Neurosensory Disorders

When assessing the client with Parkinson's disease, the nurse should observe the client for:

A stiff, masklike facial expression.

A client with multiple sclerosis (MS) is receiving discharge instructions from the nurse. Which of the following statements by the client indicates that more instruction is required?

"I will walk with my feet close together."

Which of the following statements by a client receiving carbamazepine would require additional instruction?

"If I have a seizure, I should take two pills immediately."

A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first?

Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.

According to hospital policy, a nurse in charge of a neurologic floor must facilitate discharges during a disaster event so clients involved in the disaster can be admitted promptly. After quickly reviewing the client census, the nurse identifies five postoperative clients who may be ready for discharge. What should the nurse do next?

Assess each client, call the physician, and ask for discharge orders if appropriate.

A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac catheterization that involved a femoral puncture. The client is reminded to keep his leg straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is responsible for three other clients who underwent cardiac catheterization. What's the best step the nurse can take?

Ask the staffing coordinator to assign a nursing assistant to sit with the client.

What assessment findings would the nurse expect to find with a client with progressive myasthenia gravis?

Muscle weakness, difficulty swallowing, double vision, and difficulty speaking

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent:

Contractures.

A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests?

EEG, blood cultures, and neuroimaging studies

The nurse is caring for a client with a subdural hematoma. Which of the following is the priority outcome?

Ensure airway patency and optimal oxygen levels and protect from injury.

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the client's first response to pain will be to:

Escape the source of pain.

A client with glaucoma is to receive 3 gtt of acetazolamide in the left eye. What should the nurse do?

Have the client look up while the nurse administers the eyedrops.

The nurse is administering eyedrops to a client with glaucoma. Which is a correct technique for instilling the eyedrops? The eyedrops are placed:

In the lower conjunctival sac.

The nurse is assessing a client with a head injury. On admission, the pupils were equal; now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What would this change in neurologic status of the client suggest to the nurse?

Increased intracranial pressure

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

Increased intracranial pressure (ICP)

The best method to remove cerumen from a client's ear involves:

Irrigating the ear gently.

A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plans the client's nursing care with the understanding that acute angle-closure glaucoma:

Is a medical emergency that can rapidly lead to blindness.

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?

Jugular vein distention

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate?

Limiting fluid intake to 1,000 mL/day

Which of the following nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?

Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport.

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

Rising blood pressure and bradycardia

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

Risk for injury related to neurologic deficit

A client with chronic back pain is admitted to the medical-surgical floor and is receiving multiple pain medications and an antidepressant for pain control. The physician's orders include a physical therapy consult for ambulation and back strengthening, magnetic resonance imaging (MRI) of the lumbar spine, and a computed tomography (CT) scan of the abdomen. How should the nurse schedule therapy and diagnostic tests?

Schedule the MRI of the lumbar spine first, then the physical therapy consult, and then the CT scan.

What assessment findings would indicate an emergency myasthenia crisis?

Severe dyspnea, intensification of dysphagia, and dysarthria

Which is the most effective way for a nurse to assess for posterior nasal bleeding in a client who has had nasal surgery?

Use a penlight to inspect the back of the pharynx for bleeding.

A client is color blind. The nurse understands that this client has a problem with:

cones.

A nurse is documenting a health assessment when the client states having problems with balance, as well as, fine and gross motor function. When collaborating with the health team, in which area on the illustration of the brain would the nurse highlight as an area of concern?

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A nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy.

A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy?

muscle rigidity

When determining how to administer analgesics to a client who has been receiving opiates for pain relief administered by injection, the nurse should consider using patient-controlled analgesia since it is more effective because:

the client will control the amount of pain medication administered.

The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate?

the head of the bed elevated 15 to 20 degrees

A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client?

"You are in the hosipital. You were in an accident and unconscious."

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate an understanding of the instructions? Select all that apply.

-"If brushing my teeth is too painful, I'll try to rinse my mouth instead." -"I'll try to chew my food on the unaffected side." -"Drinking fluids at room temperature should reduce pain."

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply.

-The physician was correct to stop resuscitation efforts. -By calling a code blue, the nurse disregarded the client's advance directives and DNR order.

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent?

Succinylcholine

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition?

decrease in level of consciousness (LOC)

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. The nurse should:

notify the health care provider (HCP).

A client with a ruptured intervertebral disc at L4-5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. The nurse interprets this finding as indicating:

postural deformity.