Neurosensory Disorders
is a medical emergency that can rapidly lead to blindness.
A client has been diagnosed with an acute episode of angle-closure glaucoma. The client asks the nurse what will be done. What should the nurse tell the client about this health problem? Acute angle-closure glaucoma:
Occipital
A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?
"You should review this information with your healthcare provider at every admission."
A 35-year-old client diagnosed with multiple sclerosis three years ago presents the nurse with an advance directive refusing intubation, mechanical ventilation, and tube feedings. How should the nurse respond?
Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport.
A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. The client's level of consciousness is decreased, and they require nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?
Maintain a patent airway. Assess level of consciousness. Administer intravenous fluids. Prevent urinary incontinence. Protect skin integrity.
A client has been admitted to the neurosurgical unit after a motor vehicle accident that resulted in a closed head injury. The client is currently unconscious. The nurse has completed the initial assessment. Place the following interventions in order of priority. All options must be used.
Bradycardia & widened pulse pressure
A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included a temperature of 99°F (37°C), pulse of 100 bpm, respiration rate of 18 breaths/min, and blood pressure of 140/70 mm Hg. The nurse should report which change(s) to the health care provider (HCP)? Select all that apply.
Muscle contraction is palpable and visible.
A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. Which assessment finding should the nurse anticipate?
Administer rapid infusion of IV fluids
A client is admitted with a spinal cord injury at level C3. The nurse notes a heart rate of 50 beat/minute and a blood pressure of 90/60 mmHg. What is the nurse's priority action?
Unequal pupil size
A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?
Hemiplegia, seizures, and decreased level of consciousness (LOC)
A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?
Raccoon's eyes and Battle's sign
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing
Risk for injury
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?
Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head.
A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply.
The client has developed tolerance to the dose of morphine.
After 5 days of hospitalization, a client who is receiving morphine sulfate for pain control asks for pain medication with increasing frequency and exhibits increased anxiety and restlessness. The vital signs are within normal ranges. What is a possible cause of this behavior?
Bending over the sink to wash face
After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which activity would be contraindicated?
Sodium
An older adult has vertigo accompanied by tinnitus as the result of Ménière disease. The nurse should instruct the client to restrict which dietary element?
Vertigo, nausea, ataxia
Following an infection, the client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which symptom? Select all that apply.
Activate the Rapid Response Team
Following surgery for removal of a brain tumor, a client is coughing and short of breath and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg, pulse rate of 120 bpm, and respiratory rate of 30 shallow breaths/min. What should the nurse do first?
Use sunglasses that wrap around the side of the face when in bright light.
One day after cataract surgery, the client is having discomfort from bright light. What should the nurse advise the client to do?
Sudden eye pain
The nurse is assessing a client who has acute angle-closure glaucoma. The nurse should determine if the client has experienced which symptom?
Blurry in the middle
The nurse is assessing a client with macular degeneration. Identify the illustration that best depicts what clients with this disorder typically see.
Level of consciousness. Motor strength. Vital signs. Decreased urine output.
The nurse is caring for a child with a head injury. Place the following assessments in order of priority, starting with the nursing assessment the nurse should perform first.
The test may require removal of watches, bracelets, or earrings. A contrast dye may be given before the test. Throat irritation and facial flushing may occur if contrast dye is used. It is necessary to report any known allergies to iodine or seafood prior to the procedure.
The nurse is caring for a client who is scheduled to undergo a computerized tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information would the nurse include in a preprocedural teaching plan? Select all that apply.
Tell the client to march in place
The nurse is planning care for a client with Parkinson disease who is experiencing freezing of gait with difficulty initiating movement. Which action should the nurse take?
mood disorders balance problems visual disturbances
The nurse is planning care for a client with multiple sclerosis. Which problems should the nurse expect the client to experience? Select all that apply.
"I'll try to chew my food on the unaffected side." "Drinking fluids at room temperature should reduce pain." "If brushing my teeth is too painful, I'll try to rinse my mouth instead."
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.
The tremors sometimes disappear with purposeful and voluntary movements.
The nurse observes that when a client with Parkinson disease unbuttons their shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors?
Ease the client to the floor. Maintain a patent airway. Obtain vital signs. Record the seizure activity observed.
The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.
"Your child needs all of the medicine so the infection clears."
The parent of a child who is taking an antibiotic for bilateral otitis media tells the nurse that they have stopped the medicine since the child is better and they are saving the rest of the medication to use the next time the child gets sick. What should the nurse tell the parent?
Muscle weakness, difficulty swallowing, double vision, and difficulty speaking
What assessment findings would the nurse expect in a client with progressive myasthenia gravis?
30-degree head elevation
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?
"Avoid hot baths and showers."
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
Supine with the head midline
Which is the best positioning for a client who has a fractured spine as a result of a diving accident?
Medicate the client with an antiemetic, as prescribed.
A short time after cataract surgery, a client has nausea. What should the nurse do first?
lateral recumbent, with chin resting on flexed knees
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?
Establishing an intermittent catheterization routine every 4 hours
A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?
Spontaneous eye opening & Orientation to person, place, time
A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the client's score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply.
Rest in an air-conditioned room
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to
Rest in an air-conditioned room.
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to
