Neurosensory Disorders PrepU
A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. What information should the nurse include in the teaching plan for this client?
setting a regular time for elimination
The nurse is preparing a client who had cataract surgery for discharge. Which is the primary goal for this client?
Promote safety at home.
A registered nurse (RN) and licensed practical nurse (LPN) are administering medications on the neurologic floor. The LPN prepares to administer phenytoin to a client with a history of seizures. The LPN walks into the room and hands the medication to a nursing assistant. The LPN asks the nursing assistant to give the client the medication after completing the client's morning care. What should the registered nurse do?
Remind the LPN that it is the LPN's duty to administer the medications.
Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?
Risk for injury related to vertigo
After cataract removal surgery on the left eye, the client sits up and reports having sharp pain in the operative eye. What should the nurse do next?
Contact the health care provider (HCP).
The risk for injury during an attack of Ménière disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?
"Assume a reclining or flat position."
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
"Avoid hot baths and showers."
As a first step in teaching a female client with a spinal cord injury and quadriplegia about their sexual health, the nurse assesses the client's understanding of their current sexual functioning. Which statement by the client indicates they understand their current ability?
"I can participate in sexual activity but might not experience orgasm."
A nurse is educating a client recently diagnosed with early glaucoma. Which client statement indicates further teaching is necessary?
"I will take my latanoprost eye drops as soon as I start to feel pain."
The nurse is teaching a young female about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client makes which statement?
"I'll use one of the barrier methods of contraception."
The nurse assigned to telephone triage returns the call of a parent whose teenager experienced a hard tackle last night. The parent reports, "They seemed dazed after it happened, and the coach had them sit out the rest of the game, but they're fine now." What is the most appropriate instruction for the nurse to give?
"Your child can't return to play until they have been evaluated by a health care provider (HCP)."
A nurse is educating a client's family on Alzheimer's disease. Which statement by the nurse would cause the charge nurse to intervene?
"Routine administration of donepezil at the same time every day can cure the disease."
A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin. Client teaching about this drug should include which instruction?
"Schedule follow-up visits with your physician for blood tests."
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate?
"The most common cause of dementia in the elderly is Alzheimer's disease."
A nurse is preparing to administer phenytoin to a 99-lb (45-kg) client with a seizure disorder. The medication administration record documents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin should be administered in the first dose? Record your answer as a whole number.
75
After 1 month of therapy, a client in spinal shock begins to experience muscle spasms in the legs and calls the nurse in excitement to report the leg movement. Which response by the nurse would be the most accurate?
"The movements occur from muscle reflexes that cannot be initiated or controlled by the brain."
Which statement indicates that a client understands the nurse's teaching about phenytoin for the diagnosis of seizures?
"This medication will not cure my disease."
A client with a cataract tells the nurse about being afraid of being awake during eye surgery. Which response by the nurse would be the most appropriate?
"What is it that disturbs you about the idea of being awake?"
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?
"You should review this information with your healthcare provider at every admission."
The nurse is caring for a client admitted with seizures. Which nursing action is important when caring for a client during a postictal state? Select all that apply.
-keeping the client side lying -padding the side rails -setting up suction
When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of
10 to 20 mm Hg.
A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?
15
The nurse is explaining to a client who had rhinoplasty 2 days ago how to manage discomfort at home. Which measure should the nurse suggest?
Apply an ice pack.
What should a nurse do when administering pilocarpine?
Apply pressure on the inner canthus to prevent systemic absorption.
The nurse is preparing to administer propranolol to a client for control of migraine headaches. The client also has a prescription for sumatriptan as needed for a headache. The client's pulse rate is 56 bpm. What should the nurse do next?
Assess blood pressure.
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?
Check the equipment.
The nurse is planning care for a client with a head injury. What should the nurse do first when the client begins to have clear drainage from the nose?
Collect the drainage.
A client who is prescribed by the health care provider (HCP) to take aspirin daily to prevent thrombus formation reports having ringing in their ears. The nurse advises the client to take which measure?
Contact the HCP.
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?
Face the client and establish eye contact.
The client with a lumbar laminectomy asks to be turned onto their side. How should the nurse assist the client?
Get another nurse to help logroll the client into position.
A client in the postanesthesia care unit with a left below-the-knee amputation has pain in the left big toe. What should the nurse do first?
Give the client the prescribed opioid analgesic.
The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions?
Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.
A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the priority?
Instruct the client to remain in bed.
A nurse is assessing a client with meningitis. The nurse places the client in a supine position and flexes the client's leg at the hip and knee. The nurse notes resistance when straightening the knee and the client reports pain. The nurse should document what neurologic sign as positive?
Kernig's sign
The nurse is planning care with a client newly diagnosed with myasthenia gravis. Which is an appropriate goal to establish?
Maintain respiratory function.
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays have not been read, so the nurse does not know whether the client has a cervical spinal injury. The nurse develops a plan of care and includes which action?
Maintain the client in a flat position, except for logrolling as needed.
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. What should the nurse do next?
Notify the health care provider (HCP).
The nurse from the previous shift identified a client as a high risk for falls. The oncoming nurse finds the client on the floor at the beginning of the shift. The nurse assesses the client and notes no injuries. What is the best action by the nurse?
Notify the health care provider, and document the fall in the chart, including location, injuries, the fact the health care provider was notified, and any changes to the care plan.
A client has short-term memory loss. Which action by the nurse will be most effective to help the client cope with memory loss?
Place a single-date calendar where the client can view it.
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?
Tell the client to march in place.
When determining how to administer analgesic medications to a client who has been receiving opiates for pain relief administered by injection, the nurse should consider using patient-controlled analgesia (PCA). Which is the expected outcome of using PCA?
The client will control the amount of pain medication administered.
Sodium polystyrene sulfonate is prescribed for a client following a crush injury. Which finding indicates the drug has been effective?
The serum potassium is 4.0 mEq/L (4.0 mmol/L).
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?
The tremors sometimes disappear with purposeful and voluntary movements.
The nurse notices that a client with Parkinson disease is coughing frequently when eating. Which action should the nurse take?
Thicken all liquids before offering them to the client.
The nurse is assigned to four clients. After receiving a change-of-shift report at 0700, the nurse should assess which client first?
a 63-year-old with multiple sclerosis who has an oral temperature of 101.8°F (38.8°C) and flank pain
Which client requires increased sensory stimulation to prevent sensory deprivation?
a 65-year-old client who has employment-induced presbycusis and advanced glaucoma
The nurse is teaching a client with Ménière disease to recognize when they might have an attack. What should the nurse tell the client to recognize as an indication they might have an attack?
a feeling of inner ear fullness
The nurse is assessing the client with Parkinson disease. Which finding is expected?
a stiff, masklike facial expression
The nurse is assessing a client for potential subdural hematoma development after a head injury. Which manifestation does the nurse anticipate seeing first?
alteration in level of consciousness
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
absence of reflexes along with flaccid extremities
A client who had a serious head injury with increased intracranial pressure and short-term memory loss is to be discharged to a rehabilitation facility. Which outcome of rehabilitation during the first 3 days is realistic for the client?
actively participate in the rehabilitation process
The nurse assesses for euphoria in a client with multiple sclerosis, looking for what characteristic clinical manifestations?
an exaggerated sense of well-being
A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?
an isolation room three doors from the nurses' station
A nurse has received a shift report on four clients. Which client should the nurse assess first?
an older adult returning to the unit after having a carotid endarterectomy
A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which area that is a potential pressure point when the client is in a side-lying position?
ankles
The nurse is assessing a client who had an episode of autonomic dysreflexia. What should the nurse assess first?
bladder distention
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates
cranial nerves IX and X.
A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate?
meningeal irritation
A client was running along an ocean pier, tripped on an elevated area of the decking, and struck their head on the pier railing. According to friends, "The client was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, the client began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?
declining level of consciousness (LOC)
Which nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma?
disorientation, increasing blood pressure, bradycardia, and bradypnea
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates
dysfunction in the brain stem.
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order
electromyography (EMG).
The nurse is planning the care for a client who has had a posterior fossa (infratentorial) craniotomy. What should the nurse avoid when positioning the client?
elevating the head of the bed to 30 degrees
Atropine sulfate is contraindicated as a preoperative medication for which client?
glaucoma
The nurse is assisting a client with multiple sclerosis (MS) set long-term goals. Which goal is realistic?
improved muscle strength
The nurse is teaching the client who has had laser surgery for retinal detachment. What should the nurse tell the client about activity while recovering from surgery?
increased gradually; the client can resume usual activities in 5 to 6 weeks.
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)
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?
jugular vein distention
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?
lateral recumbent, with chin resting on flexed knees
A parent of a child with a moderate head injury asks the nurse, "How will you know if my child is getting worse?" The nurse should tell the parents that the best indicator of the child's brain function is which factor?
level of consciousness (LOC)
A client recovering from a closed head injury is restless and agitated. The client still has a central venous catheter in place for antibiotic therapy. The nurse doesn't want to sedate the client, but needs to protect the catheter and other less-restrictive measures have failed. Which method of restraint is best for this client?
mitt restraints applied to both hands
Which of the following nursing intervention can prevent a client from experiencing autonomic dysreflexia?
monitoring the patency of an indwelling urinary catheter
The nurse is caring for a client with a T-5 spinal cord injury. The client is on bed rest and has an indwelling urinary catheter. The client has a pounding headache, profuse diaphoresis, and nausea. Which nursing action is the priority?
placing the client upright in a sitting position
After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eye drops. What is the expected outcome of applying pressure?
prevents the medication from entering the tear duct.
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing
raccoon's eyes and Battle's sign.
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?
sodium
A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority?
risk for injury
After the client returns from surgery for a deviated nasal septum, in which position should the nurse place the client?
semi-Fowler
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the intravenous (IV) line. The nurse contacts the health care provider (HCP) and explains the situation and background. What type of restraint should the nurse recommend the HCP order?
soft "mitten" restraints
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should
stay with the client and encourage them to eat.
A nurse is monitoring a client for adverse reactions to atropine eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?
tachycardia
The nurse is assessing a client with Parkinson disease. Which is an initial sign of Parkinson disease?
tremor
A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by
turning the client's head suddenly while holding the eyelids open.
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences.
The nurse is planning care with a client who has undergone surgery for retinal detachment. Which goal is a priority?
Prevent an increase in intraocular pressure.
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?
attaching braces or splints to each foot and leg
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation.
The nurse is caring for a client with an injury to the thalamus. What information should the nurse include in the care plan?
Monitor the temperature of the bathwater.
The nurse has administered mannitol IV. What assessment should the nurse make after administering this drug?
Monitor urine output.
The nurse is developing a teaching plan with a client with seizures who is going home with a prescription for gabapentin. What information should the nurse give the client about taking gabapentin?
Notify the health care provider (HCP) if vision changes occur.
A client is experiencing autonomic dysreflexia. What should the nurse do first?
Place the client in the Fowler position.
A new nurse has been assigned to the neurologic intensive care unit. Which client would be best to assign the nurse? A client:
admitted 48 hours ago with bacterial meningitis who requires antibiotic administration
A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment?
to prevent vision loss
Which action is contraindicated for a client with seizure precautions?
assessing the client's oral temperature with a glass thermometer
A short time after cataract surgery, a client has nausea. What should the nurse do first?
Medicate the client with an antiemetic, as prescribed.
A registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel are caring for a group of clients. The RN asks the assistive personnel to check the pulse oximetry level of a client who underwent a laminectomy. The assistive personnel reports that the pulse oximetry reading is 89% on room air. The client has a prescription for oxygen at 2 L/min for a pulse oximetry level below 92%. The RN is currently assessing a postoperative client who just returned from the postanesthesia care unit. How will the RN proceed?
Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?
compliance with the prescribed medication regimen
A client is color blind. The nurse understands that this client has a problem with
cones
A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a corticosteroid ointment, one-half inch in the lower conjunctival sac four times a day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent
increased intraocular pressure (IOP).
A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean them from sedation therapy. A nurse needs further assessment data to determine whether
the nurse will have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.
