Neurology A Review

The nurse in the outpatient clinic assesses a client diagnosed with trigeminal neuralgia. The nurse should intervene if the client makes which of the following statements?

"I drink coffee with breakfast and after dinner." -> hot foods can trigger a pain episode; instruct client to avoid foods that are too hot or too cold.

the client diagnosed with quadriplegia after spinal cord injruy is often tearful. when the nurse suggests referral to a rehabilitation hospital, the client says, "what's the use? I'll never be good for anything anyway" which response by the nurse is most appropriate?

"I encourage you to talk about your feelings."

The physician order gabapentin (Neurontin) for a client complaining of neuralgia. the client tells the nurse the client has difficulty swallowing pills. which of the following responses by the nurse is best?

"Open the capsule and sprinkle it in juice and or applesauce."

the nurse instructs the family of a patient diagnosed with Parkinson's. which of the following statements by the family reflects a need for further education?

"we will buy lots of soup for dad." -> thin liquids are difficult to swallow; offer a diet of semisolids with thick liquids; sit in upright position; encourage patient to think through the sequence involved in swallowing.

the client diagnosed with cervical spine cord injury says to the nurse, "my wife is avoiding me. She doesn't love me anymore because im paralyzed!" which is the nurse's MOST appropriate response?

"you seem very upset. Tell me how your wife is avoiding you."

Diazepam is ordered for a 38-pound-child diagnosed with a seizure disorder. the ordered does of diazepam is 0.05 mg/kg. how many mg will the nurse administer to deliver the ordered dose?

0.86 mg 38 lbs/ 2.2= 17.2727 kg 17.2727 X 0.05 mg= 0.36 mg

the nurse notes the client is able to open the eyes spontaneously, follow simple commands, and is oriented to person, place, and date. which glasgow some scale score does the nurse correctly assign to the client?

15

The nursing instructor prepares a class about intracranial hemorrhage for nursing students. which are risk factors for an intracranial hemorrhage?

Arteriosclerosis and hypertension

The nurse in the outpatient clinic cares for a client diagnosed with Bell's palsy. Which action should the nurse take first?

Assess the client's pain experience. -> assessment is always important to providing accurate, effective care.

The nurse identifies that respiratory paralysis may occur if a client experiences a spinal cord injury above which level?

C4

the nurse cares for a client receiving carbamaepine (Tegretol). the nurse understands that carbamazepine (Tegretol) is administered for which of the the following diseases?

Diabetic neuropathy and trigeminal neuralgia -> can lessen the pain of both diabetic neuropathy and trigeminal neuralgia; important to monitor intake and output, supervise ambulation, monitor CBC, take with meals, and wear protective clothing due to photosensitivity

the nurse cares for a client receiving magnesium sulfate IV, and the nurse notes that the client's deep tendon reflexes are decreased. which action should the nurse take first?

Discontinue the IV infusion

A client has a diagnosis of meningitis. A nurse assesses the client. The nurse notes that when the client flexes the heard, the client also flexes the hip and knee. Which action(s) by the nurse is Best?

Immediately report this finding to the health care provider. -> Brudzinski sign is an indication of meningeal involvment; this is the only correct answer in that we do not know if the HCP is aware; other signs or symptoms of meningitis include headache, fever, photophobia, and nuchal rigidity; Kernig's sign (when hip is fleed to 90 degrees, complete extension of knee is restricted and painful), and changes in LOC.

Which of the following nursing goals is MOST realistic and appropriate in planning care for a patient with Parkinson's disease?

Maintain optimal function within the patient's limitations. -> Parkinson's is an irreversible disease that leads to permanent physical limitations; it is most appropriate and realistic to get the patient to maintain optimal functioning within the limitations of his disease process.

The nurse cares for a client diagnosed with absence seizures. It is MOST important for the nurse to take which of the following actions?

Monitor the patient for brief interruptions of consciousness. -> absence seizures are characterized by a momentary episode of loss of consciousness; patient may have a blank stare for a few seconds, or may stop talking in the middle of a sentence; after the seizure the patient is often unaware that he has lost consciousness.

the nurse assesses the client diagnosed with early alzheimer's disease. which action by the nurse provides the best information about the client's ability to participate in self-care activities?

Stay with the client during the bath and observe the client's ability.

The client was diagnosed with amyotrophic lateral sclerosis (ALS) one month ago. The client discusses the progress of the disease with the nurse and suddenly shouts, "Leave me alone. I can't talk about this with you anymore." Which is the nurse's MOST accurate interpretation of the client's behavior?

The client is in the anger phase of a grief reaction. -> common reactions to terminal diagnosis include progression through 5 stages; second stage is anger and the nurse should recognize that the anger is not a personal affront.

The nurse identifies which are the classic signs of Parkinson's disease?

Tremor, bradykinesia, and rigidity. -> these signs result from a depletion of dopamine levels in the basal ganglia. Parkinson's disease is a chronic disease of the nervous system characterized by fine and slowly spreading tremor, muscular rigidity, and altered gate; sight and hearing are intact; disease is progressive but slow, does not lead to paralysis

which information should the nurse provide to the client who is about to have a Caloric test as a part of the neurological assessment?

Vertigo and dizziness may occur during the examination. -> Caloric test is an assessment of the vestibular portion of the eighth cranial nerve; sometimes unpleasant symptoms such as vertigo, dizziness, N/V accompany this test; Caloric test causes nystagmus, which is rapid involuntary eye movements

The nurse in the emergency department admits patients from a multicar accident. Which of the following patients should the nurse attend to first?

clear fluid from the ears could be a sign of a basilar skull fracture; the fluid should be analyzed for glucose, which is elevated if there is cerebrospinal fluid leakage.

the nurse cares for the client diagnosed with Meniere's disease. which assessment finding is consistent with the process?

client reports sudden, incapacitating attacks of vertigo

which intervention should the nurse identify as most important when designing a plan of care for the client diagnosed with guillain-barre syndrome?

monitor for the function of cranial nerves IX and X

The nurse performs assessments in the well-baby clinic. The nurse identifies which finding is a warning sign of cerebral palsy?

the infant has poor head control after 3 months

The nurse cares for the client diagnosed with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). the nurse would expect to observe which finding during the review of the client's laboratory results?

decreased serum sodium levels.

The nurse monitors the client diagnosed with myasthenia gravis. Which symptom would alert the nurse to a potential onset of myasthenic crisis?

difficulty speaking

the client is diagnosed with right-sided hemiplegia after a stroke. the nurse notes resistance to extension of the client's right knee during range of motion (ROM). which should the nurse conclude?

the client is developing a flexion contracture of the knee joint?

the nurse instructs the client diagnosed with early Parkinson's disease about how to limit postural deformities. which observation indicates to the nurse that the client understands the teaching?

the client is doing range of motion exercises when the nurse walks into the room.

during the nursing history, the admitting nurse attempts to identify the aura of the client diagnosed with grand mal seizures. which of the following statements accurately describes an aura?

unusual sensations prior to the seizure-> an aura can be described as a series of unusual sensations that occur as a prodrome to the seizure attack; prodromal symptoms occur in about 50% of all seizure patients and usually include a change in sensation or in affect; the exact character of the aura varies from person to person, but may include numbness, flashing lights, dizziness, smells. and spots before the eyes

the nurse identifies which finding is characteristic of chronic pain?

weight loss or gain fatigue

the nurse cares for the client diagnosed with quadriplegia who is on a ventilator. which task can the nurse delegate to the nursing assistive personnel (NAP) assigned to help with client's care?

assist with feeding the client

The nurse visits the family with three small children who live in a 3 bedroom home built in 1952. The nurse counsels the family about how to avoid lead poisoning. The nurse determines that teaching is effective if the parents make which statement?

"I wet mop all of my floors and wash all of the window sills weekly."

the NAP cares for a client diagnosed with a subdural hematoma who has numerous ecchymoses areas and cigarette burns on the body? elder abuse is suspected. the NAP says to the nurse, "every time I see her family, I get so angry. how could anyone deliberately hurt a loved one?" which response by the nurse is most helpful to the NAP?

"It is very upsetting, isn't it?"

The nurse describes the emergency plan of care when caring for a person diagnosed with a spinal cord injury. which statement indicates the nurse requires ADDITIONAL teaching?

"The head should be held in gentle traction to prevent further injury to the cervical spine."-> traction should be placed on the spine without an x-ray to guide the movement and manipulation of the vertebrae; this will prevent further injury to the spinal cord and nerves.

which statement should the nurse include in the teaching plan when preparing the client for a brain scan?

"You will receive an intravenous injection of an agent that will be traced by a scanner."-> client is given an IV injection f a radiopharmaceutical agent. the radioactivity is traced by a scanner that prints a picture; brain scan is an imaging study of the brain that looks at both structure and function; may be done with or without contrast medium; nursing considerations include assessing the client for allergies to medium agent if used and to elevate kidney function since dye is excreted through the kidneys

While bathing the client diagnosed with a basal skull fracture, the nurse notes that drainage from the client's left ear has stained the bed sheet with a halo-type effect. The drainage tests positive for glucose. The nurse recognize the client is at risk for which condition?

An inflammatory process of the meninges (meningitis)

The nurse plans care for an elderly patient recently admitted for acute pulmonary edema. The nurse understands which of the following nursing assessments is MOST important to prevent the patient from experiencing sensory deprivation?

Assess support system for the family. -> assessing the family support system is critical in identifying appropriate support persons for a patient who is isolated while hospitalized; part of the nurse's role would be to schedule consistent staff contact and encourage visitors to decrease isolation and enhance sensory stimulation.

An unconscious client arrives emergency department following fall that resulted in a severe head injury. Which action should the nurse take FIRST?

Assess the patency of the airway. -> first priority of nursing management is to assure patency and protection of the airway; method of prioritization is utilizing airway, breathing, and circulation; assessment and interventions must be completed for each category before proceeding to the next sequence; changes in vitals, confusion, disturbances of consciousness, sudden onset of neurologic deficits, pupillary abnormalities, sensory dysfunction, visual and/or hearing impairment; etc.

The nurse is caring for a patient with a diagnosis of possible stroke. The client's daughter reports that the client has a history of hypertension that is not managed well. the client is taking antihypertensive medication and hormone replacement therapy. the client's only activity is managing the home, and the client appears overwight. the nurse identifies which is the MOST important risk factor for this client to develop a stroke?

Hypertension. -> hypertension is a major risk factor to developing a CVA.

The nurse prepares a client for discharge from the neurological unit. The client must sleep with the head of the bed elevated 30 degrees, and the client cannot afford to buy a hospital bed that can be adjusted with levers or electronic devices. The nurse learns the client's insurance company will also not pay for the bed. What is the best action for the nurse to take?

Instruct the client to collect or buy several pillows. -> pillows can be used to raise the head of the client to the correct 30 degree elevation; these would also be comfortable, thereby enhancing sleep; if the client has enough pillows at home, new ones may not need to be purchased.

The client diagnosed with damage to the 5 and 6th vertebrae is one a Stryker frame and has crutchfield tongs in place. After the morning baseline assessment, which is the nurse's FIRST priority for care?

Perform necessary measures to clear bronchial and pharyngeal secretions.

The nurse cares for the client diagnosed with a spinal cord injury. The nurse performs discharge teaching about how to prevent contractures from occurring. which activity should the nurse teach the family/caretakers that they will need to do for the client?

Perform range of motion exercises. -> passive ROM exercise should be performed for the client at least 4 times daily to prevent contractures; ROM exercises should be implement ASAP when the client is immobile.

The nurse cares for the client on the med/surg unit. which client should the nurse see FIRST?

a newly admitted client diagnosed with a head injury. -> client with the head injury is the most unstable and has the most serious condition of the 4 clients; head injury can cause increased intracranial pressure and a changing level of consciousness. The RN needs to immediately assess and elevate this client for any problems; establishing priorities enables the nurse to attend to the client's most important needs and helps the nurse organize care. Situations that could cause physical harm to the client if left untreated have the highest priority; using Maslow's hierarchy of needs enables the nurse to establish priorities.

Prior to surgery for myelomenigocele, which action should the nurse perform to care for the area of the defect?

apply a moist, sterile dressing

the nurse cares for the client being evaluated for Guillain- Barre Syndrome. which sign is most suggestive of guillain-barre syndrome?

ascending paralysis

the nursing instructor prepares a class about stroke to teach nursing students. which is a known risk factor for a stroke?

atrial fibrillation

which symptoms can the nurse expect the client diagnosed with Meniere's disease to exhibit?

episodic attacks of vertigo, fluctuating hearing loss, tinnitus, and ear fullness accompanied by nausea and vomiting -> Meniere's disease is caused by dilation of the endolymphatic system; signs and symptoms include tinnitus, unilateral sensorineural hearing loss, and veritgo; treatment includes salt and fluid restriction to decrease amount of endolymphatic fluid, antihistamines, antiemetics, and surgery

The nurse cares for the client diagnosed with a left hemisphere stroke. One moment the client is very depressed and cries, and the next the client is euphoric and breaks into inappropriate laughter. How should the nurse address this behavior in the plan of care?

explain to the family that the client's behavior is not intentional. -> it is very important to explain to the client's family that his behavior is a symptoms of the stroke and not purposeful behavior. Stroke is a sudden disruption in blood supply to brain, resulting in a sudden loss of brain function that may be temporary or permanent; caused by thrombosis, embolism, ischemia, or hemorrhage

the nurse finds a client diagnosed with Meniere's disease leaning over the sink in the room and clutching it with both hands. after determining that the client is having an acute attack, which action should the nurse take first?

help the client back to bed and place a pillow on either side of the client's head.

the nurse cares for the client diagnosed with a spinal cord tumor. the client reports pain. the client has diarrhea as an adverse affect of intravenous antibiotics. these interventions are required to care for this client. which would the nurse do first?

medicate the client for pain -> relieving the client's pain is first priority in this list; other needs can be met after the pain is alleviated; pain is often referred to as the 5th vital sign and is defined as "whatever the person says it is, and it exists whenever the person says it does." can be acute or chronic; culture and past experiences with pain are major factors that influence pain experiences

which intervention should the nurse include in the plan of care for the client diagnosed with an acute attack of Meniere's disease?

medications and fluids to be given IV -> severe vertigo often triggers N/V, making it difficult for clients to retain medications, foods, and fluids ingested orally.

which nursing intervention is most beneficial to the client diagnosed with multiple sclerosis who is experiencing diplopia?

patch one eye

the nurse knows which of the following statements describes an important consideration when spinal anesthesia is used?

patients must be protected from injury since sensation is impaired-> frequently assess sensation and voluntary movement; other side effects include hypotension and HA

Which transmission-based precaution should the nurse implement when caring for the client suspected of having Neisseria meningitidis meningitis?

private room and put on a mask if within 3 feet of the client.-> organism that causes Neisseria m. spreads by droplet.

The nurse performs an assessment for the client reporting severe HA and new onset seizure activity. After completing the client's admission, the nurse says good-bye and leaves the client chatting with the client's family. The next day, the nurse finds the client difficult to rouse. The systolic BP is elevated, pulse pressure is widening, and the client has bradycardia. Which is the CORRECT interpretation of these findings?

rising intracranial pressure -> when ICP rises, the combination of cardiac and vascular reflexes are activated, causing a classic rise in systolic BP, fall in diastolic BP, and decrease in HR called "Cushing's Triad."

Which finding does the nurse expect to see when assessing the client diagnosed with Parkinson's disease?

shuffling, propulsive gait.

which is the highest priority nursing action to include in the plan of care for the client diagnosed with myasthenia gravis?

teach coughing and deep breathing techniques

the client with hemiplegia. which aspects of the client's condition is it essential for the nurse to consider when applying a leg brace?

the client has no sensation in the leg to which the brace is applied. -. if the client has no sensation, will not be able to detect if the brace is too tight; hemiplegia is paralysis of one side or the body; client may recognize only one side of body; nursing considerations include protecting client from injury and providing supportive devices to prevent subluxation or dislocation of affected joints.

the nurse cares for the infant immediately after insertion of a shunt due to hydrocephalus. which observation by the nurse should be reported to the health care provider immediately?

the infant's pupils are dilated-> indicates intracranial pressure

the nurse finds a client diagnosed with Meniere's disease leaning over the sink in the room and clutching it with both hands. after determining that the client is having an acute attack, which action should the nurse take first?

help the client back to bed and place a pillow on either side of the client's head.-> vertigo feels like room is spinning; may cause client to fall; lying down will prevent injury; pillows on either side of the head will prevent movement, which aggravates the vertigo.

the nurse instructs a client receiving phenytoin sodium. the nurse determines further teaching is necessary if the client makes which statement?

"If my urine changes color, I should immediately go to the ED."

the nurse cares for the client diagnosed with a stroke. the health care provider orders enteral feeding. the client's partner asks the nurse, "why is my partner not getting parenteral nutrition (PN)?" which statement by the nurse is most appropriate?

"Your partner's gastrointestinal tract can still digest feedings." -> stroke will affect motor movement and the client may not be able to eat; however, the body is still able to digest food once it is in the stomach.

the nurse instructs a client diagnosed with Bell's palsy. It is most important for the nurse to make which statement about a nighttime care?

"apply an eye shield over the affected eye."-> corneal abrasion can cause blindness; this can occur with Bell's palsy, because the client is unable to close the eye.

the nurse cares for the client diagnosed with a serious closed head injury. the client's parent says to the nurse, "will my child be all right? Is my child going to die? I'm so scared." which response by the nurse to the child's parent is best?

"It must be frightening to see your child hurt."

The nurse cares for a patient suspected of having a seizure disorder. the patient tells the nurse, "I smelled oranges today and there wasn't one of my tray." which of the following responses by the nurse is BEST?

"have you experienced this sensation before?" -> the nurse should suspect at this time that the patient is describing an aura; this specific warning serves a useful purpose in that it enables the individual to seek safety and privacy before the onset of the seizure; the aura represents the local signature of the attack, and is the result of abnormal stimulation of the cortical area.

the client is diagnosed with an incomplete C8 spinal cord injury. the client and the nurse discuss the client's potential living arrangements after discharge. which client statement to the nurse, indicates the client understands the limitations due to the spinal cord injury?

"i will be able to drive my care once it is outfitted with hand controls."-> client with an incomplete transection of the spinal cord at level C8 will be minimally independent in care and will be in a wheelchair; these clients will be able to drive an automobile with hand controls; client will not be able to ambulate, nor will the client have full bladder or bowel control

the nurse cares for an elderly client admitted for chest pain. the client says to the nurse, "I know my children visited my today, but they deny it. What's going on? I'm so mixed." The nurse suspects such distortions in thinking are due to sensory alterations. Which of these actions by the nurse is BEST?

Allow the client to discuss the "mixed-up" feelings. -> sensory deprivation occurs in institutionalized patients because of an inadequate quality or quantity of stimulation; the nurse should help a person in the situation realize that is a temporary that he is experiencing, caused by sensory deprivation; will help relieve his anxiety that this is not a permanent situation and is part of his disease.

the nurse plans care for the infant diagnosed with a myelomeningocele. Which principle of nursing care is MOST important to apply when caring for this infant?

Asepsis-> infection may cause meningitis and damage the brain; the central nervous system is very delicate; asepsis is extremely important

the client diagnosed with a spinal cord injury is treated with halo traction. which intervention should the nurse include in the client's plan of care?

Clean pin sites according to institutional policy. -> purpose of traction is to immobilize fracture, alleviate pain and muscle spams, prevent or correct deformities, and promote healing.

The nurse cares for a patient diagnosed with a closed head injury and increased intracranial pressure. Which of the following actions by the nurse is BEST?

Instruct patient to exhale when turning or moving in bed. -> prevents Valsalva maneuver; which raises intracranial pressure, avoid straining, administer stool softeners.

The nurse cares for a client hospitalized for treatment of an abdominal gunshot wound. Hx reveals the client has been enrolled in a methadone maintenance clinic for the past 2 years. The nurse notes the client has no orders for contrinuation of the methadone. The nurse anticipates which activity may occur?

The client will experience N/V, and abdominal cramps

the nurse care for a patient admitted to the emergency room following an automobile accident. the patient complains of dizziness, and the physician suspects a head injury. The nurse should intervene if which of the following is observed?

The patient is leaning forward with his head over the knees. -> patients with head injuries are treated as spinal cord injuries until x-rays are completed; patient's neck should be immobilized prior to x-rays.

The nurse identifies which of the following manifestations is MOST characteristic of mysathenia gravis?

Tiredness with slight exertion. -> because of acetylcholine deficiency, transmission of nerve impulse is limited; makes it difficult to stimulate or initiate musclar movement; final result is tiredness with the slightest amount of exertion.

A patient diagnosed with Parkinson's disease has tremors of both upper arms. The nurse observes that the tremors disappear as the patient unbuttons his shirt. Which of the following statements indicates the most accurate understanding of the tremors?

Tremors decrease in severity when attention is diverted by activity. -> patients with Parkinson's usually only exhibit tremors at rest; if the patient is given an activity to perform, the tremors seem to go away due to the diversion.

the nurse understands that which of the following cranial nerves is affected in tic douloureux?

Trigeminal.-> V cranial nerve; controls jaw movement and sensation on the face and neck; tic douloureux (trigeminal neuraglia) usually affects patients older than 50; causes bouts of facial pain; treated with medication.

The nurse cares for a patient diagnosed with Menere's disease. The nurse expects the patient to exhibit which of the following?

Vertigo, hearing loss, tinnitus. -> Menere's disease is an inner ear disorder characterized by this triad of symptoms.

the nurse performs a nursing assessment on a client with a history of migraine headaches. the nurse records the list of current medications and recognizes which medications is used to treat migraine headaches?

Zolmitriptan

the nurse cares for the client diagnosed with myasthenia gravis. it is most important for the nurse to schedule personal care during what time of the day?

in the morning

the nurse assesses the client diagnosed with with transient ischemic attack (TIA). the nurse anticipates the client will report which symptom?

acute right lower extremity weakness that lasts about 15 minutes

the home care nurse visits a client living in a department living facility. the client is receiving risperidone (Risperdal). the nurse notes the client has a shuffling gait and trembles when reaching for reading glasses. the nurse did not notice these behaviors on the previous visit. which action by the nurse most appropriate?

contact the client's physician-> displaying symptoms of pseudoparkinsoniam; physician may order benztropine (Cogentin) or trihexyphenidly (Artane); instruct client to change postions slowly, and to use sunscreen and wear protective clothing

the nurse cares for a client diagnosed with ICP. which is the msot important short-term goal?

control agitation and restlessness.

an client reports to the nurse about having difficulty remembering recent events and today's date. the nurse recalls which is the most likely cause these behaviors?

dementia

which intervention might the nurse include in the plan of care for a client diagnosed with myasthenia gravis?

schedule the client's activities in the morning. -> muscle strength is usually greatest in the morning and weakens as the day progresses; muscle strength usually improves after periods of rest

the 4-month-old infant is seen in the well-child clinic. the nurse is most concerned if which finding is observed?

the infant's head lags when pulled from a lying to a sitting position

The client diagnosed with Alzheimer's disease is confused and not able to remember simple activities of daily living. The client has been living in a long-term care facility for the past 6 months. the family expresses concerns to the nurse about the client's confusion and memory loss. which response by the nurse best addresses the family's concerns about memory loss?

"Memory loss will continue to make tasks difficult for your loved one."

The nurse cares for the client diagnosed with Guillain-Barre. Which complications is MOST important for the nurse to continually assess?

Respiratory Functioning-> since guillain-barre syndrome is an inflammatory disease involving demyelination of the nerves causing ascending weakness of muscles, the client must continually be observed for respiratory compromise

which statement, if made to the nurse by the parent of an 8-month-old child, indicates delay in the child's development?

"my child has almost doubled the birth weight." -> an infant's birth weight should double by 5 months; since the infant is 8 months old, the fact that she has only now almost doubled her birth weight may indicate a possible delay in development

The nurse cares for a patient scheduled for an EEG. to prepare the patient for the test, it is most important for the nurse to state which of the following?

"the procedure is not painful but you must lie still." -> although an EEG is painless, the patient has to remain still for the duration of the test.

the nurse cares for the client diagnosed with alzheimer's disease. the client says to the nurse, "I really like this hotel." which response is the most appropriate for the nurse to make to the client?

"this is the hospital." -> clients with memory loss should be reorientation and feel demeaned by this response

the NAP works with the client diagnosed with a stroke and right-sided hemiplegia. the NAP positions the client with the right arm leg elevated and the foot against a footboard. which is the nurse's best instruction to the NAP regarding the client's position?

"you should not use a footboard, as this promotes plantar flexion rather than prevents it." -> constant pressure against the sole of the foot stimulates plantar flexion and contributes to foot drop

which clinical manifestation should the nurse anticipate when caring for a client with a history of multiple sclerosis?

1. urinary retention 3. hyperreflexia of the extremities 5. ataxia 6. decreased concentration

Which clinical manifestations should the nurse anticipate when caring for a client with a history of multiple sclerosis?

1. urinary retention.-> because of the progressive demyelination of the spinal cord, gradual weakness leading to paralysis is expected; alterd innervation of the bladder and urinary tract is expected, leading to urinary retention. 3. Hyperreflexia of the extermities. -> causes intention tremors, muscle weakness, and spasticity, paresthesia 5. Ataxia. -> impaired coordination of movement due to cerebellum or basal ganglia involvement. 6. decreased concentration. -> frontal or parietal lobe involvement lead to some cognitive changes.

when caring for a client diagnosed with Guillain-barre syndrome, which does the nurse identify as the most serious complication of this syndrome?

Respiratory failure

The child is admitted with lead poisoning. which symptom does the nurse expect to see?

anemia, hearing impairment, and distractibility-> also includes irritability, sleepiness, nausea, vomiting, abdominal pain, increased ICP; treatment includes chelation

The nurse cares for a client admitted to the med/surg unit diagnosed with a stroke. The nurse plans care to prevent the client from experiencing sensory overload. The nurse determines that which plan is MOST effective?

The nurse obtains vital signs and assists the patient with am care in one visit. -> combine activities in one visit to prevent client from becoming overly fatigued; schedule time for rest and quiet.

During the nursing history, the admitting nurse attends to identify the aura of a client diagnosed with grand mal seizures. Which of the following statements accurately describes an aura?

Unusual sensations prior to the seizure-> an aura can be described as a series of unusual sensations that occur as a prodrome to the seizure attack; prodromal symptoms occur in about 50% of all seizure patients and usually include a change in sensation or in affect; the exact character of the aura varies from person to person, but may include numbness, flashing lights, dizziness, smells, and spots before the eyes.

the nurse cares for a child experiencing seizure activity. the nurse should intercede if which intervention is observed?

a padded tongue blade is placed on the child's bedside table. -> attempt to put anything into the mouth to prevent the child biting tongue (or for any) reason may break child's teeth; epilespy is a chronic disorder characterized by recurrent seizure activity; seizures are an indication of brain or CNS irritation

the nurse care for the child with a head injury. which statement best describes decorticate posturing?

arms are flexed and held toward the core of the body

which best describes the events leading to death of neurons after an ischemic stroke?

accumulation of sodium and water inside the neurons in the affected area-> decreased formation of ATP due to decreased blood suply to the neurons; failure of the sodium-potassium pump sodium, water and calcium accumulate inside the neurons; destruction of cell membrane and decreased mitochondrial function cause death of neurons.

the nurse cares for the client diagnosed with a spinal cord injury. the nurse enters the client's room to hang an IV antibiotic. the nurse notes the client has diarrhea, and the client reports experiencing pain. which action should the nurse take first?

administer the prescribed pain medication

the nurse cares for the client diagnosed with a stroke. the client has hemiplegia, sensory/perceptual loss, and cognitive dysfunction. during the client's first 72 hours of hospitalization, which nursing diagnosis has highest priority?

altered (cerebral tissue perfusion)

an unconscious client arrives in the emergency department following fall resulted in a severe head injury. which action should the nurse take first?

assess the patency of the airway

the nurse must transfer the adult client with right-sided weakness from the bed to a wheelchair. where should the nurse position the wheelchair?

at a 45-degree angle to the head of the bed on the client's unaffected side. -> nursing considerations for transferring client includes using proper body mechanics, raising rise rail on opposite side of bed, raising bed to comfortable height for nurse, assessing client's mobility and strength, encouraging client to help as much as possible, obtaining assistance if needed for safe transfer; if client has weak side, transfer to strong side; use larger muscles of legs rather than smaller muscles of the back

when assessing the 9 month-old child, the nurse expects which reflex to be present?

babinski's

the child with attention deficit hyperactive disorder (ADHD) is taking methylpendiate. the nurse knows that methylphenidate is prescribed for this child for which effect?

central nervous system stimulant.

The nurse cares for a patient diagnosed with a spinal cord injury at the level of T3. the patient complains of a pounding headache and nasal congestion. the nurse notes that the patient has profuse sweating from the forehead and piloerection. Which of the following actions should the nurse take first?

check the foley catheter and tubing for kinks. -> if no foley is present, check for bladder distention and catheterize immediately.

The nurse notes a newly admitted patient diagnosed with a head injury has a clear nasal drainage. Which of the following actions should the nurse take FIRST?

check the nasal drainage for glucose. -> basilar skull fracture can cause leakage of cerebrospinal fluid; nurse should assess ears and nose; cerebrospinal fluid tests positive for glucose.

The nurse cares for the client after a motor vehicle accident. The client is diagnosed with an epidural hematoma. epidural hematoma is most commonly associated with which condition.

damage to the middle meningeal artery.

While the nurse ambulated the client to the bathroom, the client begins to have a seizure. which of the following actions should the nurse take FIRST?

ease the patient to the floor. -> client should be eased to the flood at the onset of the seizure; one of the primary goals of a nurse caring for a client who is having a seizure is to protect the client from injury; the person should never be left alone, and if he is in an upright position when a generalized motor seizure begins to occur, he should be lowered to the floor; and adjacent articles and equipment should be moved to prevent injury.

which joint deformities does the nurse identify as most likely the result of ineffective range of motion exercise following stroke?

flexion contracture of the wrist-> common; risk and severity can be greatly reduced by implementing effective range of motion exercise immediately following the event; ROM exercise are active or passive exercises that assess and facilitate joint mobility; include abduction, adduction, flexion, extension, inversion, eversion, pronation, supination, internal and external rotation, dorsiflexion, and plantar flexion.

the adolescent cares for the client after a skateboard accident that resulted in a belief episode of unconsciousness. the client's scalp and facial lacerations were treated and dressed in the emergency department. which nursing care measure is the highest priority?

frequently assess the client with glasgow comma scale (GCS)

the nurse instructs a client about an electroencephalogram (EEG). the nurse informs the client which of the following foods should be omitted from the client's diet before the test?

hot chocolate -> contains caffeine, beverages that contain caffeine are usually restricted prior to prior to EEG for 1 or 2 days

the client diagnosed with a left-sided stroke has difficulty swallowing. a gastrostomy tube is inserted for enteral feedings. how should the nurse position the client when administering a gastrostomy tube feeding?

in high fowler's or with head of bed elevated 30 degrees-> position helps lowers the risk of aspiration; enteral tube feeding is delivery of liquid food to the stomach, distal duodenum, or proximal jejunum by way of a tube; can be continuous or intermittent; nursing considerations include ensuring that the feeding is at room temperature, elevating head of bed at least 30 degrees, verifying tube placement, checking for gastric residual, returning residual to stomach unless greater than 100 mL, flushing tubing with 30 mL water, initiating feeding, and flushing tubing with 30 mL water

which mobility goal can be the nurse expect for the client diagnosed with a spinal cord injury at the level of L5?

independent ambulation without equipment.

which nursing action will prevent injuries related to sensory problems for the client diagnosed with multiple sclerosis?

inspect the client's body parts frequently for injury -> clients diagnosed with MS or their health care provider needs to inspect the body for injury; MS clients may have an injury and not be aware of it due to lack of sensation; MS is a progressive disorder of nurse impulse transmission characterized by demyelination of white matter throughout brain and spinal cord.

the nurse enters the room of a client admitted for evaluation of a convulsive disorder. the family members report the client just had a seizure. after determining vitals are normal, there are no injuries, and placing the client in side-lying position, which action will the nurse take next?

interview the family about what they observed and accurately document their response using their own words.

a patient is admitted to the hospital with symptoms of myasthenia gravis. when caring for this patient, the nurse should give priority to which of the following nursing goals?

maintain respiratory function. -> because of acetylcholine deficiency, the conduction of nurse impulses is either limited or blocked at the myoneural junction; results in easy fatigability and muscle weakness of the respiratory muscles that could lead to a respiratory arrest if untreated.

the nurse cares for clients on the rehabilitation unit. a client reports having trouble focusing the eyes when trying to read. the nurse learns the client has not had a problem in the past. the nurse notes the client has been receiving phenobarbital for more than a year. it is most important for the nurse to take which action?

obtain an order for a blood specimen. -> nystagmus is early sign of toxicity; other signs include confusion, dyspnea, and slurred speech; therapeutic blood levels are 10-40 microgram/mL

the client diagnosed with a traumatic brain injury develops a temperature of 104 degrees F. which is the most important intervention for the nurse to take?

place the client on an automatic cooling blanket -> hyperthermia increases metabolic rate and cerebral oxygen demand

the nurse identifies a nursing diagnosis of "altered nutrition: less than body requirements related to inability to feed self," for a client with right-sided hemiplegia. which intervention is most appropriate to improve the client's nutrition?

provide a pureed diet. -> pureed, soft, or semisoft foods are easier to swallow than liquid food, position client in upright position with head and neck positioned slightly forward and flexed.

the rehabilitation nurse cares for the client diagnosed with a cervical spinal cord injury. the client tells the nurse, "I feel lousy. my vision is blurry and I have a pounding headache." the nurse takes the client's blood pressure and notes that it is 210/120. the nurse observes the client's urinary catheter is kinked. which action should the nurse takes first?

raise the head of the bed 45 degrees

the nurse performs a neurological assessment of the client. the client has a glasgow come score of 3. which nursing diagnosis indicates the nurse correctly analyzes the neurological assessment findings?

self-care deficit

the nurse cares for the client in a coma due to a head injury. the client's parents ask the nurse, "should we even visit our son? he is comatose and does not even know if we are here or not?" which is the best way for the nurse to respond to the client's parents?

suggest to the parents that their presence is important, even though the client does not seem to have awareness.

the nurse cares for the client diagnosed with multiple sclerosis (MS) experiencing motor weakness. which nursing action should be included in the client's plan of care to promote optimal mobility?

support the client when ambulating-> supporting the client is necessary due to the motor weakness to provide safety and prevent falls; client should also walk with a wide base, which will aid balance and movement

the nurse cares for the client diagnosed with a stroke resulting in paralysis on the right side. the client needs to be transferred from the bed to the wheelchair. which is the correct transfer technique for the nurse to use?

support the standing client for a minute before moving towards the wheelchair-> this allows the nurse assess the client in an upright position, assuring her ability to move to the next phase of the transfer process; extending the joints in this manner and allowing the body's forces to be exerted is essential for integrity of the bones

The client experiences extreme muscles weakness, fatigue, and diplopia. the health care provider decides to test for myasthenia gravis using an injection of edrophnoium. the nurse identifies which results in positive for the diagnosis of myasthenia gravis?

the client experiences a dramatic but temporary improvement in symptoms within 30 seconds of the edrophonium (Tensilon) injection

the nurse cares for the client diagnosed with an intracranial bleed. the nurse notes pupils are not equal (two mm and five mm), the larger pupil is non-reactive to light, and the client only responds to pain. which explanation does the nurse determine based on this assessment?

the client has symptoms of intracranial pressure-> when pressure is applied to cranial nerve III, dilation may first occur on the ipsilateral side; this pupil does not react to light; as cerebral pressure increases, both cerebral hemispheres are affected, and bilateral pupil dilation and fixation may occur

the nurse performs the assessment of the client diagnosed with increased ICP. the nurse notes the pupils are dilated and fixed. the client is more difficult to rouse. how should the nurse interpret this data?

the client's condition is deteriorating. -> as the pressure within the rigid cranium increases, circulation to the brain diminishes, resulting in deeping stupor, fixed dilated pupils, coma, and eventual death.

the nursing assistive personnel (NAP) placed the client with right-sided hemoplegia in the prone position with the client's feet hanging off the end of the bed. the client is no acute distress when the nurse checks on the client. which is the nurse's most appropriate conclusion regarding client's position?

this is an appropriate position-> prone position is excellent if the client is able to tolerate it; skin breakdown is decreased, and the hips and knee joints are extended by means of gravity; allowing the feet to hang off the end of the bed counteracts footdrop; purposes of positioning are to maintain proper body alignment, prevent injuries, optimize ROM and comfort, facilitate breathing, eliminate secretions, promote cardiovascular function, encourage normals ADLs such as feeding, bathing, elimination, and sleep; prevent of pressure, friction, and skin shear is necessary.

the nurse assesses the client diagnosed with a head injury and notes the client's arms are stiffly extended, abducted, and hyperpronated. the client's legs are hyperextended with plantar flexion of the foot. which is the best way for the nurse to interpret the client's position?

this is decerebrate posturing and results from disruption of motor fibers in the midbrain and brainstem.

the nurse cares for the client diagnosed with severe traumatic brain injury with increased ICP. what is the rationale for the fluid restriction?

to decrease cerebral edema

The nurse cares for a client with a Glascow coma scale of 7. the nurse identifies it is important to give eye care to this patient for which reason?

to prevent corneal irritation. ->score of 7 or less on Glascow come scale indicates patient is comatose and the eyes may stay partially open causing the corneas to dry out and become irritated; treatment or preventive care involves keeping the corneas moist by using methylcellulose eyedrops or artificial tears; if corneal reflexes is absent, a protective shield should be put over the eyes to prevent scratches to the corneas.

the nurse cares for the child after a lumbar puncture. the child asks the nurse, "why do I have to be flat in bed?" which is the correct rationale for the nurse provide?

to prevent headache -> CSF leakage at the puncture site is believed to causes HA; normally, CSF stabilizes the brain, but diminsed CSF volume causes tension on pain-sensitive structures when the client is upright; persistent post-lumbar puncture HA that do not respond to rehydration and bed rest may be treated with an epidural blood patch

the nurse performs a Caloric test as part of the neurological assessment of the client. which information does the client need to know before the Caloric test?

vertigo and dizziness may occur during the examination. -> caloric test is an assessment of the vestibular portion of the eighth cranial nerve; sometimes, unpleasant symptoms such as vertigo, dizziness, nausea, and vomiting accompany this test; caloric test causes nystagmus, which are rapid involuntary eye movements.

the nurse cares for the child with a closed head injury. which symptoms correctly indicate to the nurse increased intracranial pressure?

widening pulse pressure and a lowered pulse-> these two symptoms are classic characteristics of increased ICP; the cranium is a closed cavity with no room for expansion except in infants whose fontanels have not closed; increase in pressure causes shifting of brain; causes of increased ICP include bleeding, tumors, and edema

the nurse cares for a newborn delivered by a mother addicted to narcotics. during which of the following times is the nurse most likely observe symptoms of narcotic withdrawal?

within 24-72 hours after birth