Neurosensory ATI

client had a craniotomy 3 weeks ago & remains unconscious. While bathing client, the AP talk to him about current events. Clients wife asks about AP's actions. What statement reinforces clients wife the importance of talking to client ?

"Clients like your husband, who are unconscious, may still be able to her." (provides sensory stimulation & should be encouraged)

collecting data from client 6 days post craniotomy for removal of an intracerebral aneurysm. What's a statement from client indicating an early sign of ↑ ICP ?

"Could you get me my emesis basin? I feel nauseated" {nausea/vomiting may occur w/ ↑ ICP. Classic 3 symptoms of ↑ ICP in a conscious client are nausea, headache, & diplopia (double vision)}

nurse is shopping & finds a woman who has collapsed w/ right sided weakness & slurred speech. Appropriate action ?

call emergency management services (client displays symptom of a stoke & is a medical emergency)

caring for unconscious client following cerebral hemorrhage. Highest priority nursing intervention ?

suction saliva from clients mouth (unable to indep. maintain a clear airway & is at risk for ineffective airway clearance)

caring for client 1 day postop following spinal fusion. When assisting client, nurse should expect what intervention ?

log roll client Q2hrs (should log roll from side→back or back→side Q2hrs) (should avoid prolonged sitting; clear drainage on spinal dressing could indicate a cerebrospinal fluid leak. Nurse should report this to surgeon asap; when sitting in chair, clients feet should rest on floor)

caring for client who has primary dementia. What manifestations are expected ?

forgetfulness gradually progressing to disorientation (appears 1st as forgetfulness); (loss of functioning progresses slowly form impaired language skills & difficulty w/ ordinary, daily activities to severe memory loss & complete disorientation w/ withdrawal from social interaction)

nurse is giving shift report using SBAR to oncoming nurse on client who has traumatic brain injury. When reporting info about client, whats included in situation segment of SBAR ?

history of the injury (under the 'situation' segment of SBAR; include the Glasgow coma scale under 'assessment' segment; include intra cranial pressure readings under 'assessment' segment; include the med that is needed during the next shift under the 'recommendation' segment)

caring for client following surgical tx for a brain tumor near the hypothalamus. What's client at risk for ?

inability to regulate body temp {hypothalamus controls body temp, fluid balance, particular emotions (such as pleasure & fear), sleep, & appetite}

caring for client diag w/ myasthenia gravis. What indicates client is experiencing an advanced symptom of this disease ?

incontinence (bowel & bladder incontinence)

assessing a client who has an 8 score using Glasgow Coma Scale to evaluate LOC. What nursing statement most accurately describes score ?

indicates the need for total nursing care (client is in a coma & require total nursing care) (a seep coma who be a score of 3)

planning care for client newly diagnosed with myasthenia gravis. Nurse determines highest priority concern when providing care is...

ineffective breathing pattern (MG is a chronic neuromuscular disease characterized by varying degrees of muscular weakness. MG is caused by a defect in the transmission of nerve impulses due to the body's inability to use the neurotransmitter acetylcholine at the neuromuscular junction. The classic manifestation of MG is muscle weakness that increases during periods of activity & improves after a period of rest. Typically involved muscles are those that control eye movement, facial expression, chewing, swallowing, & talking. Since the muscles that control breathing may also be involved using the airway, breathing, circulation ABC priority setting framework, this would represent the highest priority in the clients care)

caring for client w/ multiple sclerosis. What clinical finding is associated w/ nystagmus in this client ?

involuntary movement of the eyes

assisting w/ adm of client w/ a concussion following vehicle crash. Whats an early sign of ↑ ICP ?

lethargy (LOC is most important indicator)

assessing client who was involved in automobile accident for corneal reflexes. What action should nurse implement ?

lightly touch eye with a wisp of cotton (corneal reflexes result from loss of ability to blink, due to head injury or stroke)

caring for client w/ meningitis who has temp of 103.5°F & has been placed on hypothermia blanket. While using this therapy, nurse understands client must be carefully observed for which complication ?

shivering {hypothermia (cooling) blanket, if used improperly (at inappropriately ↓ temps, or w/out skin protection), can cause client to cool too fast → shivering}

caring for client who has progressive presbycusis. Whats an appropriate nursing action ?

speak directly to the client in a normal, clear voice

monitoring client who has a traumatic head injury. What manifestations should nurse report stat to provider ?

sudden sleepiness (sign of ↑ ICP)

caring for client who has paralegia following automobile accident. On an intermittent urinary cath program. What finding indicates need for cath ?

suprapubic discomfort (indicator of bladder distension. Should perform intermittent cath when distention is present to prevent bladder trauma)

providing information to family. Client prescribed donepezil (Aricept) for Alzheimer's disease. What med information should be included ?

syncope episodes may occur (which places the client at risk for falling due to an adverse effect of bradycardia; taken at bedtime for best effect in improving cognition; monitor for diarrhea)

collecting data for a neurological assessment for a client receiving tx for head trauma. What info is needed for function of the 3rd cranial nerve ?

instruct the client to look up & down without moving his head (extraocular eye movements)

caring for adult client who is undergoing eval for a possible brain tumor. When performing neuro exam, whats most reliable indicator of cerebral status ?

LOC

caring for client who sustained a basal skull fracture. Notices a thin stream of clear drainage coming from right nostril. Priority nursing action ?

test the drainage for glucose (because of high risk of cerebral spinal fluid leak w/ basal skull fractures)

collecting data on client who has possible diag of Guillain-Barre syndrome GBS. appropriate question for nurse to ask ?

"Have you had a recent upper resp infection?" (upper resp infections are associated w/ GBS; ask if received vacc for flu, strept A, or rabies associated w/ GBS)

client is a quadriplegic from a spinal cord injury & is adjusting to home environment. What client statement indicates adapting ?

"I am using the modified feeding utensils at every meal. I still spill, but I'm getting better."

reinforcing teaching about phenytoin (Dilantin). What statement indicates need for further teaching ?

"I'll be glad when my seizures stop so i can quit taking this med" (anticonvulsant meds commonly require taking for life, & phytoin should ∅ be stopped unless indicated)

reinforcing discharge instructions to multiple sclerosis (MS) pt. Client reports symptoms of diplopia, dysmetria, & sensory change. Appropriate statement ?

"Implement a schedule to include periods of rest" (schedule periods of exercise followed by periods of rest to maintain muscle strength & coordination)

talking with an older adult client recovering from a cerebrovascular accident. Client states "i feel like less of a man. My wife says she is thankful I am alive but I'm sure this is not how she expected us to spend out retirement years." Appropriate response ?

"In what ways do you feel like you are less of a man?"

caring for client with aphasia following stroke. Family member asks how she should communicate w/ client. Appropriate response ?

"Incorporate nonverbal cues in the conversation." (enhances clients ability to comprehend & use language)

caring for hospitalized older adult F who has hemiplegia from a cerebrovascular accident. Clients adult son is distressed over mothers crying & deteriorating condition. Appropriate response ?

"It must be hard to see your mother so ill & upset" (demonstrates empathy & acknowledges sons feelings of helplessness & powerlessness)

client is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Whats a statement indicating need for teaching ?

"It's unfortunate that I have to be in the hospital for this tx." (client must attach electrode pads to skin of choice & should remove hair for pads)

caring for client who has Meniere's disease. When asked by client if he's allowed to ambulate indep., whats an appropriate response ?

"Please ring for assisstance when you wish to get out of bed." (Tinnitus, one-sided hearing loss, & vertigo are all manifestations of Meniere's → ↑risk for falls)

reinforcing teaching for client/family receiving tx for a spinal cord injury w/ a halo fixation device. Whats an appropriate statement ?

"The purpose of this device is to immobilize the cervical spine."

caring for client who reports throbbing headache after lumbar puncture. What are appropriate nursing actions ?

- Adm the clients PRN pain meds - Darken the clients room & close the door - Keep the client flat in bed for several hours - INCREASING fluids is helpful in replacing the cerebrospinal fluid that was removed during the procedure, unless contrain

planning care for client who has quadriplegia. What nursing actions are most essential for prevention of pulmonary emboli PE ?

- assess legs for redness (indication of thrombophlebitis formation & possible PE) - apply elastic compression stockings (to prevent thrombophlebitis formation & possible PE & improve blood return to the heart) - perform passive range of motion exercises (to improve blood return to the heart & prevent thrombophlebitis formation & possible PE) - monitor INR result (to determine if client bleeding time is w/in normal limits to prevent thrombophlebitis formation & possible PE) (NEVER massage calves, which may dislodge a thrombus & cause a pulmonary emboli & possible PE)

instructing coworkers about how to minimize low back pain & avoid episodes of back pain. What strategies should nurse include ?

- avoid prolonged sitting (staying in any 1 position for too long can worsen back pain, change positions frequently) - sleeping in a side-lying position w/ flexed knees (prevents pressure on the support muscles & lumbosacral joints) - try shoe insoles (especially for people who must stand/walk for extended periods at work) (apply moist heat for 10-30 m < 4 times/day; firm mattress for support)

creating plan of care for client who has a tonic-clonic seizure disorder. What seizure precautions should nurse implement ?

- provide a suction setup at the bedside (to prevent aspiration) - ↑ side rails when in bed (prevent fall) - place bed in lowest position (prevent injury from fall) - keep an o2 setup at bedside (to adm O2 during seizure)

collecting data from client who has a herniated intervertebral disc. Whats an expected finding ?

- tingling in the arms. - shoulder pain. (particularly top of shoulders) - stiff neck.

developing plan of care to prevent skin break down for client w/ a spinal cord injury & paralysis. Appropriate nursing action ?

- using pillows to keep heels off the bed surface (prevent skin breakdown on clients heels) - minimize skin exposure to moisture (precent skin breakdown) (implement a 2hr turning sched; should apply lotion & avoid applying powder to skin)

collecting data on client who has meningitis & notes when passively flexing clients neck there is an involuntary flexion of both legs. What condition is client displaying ?

Brudzinski sign (manifesting Brudzinski sign, flexes hips & knees when neck is flexed, common sign of meningitis)

preparing a presentation about various herbal remedies. What herbal supp might be used to help boost their memory ?

Ginkgo biloba (Valerian: sedation & anxiety relief for sleep issues; Goldenseal: antiseptic properties, especially w/ topical app; St. John's wort: depression)

caring for client w/ Alzheimer's disease who is hospitalized for tx of pneumonia. During night shift, client is found climbing into bed of another client, who becomes upset & frightened. What action should nurse take ?

assist client to his room (clients w/ Alzheimer's disease frequently need assistance w/ orientation to their surroundings)

older adult client in a long-term cf has a cerebrovascular accident CVA 4 weeks ago & has been unable to move independently since that time. The nurse caring for her should observe for what finding that indicates a complication of immobility ?

a reddened area over the sacrum (over bony prominence is stage 1 pressure ulcer, a complication of immobility) (depending on location & extent of CVA, varying degrees of leg stiffness & mobility impairment are typical findings; presbycusis, or age-related sensorineural hearing loss, is typical among older adults & not a complication of immobility)

caring for a 26 yo who has a seizure disorder & reports experiencing an aura. Nurse understands client is describing what ?

a sensory warning that a seizure is imminent (aura may be similar to a hallucination & may involve any of the senses. Ex: "hearing bells", "seeing lights", or "smelling something")

caring for client who has a spinal fracture & complete spinal cord transection at level of C5. What rehabilitation goals should nurse expect to find in plan of care ?

ability to self-feed w/ use of adaptive equipment (client w/ spinal cord transection at 5th cervical vertebrae should have full neck, partial shoulder, back, biceps, & gross elbow movements. A realistic rehab goal is ability to feed self with use of adaptive equipment) (client w/ a transection at C5 can use an electric or modified manual wheelchair) (client w/ a transection in sacral area might have full/partial bowel & bladder control, but not w/ a cervical transection) (client w/ transection at C6 or lower should be able to transfer from bed to chair independently)

client sustained multiple injuries related to motor vehicle crash. When monitoring for manifestations of pneumothorax, what should nurse observe for ?

absence of breath sounds (will have diminished/absent breath sounds on affected side due to partial/total collapse of lung)

older adult who has weakness on her left side due to cerebrovascular accident. She becomes upset when eating, because liquids seep out of her moth on the weak side. Whats appropriate nursing intervention ?

add thickener to fluids to increase their consistency

nurse in ED is preparing care for client who is brought in w/ multiple system trauma following vehicle crash. Priority focus care ?

airway protection (airway, breathing, circulation)

collecting data from client who was bitten by a tick. Nurse should ✓ for common early manifestations of Lyme disease, including flu-like manifestations, fever, &....

an expanding circular rash (early: fever, flu-like & erythema migrans, an expanding circular rash "bulls-eye" often at the bite site, the thighs & knees)

client difficult to arouse & sleeps several hrs following generalized tonic-clonic seizure. When documenting finding, describe as...

being postictal (postictal phase is recovery period following tonic-clonic seizure. Clients might be confused or agitated after a seizure & might sleep for several hrs)

nurse is caring for client w/ a spinal cord injury at T-4. Nurse understands that client is at increased risk for autonomic dysreflexia & that this physiologic reaction could be triggered by what ?

bladder distention (autonomic dysreflexia can occur w/ spinal cord injury at/above T-6 level. A. dysreflexia happens when theres irritation, pain, or stimulus to nervous system below level of injury. Most are related to bladder, bowel, & skin)

a nurse at a community health clinic is caring for a client reporting headache & stiff neck. Whats 1st action ?

check the client's temperature (should ✓ temp if reporting symptoms of meningitis)

caring for client who has an evacuation of a subdural hematoma. Immediately after evacuation, whats priority nursing action ?

check the oximeter (airway, breathing, circulation. Poor 02 exchange may cause cerebral edema) (monitor for CSF leak; assess for ↑ temp; monitor for signs of ↑ICP)

caring for client at risk for increased intracranial pressure, monitors for indications that pressure is increasing. Nurse should check function of the 3rd cranial nerve by...

checking pupillary response to light (cranial nerve III, oculomotor nerve, is responsible for pupillary response to light)

modifying the diet of a client who has Parkinson's disease that's prescribed a monamine oxidase inhibitor (MAOI). What foods should be eliminated ?

cheese (it contains tyramine which may cause hypertensive crisis)

client has a cerebral aneurysm. What finding should nurse report ?

client asks that his bed linens be changed after an episode of urinary incontinence (urinary incontinence indicates a loss of reflex function, indicating ICP)

caring for client with Parkinsons disease. Prescribed 25 mg diphenhydramine (Benadryl) PO 3 times daily. Based on med regimen, whats expected therapeutic outcomes ?

decreased tremors (antihistamines have mild central anticholinergic & sedative effects that may help reduce tremors & muscle stiffness)

ED nurse is assisting care of a client who has myasthenia gravis & is in crisis. What factors can cause myasthenic crisis ?

developing a respiratory infection (most common triggers: resp infection, not taking or taking too little of meds, surgery, & pregnancy)

client w/ Parkinson disease shows signs of dyskinesia. What physical manifestations should nurse expect ?

difficulty moving

nurse preparing home instructions for client who has epilepsy. What info should nurse include in teaching ?

eat food ↑ in fiber to have a daily bowel movement (to avoid constipation which may trigger a seizure) (should recommend client avoid drinking coffee each day, because caffeine may act as a seizure trigger; recommend client take a shower rather than a tub to avoid drowning if client has seizure while bathing; recommend client exercise in a cool area rather than warm because excessive her may trigger seizure)

caring for client who has increased ICP. Whats an appropriate nursing intervention ?

elevate HOB 30° (to promote ↓ ICP; avoid coughing which ↑ICP; provide a nonstimulating environment to limit risk of seizure activity; client on a fluid restriction to avoid ↑ICP)

implementing precautions for client who has a cerebral aneurysm. Whats actions should nurse take ?

elevate the head of bed 30° (should elevate hob 30° to support venous return & lower ICP)

implementing a plan of care for client w/ a cerebral aneurysm. What nursing measures should be implemented ?

encourage exhaling through mouth when defecating (to decrease strain possible rupture of the aneurysm)

planning care for client postop who is having headaches due to receiving spinal anesthetic. Whats suggested for inclusion in plan of care ?

encourage increased intake of fluids (increased oral fluid intake promotes increases intracranial pressure which may relieve spinal headaches)

caring for client who has an intracranial aneurysm & requires precautions. Whats an appropriate nursing intervention ?

minimize environmental stimuli (at risk for rupture & should avoid any stimulation that could cause anxiety, such as noise or bright lights; raise hob 15-30°; remain on bed rest)

monitoring client under conscious sedation. What finding requires immediate intervention ?

no response to verbal stimuli (should be able to respond to questions & commands. No response to verbal stimuli may indicate loss of consciousness/coma)

nurse enters the room & finds client on the floor in clinic phase on a tonic-clonic seizure. Appropriate intervention ?

place a pillow under clients head (to protect from injury during seizure)

monitoring spinal cord injury & suspects autonomic dysreflexia. What action should be implemented 1st ?

place the client in a sitting position (to decrease the symptom of hypertension for autonomic dysreflexia)

a family member is instructed on interventions for safe swallowing for client who has residual effects from a stroke. Whats most important concept for family members to understand ?

place the client in the upright position to facilitate swallowing (greatest risk for client is injury from aspiration)

assisting care of a client w/ increased ICP & is told by charge that client demonstrates decorticate posturing. Whats expected to observe ?

plantar flexion of the legs (decorticate posturing is a result of lesions of the corticospinal tracts)

caring for client w/ spinal cord injury at level C-8 admitted for comprehensive rehabilitation. What long-term goal is appropriate w/ regard to clients mobility ?

propel a wheelchair equipped w/ knobs on the wheels (injury to C-8 has full use of shoulders & arms but will likely experience hand weakness)

conducting a Parkinson's disease group for family. What should nurse reinforce in the teaching ?

provide client supervision (to create a safe & respectful environment. Provide exercise program to improve mobility, alternate w/ rest periods. Should also decrease excess environmental noise to increase clients ability to concentrate on listening)

creates plan of care for client who has a traumatic head injury to determine motor function response. What client response to painful stimulus is w/in normal limits ?

pushes the painful stimulus away (normal response that is purposeful & appropriate) (client who extends the body part toward the stimuli indicates ↑ICP; client who shows ∅ reaction to painful stimuli may indicate flaccidity & may be neurological impaired; client who flexes the upper & extends the lower extremities indicates decorticate or decerebrate)

being transferred to a rehab 3 weeks post cerebrovascular accident (CVA). Because the CVA involved the left side of brain, nurse should help plan what goal ?

re-establish the ability to communicate effectively (a CVA is an interruption of blood supply to a part of brain, resulting in O2-deprived brain tissue. The left hemisphere is usually dominant for language. Nurse anticipates client will have some degree of aphasia & will require communication-focused nursing interventions & speech therapy)

planning preventative care for client who had traumatic brain injury & is emerging restlessly form a coma. Appropriate nursing action ?

reduce stimuli (↓ # of visitors, remain calm, & create a quiet environment)

caring for older adult client w/ Alzheimer's & becomes agitated & combative when approached this morning for hygiene care. Appropriate action ?

remain calm & talk quietly to the client (by talking quietly... distracts from refusal & then reintroduce idea of morning care)

diagnosed with myasthenia gravis (MG). Whats a complication of MG nurse should observe for ?

respiratory difficulty (progressive weakness of the diaphragmatic & intercostal muscles may cause resp distress)

collecting data on adult who has meningococcal meningitis. Whats an appropriate finding ?

severe headache (due to meningeal inflammation; tachycardia; decreased muscle tone; disorientation to time, person, & place)

an older adult in a long-term care facility has dementia & begins to have frequent episodes of urinary incontinence. After provider determines no medical cause for incontinence, what intervention should nurse initiate to manage this behavior ?

take client to the bathroom on an every-2-hr schedule (important to attempt measure that might help prevent incontinence before resorting to measures that can cause complications like infection & skin breakdown. For some, toileting can help manage this prob)

client has a severe head injury. What finding indicates development diabetes insipidus (DI) ?

urine output 250 ml/hr (the resulting decrease in antidiuretic hormone results in an increasingly high output of very dilute urine)