NRSG 2300 Unit 13

The nurse enters the client's room and finds the client with an altered level of consciousness. Which is the nurse's priority concern? A. Airway clearance B. Deficient fluid volume C. Risk for impaired skin integrity D. Risk of injury

A. Airway clearance

Which activity should be avoided in clients with increased ICP? A. Enemas B. Minimal environmental stimuli C. Position changes D. Suctioning

A. Enemas

The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe? A. Headache and nuchal rigidity B. Hyporeflexia in the lower extremities C. Numbness and vomiting D. Ptosis and diplopia

A. Headache and nuchal rigidity

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? A. Seizure was 1 minute in duration including tonic-clonic activity B. Sleeping quietly after the seizure C. The client cried out before the seizure began D. Seizure began at 1300 hours

A. Seizure was 1 minute in duration including tonic-clonic activity

During assessment of a patient who has been taking Dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? A. Ataxia B. Gingival hyperplasia C. Diplopia D. Alopecia

B. Gingival hyperplasia

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? A. 6 B. 9 C. 3 D. 15

C. 3

A client with a neurologic deficit is feeling frustrated because it is very difficult to pronounce words since having a stroke. The client is struggling with: A. Dysphagia B. Dysphasia C. Dysarthria D. Ataxia

C. Dysarthria

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? A. High in protein and low in carbohydrate B. Restricts protein to 10% of daily caloric intake C. At least 50% carbohydrate D. Low in fat

A. High in protein and low in carbohydrate

A client is suspected to have bacterial meningitis. What is the PRIORITY nursing intervention? A. Encourage oral fluid intake B. Prepare the client for a CT scan C. Assess the CSF fluid laboratory test results D. Administer prescribed antibiotics

D. Administer prescribed antibiotics

Which is a late sign of increased ICP? A. Irritability B. Slow speech C. Headache D. Altered respiratory patterns

D. Altered respiratory patterns

The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing ICP. The earliest sign of increasing ICP is: A. Slowing of heart rate B. Elevation of systolic blood pressure C. Widening pulse pressure D. Change in level of consciousness

D. Change in level of consciousness

A nurse is working in the neurologic ICU and admits from the ED a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned with shoulders adducted, arms extended, forearms pronated, hands flexed and plantar flexion. Which posturing is the patient exhibiting? A. Tonic clonic B. Decorticate C. Flaccidity D. Decerebrate

D. Decerebrate

The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority? A. Praise client when using adaptive equipment B. Assess client for ability to ambulated independently C. Provide instruction on blood-thinning medication D. Include client in planning of care and setting of goals

D. Include client in planning of care and setting of goals

A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising ICP? A. Periorbital edema B. BP of 100/60 mmHg C. Nausea D. Lethargy

D. Lethargy

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a BP of 170/88 mmHg, HR of 92, and RR of 24. On which bodily system does the nurse focus the nursing assessment? A. Respiratory B. Endocrine C. Cardiovascular D. Neurovascular

D. Neurovascular

A nurse is caring for a client with a brain tumor and increased ICP. Which intervention should the nurse include in the care plan to reduce ICP? A. Provide sensory stimulation B. Administer stool softeners C. Position the client with the head turned toward the side of the brain tumor D. Encourage coughing and deep breathing

B. Administer stool softeners

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? A. A partial seizure B. An absence seizure C. A myoclonic seizure D. A tonic-clonic seizure

B. An absence seizure

Which medication classification is used preoperatively to decrease the risk of postoperative seizures? A. Corticosteroids B. Anticonvulsants C. Antianxiety D. Diuretics

B. Anticonvulsants

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence? A. The client grasps the affected arm at the wrist and raises it B. The client arranges a community service to deliver meals C. The client ambulates with the assistance of one D. The client uses a mechanical lift to climb steps

A. The client grasps the affected arm at the wrist and raises it

A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "you don't know what you are doing!" What is the BEST reaction by the nurse? A. Accept the patient's behavior and do not take it personally B. Explain that the client is getting good care C. Discontinue the bath and resume it later D. Request that the patient be cared for by another nurse

A. Accept the patient's behavior and do not take it personally

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A. Loosen the client's restrictive clothing B. Place client in high Fowler position C. Open the client's jaws to insert an oral airway D. Restrain the client to prevent injury

A. Loosen the client's restrictive clothing

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? A. Maintaining a patent airway B. Inserting an NG tube as prescribed C. Providing appropriate pain control D. Maintaining accurate records of intake and output

A. Maintaining a patent airway

A client with a traumatic brain injury has already displayed early signs of increasing ICP. Which of the following would be considered late signs of increasing ICP? A. Loss of gag reflex and mental confusion B. Decerebrate posturing and loss of corneal reflex C. Mental confusion and pupillary changes D. Complaints of headache and lack of pupillary response

B. Decerebrate posturing and loss of corneal reflex

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? A. The client will verbalize an understanding of feelings that preempt seizure activity B. The client will remain free of injury if a seizure does occur C. The client will take the seizure medication at the same time daily D. The client will post emergency numbers on the refrigerator for ease of obtaining

B. The client will remain free of injury if a seizure does occur

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? A. Place a cooling blanket beneath the client B. Turn the client to the side during a seizure and do not restrain movements C. Provide oxygen or anticonvulsants, whichever is available D. Suction the client's mouth and pharynx

B. Turn the client to the side during a seizure and do not restrain movements

The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client? A. Assessing the client's ability to follow complex commands B. Assessing the client's judgment C. Assessing the client's verbal response D. Assessing the client's response to pain

C. Assessing the client's verbal response

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing: A. Choking B. Falls C. Complications D. Infection

C. Complications

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? A. Sensory B. Absence C. Generalized D. Jacksonian

C. Generalized

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? A. Inability to stand with eyes closed and arms extended without swaying B. Numbness and tingling in the lower extremities C. Neck flexion produces flexion of the knees and hips D. Pain upon ankle dorsiflexion of the foot

C. Neck flexion produces flexion of the knees and hips

The nurse is caring for a patient with increased ICP. The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? A. Copes with sensory deprivation B. Registers normal body temperature C. Obeys commands with appropriate motor responses D. Pays attention to grooming

C. Obeys commands with appropriate motor responses

Which of the following drugs may be used after a seizure to maintain a seizure-free state? A. Valium B. Ativan C. Phenobarbital D. Cerebyx

C. Phenobarbital

A nurse working in the neurologic ICU admits from the ED a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient has decerebrate posturing. Based on this initial observation, what would the nurse predict about this patient's prognosis? A. Excellent B. Fatal C. Poor D. Good

C. Poor

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely? A. Negative Kernig's sign B. Increased intake C. Positive Brudzinski's sign D. Hyper-alertness

C. Positive Brudzinski's sign

The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following? A. Negative Brudzinski's sign B. Hyper-alertness C. Positive Romberg sign D. Positive Kernig's sign

D. Positive Kernig's sign

A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase? A. Destabilizing client's condition B. Assessing vital signs frequently C. Reporting changes to the physician D. Preventing further neurologic damage

D. Preventing further neurologic damage

A client the nurse is caring for experiences a seizure. What would be a priority nursing action? A. Suction the mouth during the convulsion B. Restrain the client during the seizure C. Insert a tongue blade between the teeth D. Protect the client from injury

D. Protect the client from injury

A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? A. Bedrest at home for 72 hours B. Admission to the nearest hospital for observation C. No treatment unless the roommate begins to show symptoms D. Treatment with antimicrobial prophylaxis as soon as possible

D. Treatment with antimicrobial prophylaxis as soon as possible

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? A. Equal response B. Constricted response C. Rapid response D. Unequal response

D. Unequal response