NSG 203 Neurosensory Disorders
The health care provider prescribed t-PA, a thrombolytic agent. The order is for 0.9 mg/kg over 1 hour. The client weighs 110 lb (50 kg). What is the total dose in milligrams the client will receive? Record your answer using a whole number.
45 0.9 mg/kg × 50 kg = 45 mg.
A client with a suspected brain tumor is scheduled for computed tomography (CT). When preparing the client for this test, what nursing intervention does the nurse implement?
Determining whether the client is allergic to iodine, contrast dyes, or shellfish
A 58-year-old client complaining of difficulty driving at night states that the "lights bother my eyes." The client wears corrective glasses. The nurse would expect the physician to have the client increase his or her intake of which vitamin because the client is experiencing a deficiency in this
Vitamin A
When teaching a client about levodopa and carbidopa therapy for Parkinson's disease, the nurse should include which instruction?
"Be aware that your urine may appear darker than usual."
What should the nurse do when administering pilocarpine?
Apply pressure on the inner canthus to prevent systemic absorption.
The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first?
Call the physician immediately.
The nurse is reviewing the medical record for a client in a long-term care facility. The nurse notes an entry by the primary care physician indicating the client is colorblind. The nurse understands this condition results from a problem with which structure(s) of the eye?
Cones
The nurse is collecting data on a geriatric client with senile dementia. When reviewing this client's file, which neurotransmitter condition is the nurse likely to find in the client's history as a contributory factor to his or her cognitive changes?
Decreased acetylcholine level
A nurse is caring for a client who has sustained a closed head injury. What nursing intervention should the nurse implement to prevent an increase in intracranial pressure (ICP)?
Elevate the head of the bed 30 degrees.
Which nursing intervention takes priority for the client having a tonic-clonic seizure?
Maintaining a patent airway
A client has a diagnosis of stroke versus transient ischemic attack (TIA). Which statement demonstrates the difference between a TIA and a stroke?
TIAs typically resolve in 24 hours.
A client has a cervical spinal cord injury at the level of C5. Which condition would the nurse anticipate during the acute phase?
The need for mechanical ventilation
Which symptom would the nurse expect to find when collecting data from a client with Ménière disease?
Tinnitus
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
carefully move him to a flat surface and turn him on his side.
A client is admitted to the hospital after being involved in a motor vehicle accident. X-rays reveal that the client has a comminuted fracture of the left femur and a head laceration. A family member asks the nurse why opioid pain medication is not being administered for the client's pain. What is the best response by the nurse?
"A head injury is suspected, and the depressive effects of opioids will interfere with monitoring of neurologic function."
A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint?
"I'm sorry you haven't been bathed. I'm available to bathe you now."
A nurse is caring for a child with spina bifida. The child's mother asks the nurse what she did to cause the birth defect. Which statement would be the nurse's best response?
"The cause is unknown and there are many environmental factors that may contribute to it."
A client who's receiving phenytoin to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?
10 to 20 mcg/ml
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. When reviewing the client's chart, the nurse expects to find which documentation that confirms the client has Myasthenia gravis?
A positive edrophonium (Tensilon) test
The nurse is discussing the purpose of an EEG with the family of a client who has massive cerebral hemorrhage and loss of consciousness. Which response by the nurse would be the most accurate in describing what the test measures?
Activity of the brain
A client with a subarachnoid hemorrhage is prescribed nimodipine 60 mg po every 4 hours. The client's pulse is 82/min, blood pressure is 170/88 mmHg, intracranial pressure (ICP) is 15 mmHg before the administration of the prescribed dose. What is the best action of the nurse?
Administer the full dose as prescribed. it would be held only if the pulse is below 60
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.
The nurse is reinforcing education to a client taking phenytoin for the treatment of seizures. The client asks, "Can I still have my beer every day"? What is the best response by the nurse?
Alcohol decreases the effectiveness of phenytoin
A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client?
An isolation room close to the nurses' station
Parent and client education should stress which rule in relation to the differences in bioavailability of different forms of phenytoin?
Avoid switching formulations without the primary health care provider's approval.
The nurse observes clear fluid is draining from the nose of a client who had a head trauma 3 hours ago. Which condition does the nurse suspect from this observation?
Basilar skull fracture
A client injures his or her spinal cord in a diving accident. Which cerebral vertebral level would the nurse associates the injury site if the client is unable to breathe spontaneously?
C4
A client is thrown from an automobile during a collision. The nurse knows that the client will be able to maintain gross arm movements and diaphragmatic breathing if the injury occurs at what vertebral level?
C5
A nurse is caring for a client who has a history of epilepsy. After the client experiences a generalized tonic-clonic seizure, what is the priority nursing action?
Check the client's vital signs and remove restrictive clothing.
A client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from the ears and nose. Which nursing intervention is appropriate?
Checking the fluid for glucose with a dipstick
When educating the family of a child with seizures, it's appropriate to tell them to call emergency medical services in the event of a seizure if which complication occurs?
Continuous vomiting for 30 minutes after the seizure
Family members would like to bring in a birthday cake for a client with nerve damage. What cranial nerve will the nurse assess to determine if it is functioning so the client can chew?
Cranial nerve V
A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then he became alert and behaved as though nothing had happened." Shortly afterward, he 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 would expect to observe which sign first?
Declining level of consciousness
A client is newly diagnosed with myasthenia gravis. When reinforcing education what should the nurse indicate as the cause of this disease?
Destruction of acetylcholine receptors, causing muscle weakness
The nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?
Elevate the head of the bed to 30 degrees.
A client is admitted into a medical unit confused and agitated. Which nursing measure should the nurse implement first to keep the client safe?
Encourage family, friends, or a sitter to stay with client.
A client is admitted with Ménière's disease. Which instruction should the nurse reinforce in client teaching?
Get up slowly, turning the entire body.
When contributing to the development of an education session on glaucoma for the community, which statement would the nurse emphasize?
Glaucoma can be painless with loss of peripheral vision
The nurse is caring for a client with stroke in evolution. Which nursing intervention is priority?
Have tracheal suction available at all times
A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?
Helicopod
The health care provider prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question prior to administration?
Heparin sodium
A neonate is diagnosed with bacterial meningitis. For which priority signs and symptoms will the nurse monitor? Select all that apply.
Hypothermia Irritability Hyperthermia
A client admitted to the hospital with a subarachnoid hemorrhage (SAH) reports severe headache, nuchal rigidity, and projectile vomiting. The nurse suspects that lumbar puncture (LP) may be contraindicated due to which circumstance?
Increased intracranial pressure (ICP)
When obtaining the vital signs of a client with multiple traumatic injuries, the 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)
In a client with amyotrophic lateral sclerosis and respiratory distress, which finding does the nurse observe for as the earliest sign of reduced oxygenation?
Increased restlessness
A client with meningitis is being prepared for a lumbar puncture. In which position should the nurse place the client for this procedure?
Laterally, with knees drawn up to the abdomen and chin touching the chest
To evaluate the effectiveness of levodopa-carbidopa in a client with Parkinson disease, the nurse would observe for which outcome?
Lessened rigidity and tremor
An older adult client admitted to the hospital with chest pain has difficulty hearing. Which method should the nurse use when collecting data from this client?
Lower voice pitch while facing the client
A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take?
Make arrangements for the client to receive information about advance directives.
A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough violently. What should the nurse do?
Make sure a tonsil suction device is readily available while providing mouth care.
A client is admitted with myasthenia gravis. Which nursing intervention should be priority
Monitor respiratory status
A client is admitted with myasthenia gravis. Which nursing intervention should be priority?
Monitor respiratory status
An adult client was admitted with myasthenia gravis. While reviewing the client's chart, the licensed practical nurse (LPN)/licensed vocational nurse (LVN) noticed the medication administration record (MAR). Based on the information, what should the nurse do next
Notify the registered nurse and question the morphine sulfate.
An adult client was admitted with myasthenia gravis. While reviewing the client's chart, the licensed practical nurse (LPN)/licensed vocational nurse (LVN) noticed the medication administration record (MAR). Based on the information, what should the nurse do next?
Notify the registered nurse and question the morphine sulfate.
A client is admitted to the emergency department with a suspected overdose of an unknown drug. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation.
A 70-year-old client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis, which of the following objectives is appropriate?
Promoting weight-bearing exercises
The nurse is planning care for a client who suffered a stroke in the right hemisphere of his brain. What should the nurse do?
Provide close supervision because of the client's impulsiveness and poor judgment.
Which method should the nurse use to properly instill eardrops in an adult client with otitis externa?
Pull the pinna up and back
A nurse is preparing a client with suspected herniated nucleus pulposus (HNP) for myelography. Which nursing intervention should the nurse perform before the test?
Question the client about allergy to iodine
The nurse is monitoring a client with a symptom of increased intracranial pressure (ICP) after head trauma. What observation does the nurse recognize as an early sign?
Restlessness and confusion
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes highest priority?
Risk for injury related to neurologic deficit
A nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement?
Schedule the administration of the medication before meals.
Which measure should the nurse emphasize when reinforcing education for a client with multiple sclerosis (MS) to avoid exacerbation of the disease?
Sleep 8 hours each night.
A client with Alzheimer's disease has a nursing diagnosis of Imbalanced nutrition: less than body requirements related to forgetfulness. What nursing intervention should be included in the care plan to encourage adequate nutritional intake for this client?
Stay with the client and encourage him or her to eat.
When assisting with the education of the family of a client with C4 quadriplegia on how to perform tracheostomy suctioning, which instruction should the nurse be sure to include?
Suction for 10 to 15 seconds at a time.
A client accidentally splashes chemicals into his 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
A client is prescribed sumatriptan. Which conditions would cause the nurse to question this health care provider's order? Select all that apply.
Uncontrolled hypertension Myocardial infarction Hypersensitivity reaction Cerebrovascular accident
A client with a subdural hematoma was given mannitol. Which result would best show the effectiveness of the medication?
Urine output of 65 ml/hour
The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding should the nurse consider abnormal?
Urine retention or incontinence
A nurse is developing a teaching plan for a client who will undergo a stapedectomy for the treatment of otosclerosis. Which instruction should the plan include?
Vertigo and dizziness are common after surgery.
A nurse instills atropine drops on both eyes of a client undergoing an ophthalmic examination. Which instruction should the nurse reinforce after administering the medication?
Wear dark glasses in bright light because the pupils are dilated
An otherwise healthy adolescent has meningitis and is receiving IV and oral fluids. The nurse should monitor this teen's fluid balance to decrease the risk of what complication?
cerebral edema
A nurse gathers data on a client to determine cerebral functioning. Which areas should the nurse focus on as part of this evaluation? Select all that apply.
decision making abstract reasoning perception of stimuli
A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:
demonstrate eyedrop instillation.
When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:
elevate the head of the bed 90 degrees during meals.
A nurse is caring for a client who had a lumbar laminectomy 2 days ago. Which finding should the nurse report to the health care provider?
urine retention or incontinence
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
"Avoid hot baths and showers."
A client is scheduled for an electroencephalogram (EEG) after having a seizure for the first time. Which instruction does the nurse provide to the client as preparation for this test?
"Avoid stimulants and alcohol for 24 to 48 hours before the test."
A quadriplegic client is prescribed baclofen, 5 mg by mouth three times daily. The client asks what is the indication for baclofen. How would the nurse respond?
"Baclofen is indicated when there are muscle spasms with paraplegia or quadriplegia from spinal cord lesions."
Which statement indicates that a client needs additional education after cataract surgery?
"I can't wait to pick up my granddaughter."
When discharging a client from the hospital after a laminectomy, the nurse recognizes that further education is necessary when the client makes which statement?
"I can't wait to toss my granddaughter up in the air."
A child is diagnosed with chronic otitis media. Which statement made by the mother indicates an understanding of this condition?
"I'll tell my relatives they can't smoke around the baby."
The parent of a child with a history of closed-head injury asks the nurse why her child would begin having seizures without warning. Which response by the nurse is the most accurate?
"It's not unusual to develop seizures after a head injury because of brain trauma."
Which statement by the parent of a child with cerebral palsy indicates that a nurse's education has been successful?
"My child will need continual therapy to maintain functioning."
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 client is receiving pilocarpine eye drops. Which statement made by the client shows correct understanding about the medication?
"The medication will help decrease pressure in my eyes."
A nurse is caring for a client who underwent surgical repair of a detached retina in the right eye. Which nursing interventions should the nurse perform? Select all that apply.
Approach the client from the left side. Discourage bending down. Orient the client to the environment. Administer a stool softener.
A nurse performs a neurologic data collection on a client reporting headache and dizziness. Which data collection technique helps determine the motor function of cranial nerve VII?
Asking the client to frown, smile, and raise his eyebrows
A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair. How should the nurse intervene first?
Assist the client to a side-lying position on the floor, and protect her with linens.
A client is diagnosed with a brain tumor. As the nurse is assisting the client from the bed to the chair, a generalized seizure occurs. Which action should the nurse perform first?
Assist the client to the floor, and place the client in a side-lying position.
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.
Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head.
To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse's priority?
Cerebral edema
A client is recovering from a stroke and will be discharged in a few days. When helping to develop this client's discharge plan, the nurse should include which interventions? Select all that apply.
Discuss home care needs with the client before the day of discharge. Encourage outside assistance from community agencies and resources.
The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply.
Eat a low-purine diet. Limit alcohol intake.
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?
Elevated 30 degrees
A client who sustained a closed head injury in a skating accident pulls out his feeding tube, I.V. catheter, and indwelling urinary catheter. To ensure this client's safety, a physician prescribes restraints. Which action should a nurse take when using restraints?
Fasten the restraint to the bed frame using a quick-release knot.
An 86-year-old client with a stroke in evolution and a history of coronary artery disease is brought to the medical-surgical floor. His medications include heparin and isosorbide. The nurse should monitor the client for which condition?
Hypotension
The nurse educator presents an in-service on how to formulate a nursing diagnosis of Risk for imbalanced body temperature for a client who suffers a stroke after surgery. The expected outcomes incorporate assessment of the client's temperature to detect abnormalities. The educator will include in the lecture that the thermoregulatory centers are located in which part of the brain?
Hypothalamus
A client comes to the emergency department after hitting his head in a motor vehicle collision. The client is alert and oriented. Which nursing intervention should be done first?
Immobilize the client's head and neck.
A client is receiving an I.V. infusion of mannitol after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding the most significant?
Increased urine output
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?
Ineffective breathing pattern
The nurse is presenting a lecture on vertigo at a community setting. The nurse will include that the client with vertigo may have a problem with which portion of the ear?
Inner ear
A client with a spinal cord injury has a neurogenic bladder. When planning for discharge, the nurse anticipates that the client will need which procedure or program?
Intermittent catheterization
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 does Brudzinski's sign indicate?
Meningeal irritation
A client has a history of seizures. While the client is being transported to the medical imaging laboratory for a brain scan, a seizure occurs. What should the nurse do first?
Move furniture away from the client.
A client with breast cancer reports back pain and difficulty in moving her legs. Which nursing intervention is most appropriate?
Notify the health care provider.
A nurse is caring for a client who meets brain-death criteria. Which nursing intervention is most appropriate at this time?
Notify the organ donor association.
A client's chronic, progressive hearing loss results from excess bone formation around the oval window, which impedes normal stapes movement and prevents sound transmission. The nursing student is researching the disorder. What is the clinical terminology for this correctable middle ear disorder that the student would utilize in her research?
Otosclerosis
A client at the eye clinic is newly diagnosed with glaucoma. What should the nurse inform the client might occur if administration of the medication is not closely adhered to?
Permanent vision loss
Which nursing intervention would be included to support the goal of avoiding injury, respiratory distress, or aspiration during a seizure?
Place a hand under the child's head for support.
A nurse is positioning a client with flaccid left-sided hemiparesis in bed following a cerebral vascular accident (CVA). Which is the nurse's best intervention?
Position the left arm supported on a pillow.
The nurse is monitoring a client for adverse reactions to atropine sulfate eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?
Tachycardia
The nurse is obtaining vital signs for a client with a seizure disorder. Which method would the nurse use to obtain the most accurate measure?
Take an axillary temperature instead of an oral temperature.
The parent of a child with a ventriculoperitoneal shunt calls the nurse saying that her child has a temperature of 101.2° F (38.4° C), a blood pressure of 108/68 mm Hg, and a pulse of 100 beats/minute. The child is lethargic and vomited the night before. Other children in the family have had similar symptoms. Which nursing intervention is most appropriate?
Tell the mother to bring the child to the primary health care provider's office.
A nurse is assigned to care for an elderly client diagnosed with labyrinthitis (inflammation of the inner ear). Which findings should the nurse expect in the client?
The client will ambulate safely in the home.
A community nurse is leading a support group discussion on the progressive nature of multiple sclerosis (MS). Arrange the following degenerative changes in the order in which they occur. Use all of the options.
The immune system attacks myelin. Demyelination throughout the central nervous system. Degeneration of axons. Plaque formation that interrupts nerve impulses. Periodic and unpredictable exacerbations and remissions.
A client is having a grand mal seizure. Which actions should the nurse take during the active seizure phase? Select all that apply.
Turn to the lateral position. Remove dangerous objects. Protect from injury.
A nurse is collecting data on an 8-month-old for signs of neurologic deficit and increased intracranial pressure (ICP). Which findings should the nurse expect to observe?
altered level of consciousness
Which hormone deficiency should the nurse suspect as the underlying cause of diabetes insipidus in a postoperative craniotomy client?
antidiuretic hormone (ADH)
The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:
destruction of acetylcholine receptors.
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).
When obtaining the health history from a client with retinal detachment, the nurse expects the client to report:
light flashes and floaters in front of the eye.
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
raccoon eyes and Battle's sign.
The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in a room set at a comfortable temperature.
A nurse is collecting data on a client who sustained a head injury after a fall from the roof. What signs and symptoms should the nurse observe the client for?
restlessness, disorientation, pupil dilation, and projectile vomiting
The nurse receives a physician's order to administer 1,000 mL of intravenous (IV) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.
31 Explanation: The drip rate is calculated using the following formula: Volume of infusion (in milliliters)/Time of infusion (in minutes) × drip factor (in drops/milliliter) = drops/minute. Therefore, 1,000 mL/480 minutes × 15 drops/mL = 31 gtt/minute.
The nurse is preparing to administer carbamazepine oral suspension, 150 mg by mouth. The pharmacy has dispensed carbamazepine suspension 100 mg/5 mL. How many milliliters of carbamazepine should the nurse administer to the client? Record your answer using one decimal place.
7.5 To calculate the dose, the nurse should use this equation: 100 mg/5 mL = 150 mg/X 100X = 750 X = 7.5 mL.
Which client would be most at risk for secondary Parkinson disease caused by pharmacotherapy?
A 30-year-old client with schizophrenia taking chlorpromazine
Which client on the rehabilitation unit is most likely to develop autonomic dysreflexia?
A client with a high cervical spine injury
Identifying factors that trigger seizure activity could lead to which alteration in the child's environment or activities of daily living?
Avoid striped wallpaper and ceiling fans.
A young child has had multiple ear infections and is brought to the clinic screaming and holding the right ear. Which most common complication related to acute otitis media does the nurse expect this client is experiencing?
Eardrum perforation
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?
Edrophonium
The nurse is assisting a client with cerebrovascular accident (CVA) with feeding. Which nursing action(s) promotes safety when feeding the client? Select all that apply.
Elevate the head of the bed. Check the mouth after feeding. Have client in a sitting position.
After a stroke, a 75-year-old client is admitted to a health care facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which action is a priority for this client?
Elevating the head of the bed to 30 degrees
A nurse is educating the parents of a 1-year-old infant with otitis media. Which statement regarding predisposing factors for otitis media would be most accurate for the nurse to make
Eustachian tubes are short, wide, and straight and lie in a horizontal plane."
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway, attends to the client's immediate needs, and then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, the examination must be brief but will include which nursing intervention?
Evaluation of the corneal reflex response
Which nursing data should be given the highest priority for a child with clinical findings related to tubercular meningitis?
Signs of increased intracranial pressure (ICP)
A client is admitted to an acute care facility with a diagnosis of stroke. The nursing student is reviewing the client's history. Which history findings noted will the student report as risk factors for stroke? Select all that apply.
Smoking ½ pack of cigarettes a day Hypertension Obesity
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 of the following responses did the nurse assess in this client? Select all that apply.
Spontaneous eye opening. Orientation to person, place, and time. Explanation: The Glasgow Coma Scale is a tool to assess a client's response to stimuli. To achieve a perfect score of 15 on the Glasgow Coma Scale, the client would have to open his eyes spontaneously (4), obey verbal commands (6), and be oriented to person, place, and time (5)
When using a Snellen alphabet chart, the nurse records the client's vision as 20/40. What does this evaluation determine for the client?
The client can see at 20 feet what the person with normal vision sees at 40 feet.
A client who is paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?
The client uses a mirror to inspect skin.
A client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière's disease. When reviewing this client's chart, the nurse expects to find which signs and symptoms?
Vertigo, tinnitus, and hearing loss
A client was diagnosed with having right subarachnoid hemorrhage. The nurse should plan to place the client in which position?
With the head of the bed elevated
One hour after receiving pyridostigmine, a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the health care provider and prepares to administer which medication?
Atropine
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
The neurologic unit has identified a 30% occurrence of pressure ulcers in clients admitted with the diagnosis of stroke. Which of the following actions should be included in the unit's performance improvement plan?
Creating a spreadsheet on which nursing staff should document repositioning of clients admitted with a stroke
A nurse collecting data on a post craniotomy client finds the urinary catheter bag with 1,500 mL the first hour and the same amount for the second hour. Which complication should the nurse suspect as a cause of this amount of output?
Diabetes insipidus
After a motor vehicle accident, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Which position should the nurse restrict this client until such an injury is ruled out?
Flat, except for logrolling as needed
What is the function of cerebrospinal fluid (CSF)?
It cushions the brain and spinal cord.
The physician prescribes diazepam, 10 mg I.V., for a client experiencing status epilepticus. Which action would the nurse follow when administering I.V. diazepam?
It should be administered no faster than 5 mg/minute in an adult.
The nurse is making assignments for the day. Which of the following tasks can be safely assigned to unlicensed assistive personnel (UAP)?
Measuring the intake of a client with multiple sclerosis
A nurse is providing discharge instructions on phenytoin to a female client with tonic-clonic seizure disorder. Which instructions should the nurse include? Select all that apply.
Monitor the body for any skin rash. Perform good oral hygiene, including daily brushing and flossing. Receive necessary periodic blood work. Report any problems with walking or coordination, slurred speech, or nausea.
A client with a T1 spinal cord injury arrives at the emergency department with a blood pressure of 82/40 mm Hg, pulse rate of 34 beats/minute, dry skin, and flaccid paralysis of the lower extremities. Which condition would most likely be suspected?
Neurogenic shock
While in the emergency department, a client with C8 quadriplegia develops a blood pressure of 80/44 mm Hg, pulse of 48 beats/minute, and respiratory rate of 18 breaths/minute. The nurse suspects which condition?
Neurogenic shock
When obtaining data about pupillary responses, which method should the nurse use to evaluate pupil accommodation?
Observe for pupil constriction and convergence while focusing on an object coming toward the client.
The nurse is caring for a client that underwent a stapedectomy. Which position would have the greatest benefit for prevention of complications and promotion of comfort?
On the unaffected side
The nurse is working on a surgical floor. The nurse must logroll a client following a:
laminectomy.
In caring for a child immediately after a head injury, the nurse notes a blood pressure of 110/60, a heart rate of 78 beats/minute, dilated and nonreactive pupils, minimal response to pain, and slow response to name. Which symptom would cause the nurse the most concern?
Nonreactive pupils
A client who experienced a severe stroke develops a fever and a cough that produces thick, yellow sputum. A nurse observes sediment in the client's urine in the indwelling urinary catheter tubing. Based on these findings, which action should the nurse take?
Notify a physician of the findings.
A nurse is caring for a client with a closed head injury. What is the appropriate action by the nurse?
Notify the health care provider of a blood pressure change from 147/72 to 176/70.
A client was hit in the head with a baseball during practice. Which discharge instructions should the nurse reinforce?
Wake client every hour and check orientation to person, time, and place.
