Neurological

The client diagnosed with Guillain-Barre syndrome is scheduled to receive plasmapheresis treatments. The client's spouse asks the nurse about the purpose of plasmapheresis. Which explanation is correct? 1. "Plasmapheresis removes excess fluid from the bloodstream." 2. "Plasmapheresis will increase the protein levels in the blood." 3. "Plasmapheresis removes simulating antibodies from the blood." 4. "Plasmapheresis infuses lipoproteins to restore the myelin sheath."

(3) "Plasmapheresis removes simulating antibodies from the blood." Rationale: Plasmapheresis is a procedure in which harmful antibodies are removed from the blood. During the procedure, blood is removed from he client, the plasma is separated, and blood cells without the plasma are returned to the client.

The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication? 1. Autonomic dysreflexia 2. Septic emboli 3. Cardiac dysrhythmias 4. Respiratory failure

(4) Respiratory failure. Rationale: It is most important for the nurse to monitor for respiratory failure. Ascending paralysis that occurs for GBS can affect the innervation of the muscles used for respiration, leading to respiratory failure.

A nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. Which of the following statements by the client indicates an understanding of the teaching? 1. "An aura is a sensory warning that a seizure is imminent." 2. "An aura is a continuous seizure in which seizures occur in rapid succession." 3. "An aura is a period of sleepiness following the seizure." 4. "An aura is a brief loss of consciousness accompanied by staring."

1. "An aura is a sensory warning that a seizure is imminent." Rationale: An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can be report hearing bells, seeing lights, or smelling an odor.

The client has had recurrent episodes of low back pain. Which statement indicates that eh client has incorporated positive lifestyle changes to decrease the incidence of future back problems? 1. "I stoop and avoid bending and twisting when lifting objects." 2. "I can walk farther if I wear my old comfortable shoes." 3. "I can walk only on weekends but walk 5 miles each day." 4. "I sit for 2 to 3 hours with my legs elevated for pain control."

1. "I stoop and avoid bending and twisting when lifting objects." Rationale: Stooping and avoid bending and twisting motions when lifting objets lessen the likelihood of injury.

The office nurse should direct a client on the phone to seek care at the hospital emergency department based on which statement. 1. "My legs are weak and now I'm having trouble getting a good breath." 2. "My shaky hand is no better than last visit. In fat, I think it's getting worse." 3. "The double vision went away when I put my eye patch on." 4. My headache doesn't seem any better even though I gave up coffee."

1. "My legs are weak and now I'm having trouble getting a good breath." Rationale: What the client describes is a classic ascending progression of Guillain Barre syndrome. The muscular weakness may ascend to include the diaphragm. Total respiratory paralysis can occur, requiring ventilatory support

The experienced nurse is instructing the new nurse on subarachnoid hemorrhage. The nurse evaluates that the new nurse understands the information when the new nurse makes which statements? Select all that apply? 1. "Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm." 2. "Subarachnoid hemorrhage occurs during sleep and is noticed when the client awakens." 3. "The client experiencing a subarachnoid hemorrhage may state having a severe headache." 4. "tissue plasminogen activator (tPA) should be given to treat a subarachnoid hemorrhage." 5. "A subarachnoid hemorrhage often results in the cerebrospinal fluid appearing bloody."

1. "Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm." 3. "The client experiencing a subarachnoid hemorrhage may state having a severe headache." 5. "A subarachnoid hemorrhage often results in the cerebrospinal fluid appearing bloody." Rationale: (1). A subarachoid hemorrage is usually caused by rupture of a cerebral aneurysm. (3) Irritation of the meninges from bleeding into the subarachoid spaces causes a severe headache (5) Bleeding into the subarachnoid space will cause the CSF to the bloody.

An abnormal electroencephalogram (EEG) indicates that a 2-year told client has epilepsy, but the parents say they have never observed a seizure. The pediatric nurse concludes that the child may be experiencing which type of seizure? 1. Absence 2. Myoclonic 3. Jacksonian 4. Grand mal

1. Absence Rationale: Also known as petit Mal seizures, absence seizures may be no more observable than brief staring instances.

The nurse is caring for the client with an Sci at the level fo sixth cervical vertebra. Which findings support the nurse's conclusion that the client may be experiencing autonomic dysreflexia? Select all that apply. 1. Blurred vision 2. BP 198/102 mmHg 3. Heart rate 150 bpm 4. Extreme headache 5. Sweaty face and arms

1. Blurred vision 2.. BP 198/102 mmHg 4. Extreme headache 5. Sweaty face and arms Rationale: (1) Blurred vision results from the hypertension occurring with autonomic dysreflexia (2) Hypertension is a symptoms of autonomic dysreflexia from overstimulation of the sympathetic nervous system (4) headache results from the hypertension occurring with autonomic dysreflexia (5) sweating results from the sypmathetic stimulation above the level of injury

The nurse is implementing interventions for the client who has increased ICP. The nurse knows that which result will occur if the increased ICP is left untreated? 1. Displacement of brain tissue 2. Increase in cerebral perfusion 3. Increase in the serum pH level 4. Leakage of cerebrospinal fluid

1. Displacement of brain tissue Rationale: If untreated, increased ICP causes a shift in brain tissue and can result in irreversible brain damage and possibly death.

A nurse is performing a neurologic assessment for a client who has a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement? 1. Dysphagia 2. Positive-Babinski sign 3. Decreased deep-tendon reflexes 4. Ataxia

1. Dysphagia Rationale: Dysphagia, or difficulty swallowing, can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus).

Which assessment finding in a 35-year-old client with a intracranial hematoma should concern the nurse? 1. Hamstring pain when the hip and knee are flexed and then extended. 2. Curling of the toes when the bottom of the foot is stroked in upward motion. 3. Muscle aches and cramping, especially at night 4. Cogwheel and lead pipe rigidity.

1. Hamstring pain when the hip and knee are flexed and then extended. Rationale: Hamstring pain with hip and knee flexion and then extension is called positive Kernig's sign: this is common in intracranial hematomas

The client with MS tells the nurse about extreme fatigue. Which assessment findings should the nurse identify as contributing to the client's fatigue? Select all that apply. 1. Hemoglobin 9.5 g/dL and hematocrit is 31.8% 2. Taking baclofen 15 mg 3 times per day 3. Working 4 to 8 hours per week in the family business 4. Stopped taking amitriptyline 8 weeks earlier 5. Presence of cardiac murmur at the tricuspid valve 6. Bilateral leg weakness noted when walking in room

1. Hemoglobin 9.5 g/dL and hematocrit is 31.8% 2. Taking baclofen 15 mg 3 times per day 4. Stopped taking amitriptyline 8 weeks earlier 5. Presence of cardiac murmur at the tricuspid valve 6. Bilateral leg weakness noted when walking in room

The client, undergoing testing for a possible brain tumor, ask the nurse about treatment options. The nurse's response should be based on knowing that treatment of a brain tumor depends on which factors? Select all that apply? 1. How rapidly the tumor is growing 2. Whether the tumor is malignant or benign 3. Cell type from which the tumor originates 4. Where the time is located within the brain 5. The client's age and type of insurance

1. How rapidly the tumor is growing 2. Whether the tumor is malignant or benign 3. Cell type from which the tumor originates 4. Where the time is located within the brain Rationale: (1) Surgery, radiation therapy, and/or chemotherapy may be used to treat a slowly or rapidly growing tumor (2) surgery, radiation therapy, and/or chemotherapy may be used to treat a benign or malignant tumor (3) Surgery, radiation therapy, and/or chemotherapy may be used to treat tumors of different cell types. (4) the summer's location is the brain may affect whether surgery is an option or whether the surgical approach with radiation therapy is used to treat the tumor.

The nurse is assessing the client with tentative diagnosis of meningitis. Which findings should the nurse associate with meningitis? Select all that apply 1. Nuchal rigidity 2. severe headache 3. Pill-rolling tremor 4. Photophobia 5. Lethargy

1. Nuchal rigidity 2. Severe Headache 4. Photophobia 5. Lethargy Rationale: (1) Irritation of the meninges causes nuchal rigidity (stiff neck) (2)Irritation of the meninges causes severe headache (4) Irritation of the meninges causes photophobia (light irritates the eyes). (5) Lethargy, pathological state of sleepiness or unresponsiveness, indicates a decreased level of consciousness, indicates a decreased level of consciousness which is associated with meningitis

The nurse is administering mannitol IV to decrease the client's ICP following a craniotomy. Which laboratory test result should the nurse monitor during the client's treatment with mannitol? 1. Serum osmolarity 2. White blood cell count 3. Serum cholesterol 4. Erythrocyte sedimentation rate (ESR)

1. Serum osmolarity Rationale: Mannitol (Osmitrol), an osmotic diuretic increases the serum osmolarity and pulls fluid from the tissues, thus decreasing osmolarity edema postoperatively. Serum osmolarity levels should be assessed as a parameter's determine proper dosage.

A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect? 1. Swelling behind the affected ear. 2. Facial drooping on the affected side. 3. Nystagmus on the affected side. 4. Pearly gray color of the affected eardrum.

1. Swelling behind the affected ear. Rationale: Mastoiditis refers to an inflammation of the temporal bond behind the ear. Manifestations of mastoiditis include swelling and pain behind the ear.

The nurse is instructing the client who has been in the hospital with bacterial meningitis and will be going home soon. Which of the following will be of the highest priority? 1. Take all of the antibiotics as directed until completely gone. 2. Eat a high-protein, high-caloric diet 3. Exercise daily, beginning with active ROM 4. Get at least 8 hours of sleep per night with frequent rest periods.

1. Take all of the antibiotics as directed until completely gone Rationale: It is essential that the client recovering from bacterial meningitis take all the prescribed antibiotic as directed. Failure to do so puts the client at risk for relapse of symptoms and contributes to development of bacterial resistance to antibiotics.

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? 1. The client rigidly extends his arms. 2. The client internally flexes his wrists 3. The client curls into a fetal position 4. The client internally rotates his legs.

1. The client rigidly extends his arms. Rationale: A client who exhibits a decerebrate posture rigidly extends and pronates his four extremities and externally rotates his wrists. Decerebrate posturing indicates severe brain stem injury and late neurologic decline.

A nurse is assessing a client who has a closed head injury and has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? 1. The client's serum osmolarity is 310 mOsm/L. 2. The client's pupils are dilated. 3. The client's heart rate is 56/min. 4. The client is restless.

1. The client's serum osmolarity is 310 mOsm/L. Rationale: Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP.

The home health nurse evaluates the foot care of the dark skinned African client who has peripheral neuropathy? Which client actions in providing foot care are appropriate? select all that apply. 1. Uses a mirror and visually inspects the foot on a daily basis. 2. Lotions the feet and legs daily, avoiding between the toes 3. Goes barefoot when indoors to help dry and air out the feet 4. Wears warm socks and boots when outside in cold weather. 5. Trims toenails weekly so they have a rounded contour 6. Inspects the feet for redness and other signs of inflammation

1. Uses a mirror and visually inspects the foot on a daily basis. 2. Lotions the feet and legs daily, avoiding between the toes 4. Wears warm socks and boots when outside in cold weather. Rationale: (1) Using a mirror allows for visual inspection of the bottom of the feet and between the toes for areas of breakdown (2) Keeping the skin adequately lubricated with lotion prevents drying and cracking. Lotion should not be applied between the toes because it increases moisture and the risk for infection. (4) Wearing appropriate clothing protects the skin from injury because sensation is diminished with peripheral neuropathy.

A nurse is assessing a client who has sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? 1. Widened pulse pressure 2. Tachycardia 3. Periorbital edema 4. Decrease in urine output

1. Widened pulse pressure Rationale: A widening of the pulse pressure, the different between the systolic and diastolic pressure, is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting

The female client with an incomplete T6 spinal cord transection asks the nurse for sexual health advice and the possibility of ever conceiving. Which statements by the nurse will be helpful to the client? Select all that apply. 1. "you need to continue to use contraceptives if you do not wish to have children." 2. "Unfortunately, your injury prevents you from being able to conceive children." 3. "Because feeling is affected, it is not likely that you will be able to deliver a baby." 4. "sexual intercourse is generally prohibited because it can worsen your condition." 5. "you can engage in sexual intimacy, but you may not be able to feel an orgasm."

1. You need to continue to use contraceptives if you do not wish to have children. 5. You can engage in sexual intimacy, but you may not be able to feel an orgasm. Rationale: (1) Although the client has an incomplete T6 SCI, the woman is still capable of becoming pregnant. (5) The client may not be able to feel an orgasm after an incomplete T6 SCI

The nurse is teaching the client who is scheduled for an outpatient EEG. Which instructions should the nurse include? 1. Remove all hairpins before coming in the EEG test 2. Aid eating or drinking at least 6 hours prior to the test 3. Some hair will be removed with a razor to place electrodes. 4. Have blood drawn for a glucose level 2 hours before the test.

1. remove all hairpins before coming in the EEG Test Rationale: In an EEG, electrodes are placed on the scalp over multiple areas of the brain to detect and record patterns of electrical activity. Preparation includes clean hair without any objects in the hair to prevent inaccurate test results.

The tonic in tonic-clonic seizures lasts for this long

10-20 seconds

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching? 1. "Place a warm compress on your forehead." 2. "Darken the lights." 3. "Light a scented candle." 4. "Drink a caffeinated beverage."

2. "Darken the lights." Rationale: The nurse should instruct the client to lie down in a dark room to reduced migraine pain.

The nurse is monitoring clients for development of a brain abscess. Which client would be the nurse's lowest priority for monitoring for a brain abscess? 1. Client with endocarditis 2. Client with idiopathic epilepsy 3. Client who had a liver transplant 4. Client with meningitis

2. A client with idiopathic epilepsy Rationale. This is the most appropriate response because it focuses on the client's concern, encourages verbalization, and solicits more information.

The home health nurse concludes that more teaching may be necessary after making which observation during the first home visit to a client discharged after a stroke? Select all that apply. 1. A commode is observed at the bedside 2. A fluid restriction chart is on the refrigerator 3. Metamucil is on the kitchen counter. 4. Hand weights are next to the couch 5. There is a small scatter rug at the side of the bed

2. A fluid restriction chart is on the refrigerator 5. There is a small scatter rug at the side of the bed Rationale: Fluid restriction may be needed in the period immediately following a stroke, but this is not necessary after discharge to home. Small rugs can increase the risk for falls and should be removed.

A client calls the telephone triage nurse to report fever, nausea, chills and malaise. The nurse instructs the client to come immediately to the emergency department after the client shares which additional data? 1. A bad headache 2. A stiff sore neck 3. A heart rate of 106 4. A roommate with the same symptoms.

2. A stiff sore neck Rationale: A stiff sore neck is a sign of meningeal irritation and possible meningitis. The nurse may further inquire if flexion of the neck causes pain and the hip and knee to flex (Brudzinski's sign) and how high the fever is.

When assessing the client with meningitis, the nurse looks for which manifestations as a frequent first sign of increased intracranial pressure? 1. A rising systolic blood pressure 2. Change in mood or attention level 3. Irregular respiratory rate and depth 4. Bounding radial pulse

2. Change in mood or attention level Rationale: The first signs of increased intracranial pressure are often subtle changes in level of consciousness

A nurse is assessing a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, following by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? 1. Orthopnea 2. Cheyne-Stokes 3. Paradoxical 4. Kussmaul

2. Cheyne-Stokes Rationale: Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths, following by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.

The client recently diagnosed with Guillain Barre syndrome is drooling and having difficulty swallowing secretions. When the family asks why this occurs, the nurse indicates that which of the following is the cause? 1. Obstructed blood flow to the midbrain 2. Demyelination of cranial nerves responsible for swallow and gag reflex 3. Enlargement of the parotid and salivary glands 4. Deficiency in thiamine and pyridoxine in the central nervous system.

2. Demyelination of cranial nerves responsible for swallow and gag reflex Rationale: Guillain-Barre syndrome is an acute demyelinating disorder that less commonly may present with initial weakness in the cranial nerves that progresses downward. Impairment of cranial nerve IX and X will affect swallowing.

A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? 1. Reduced left-side motor function 2. Difficulty with speech 3. Impulsive behavior 4. Neglect of the left side of the body

2. Difficulty with speech Rationale: The left hemisphere of the brain is usually the dominant side and is responsible for language. This is always true for right-handed clients and for the majority of left-handed clients. Since this client is recovering from a left-hemisphere stroke, the nurse should anticipate that the client will have aphasia and require speech therapy to establish communication.

The nurse in the ED documents that the newly admitted client is "postictal upon transfer." What did the nurse observe? 1. Yellowing of the skin due to a liver condition 2. Drowsy or confused state following a seizure 3. Severe itching of the eyes from an allergic reaction 4. Abnormal sensations including tingling of the skin

2. Drowsy or confused state following a seizure. Rationale: The client had experienced a tonic-clonic seizure recently and is now in a state of deep relaxation and is breathing quietly. During this period the client may be unconscious or awakes gradually, but is often confused and disoriented. Often the client is amnesic regarding the seizure.

The client has right homonymous hemianopia following an ischemic stroke. The nurse asks the NA to help the client with meals knowing that this problem may result in which client response? 1. Tendency to fall to the contralateral side 2. Eating food on only half of the plate 3. Using the silverware inappropriately 4. Choking when swallowing any liquids

2. Eating food on only half of the plate Rationale: Homonymous hemianopia (hemianopsia) is a visual field abnormality that results in blindness in half of the visual field in the same side of both eyes. It results from damage to the optic tract or occipital lobe.

The nurse is caring for the client who has limited intake due to dysphagia following an ischemic stroke. Which serum laboratory result should the nurse review to verify that the client is dehydrated? 1. Elevated serum creatinine 2. Elevated blood urea nitrogen 3. Decreased hemoglobin 4. Decreased prealbumin

2. Elevated blood urea nitrogen Rationale: The BUN is elevated when the client is dehydrated due to the lack of fluid volume to excrete was products.

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? 1. Elevated glucose 2. Elevated protein 3. Presence of RBCs 4. Presence of D-dimer

2. Elevated protein Rationale: An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include an increase of protein in the cerebrospinal fluid.

The client is in status epilepticus. Which interventions, if prescribed, should be included in this client's immediate treatment? Select all that apply? 1. Administer dexamethasone intravenuously 2. Give oxygen and prepare for endotracheal intubations. 3. Obtain a defibrillator and prepare its use immediately 4. Remove nearby objects to protect the client from injury 5. Administer lorazepam intravenously STAT.

2. Give oxygen and prepare for endotracheal intubation 4. Remove nearby objects to protect the client from injury 5. Administer lorazepam intravenously STAT Rationale: (2) Status epilepticus is a medical emergency. The client is at risk for brain hypoxia and permanent brain damage. The client needs additional oxygen, and intubation will secure the airway (4) Care is taken to protect the client from injury during the seizure (5) Either lorazepam (ativan) or diazepam (valium) is administered initially to terminate the seizure because they can be administered more rapidly than phenytoin.

The client, diagnosed with an ischemic stroke, is being evaluated for thrombolytic therapy. Which assessment finding should prompt the nurse to withhold thrombolytic therapy? 1. Brain CT scan results show no bleeding 2. Had a serious head injury four weeks ago 3. Has a history of type 1 diabetes mellitus 4. Neurological deficits started 2 hours ago

2. Had a serious head injury four weeks ago Contra/complications to thrombolytic therapy for the client with an ischemic stroke include a serious head injury within the previous 1 months. This would put the client at risk of developing serious bleeding problems specifically cerebral hemorrhage.

The home care nurse is counseling the client who has MS. The client is e experiencing weakness, ataxia, intermittent adductor spasms of the hips and occasional incontineance from loss of bladder sensation. Which self-care measures should the nurse recommend? select all that apply. 1. "Adductor spasms can be relieved by taking a hot bath." 2. "If a muscle is in spasm, stretch and hold it and then relax." 3. "Rest first and then walk as able using a walker for support." 4. "When walking, eep feet close together, legs slightly bent." 5. "Set an alarm to remind you to void 30 minutes after fluid intake."

2. If a muscle is in spasm, stretch and hold it and then relax 3. Rest first and then walk as able using a walker for support." 5. "Set an alarm to remind you to void 30 minutes after fluid intake." Rationale: (2) A stretch-hold-relax is often helpful for relaxing the muscle and treating muscle spasm (3) Walking will help improve the gait, strengthen weakened muscles, and help relieve spasticity in the legs. If a muscle group is irreversible by affected by MS other muscles can learn to compensate. A walker should be used for safety to help prevent falling. (5) Drinking fluids and then using an alarm to void 30 minutes later may be helful in reducing incontinence from loss of bladder sensation.

The client who has Type I DM, is scheduled for an MRI of the brain after an MVA. Which intervention should the nurse implement to prepare the client for the test? 1. Make the client NPO for six hours before the MRI and hold the morning insulin dose. 2. Inform the client that the machine is noisy and that earplugs can be worn during the test. 3. Explain that the extremity used for injection must remain straight for a few hours after MRI 4. Ensure that the serum BUN and creatinine levels are obtained and evaluated prior to the MRI

2. Inform the client that the machine is noisy and that earplugs can be worn during the test. Rationale: Clients are given earplugs to wear while undergoing the test because the machine makes a loud clanging noise that is unpleasant.

The nurse would prevent corneal abrasion in a client with myasthenia graves by performing which nursing intervention? 1. Doing a saline eye irrigation every shift 2. Instilling artificial tears in the eyes every 1 to 2 hours 3. Ensuring the client's contact lenses are on while awake 4. Providing sunglasses when client is outside

2. Instilling artificial tears in the eyes every 1 to 2 hours Rationale: Corneal abrasion in the client with myasthenia graves is caused by dryness of the cornea from inability to close the eyelids and blink. It I can be prevented by application of artificial tears every 1 to 2 hours.

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? 1. Reorient the client. 2. Protect the client's head. 3. Loosen constrictive clothing. 4. Turn the client on his side.

2. Protect the client's head. Rationale: The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The client is at greatest risk for injury from hitting his head; therefore, the first action is to protect the client's head from injury.

The nurse is assisting the client who sustained a C5 SCI to cough using the quad coughing technique with which actions? select all that apply. 1. Places a suction catheter in the client's oral cavity to stimulate the cough reflex 2. Puts hands on the upper abdomen, has client inhale; pushes upward during a cough 3. Cups the hands and percusses the client's anterior, lateral, and posterior lung fields. 4. Hyperoxygenates the client by using a resuscitation bag to deliver 100% oxygen 5. Elevates the head of the bed to a high Fowler's position if the client is sitting in bed.

2. Puts hands on the upper abdomen, has client inhale, pushes upward during a cough 5. Elevates the head of the bed to a high Fowler's position if the client is sitting in bed. Rationale:(2) The nurse's hand placement and pushing upward during a cough help to overcome the impaired diaphragmatic function that occurs with a C5 SCI (5) Elevating the head of the bed will promote lung expansion, thus enabling a stronger cough

The nursing assesses the client, who was inured in a diving accident 2 hours earlier. The client is breathing independently but has no movement or muscle tone from below the area of injury. A CT scan reveals a fracture of the C4 cervical vertebra. The nurse should plan interventions for which problems? 1. Complete spinal cord transection 2. Spinal shock 3. An upper motor neuron injury 4. Quadriplegia

2. Spinal Shock Rationale: The client is experiencing spinal shock that manifests within a few hours after the injury. Hypotension, flaccid paralysis and absence of muscle contractions occur. Spinal shock lasts 7 to 20 days, and the sci cannot be classified accurately until spinal shock resolves.

The nurse is caring for the client who has severe craniocerebral trauma. Which finding indicates that the client is developing DI? 1. Blood glucose level at 230 mg/dL 2. Urinary output 1500 mL over 4 hours 3. Urine specific gravity 1.042 4. Somnolent when previously alert

2. Urinary output 1500 mL over 4 hours Rationale: The lack of ADH that occurs in DI prevents excepting a large amount of pale, diluted urine.

The nurse is caring for the older adult client with normal pressure hydrocephalus (NPH). Which treatment measure should the nurse anticipate? 1. Carotid endarterectomy 2. Ventriculoperitoneal shunt 3. Insertion of a lumbar drain 4. Anticonvulsant medications

2. Ventriculoperitoneal shunt Rationale: NPH is treated with the placement of a permanent shunt in a lateral ventricle of the brain to the peritoneal cavity. The excess CSF drains into the peritoneal cavity.

Spinal precautions are ordered for the client that sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse's priority when receiving the client in the ED? 1. Assessing the client using the Glasgow Coma Scale (GCS) 2. Assessing the level of sensation in the client's extremities. 3. Checking that the cervical collar was correctly placed by EMS (prevent injury) 4. Applying anti-embolism nose to the client's lower extremities

3. Checking that the cervical collar was correctly placed by EMS Rationale: Maintaining the correct placement of the cervical collar will keep the. client's head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar is correctly placed will prevent further injury, it is priority.

The nurse learns in report that the client admitted with a vertebral fracture has a halo external fixation devise in place. Which intervention should be nurse plan? 1. Ensure the traction weight hangs freely 2. Remove the vest from the device at bedtime 3. Cleanse sites where the pins enter the skull 4. screw the pins in the skull daily to tighten.

3. Cleanse sites where the pins enter the skull. Rationale:A halo exert fixation device is a static devise that consists of "halo" that is screwed into the skull by four pins. It is attached to a vest that the client wears. The device provides immobilization ad stability to the spinal cord while healing occurs with or widened surgical intervention. Care includes inspection and cleansing of the pins sites.

The client underwent a lumbar laminectomy with spinal fusion 12 hours earlier. Which nursing assessment finding indicates that the client has a leakage of CSF? 1. Backache not relieved by narcotic analgesic 2. 50 mL of serosanguineous fluid in the bulb drain 3. Clear fluid drainage noted on the surgical dressing 4. Sudden spike in temperature to 101.3 F (38.3C)

3. Clear fluid drainage noted on the surgical dressing Rationale: clear drainage on the surgical dressing is indicative of CSF leak.

The community health nurse interprets that clients who live in a swampy bayou area in the southern United States might be at risk of contracting which health problem? 1. Meningitis 2. Parkinson's disease 3. Encephalitis 4. Multiple sclerosis

3. Encephalitis Rationale: Mosquitoes, the vectors that transport encephalitis, are found in large numbers in swampy areas.

The client, who had a stroke, follows the nurse's instructions without problems, but an attempt to verbally respond to the nurse's question was garbled. The nurse should identify that the client has which type of aphasia? 1. Receptive aphasia 2. Global aphasia 3. Expressive aphasia 4. Anomic aphasia

3. Expressive aphasia Rationale: The nurse should identify that the client has expressive aphasia (Broca's aphasia or non-fluent aphasia). The client is able to comprehend and responds appropriately. The client may attempt to speak but has difficulty communicating with the correct words.

A 76-year old woman arrives at the emergency department by ambulance with a possible stroke. Vital signs are pulse 90, blood pressure 150/100, respirations 20. Thirty minutes later, vital signs are pulse 78, blood pressure 170/90, respirations 24 and irregular. The nurse should take which action at this time? 1. Ask the woman to describe how she's feeling. 2. check the client's phenytoin (dilantin) level 3. Get an order to decrease the rate of IV fluids. 4. Offer the client clear liquids to prevent dehydration.

3. Get an order to decrease the rate of IV fluids. Rationale: The client is showing signs of rising intracranial pressure, and reducing the rate of IV fluids prevents hypervolemia that would worsen the rising the intracranial pressure.

A nurse is assessing a client who is admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment data the nurse should collect to determine a change in the client's neurologic status? 1. Vital signs 2. Body posture 3. Level of consciousness 4. Examination of pupils

3. Level of consciousness The nurse should apply the urgent vs. non-urgent priority-setting framework. Using this framework, the nurse should consider urgent needs the priority because they pose more of a risk to the client. The nurse might also use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify the most urgent finding. Therefore, the priority assessment is level of consciousness. A change in the client's level of consciousness can be the first indication of a change in neurologic status.

What would the nurse do as priority when caring for the client with myasthenia graves to minimize the risk for complications of the disease? 1. Inspect for hemorrhage. 2. Assess for viral pneumonia 3. Offer to cut the client's food as needed 4. Provide the client with a bedside commode

3. Offer to cut the client's food as needed Rationale: When the muscles involved in chewing and swallowing, as well as the diaphragm and intercostal muscles, are weak the client may aspirate or experience poor gas exchange; both increase the risk for pneumonia. Options that protect the airway always have highest priority.

A nurse in an acute care facility is preparing to admit a client who has myasthenia graves. Which of the following supplies should the nurse place at the client's bedside? 1. Metered-dose inhaler 2. Continuous passive motion machine 3. Oral-nasal suction equipment 4. External defibrillator pads

3. Oral-nasal suction equipment Rationale: The client who has myasthenia graves is at risk for aspiration because of progressive weakness of the oropharyngeal muscles. Myasthenia graves causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.

In providing for the safety of the client during a grand Mal seizure, the nurse performs which of the following interventions? Select all that apply. 1. Position the client on his back. 2. Gentle place a padded tongue blade between the teeth 3. Remove nearby objects that could lead to client injury 4. Apply oxygen immediately via mask 5. Note the length and progression of the seizure.

3. Remove nearby objects that could lead to client injury 5. Note the length and progression of the seizure. Rationale: The nurse's priority is to protect the client from injury. The nurse would note and then document when the seizure began, how it progressed, when it ended, and associated client findings

A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions? 1. Trendelenburg 2. Prone 3. Semi-Fowler's 4. Sims'

3. Semi-Fowler's Rationale: To prevent an increase in intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30 degrees. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure.

A hospitalized client diagnosed with seizures has a vagus nerve stimulation (VNS) device implanted. The nurse determines that the VNS is working properly when making which observation? 1. It stimulated a heartbeat when bradycardia occurred during a seizure 2. It defibrillated a lethal rhythm that occurred during the client's seizure. 3. The client activates the VNS devise to stop a seizure from occurring 4. The client activates the device at seizure onset to prevent aspiration.

3. The client activates the VNS device to stop a seizure from occurring Rationale: A VNS is a medical device that is implanted in the chest and stimulates the vagus nerve to control seizures unresponsive to medical treatment. Clients who experience auras before a seizure use a magnet to activate the VNS to stop the seizure.

The nurse is caring for the client who, 6 weeks after an MVA, was diagnosed with a mild TBI. Which information in the client's history of the injury should the nurse associate with the TBI? Select all that apply. 1. The client has had no episodes of vomiting after the accident 2. The client remembers events before and right after the accident 3. The client has had headache and dizziness daily since the accident. 4. The client has difficulty concentrating and focusing while at work. 5. The client lost consciousness momentarily at the time of the injury.

3. The client has had headache and dizziness daily since the accident. 4. The client has difficulty concentrating and focusing while at work. 5. The client lost consciousness momentarily at the time of the injury. Rationale: (3) Recurrent problems with headache and dizziness are the most prominent symptoms of mild TBI. (4) Cognitive difficulties including inability to concentrate and forgetfulness, occur with mild TBI. (5) At the time of the accident, the person with mild TBI may experience a loss of consciousness for a few seconds or minutes

A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect? 1. Tonic-clonic seizures 2. Report of a severe headache 3. Weakness of the lower extremities 4. Decreased level of consciousness

3. Weakness of the lower extremities Guillain-Barre syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities.

Which instructions would the nurse give to a client with multiple sclerosis who has urinary retention? 1. "Run water whenever you experience difficulty initiating urination." 2. "Decrease your fluid intake to prevent urgency." 3. "Drink a caffeinated beverage to promote the ability to form urine." 4. "Catheterize your bladder according to the schedule we discussed."

4. "Catheterize your bladder according to the schedule we discussed." Rationale: Urinary retention in the client with multiple sclerosis is a sequela of impaired conduct of nerves innervating the bladder. Performing self-catheterization will drain the bladder and help prevent urinary tract infection.

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching? 1. A TIA can cause irreversible hemiparesis 2. A TIA can be the result of cerebral bleeding 3. A TIA can cause cerebral edema 4. A TIA can precede an ischemic stroke

4. A TIA can precede an ischemic stroke Rationale: TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include loss of vision in one eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness and weakness.

An unconscious client has left-sided paralysis. Which intervention should the nurse implement to best prevent foot drop? 1. Ensure that the feet are firmly against the footboard. 2. Use pillows to elevate the legs and support the soles. 3. Perform range of motion to the legs and feet daily. 4. Apply a foot boot brace, 2 hours on and 2 hours off.

4. Apply a foot boot brace, 2 hours on and 2 hours off. Rationale: Applying a foot brace provides good support to prevent foot drop. Removing and reapplying it ever two hours allows for pressure reduction and promotes circulation.

The client who has expressive aphasia is having difficulty communicating with the nurse. Which action by the nurse would be most helpful? 1. Position the client facing the nurse 2. Enunciate directions very slowly 3. Use gestures and body language 4. Ask the client to point to needed objects

4. Ask the client to point to needed objects Rationale: Asking the client to point to needed objects would be most helpful when the client is having difficulty communicating with the nurse.

The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs? 1. BP 190/84, HR 150, and an irregular respiratory pattern 2. BP 80/50, HR 50, and Kussmaul respirations 3. BP 80/50, HR 150, and Cheyne-Strokes respirations 4. BP 190/84, HR 50, and an irregular respiratory pattern

4. BP 190/84, HR 50, and an irregular respiratory pattern Rationale: The brain stem's final effort to maintain cerebral perfusion is seen with an increased systolic blood pressure, bradycardia and an irregular respiratory pattern know as Cushing's response.

The nurse is caring for the client with a leaking cerebral aneurysm. What is the earliest sign that would indicate to the nurse that increased ICP may be developing? 1. Change in pupil size and reaction 2. Sudden drop in the blood pressure 3. Experiencing diminished sensation 4. Change in the level of consciousness

4. Change in the level of consciousness Rationale: A change in the level of consciousness is the first sign of neurological deterioration and is often associated with the development of increased ICP.

The nurse assessed the client newly diagnosed with MG. Which finding should the nurse recognize as being unrelated to the diagnosis? 1. Drooping eyelids 2. Slurred speech 3. Weak power extremities 4. Circumoral tingling

4. Circumoral tingling

The client is at risk of septic emboli after being diagnosed with meningococcal meningitis. Which action by the nurse directly addresses this risk? 1. Monitoring vital signs and oxygen saturation levels hourly 2. Planning to give meningococcal polysaccharide vaccine 3. Assessing neurological function with the Glasgow Coma Scale q2h 4. Completing a thorough vascular assessment of all extremities q2h

4. Completing a thorough vascular assessment of all extremities q2h Rationale: Frequent vascular assessments will detect vascular compromise secondary to septic emboli. Early detection allows for interventions that will prevent gangrene and possible los of limbs.

The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse perform to test the cerebellar function of the client? 1. With the client's eyes shut, ask whether the touch with a cotton applicator is sharp or dull. 2. Ask the client to close the eyes, then hold hands with palms up perpendicular to the body. 3. Ask the client to grasp and squeeze, with each hand at the same time, the hands of the nurse. 4. Have the client place the hands on the thighs, then quickly turn the palms up and then down. (REPETITIVE-TEST COORDINATION).

4. Have the client place the hands on the things, then quickly turn the palms up and then down.

The client who has a deteriorating status after having a stroke, has a rectal temperature of 102.3 F. Which should be the nurse's rationale for initiating interventions to bring the temperature to a normal level: 1. A normal temperature will strengthen the client's immune system 2. A hypothermic state may increase the client's chance of survival 3. A normal temperature will decrease the Glasgow Coma Scale score 4. Hyperthermia increases the likelihood of a larger area of brain infarct.

4. Hyperthermia increases the likelihood of a larger area of brain infarct. Rationale: The nurse should initiate temperature reduction measures because a temperature elevation in the client post stroke can cause an increase in the infarct size. This may be due to the increased oxygen demand with hyperthermia and peripheral vasodilation that decreases cerebral perfusion.

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? 1. Flushing of the lower extremities 2. Hypotension 3. Tradycardia 4. Report of headache

4. Report of headache Rationale: Autonomic dysreflexia is a neurologic emergency that can occur in clients who has a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.

The nurse is assessing the client following a closed head injury. When applying nailed pressure, the client's body suddenly tiffins, the eyes roll upward, and there is an increase in salivation and loss of swallowing reflex. Which observation should the nurse document? 1. Decerebrate posturing observed 2. Decorticate posturing observed 3. Positive Kernig's sign observed 4. Seizure activity observed

4. Seizure activity observed Rationale: Body stiffening eye rolled upward, increase in salivation, and a loss of swallowing reflex are signs consistent with the tonic phase of tonic-clonic seizure. This phase is followed by the clonic phase with violent muscle contraction.

A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insidious (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI? 1. Blood urea nitrogen (BUN) 2. Blood glucose 3. Urine Ketones 4. Specific gravity

4. Specific gravity Diabetes insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, infection, or a tumor. It is a condition in which an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure? 1. The client has a new tattoo 2. The client is unable to sit upright. 3. The client has a history of peripheral vascular disease. 4. The client has a pacemaker.

4. The client has a pacemaker. An MRI uses strong magnets and radio waves that are evaluated using computer technology to view three-dimensional images of the body. Since an MRI is magnetically generated, it is not indicated for use in the presence of certain medical implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures.

The clonic in tonic-clonic seizures lasts for this long

40 seconds

Causes of seizures

Acid-base imbalance Fever Head injury CNS infections CVAs Hypoglycemia Brain tumors Drug withdrawal Stopping seizure medications

Seizure precautions

Airway Breathing Circulation Safety Time the seizures Identify pseudo-seizures

This part of the lobe is removed for seizure surgical interventions

Anterior temporal lobe

Hypotonia due to Guillain-Barre syndrome leads to this

Areflexia

This is when the person falls to the ground ("drop attack")

Atonic

This phase of seizures is a sensory warning of seizures

Aural phase

Signs and symptoms of Guillain-Barre syndrome

Bilateral weakness of the lower extremities Paresthesia Hypotonic ANS dysfunction Pain Respiratory failure

Signs and symptoms of typical absent seizures

Brief staring spells

ANS dysfunction due to Guillain-Barre syndrome may lead to this

Cardiovascular dysfunction Arrhythmias

This is the loss of consciousness and muscle tone causing limb jerking

Clonic

Signs and symptoms of tonic-clonic seizures

Cyanosis Excessive salivation Tongue/cheek biting

Signs and symptoms of antiepileptics

Diplopia Drowsiness Ataxia Mental slowing

These types of antiepileptics are used for the treatment of absent and myoclonic seizures

Divalproex (Depakote) Clonazepam (Klonopin)

Rabenzine helps with this neurotransmitter

Dopamine

This is spontaneously recurring seizures

Epilepsy

Risk factors for epilepsy

Family history African-American Male Alzheimer's disease Stroke

Loss of consciousness for generalized seizures last of this long

Few seconds to several minutes

Weakness due to Guillain-Barre syndrome is worst at this time

First few weeks

Plasmapheresis is good for Guillain-Barre syndrome but only works within this timeframe

First three weeks

Signs and symptoms of the aural phase of seizures

Flashing lights Zig-zag lights Different abnormalities Hearing abnormalities

This type of seizure affects one side of the brain

Focal seizures

Characteristics of myoclonic

Forceful enough to cause a fall Usually in brief seizures Occurs in clusters

Types of broad spectrum antiepileptics

Gabapentin (neurontin) Lamotrigine (Lamictal) Topiramate (Topamax) Levetiracetam (Keppra)

Facial seizures may develop into this

Generalized (secondary)

This type of seizure affects both side of the brain

Generalized seizures

Tonic-clonic seizures is also called this

Grand mal seizures

Diagnosis of Guillain-Barre syndrome

History and signs and symptoms CSF EMG MRI*

The bilateral weakness of Guillain-Barre syndrome lasts this long

Hours to weeks

Rapid-acting antiepileptic medications for status epilepticus

IV Lorazepam (Ativan) IV Diazepam (Valium)

Treatment for Guillain-Barre syndrome

IV ig Supportive care Plasmapheresis

This phase of seizures is the person is having a full-blown seizure

Ictal phase

This is the etiology for epilepsy

Idiopathic

This type of cranial nerve disorder means that either the motor or sensory is affected

Mononeuropathy

this is a sudden excessive jerk

Myoclonic

If a generalized seizure develops from a focal seizure, this needs to happen

Neurological checkup and EEG

Pain from Guillain-Barre syndrome is usually worst at this time

Night

Signs and symptoms of generalized seizures

No aura Loss of consciousness

CSF will show this for the diagnosis of Guillain-Barre syndrome

Normal protein initially and high proteins 7-10 days after

This should be assessed in a neurological assessment for drug toxicity of antiepileptics

Nystagmus Poor hand/gait coordination Cognitive functioning Alertness

This symptom of Guillain-Barre syndrome is usually due to paresthesia

Pain

Paresthesia due to Guillain-Barre syndrome leads to this

Paralysis

Cranial nerve disorders are also known as this

Peripheral neuropathies

Status epileptics is a neurological emergency because it can lead to this

Permanent brain damage Respiratory compromise

Absence seizures are also called this

Petit mal

Long-acting antiepileptic medications for status epilepticus

Phenytoin Phenobarbital

These types of antiepileptics are used for the treatment of generalized tonic-clonic and focal seizures

Phenytoin (Dilantin) Carbamazepine (Tegretol) Phenobarbital (Luminal) Divalproex (Depakote)

This type of cranial nerve disorder means that both the motor and sensory are affected

Polyneuropathy

This phase of seizure is when the person is resting and recovering from the seizure

Postictal phase

This type of headache is not caused by another medical condition

Primary headache

This phase of seizures usually occurs hours to days before seizures

Prodromal phase

Phases of the signs and symptoms of seizures

Prodromal phase Aura phase Ictal phase Postictal phase

Signs and symptoms of the postictal phase of seizures

Prolonged sleep Memory loss of the seizure

The most serious sign and symptoms of Guillain-Barre syndrome

Respiratory failure

An MRI for Guillain-Barre syndrome is used for this

Rule out multiple sclerosis

This type of headache is caused by another disease

Secondary headache

Causes of epilepsy

Severe brain injury/congenital birth defect/genetic Infection Metabolic dysfunction Trauma Brain tumor

Causes of secondary headaches

Sinus infection Neck injury CVA

Postictal signs and symptoms of tonic-clonic seizures

Sleepy Lethargy HA No memory of the seizure Abnormal feeling for hours to days later

Types of strange behavior in complex seizures

Smacking lips Picking themselves Walking away

This type of seizure is a constant seizure or seizures in rapid succession without the return to consciousness between seizures

Status epilepticus

Complications of epilepsy

Status epilepticus Tonic-clonic static epilepticus

Secondary generalized seizures may develop into this

Todd's paralysis

This is the sudden increase in tone of the extensor muscles

Tonic

Types of generalized seizures

Tonic-clonic Typical absence Atypical absence

Areflexia due to Guillain-Barre syndrome may cause this

Upper respiratory infectionUrinary tract infection