxing form of activity." Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client must be aware of the lifestyle changes needed to maintain independence. The client should carry medical identification about the presence of the condition. Taking medications an hour before mealtime gives greater muscle strength for chewing and is indicated. The client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. The client should avoid situations and other factors, including stress, infection, heat, surgery, and alcohol, that could worsen the symptoms.

The nurse is performing an assessment on a client suspected of having trigeminal neuralgia (tic douloureux). Which assessment question would elicit data specific to this disorder?

"Have you had any sharp pain or any twitching in any part of your face?" Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last from seconds to minutes. The pain often is described as either stabbing or similar to an electric shock. It is accompanied by spasms of the facial muscles that cause twitching of parts of the face or mouth, or closure of the eye.

The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks?

"I need to be sure to consume foods that are low in sodium." Dietary changes, such as salt and fluid restrictions, that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed. Although helpful to treat other disorders, low-fat, low-carbohydrate, and low-cholesterol diets are not specifically prescribed for the client with Ménière's disease.

The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional teaching if the client makes which statements?

"I will expose my face to cold to decrease the pain." Exposure to cold or drafts is avoided in Bell's palsy because it can cause discomfort. Prevention of muscle atrophy with Bell's palsy is accomplished with facial massage, facial exercises, and electrical nerves stimulation. Local application of heat to the face may improve blood flow and provide comfort.

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further education if the client makes which statement?

"I'll try to eat my food either very warm or very cold." Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If toothbrushing triggers pain, an oral rinse after meals may be helpful instead.

The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse should plan to ask the client which question to elicit the most specific information regarding this disorder?

"Is the pain experienced a stabbing type of pain?" Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last for seconds to minutes. The pain often is characterized as stabbing or as similar to an electric shock. It is accompanied by spasms of facial muscles that cause twitching of parts of the face or mouth, or closure of the eye.

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home?

"Was the client awake and talking right after the injury?" Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies. It is important for the nurse to assist in the differentiation between epidural hematoma and other types of head injuries.

A nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding?

22 mm Hg Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion.

The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client?

400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon Spacing fluid intake over the day helps the client with a neurogenic bladder to establish regular times for successful voiding. Omitting intake after the evening meal minimizes incontinence or the need to empty the bladder during the night.

The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is a priority nursing intervention?

Assist the client to eat with the left hand to build strength. Right-sided hemiparesis is weakness of the right arm and leg. The nurse should teach the client to use both sides of the body to increase strength and build endurance.

The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit the most specific information regarding this client's disorder?

"Are you having any difficulty chewing food?" Bell's palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulties.

The nurse is performing an assessment on a client with a diagnosis of thrombotic brain attack (stroke). Which assessment question would elicit data specific to this type of stroke?

"Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?" Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on one side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.

The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Dilantin). Which statement, if made by the client, would indicate an understanding of the information about this medication?

"I need to perform good oral hygiene, including flossing and brushing my teeth." The client should perform good oral hygiene, including flossing and brushing the teeth. The client also should see a dentist at regularly scheduled times because gingival hyperplasia is a side effect of this medication. The client should avoid alcohol while taking this medication. The client should also be instructed that follow-up serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn. The client should not adjust medication dosages.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?

"We need to remind him to turn his head to scan the lost visual field." Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

An adult client has a diagnosis of hydrocephalus. The nurse plans care, knowing that this condition leads to more serious neurological consequences in adults as a result of closure of which structures?

Cranial sutures The closure of cranial sutures during childhood prevents expansion of the cranial vault when hydrocephalus occurs in the adult. This leads to increased neurological changes with lesser degrees of hydrocephalus compared with hydrocephalus during early childhood. The other structures identified are associated with cerebrospinal fluid formation and circulation, but these do not close off.

Acetazolamide (Diamox) is prescribed for a client hospitalized with a diagnosis of a supratentorial lesion. The nurse understands that which is the primary action of the medication?

Decrease in cerebrospinal fluid production Acetazolamide (Diamox) is a carbonic anhydrase inhibitor. It is used in the client with or at risk for increased intracranial pressure to decrease cerebrospinal fluid production.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery?

A positive Brudzinski sign Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski sign, and positive Kernig sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest.

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's-eyes maneuver) if which condition is present in the client?

A cervical cord injury In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item?

A hearing aid The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker.

The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional?

A neuropsychologist Clients with cognitive deficits after head injury may benefit from referral to a neuropsychologist, who specializes in evaluating and treating cognitive problems. The neuropsychologist plans an individual program of therapy and initiates counseling to help the client reach maximal potential. The neuropsychologist works in collaboration with other disciplines that are involved in the client's care and rehabilitation.

The nurse is performing the oculocephalic response (doll's-eyes maneuver) test on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as for the head. How should the nurse document these findings?

Abnormal In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem.

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action?

Acknowledge the client's anger and continue to encourage participation in care. Adjusting to paralysis is physically and psychosocially difficult for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence. The family also is in crisis and needs the nurse's support and should not be relied on to provide care. The nurse cannot simply neglect the client until the client is ready to participate. Option 3 represents a factual but noncaring approach to the client and is not therapeutic.

The nurse is evaluating the respiratory outcomes for a client with Guillain-Barré syndrome. The nurse determines that which is the least optimal outcome for the client?

Adventitious breath sounds Satisfactory respiratory outcomes for a client with Guillain-Barré syndrome include clear breath sounds on auscultation, spontaneous breathing, normal vital capacity, normal arterial blood gas levels, and normal pulse oximetry. Adventitious breath sounds are an abnormal finding.

A client has a neurological deficit involving the limbic system. Which assessment finding is specific to this type of deficit?

Affect is flat, with periods of emotional lability The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

A nurse is evaluating the neurological status of a client. To assess the function of the limbic system, the nurse should gather data about which item?

Affect or emotions Affect and emotions are part of the role of the limbic system and involve both hemispheres of the brain. Pain is a complex experience involving several areas of the central nervous system. The response to verbal stimuli is part of the level of consciousness, which is under the control of the reticular activating system and both cerebral hemispheres. Insight, judgment, and planning are part of the functions of the frontal lobes of the brain in conjunction with association fibers connecting to other areas of the cerebrum.

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which complication?

Altered breathing pattern Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client. This is a risk for clients with spinal cord injury in the lower cervical area. Ineffective oxygen consumption occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane. Increased susceptibility to aspiration and increased likelihood of injury are unrelated to the focus of the question.

An 84-year-old client in an acute state of disorientation is brought to the hospital emergency department by his or her daughter. The daughter states that the client was "clear as a bell this morning." The nurse determines from this piece of information that which is an unlikely cause of the disorientation?

Alzheimer's disease Alzheimer's disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Evaluation is necessary to determine whether hypoglycemia, medication use, or impaired cerebral circulation has had a role in causing the client's current symptoms.

A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse should keep which items available at the client's bedside?

Ambu bag and suction equipment The client with myasthenia gravis may experience episodes of respiratory distress if excessively fatigued or with development of myasthenic or cholinergic crisis. For this reason, an Ambu bag, intubation tray, and suction equipment should be available at the bedside.

The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation?

An intact brainstem Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected into the auditory canal. A normal response that indicates intact function of cranial nerves III, VI, and VIII is conjugate eye movements toward the side being irrigated, followed by eye movement back to midline. Absent or dysconjugate eye movements indicate brainstem damage.

The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because the client's speech will be characteristic of which finding?

Associated with poor comprehension Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words spoken by another, and speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke's aphasia may exhibit a rambling type of speech.

The nurse is assessing a client's gait, which is characterized by unsteadiness and staggering steps. The nurse determines the presence of which type of gait?

Ataxic An ataxic gait is characterized by unsteadiness and staggering. A spastic gait is characterized by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and drag. A festinating gait is best described as walking on the toes with an accelerating pace. A dystrophic or broad-based gait is seen as waddling, with the weight shifting from side to side and the legs far apart.

A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis?

Atropine sulfate Clients with cholinergic crisis have experienced overdosage of medication. Edrophonium will exacerbate symptoms in cholinergic crisis to the point at which the client may need intubation and mechanical ventilation. Intravenous atropine sulfate is used to reverse the effects of these anticholinesterase medications. Morphine sulfate and pyridostigmine bromide would worsen the symptoms of cholinergic crisis. Protamine sulfate is the antidote for heparin.

The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do?

Avoid activities that may cause pressure near the face. The pain that accompanies trigeminal neuralgia is triggered by stimulation of the trigeminal nerve. Symptoms can be triggered by pressure such as from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by stimulation by a draft or cold air.

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. The nurse should expect to note documentation of which early symptom of this disease?

Balance and coordination problems Early symptoms of Huntington's disease include restlessness, forgetfulness, clumsiness, falls, balance and coordination problems, altered speech, and altered handwriting. Difficulty with swallowing occurs in the later stages. Aphasia and agnosia do not occur.

The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item?

Blood pressure Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. Options 2, 3, and 4 are unrelated to monitoring for Cushing's reflex.

A client who has had a brain attack (stroke) is being managed on the medical nursing unit. At 0800, the client was awake and alert with vital signs of temperature 98° F orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99° F orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action?

Call the health care provider (HCP). The important nursing action is to call the HCP. The deterioration in neurological status, decreasing pulse, and increasing blood pressure with a widening pulse pressure all indicate that the client is experiencing increased intracranial pressure, which requires immediate treatment to prevent further complications and possible death. The nurse should retake the vital signs and reorient the client to surroundings. If the client's blood pressure falls within parameters for PRN antihypertensive medication, the medication also should be administered.

The nurse is assessing a client with a neurological deficit involving the hippocampus. Which finding is indicative of this deficit?

Cannot recall what was eaten for breakfast today Recall of recent events and the storage of memories are controlled by the hippocampus, which is a limbic system structure. The cerebral hemispheres, with specific regional functions, control orientation. The limbic system, overall, is responsible for feelings, affect, and emotions. Calculation ability and knowledge of current events are under the control of the frontal lobes of the cerebrum.

The home health nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals related to decreased muscle strength. Which suggestions should the nurse give to the client? Select all that apply.

Chew food thoroughly. Cut food into very small pieces. Sit straight up in the chair while eating. Swallow when the chin is tipped slightly downward to the chest. The client avoids swallowing any type of food or drink with the head lifted upward, which could actually cause aspiration by opening the glottis. The client should be advised to sit upright while eating, not to talk with food in the mouth (talking requires opening the glottis), cut food into very small pieces, chew thoroughly, and tip the chin downward to swallow.

A nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed?

Chlorpromazine (Thorazine) Chlorpromazine is used to control shivering in hyperthermic states. It is a phenothiazine and has antiemetic and antipsychotic uses, especially when psychosis is accompanied by increased psychomotor activity. Buspirone is an anxiolytic. Prochlorperazine is a phenothiazine that is an antiemetic and antipsychotic. Fluphenazine is a phenothiazine that is used as an antipsychotic.

The nurse reviews the health care provider's (HCP) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the HCP should the nurse question?

Clear liquid diet Clients with Guillain-Barré syndrome have dysphagia. Clients with dysphagia are more likely to aspirate clear liquids than thick or semisolid foods. Passive ROM exercises can help prevent contractures, and assessing calf measurements can help detect deep vein thrombosis, for which these clients are at risk. Because clients with Guillain-Barré syndrome are at risk for hypotension or hypertension, bradycardia, and respiratory depression, frequent monitoring of vital signs is required.

A nurse is assessing a client's muscle strength and notes that when asked, the client cannot maintain his or her hands in a supinated position with the arms extended and eyes closed. How should the nurse correctly document this finding on the medical record?

Client is exhibiting pronator drift. Pronator drift occurs when a client cannot maintain his or her hands in a supinated position with the arms extended and eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Hyperreflexia is an excessive reflex action. Nystagmus is characterized by fine, involuntary eye movements. It can occur with neurological disease or as a side effect of selected medications.

The nurse is trying to communicate with a client with brain attack and aphasia. Which action by the nurse would be least helpful to the client?

Completing the sentences that the client cannot finish Clients with aphasia after brain attack often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all the responses for the client.

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP?

Confusion Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern; pupillary sluggishness and dilatation appear in the late stages.

A client who suffered a stroke is prepared for discharge from the hospital. The health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What nursing action should the nurse include in the client's plan of care?

Consider the use of active, passive, or active-assisted exercises in the home. The home care nurse must consider all forms of ROM for the client. Even a client with hemiplegia can participate in some components of rehabilitative care. In addition, the goal in home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach home care measures so that the client becomes self-reliant.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?

Consistently uses adaptive equipment in dressing self Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.

The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse reviews the health care provider's documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome?

Development of progressive muscle weakness A hallmark clinical manifestation of Guillain-Barré syndrome is progressive muscle weakness that develops rapidly. Seizures are not normally associated with this disorder. The client does not have symptoms such as a fever or headache. Cerebral function, level of consciousness, and pupillary responses are normal.

A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom?

Difficulty closing the eyelid on the affected side The facial drooping associated with Bell's palsy makes it difficult for the client to close the eyelid on the affected side. A widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bell's palsy. Paroxysms of excruciating pain are characteristic of trigeminal neuralgia.

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention should the nurse plan to implement?

Draw blood for arterial blood gas analysis. Assessment should be specific to the area of the brain involved. The respiratory center is located in the brainstem. Assessing the respiratory status is the priority for a client with a brainstem injury.

The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs more information if he or she states an intention to take which action?

Drink alcohol in small amounts and only on weekends. The client should avoid the intake of alcohol. Alcohol could interact with the client's seizure medications, or the alcohol could precipitate seizure activity. The client should take all medications on time to avoid decreases in therapeutic drug levels, which could precipitate seizures. The client should not bathe in the shower or tub without someone nearby and should not smoke alone, to minimize the risk of injury if a seizure occurs.

The nurse has completed discharge instructions for a client with application of a halo device. Which action indicates that the client needs further clarification of the instructions?

Drives only during the daytime The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room?

Electrocardiographic monitoring electrodes and intubation tray The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take?

Elevate the head of the bed. Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position.

A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family hoped. The nurse plans to implement which approach as most helpful to the client and family at this time?

Emphasize progress in a realistic manner. The most helpful approach by the nurse is to emphasize progress that is being made in a realistic manner. The nurse does not offer false hope but does provide factual information in a clear and positive manner. The nurse encourages the family to be realistic in their expectations and attitudes. The plan of care should be individualized for each client.

A client is newly admitted to the hospital with a diagnosis of brain attack (stroke) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be most concerned?

Emphysema The nurse should be most concerned about emphysema. The respiratory system is the priority in the acute phase of a brain attack (stroke). The stroke client is vulnerable to respiratory complications such as atelectasis and pneumonia. Because the client has complete hemiplegia (is unable to move) and has emphysema, these risks are very significant.

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration?

Establishing a toileting schedule A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. A Foley catheter should be used only when necessary because of the associated risk of infection. Use of diapers or pads is the least acceptable alternative because of the risk of skin breakdown.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

Exhaling during repositioning Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the glottis, which prevents intrathoracic pressure from rising.

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family?

Explaining equipment and procedures on an ongoing basis Families often need assistance to cope with the illness of a loved one. The nurse should explain all equipment, treatments, and procedures and should supplement or reinforce information given by the health care provider. Family members should be encouraged to touch and speak to the client and to become involved in the client's care to the extent they are comfortable. The nurse should allow the family to stay with the client to the extent possible and should encourage them to eat and sleep adequately to maintain strength. The nurse can help family members of an unconscious client by assisting them to work through their feelings of grief.

The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform?

Extend the tongue. Impairment of cranial nerve XII can occur with a stroke. To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse would assess the client's ability to extend the tongue.

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function by the nurse will yield the best information about these cranial nerves?

Eye movements Eye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.

A student nurse is assisting with an assessment of a client's level of consciousness using the Glasgow Coma Scale. The student understands that which categories of client functioning are included in this assessment?

Eye opening Best verbal response Best motor response Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma Scale. The three categories included are eye opening, best verbal response, and best motor response. Pupil assessment and reflex response is a necessary part of a total assessment of the neurological status of a client but is not part of this particular scale.

The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse should expect to observe which finding in the client?

Facial drooping Bell's palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). Assessment findings include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. Options 2, 3, and 4 are not associated findings in Bell's palsy.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?

Flaccid paralysis Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should avoid placing the client in which positions?

Flat, with head turned to the side The client who is at risk for or with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

Fluid separates into concentric rings and tests positive for glucose. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively?

Head of bed elevated 30 to 45 degrees, head and neck midline After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

The post-head injury client opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score?

GCS = 9 The GCS is a method is assessing neurological status. The highest possible score in the GCS is 15. A score lower than 8 indicates that coma is present. Motor response points are as follows: Obeys a simple response = 6; Localizes painful stimuli = 5; Normal flexion (withdrawal) = 4; Abnormal flexion (decorticate posturing) = 3; Extensor response (decerebrate posturing) = 2; No motor response to pain = 1. Verbal response points are as follows: Oriented = 5; Confused conversation = 4; Inappropriate words = 3; Responds with incomprehensible sounds = 2; No verbal response = 1. Eye opening points are as follows: Spontaneous = 4; In response to sound = 3; In response to pain = 2; No response, even to painful stimuli = 1. Using the GCS, a score of 3 is given when the client opens the eyes to sound. Localization to pain is scored as 5. When there is no verbal response the score is a 1. The total score is then equal to 9.

The nurse has taught a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that further instruction is needed if the client states the need to take which action?

Get out of bed by sitting straight up and swinging the legs over the side of the bed. The client is taught to get out of bed by sliding near the edge of the mattress. The client then rolls onto one side and pushes up from the bed using one or both arms. The client keeps the back straight and swings the legs over the side. Proper body mechanics includes bending at the knees, not the waist, to lift objects. Increasing fluid intake and dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening lower back muscles.

A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should avoid which action?

Giving the client thin liquids The client with dysphagia is started on a diet only after the gag and swallow reflexes have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions?

Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating.The head of the client at risk for or with increased intracranial pressure should be positioned so that the head is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the neck or turning the head from side to side.

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should plan to place the client in which position?

Head of the bed elevated 30 degrees with the head in midline position The health care provider's prescriptions are always followed with regard to positioning the client after stroke. Clients with hemorrhagic stroke usually have the head of the bed elevated to 30 degrees to reduce intracranial pressure that can occur from the hemorrhage. The head should be in a midline, neutral position to facilitate venous drainage from the brain. Extreme hip and neck flexion should be avoided to prevent an increase in intrathoracic pressure and to promote venous drainage from the brain. For clients with ischemic stroke, the head of the bed usually is kept flat to ensure adequate blood flow and thus oxygenation to the brain.

The nurse is positioning a client who has increased intracranial pressure. Which position should the nurse avoid?

Head turned to the side The head of a client with increased intracranial pressure should be kept in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

A client had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what should the nurse include in the client's assessment?

History of prior trauma Seizures that originate with specific motor phenomena are considered focal and are indicative of a focal structural lesion in the brain, often caused by trauma, infection, or drug consumption.

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP?

Hyperoxygenating before suctioning Maintaining the head and neck in midline position Maintaining the head of the bed (HOB) at 30 degrees elevation Measures aimed at preventing increased ICP in the post-stroke client include hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral position to help promote venous drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to prevent a decreased blood flow to the brain. Clustering activities can be stressful for the client and increase ICP. Maintaining 20 degree flexion of the knees increases intra-abdominal pressure and consequently ICP.

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. The nurse interprets that the hyperthermia may be related to damage to the client's thermoregulatory center in which structure?

Hypothalamus Hypothalamic damage causes persistent hyperthermia, which also may be called central fever. It is characterized by a persistent high fever with no diurnal variation. Another characteristic feature is absence of sweating. Hyperthermia would not result from damage to the cerebrum, cerebellum, or hippocampus.

A nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. The nurse concludes that which area of the client's brain is functioning adequately?

Hypothalamus The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for sensory and motor information. The limbic system is responsible for emotions. The reticular activating system is responsible for the sleep-wake cycle.

The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate (Cogentin) orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs?

Inability to urinate Benztropine mesylate is an anticholinergic, which causes urinary retention as a side effect. The nurse would instruct the client or spouse about the need to monitor for difficulty with urinating, a distended abdomen, infrequent voiding in small amounts, and overflow incontinence.

The nurse is developing a plan of care for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome?

Increase the client's awareness of the affected side. In anosognosia, the client exhibits neglect of the affected side of the body. The nurse will plan care activities that remind the client to perform actions that require looking at the affected arm or leg, as well as activities that will increase the client's awareness of the affected side.

The nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath sounds. Which judgment should the nurse formulate for the client?

Increased risk for aspiration Increased risk for aspiration is a condition in which an individual is at risk for entry of gastrointestinal (GI) secretions, oropharyngeal secretions, or solids or fluids into tracheobronchial passages. Conditions that place the client at risk for aspiration include reduced level of consciousness, depressed cough and gag reflexes, and feeding via a GI tube.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action?

Indicates that facial puffiness will be a permanent problem After craniotomy, clients may experience difficulty with altered personal appearance. The nurse can help by listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss (all of which are temporary). The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance.

A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation?

Ingestion of increased fruits and vegetables The onset or exacerbation of multiple sclerosis can be preceded by a number of different factors, including physical stress (e.g., vaccination, excessive exercise), emotional stress, fatigue, infection, physical injury, pregnancy, extremes in environmental temperature, and high humidity. No methods of primary prevention are known. Intake of fruits and vegetables is an unrelated item.

The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action?

Initiating a bowel movement every other day, 45 minutes after the largest meal of the day To manage constipation, the client should take in a high-fiber diet, bulk formers, and stool softeners. A fluid intake of 2000 mL/day is recommended. The client should initiate the bowel program on an every-other-day basis. This should be done approximately 45 minutes after the largest meal of the day to take advantage of the gastrocolic reflex. A glycerin suppository, bisacodyl suppository, or digital stimulation may be used to initiate the process. Laxatives and enemas should be avoided whenever possible because they lead to dependence.

The nurse is developing a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client?

Instruct the client to turn the head to scan the right visual field. Homonymous hemianopsia is a loss of half of the visual field. The nurse instructs the client to scan the environment and stands within the client's intact field of vision. The nurse should not patch the eye because the client does not have double vision. The client should have objects placed in the intact fields of vision, and the nurse should approach the client from the intact side.

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation?

Is likely to have perceptual and spatial disabilities The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities.

A nurse is preparing to administer a prescribed antibiotic to a client with bacterial meningitis. The nurse understands that the selection of an antibiotic to treat meningitis is based on which fact?

It is able to cross the blood-brain barrier. A primary consideration regarding medications to treat bacterial meningitis is the ability of the medication to cross the blood-brain barrier. If the medication cannot cross, it will not be effective. The duration, onset, and excretion of the medication(options 1, 2, and 3) are also of general concern but apply to all medications and not specifically to those that are used to treat meningitis.

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation?

It is possible the client can hear the family. Some clients who have awakened from an unconscious state have remembered hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is intact and act accordingly. Additionally, positive outcomes are associated with coma stimulation-that is, speaking to and touching the client.

A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. A nurse reviewing the client's record plans care, knowing that a high CO2 level will have which effect on circulation to the brain?

It will cause vasodilation of blood vessels in the brain. CO2 is one of the metabolic end products that can alter the tone of the blood vessels in the brain. High CO2 levels cause vasodilation, which may cause headache, whereas low CO2 levels cause vasoconstriction, which may cause lightheadedness. The statements included in the other options are incorrect effects.

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client?

Keep suction equipment at the bedside. Elevate the head of the bed 30 degrees. Keep the head and neck in good alignment. Administer prescribed respiratory treatments as needed. The nurse maintains a patent airway for the client with difficulty breathing by keeping the head and neck in good alignment and elevating the head of bed 30 degrees unless contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The client should be kept in a side-lying position whenever possible to minimize the risk of aspiration.

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What important nursing intervention is necessary for this client?

Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head. Avoiding extreme flexion and extension of the neck can enhance venous drainage and help prevent increased intracranial pressure. As a general rule, hyperventilation is avoided during the first 20 hours postoperatively because it may produce ischemia caused by cerebral vasoconstriction. Vital signs need to be taken and recorded at least every 1 to 2 hours. Central fevers caused by hypothalamic damage respond better to cooling (hypothermia blankets, sponge baths) than to the administration of antipyretic medications.

The home care nurse is making a visit to a client who is wheelchair bound after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)?

Leaving the client in an unchilled area of the room The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.

The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction?

Level of consciousness Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the client's level of consciousness is the most critical index of CNS dysfunction.

The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measure would be a potentially unsafe component of the precautions?

Limit caffeinated coffee to one cup per day. Aneurysm precautions include placing the client on bed rest (as prescribed) in a quiet setting. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be used. Lights are kept dim to minimize environmental stimulation. Any activity that increases the blood pressure or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides physical care to minimize increases in blood pressure. For the same reason, visitors, radio, television, and reading materials are prohibited or limited.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of occurrence?

Limiting bladder catheterization to once every 12 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action?

Listen to breath sounds. Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-injured clients unless head injury is suspected.

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium (Depakote). The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study?

Liver function studies Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determinations.

The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern?

Lung vital capacity of 10 mL/kg Respiratory compromise is a major concern in clients with Guillain-Barré syndrome. Clients often are intubated and mechanically ventilated when the vital capacity is less than 15 mL/kg. Options 1 and 3 are expected, depending on the degree of paralysis that occurs. Although orthostatic hypotension is a problem with these clients, the BP drop in option 4 is less than 10 mm Hg and is not significant.

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information?

Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable. Depression frequently may be seen in the client with spinal cord injury and may be exhibited as a loss of appetite. However, the client should be allowed to choose the types of food eaten and when they are eaten as much as is feasible because it is one of the few areas of control that the client has left. There is no information in the query of the question that would indicate that the client is anorexic, obsessive-compulsive, or has a slow metabolism.

The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record?

Mild clumsiness The initial symptom of ALS is a mild clumsiness, usually noted in the distal portion of one extremity. The client may complain of tripping and drag one leg when the lower extremities are involved. Mentation and intellectual function usually are normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations.

The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which sign is an early indication that the level of consciousness (LOC) is deteriorating?

Mild drowsiness Slight slurring of speech Less frequent spontaneous speech Early changes in LOC relate to orientation, alertness and verbal responsiveness. Mild drowsiness, slight slurring of speech, and less frequent spontaneous speech are early signs of decreasing LOC. Ptosis (drooping) of the eyelid is caused by pressure on and dysfunction of cranial nerve III. Once ptosis occurs, it is ongoing; it does not relate to LOC.

A client was seen and treated in the hospital emergency department for treatment of a concussion. The nurse determines that the family needs reinforcement of the discharge instructions if they verbalize to call the health care provider (HCP) for which client sign or symptom?

Minor headache A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the HCP or return the client to the emergency department for signs and symptoms such as confusion, difficulty awakening or speaking, one-sided weakness, vomiting, and severe headache. Minor headache is expected.

A thymectomy accomplished via a median sternotomy approach is performed in a client with a diagnosis of myasthenia gravis. The nurse develops a postoperative plan of care for the client that should include which intervention?

Monitor the chest tube drainage. A thymectomy may be used for management of clients with myasthenia gravis. The procedure is performed through a median sternotomy or a transcervical approach. Postoperatively the client will have a chest tube in the mediastinum. Lactated intravenous solutions usually are avoided because they can increase weakness. Pain medication is administered as needed, but the client is monitored closely for respiratory depression. There is no reason to restrict visitors.

The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the health care provider (HCP)?

Neck stiffness Headache is relatively common after the procedure, but neck stiffness, especially on flexion, and pain should be reported because they signal meningeal irritation. The client also is monitored for evidence of allergic reactions to the dye such as confusion, dizziness, tremors, and hallucinations. Feelings of fatigue may be normal, and back discomfort may be owing to the positions required for the procedure.

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate?

Notify the health care provider (HCP). Cerebrospinal fluid (CSF) leakage after cranial surgery may be detected by noting drainage that is serosanguineous surrounded by an area of straw-colored or pale drainage. The physical appearance of CSF drainage is that of a halo. If the nurse notes the presence of this type of drainage, the HCP needs to be notified.

A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action?

Observe the client demonstrating the transfer technique. Observation of the client's transfer technique is the initial intervention. Starting a restorative program is important but not unless an assessment has been completed first. Discussing nursing home placement would be inappropriate in view of the information provided in the question. Determining the number of falls is another important intervention, but observing the transfer technique should be done first.

The nurse is preparing for the admission to the unit of a client with a diagnosis of seizures and is preparing to institute full seizure precautions. Which item is contraindicated for use if a seizure occurs?

Padded tongue blade Full seizure precautions include bed rest with padded side rails in a raised position, a suction machine at the bedside, having diazepam (Valium) or lorazepam (Ativan) available, and providing an oxygen source. Objects such as tongue blades are contraindicated and should never be placed in the client's mouth during a seizure.

The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety?

Padding the side rails of the bed Placing an airway at the bedside Placing oxygen and suction equipment at the bedside Having intravenous equipment ready for insertion of an intravenous catheter Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if anticonvulsant medications must be administered.

A client is being hyperventilated by a mechanical ventilator to decrease the client's intracranial pressure (ICP). On monitoring arterial blood gas results, the nurse should expect values that are within which ranges?

Pao2 80 to 100 mm Hg, Paco2 25 to 30 mm Hg Hyperventilation with a Paco2 of 25 to 30 mm Hg causes cerebral vasoconstriction, which decreases intracranial blood volume and ICP. The Pao2 is not allowed to fall below 80 mm Hg, to prevent cerebral vasodilation from hypoxemia. Therefore, the remaining options are incorrect.

A client with a neurological deficit is able, with eyes closed, to identify a set of keys placed in his or her hands. A nurse observing the client interprets this to mean that which area of the brain is intact?

Parietal lobe The ability to distinguish an object by touch is called stereognosis, which is a function of the right parietal area. The parietal lobe of the brain is responsible for spatial orientation and awareness of sizes and shapes. The left parietal area is responsible for mathematics and right-left orientation. The other lobes of the brain are not responsible for this function.

The clinic nurse is reviewing the record of a client scheduled to be seen in the clinic. The nurse notes that the client is taking selegiline hydrochloride (Eldepryl). The nurse suspects that the client has which disorder?

Parkinson's disease Selegiline hydrochloride is an antiparkinsonian medication. The medication increases dopaminergic action, assisting in the reduction of tremor, akinesia, and the rigidity of parkinsonism. This medication is not used to treat diabetes mellitus, Alzheimer's disease, or coronary artery disease.

The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions should be included in the plan?

Place a blood pressure cuff at the client's bedside. Close the shades in the client's room during the day. Aneurysm precautions include placing the client on bed rest in a quiet setting. The use of lights is kept to a minimum to prevent environmental stimulation. The nurse should monitor the blood pressure and note any changes that could indicate rupture. Any activity, such as pushing, pulling, sneezing, or straining, that increases the blood pressure or impedes venous return from the brain is prohibited. The nurse provides physical care to minimize increases in blood pressure. Visitors, radio, television, and reading materials are restricted or limited. Stimulants, such as nicotine and coffee and other caffeine-containing products, are prohibited. Decaffeinated coffee or tea may be used.

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention?

Place the client in a sitting position. The client is demonstrating clinical manifestations of autonomic dysreflexia, which is a neurological emergency. The first priority is to place the client in a sitting position to prevent hypertensive stroke. Options 2 and 4 can then be done, and option 1 can be completed once initial interventions are done.

A client with a neurological problem is experiencing hyperthermia. Which measure would be least appropriate for the nurse to use in trying to lower the client's body temperature?

Placing ice packs in the axilla and groin areas Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure.

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by performing which action?

Placing the client on a bed that provides spinal immobilization Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board under it should be used.

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person?

Position the client on his or her side. Brush the teeth with a small, soft toothbrush. Cleanse the mucous membranes with soft sponges. The unconscious client is positioned on the side during mouth care to prevent aspiration. The teeth are brushed at least twice daily with a small toothbrush. The gums, tongue, roof of the mouth, and oral mucous membranes are cleansed with soft sponges to avoid encrustation and infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. The use of products with alcohol should be avoided because they have a drying effect.

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures?

Postictal status Duration of the seizure Changes in pupil size or eye deviation Seizure progression and type of movements Typically seizure assessment includes the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status.

The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client?

Prohibit or limit the use of a radio or television and reading. Environmental stimuli are kept to a minimum with subarachnoid precautions to prevent or minimize increases in intracranial pressure. For this reason, lighting is reduced by closing window blinds and keeping the door to the client's room shut. Overhead lighting also is avoided for the same reason. The nurse prohibits television, radio, and reading unless this is so stressful for the client that it would be counterproductive. In that instance, minimal amounts of stimuli by these means are allowed with approval of the health care provider.

The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position immediately after the procedure?

Prone with a small pillow under the abdomen After the procedure, the client assumes a flat position. If the client is able, a prone position with a pillow under the abdomen is the best position. This position helps reduce cerebrospinal fluid leakage and decreases the likelihood of post-lumbar puncture headache.

The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse should plan to do to ensure client safety?

Provide a clear path for ambulation without obstacles. Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Testing the shower water temperature would be useful if there were an impairment of peripheral nerves. Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively.

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client?

Provide oral hygiene after each meal. Assess swallowing ability frequently. Allow the client sufficient time to eat. Maintain a suction machine at the bedside. A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. The client should be given a sufficient amount of time to eat. Semisoft foods are easiest to swallow and require less chewing. Oral hygiene is necessary after each meal. Suctioning should be available for clients who experience dysphagia and are at risk for aspiration.

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness?

Providing information, giving positive feedback, and encouraging relaxation The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention?

Red skin areas under the jacket Red skin areas under the jacket indicate that the jacket is too tight. The resulting pressure could lead to altered skin integrity and needs to be relieved by loosening the jacket. The screws all should be properly tightened. A clean, dry lamb's wool lining should be in place underneath the jacket, and there should be a finger-width space between the jacket and the skin. In addition, the client should wear a clean white cotton T-shirt next to the skin to help prevent itching.

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint?

Reduce environmental noise. Nursing interventions to control the ICP include maintaining a calm, quiet, and restful environment. Environmental noise should be kept at a minimum. Visiting should be monitored to avoid emotional stress and interruption of sleep. Interventions should be spaced out over the shift to minimize the risk of a sustained rise in ICP.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease?

Respiratory or gastrointestinal infection during the previous month Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with acute brain attack (stroke) earlier in the day. The nurse determines that the client's airway is patent if which data are identified?

Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear The client's airway is most protected if all of the respiratory parameters measured fall within normal limits. Therefore the respiratory rate should ideally be 16 to 20 breaths/min, the oxygen saturation should be greater than 95%, and the breath sounds should be clear. The correct option is the only one that meets all three criteria.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse is contraindicated?

Restraining the client's limbs Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client.

The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan?

Restrict fluid intake for a period of 2 hours. After the lumbar puncture the client remains flat in bed for at least 2 hours, depending on the health care provider's prescriptions. A liberal fluid intake is encouraged to replace the cerebrospinal fluid removed during the procedure, unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage and assesses the client's ability to void and move the extremities.

A client is experiencing delirium. The nurse concludes that which areas of the nervous system are affected?

Reticular activating system and cerebral hemispheres Insomnia, agitation, mania, and delirium are caused by excessive arousal of the reticular activating system in conjunction with the cerebral hemispheres. The temporal lobe, hippocampus, and frontal lobe are responsible for memory. The limbic system is responsible for feelings and affect.

The nurse has given instructions to a client with Parkinson's disease about maintaining mobility. Which action demonstrates that the client understands the directions?

Rocks back and forth to start movement with bradykinesia. The client with Parkinson's disease should exercise in the morning when energy levels are highest. The client should avoid sitting in soft deep chairs because they are difficult to get up from. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to support the ability to dress self.

The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse should plan to place the client in which position?

Semi-Fowler's After supratentorial surgery (surgery above the tentorium of the brain), the head of the client's bed usually is elevated 30 degrees to promote venous outflow through the jugular veins.

A nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which position?

Semi-Fowler's position In supratentorial surgery (surgery above the brain's tentorium), the client's head is usually elevated 30 degrees to promote venous outflow through the jugular veins. The client's head or the head of the bed is not lowered in the acute phase of care after supratentorial surgery. An exception to this position is the client who has undergone evacuation of a chronic subdural hematoma, but a health care provider's (HCP) prescription is required for positions other than those involving head elevation. Additionally, the health care provider's (HCP) prescription regarding positioning is always checked and agency procedures are always followed.

A client had a transsphenoidal resection of the pituitary gland. The nurse notes drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse should look for drainage that is of which characteristic?

Serosanguineous, surrounded by clear to straw-colored fluid CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous (from the surgery) and surrounded by an area of clear or straw-colored drainage. The typical appearance of CSF drainage is that of a "halo." The nurse also would further verify actual CSF drainage by testing the drainage for glucose, which would be positive.

The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema?

Serum osmolality 280 mOsm/kg H2O After craniotomy the goal is to keep the serum osmolality on the high side of normal to minimize excess body water and control cerebral edema. The normal serum osmolality is 285 to 295 mOsm/kg H2O. A higher value indicates dehydration; a lower value indicates overhydration. Stable weight indicates that there is neither fluid excess nor fluid deficit. A difference of 50 mL in intake and output for an 8-hour shift is insignificant. The BUN of 10 mg/dL is within normal range and does not indicate overhydration or underhydration.

The nurse is teaching a client with paraplegia measures to maintain skin integrity. Which instruction will be most helpful to the client?

Shift weight every 2 hours while in a wheelchair. To maintain skin integrity, the client should shift weight in the wheelchair every 2 hours and use a pressure relief pad. A pillow is not sufficient to relieve the pressure. While the client is in bed, the bottom sheet should be free of wrinkles and wetness. Sheets should be changed as needed and more frequently than every other week. The client should use a mirror to inspect the skin twice daily (morning and evening) to assess for redness, edema, and breakdown. General additional measures include a nutritious diet and meticulous skin care.

A client with Parkinson's disease is at risk for falls because of an abnormal gait. The nurse assesses the client, expecting to observe which type of gait?

Shuffling and propulsive The parkinsonian gait is characterized by short, accelerating, shuffling steps. The client leans forward with the head, hips, and knees flexed and has difficulty starting and stopping. An ataxic gait is unsteady and staggering. A dystrophic gait is broad-based and waddling. A festinating gait is accelerating with walking on the toes.

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure?

Side-lying with the legs pulled up and the head bent down onto the chest A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the health care provider. The nurse remains with the client during the procedure to help the client maintain this position.

The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which condition that is a complication of hypothermia blanket use?

Skin breakdown When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown. The hypothermia blanket decreases the blood flow to pressure areas and can cause numbness, making it so that the client is not aware of damage to the skin. The temperature of the blanket is not cold enough to cause frostbite. Arterial insufficiency and venous insufficiency are not complications of hypothermia blanket use.

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction?

Sounds will not be heard clearly unless they are loud. The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control of environmental noise by others will be helpful for this client. Seizures are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered. The family should learn seizure precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection.

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/min range. The client is also complaining of nausea. The nurse interprets that these symptoms are because of stimulation of which cranial nerve (CN)?

Vagus (CN X) The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It is also responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve.

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure?

Spasms of the entire body The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds.

A client has suffered damage to Broca's area of the brain. The nurse providing care for this client anticipates that which area will be affected?

Speech Broca's area in the brain is responsible for the motor aspects of speech, through coordination of the muscular activity of the tongue, mouth, and larynx. The term assigned to damage in this area is aphasia. The items listed in the other options are not the responsibility of Broca's area.

A client with trigeminal neuralgia asks the nurse what causes the painful episodes associated with the condition. The nurse's response is based on an understanding that the symptoms can be triggered by which process?

Stimulation of the affected nerve by pressure and temperature The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by thermal stimuli, such as a draft of cold air.

A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse plans care, knowing that these changes are the result of which response?

Sympathetic nervous system response The sympathetic nervous system is responsible for the so-called fight or flight response, which is characterized by dilated pupils, increases in heart rate and cardiac output, and increases in respiratory rate and blood pressure. The sympathetic nervous system response affects some type of change in most systems of the body. The responses stated in the other options do not produce these effects.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?

Taking medications on time to maintain therapeutic blood levels Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

A client who had a brain attack (stroke) has right-sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem?

Teach the client to scan the environment. Hemianopsia is blindness in half the visual field. The client with hemianopsia is taught to scan the environment. This allows the client to take in the entirety of the visual field, which is necessary for proper functioning within the environment and helps to prevent injury to the client. Options 2 and 3 will not help the client adapt to this visual impairment. Eyeglasses are useful if the client already wears them, but they will not correct this visual-field deficit.

Which intervention should the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace?

Tell the client to inspect the environment for safety hazards. The client must inspect the environment for safety hazards. The client is instructed in the importance of avoiding prolonged sitting and standing. Powders and lotions should not be used because they may irritate the skin. The client should be taught to loosen the brace during meals and for 30 minutes after each meal. The client may have difficulty eating if the brace is too tight. Loosening the brace after each meal will allow adequate nutritional intake and promote comfort.

The nurse is performing an assessment on a client admitted to the nursing unit with a diagnosis of stroke (brain attack). On assessment, the nurse notes that the client is unable to understand spoken language. The nurse plans care, understanding that the client is experiencing impairment of which areas?

The auditory association areas Auditory association and storage areas are located in the temporal lobe and relate to understanding spoken language. The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record?

The client experienced paresthesias a few days before admission to the hospital. Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on one side of the body. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with brain attack (stroke) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.

The nurse is assigned to care for a client with complete right-sided hemiparesis. Which characteristics are associated with this condition?

The client is aphasic. The client has weakness in the face and tongue. The client has weakness on the right side of the body. Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in this hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The nurse is preparing a plan of care for a client with a diagnosis of brain attack (stroke). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding?

The client will exhibit neglect of the affected side. In anosognosia, the client neglects the affected side of the body. The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else.

A client has sustained damage to Wernicke's area in the temporal lobe from a brain attack (stroke). Which should the nurse anticipate when caring for this client?

The client will have difficulty understanding language. Wernicke's area consists of a small group of cells in the temporal lobe the function of which is the understanding of language. The hippocampus is responsible for the storage of memory (the client will be unable to recall past events). Damage to Broca's area is responsible for aphasia (the client will demonstrate difficulty articulating words). The motor cortex in the precentral gyrus controls voluntary motor activity (the client will have difficulty moving one side of the body).

The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care?

The client's body temperature is 98° F. Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include the following: hands and limbs are warm; body is relaxed and not curled; body temperature is greater than 97° F; the client is not shivering; and the client has no complaints of feeling cold.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area?

The left side of the body Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits.

The nurse is developing a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan?

Thicken liquids. Assist the client with eating. Assess for the presence of a swallow reflex. Provide ample time for the client to chew and swallow. Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking.

A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client?

This is not a brain attack (stroke), and many clients recover in 3 to 5 weeks. Clients with Bell's palsy should be reassured that they have not experienced a brain attack (stroke) and that symptoms often disappear spontaneously in 3 to 5 weeks. The client is given supportive treatment for symptoms. Bell's palsy usually is not caused by a tumor, and the treatment is not similar to that for migraine headaches.

A client who experienced a brain attack (stroke) several months ago still exhibits some difficulty with chewing food. The nurse plans care, knowing that the client has residual dysfunction of which cranial nerve?

Trigeminal (cranial nerve V) The motor branch of cranial nerve V is responsible for the ability to chew food. The vagus nerve is active in parasympathetic functions of the autonomic nervous system. The hypoglossal nerve aids in swallowing. The spinal accessory nerve is responsible for shoulder movement, among other things.

A client has sustained damage to Wernicke's area in the temporal lobe from a stroke (brain attack). The nurse anticipates that the client will have difficulty with which function?

Understanding language Wernicke's area consists of a small group of cells in the temporal lobe whose function is the understanding of language. Damage to Broca's area is responsible for aphasia. The motor cortex in the precentral gyrus controls voluntary motor activity. The hippocampus is responsible for the storage of memory.

The nurse is planning care for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care?

Use strict aseptic technique when touching the monitoring system. Because there is a foreign body embedded in the client's brain, vigilant aseptic technique should be implemented. Sims is side-lying, flat position. With a client who has increased ICP, the head of the bed should be elevated at least 30% to improve jugular outflow. The drainage tubing should not be routinely changed. It should remain for the duration of the monitoring. To obtain accurate ICP pressure readings, the transducer is zeroed at the level of the foramen of Monro, which is approximated by placing the transducer 1 inch above the level of the ear. Serial ICP readings should be done with the client's head in the same position.

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. The nurse understands that these symptoms are caused by stimulation of which cranial nerve (CN)?

Vagas The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It also is responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve. CN XII is responsible for tongue movement. CN XI is responsible for neck and shoulder movement. CN IX is responsible for taste in the posterior two thirds of the tongue, pharyngeal sensation, and swallowing.

An older man is brought to the hospital emergency department by a neighbor who heard him talking and found him wandering in the street at 3 am. The nurse should first determine which data about the client?

Whether this is a change in his usual level of orientation The nurse should first determine whether this behavior represents a change in the client's neurological status. The next item to determine is when the client last ate. Blood toxicology levels may or may not be needed, but the health care provider would likely prescribe these. Insurance information must be obtained at some point but is not the priority from a clinical care viewpoint.

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even-tempered, is prone to outbursts of temper now. The nurse counsels the family on the basis of an understanding that these behaviors are indicative of which condition?

Will probably be a long-term sequela of the injury Clients with moderate to severe head injury usually have residual physical and cognitive disabilities; these include personality changes, increased fatigue and irritability, mood alterations, and memory changes. The client also may require frequent to constant supervision. The nurse assesses the family's ability to cope and makes appropriate referrals to respite services, support groups, and state or local chapters of the National Head Injury Foundation.

A nurse is testing the spinal reflexes of a client during neurological assessment. Which reflex will assist in determining that the client has an adequate spinal reflex?

Withdrawal reflex The withdrawal reflex is one of the spinal reflexes. It is an abrupt withdrawal of a body part in response to painful or injurious stimuli. The cough reflex is a brainstem-associated reflex. Accommodation reflex is associated with cranial nerve III and is part of the ocular motor system. Munroe-Kellie is not a reflex; it is a doctrine or a hypothesis addressing the cerebral volume relationships among the brain, the cerebrospinal fluid, and intracranial blood and their cumulative impact on intracranial pressure.