Nur 242 exam 4

A client who had a brain attack (cerebrovascular accident, CVA) frequently cries when family members visit. The family members report being upset by the crying. Which explanation for the client's behavior would the nurse provide?

Having difficulty controlling reactions

An infant born with hydrocephalus will be discharged after insertion of a ventriculoperitoneal shunt. Which common complication would the nurse instruct the parents to report if it occurs at home?

Fever accompanied by decreased responsiveness

Which components would the nurse encourage the parent to increase in the diet of a 4-year-old child with spina bifida who spends many hours in a wheelchair? Select all that apply. One, some, or all responses may be correct.

Fiber, proteins

Family members of a client who had a brain attack (cerebrovascular accident, CVA) ask why the client cries easily and without provocation. Which explanation would the nurse provide about the client's behavior?

Has little control over this behavior

When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia?

Having suction available during meals

In which position would the nurse place a client with a spinal cord injury experiencing autonomic dysreflexia?

High Fowler to lower BP

Which assessment findings alert the nurse that the client who has a spinal cord injury is developing autonomic hyperreflexia (autonomic dysreflexia)?

Hypertension and bradycardia

Damage to which nerve explains why a client recovering from a head injury is unable to move the tongue?

Hypoglossal

A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. Which part of the client's brain would the nurse suspect is injured?

Hypothalamus

Which structure is likely damaged in a client with a head injury whose temperature rapidly increases to 102.2°F (39°C)?

Hypothalamus

Which priority intervention would the nurse perform immediately for a client with a spinal cord injury?

Immobilize and stabilize the cervical spine.

Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later, the nurse identifies that one pupil reacts more slowly than the other and the client's systolic blood pressure is increasing. For which condition would the nurse prepare to intervene?

Increased intracranial pressure

Which finding for a client with a head injury indicates increasing intracranial pressure?

Increased restlessness

Which intervention would the nurse plan for a client who has a head injury and a diminished corneal reflex in the left eye?

Instilling artificial tears frequently

Which intervention related to post-cerebrovascular accident (CVA, also known as a "brain attack") urinary incontinence would the nurse include in the client's plan of care?

Institute measures to prevent constipation.

A client manifests right-sided hemianopsia as a result of a cerebrovascular accident (CVA, also known as a "brain attack"). Which goal would the nurse include in the client's plan of care?

Instruct the client to scan surrounding

Which of these assessments leads the nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply. One, some, or all responses may be correct.

Irritability, high pitched cry, ineffective feeding behavior

Which early sign of increased intracranial pressure (ICP) would the nurse monitor in a client who sustained a head injury while playing soccer?

Lethargy

Which assessment is priority after checking airway for a client with a cervical spinal cord injury

Level of consciousness

An unconscious child is admitted to the pediatric intensive care unit with a closed head injury. What is the nurse's primary goal for this child?

Limitation of stimuli that increase intracranial pressure

Which assessment finding indicates that a client has had a stroke? Select all that apply. One, some, or all responses may be correct.

Lopsided smile Unilateral vision Incoherent speech Unable to raise right arm Symptoms started 2 hours ago

A client who sustained a head injury reports to the nurse that food always tastes unappealingly bland even though the food is has been prepared to be flavorful. Which area of the brain would the nurse suspect to be affected in the client?

Parietal lobe

Which responses would alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia?

Paroxysmal hypertension and bradycardia

A client's cerebrovascular accident results in right hemiplegia. Which exercises would the nurse incorporate into the plan of care while the client is on bed rest?

Passive range-of-motion exercises

Which mechanism of injury might be the reason for a suspected spinal cord injury in a client with a direct injury to the vertebral column from a gunshot after a mass shooting?

Penetrating trauma

The nurse is caring for a client who had a stroke and who has varying moods ranging from anger to depression to concern about the aphasia, hemiparesis, and the gavage feedings. Which behavior indicates the client's acceptance of physical limitations?

Performs tube feedings without assistance

A client who has a spinal cord injury at the T4 level wants to use a wheelchair. What exercise would the nurse teach the client to do in preparation for this activity?

Push-ups to strengthen arm muscles

Which action would the nurse implement to assist a client's development of independence, after experiencing a cerebrovascular accident (CVA) 2 weeks ago?

Reinforce success in tasks accomplished

Which priority interventions would the nurse provide to the client hospitalized with heatstroke, a body temperature of 106°F, and skin that is hot and dry? Select all that apply. One, some, or all responses may be correct

Remove the client's clothing. Immerse the client in cold water

The nurse assessed a client who experienced a recent brain attack (stroke) and has a residual right-sided hemiplegia. Which rationale explains the importance of the nurse identifying mobility restrictions or neuromuscular abnormalities when assessing this client?

Shortening and eventual atrophy of the affected muscles will occur

Which position would the nurse plan to use for the client who is having a hypertensive crisis and evolving stroke?

Side-lying

Which information would the nurse include in the discharge teaching plan for a client who sustained a cerebrovascular accident (CVA, also known as a "brain attack") with residual hemiparesis and hemianopsia?

Significance of a safe environment

Which behaviors would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain? Select all that apply. One, some, or all responses may be correct.

Slow performance and caution Impaired speech/language aphasias Awareness of deficits with depression and anxiety

A client who sustained a head injury from a fall off a ladder has clear fluid leaking from the left ear. Which action would the nurse take?

Test the ear drainage with a glucose reagent strip.

The nurse in an emergency department is assessing a young child with a head injury. The child is accompanied by a parent. Which observation would prompt the nurse to assess the child for abuse?

The child has received care for injuries twice earlier.

The spouse of a client who had a cerebrovascular accident asks the home health nurse why the client cries easily and without provocation. Which response would the nurse provide?

This behavior is a common response over which the client has little control

The nurse is caring for a client who has quadriparesis from a spinal cord injury. Which rationale explains why fluid intake would be increased for this client?

To prevent a urinary tract infection

Which rationale supports the nursing intervention to turn the client with paraplegia every 1 to 2 hours?

To prevent development of pressure injuries

Which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident (CVA, also known as a "brain attack")?

Transient ischemic attacks (TIAs)

The nurse would notify the health care provider with which finding in a child being observed following a closed head injury?

Vomiting

Which symptoms would the nurse recognize as indicative of increased intracranial pressure in a 3-year-old child? Select all that apply. One, some, or all responses may be correct.

Vomiting, irritability, headache

The nurse writes a goal of preventing renal calculi in a care plan for a client who has paraplegia. Which information provides the rationale for selecting this goal?

Accelerated bone demineralization

Which primary interventions would the nurse perform on a diabetic client who survives a fire, but has a head injury, tachycardia, and pale and ashen-colored skin? Select all that apply. One, some, or all responses may be correct.

Administering cool intravenous (IV) fluids, Placing the client in a cool environment, Managing and maintaining airway-breathing-circulation

The nurse assists a client on a rehabilitation unit after a cerebrovascular accident (CVA, also known as a "brain attack") with residual hemiparesis to walk with the use of a cane. To help achieve the goal of safe walking with a cane, which method would the nurse teach the client?

Advance the cane and the affected extremity simultaneously.

The spouse of a client who had a cerebrovascular accident seems unable to accept the goal that the client will participate in self-care. Which response would the nurse make?

Ask the spouse for assistance in planning activities most helpful to the client

Three days after admission to the hospital for a brain attack (cerebrovascular accident [CVA]), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action would the nurse take to evaluate whether the feeding is being absorbed?

Aspirate for a residual volume

Which action by the emergency department nurse is the priority for a client with heat stroke?

Assess the airway and breathing

Which intervention is a priority when caring for a child who sustained a head injury 12 hours earlier?

Assessing the level of consciousness every hour

The nurse is planning care for an immobilized client who had a stroke with right-sided hemiparesis. Which activity would the nurse include in the plan of care?

Assist the client to perform range-of-motion (ROM) exercises every 1 to 2 hours

A male client with a brain attack (cerebrovascular accident) is incontinent of urine. Which action would the nurse encourage to help the client reestablish bladder control?

Assume a standing position for voiding

Which condition of a client with hemorrhagic stroke resulting from a motor bike accident requires immediate attention?

Body temperature of 81.2°F

Which functions will the nurse assess when caring for a client with a head injury that involved the medulla? Select all that apply. One, some, or all responses may be correct.

Breathing, pulse

Which early sign of impending hydrocephalus would the nurse monitor for in an infant who has had surgery for repair of a myelomeningocele?

Bulging fontanels

A nurse is assessing a newborn with a myelomeningocele. Which clinical findings prompt the nurse to suspect hydrocephalus? Select all that apply. One, some, or all responses may be correct.

Bulging fontanels High-pitched crying A defect in the lumbosacral area

A client with a head injury has a fixed, dilated right pupil, responds only to painful stimuli, and exhibits flexion (decorticate) posturing. Which possible cause would the nurse suspect from these clinical findings?

Cerebral compression

Which education would the nurse provide the parents of a preschool child with a spinal cord injury about foods to avoid during prolonged bed rest to prevent complications associated with immobility?

Cheese bc calcium and kidney stones

A client is admitted to the hospital after sustaining a head injury. Which assessment finding indicates increased intracranial pressure?

Decrease in the level of consciousness

While caring for a client who sustained a severe head injury in an accident, the nurse observes that the client is constantly passing urine and is dehydrated. Which would the nurse suspect is the cause of the client's condition?

Decreased secretion of antidiuretic hormone

The registered nurse (RN) is caring for a client who is currently hospitalized for a stroke. Which professional management strategy will be most effective for the RN to improve the safety and quality of client care?

Delegation

The nurse is preparing to discharge a client who is partially paralyzed after a stroke. Which behaviors would the nurse alert the family of as symptoms of caregiver role strain? Select all that apply. One, some, or all responses may be correct.

Disturbed sleep patterns Reduced appetite and weight Fearful about administering medications to the client

A health care provider prescribes mannitol for a client with a head injury. Which mechanism of action is responsible for therapeutic effects of this medication?

Drawing fluid from brain cells into the bloodstream

A client admitted to the hospital with the diagnosis of a right-sided "brain attack" (stroke) is right-handed. Which task will be most difficult for this client?

Dressing every morning

A client has dysarthria after a stroke. Which goal would the nurse include in the plan of care to address this problem?

Effective communication

Which intervention would the nurse implement for an infant with increased intracranial pressure?

Elevating the head higher than the hips

Which nursing intervention would the nurse provide an infant exhibiting signs of increased intracranial pressure (ICP)?

Elevating the infant's head higher than the hips

The family members of a client with the diagnosis of cerebrovascular accident express concern that the client often becomes uncontrollably tearful during their visits. Which information would the nurse include in a response?

Emotional lability is often associated with brain trauma

For optimum nutrition, which intervention would the nurse implement when determining a client, who sustained a cerebrovascular accident (also known as a "brain attack"), needs assistance with eating?

Encourage the client to participate in the feeding process

Which action will the nurse complete when preparing a stroke client for cerebral imaging with iodine-based contrast dye?

Ensure a recent creatinine level has been assessed.

When a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures, which actions would the nurse take first?

Establish an airway and stabilize the cervical spine.

The client with which National Institutes of Health Stroke Scale (NIHSS) score would be treated first?

3 for facial palsy

109 F

42.8 C (109-32):5/9

A young adult client who has permanent paralysis secondary to a spinal cord injury says, "I wish God would end my suffering and take me." Which response would the nurse use?

"Being incapacitated is difficult for you.

Which parent education would the nurse provide the parents of an infant recently diagnosed with communicating hydrocephalus?

"There is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately."

Which amount of time is the maximum amount the nurse would permit an older adult with a cerebrovascular accident (CVA, also known as "brain attack") to remain in one position?

1 to 2 hours

The nurse is assessing a client who was admitted with a head injury. The nurse finds that the client is unable to understand written or verbal speech. Which condition would the nurse suspect?

Aphasia

Which nursing intervention is the priority for a client with stroke who is transitioned from the emergency department (ED) to other settings?

Assessing the level of consciousnes

Which information would the nurse include when explaining the cause of transient ischemic attacks (TIAs) to a client?

Atherosclerotic plaques within arteries

Which is the priority focus of nursing care for a client with a spinal cord injury during the immediate postinjury period?

Avoiding flexion or hyperextension of the spine

A client who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO 2 of 33 mm Hg. Which action would the nurse take?

Continue to monitor for signs of increasing intracranial pressure.

A client who sustained head injuries is admitted to the hospital. During assessment of cranial nerves, the nurse notices that the client lost the perception of taste, especially in the anterior portion of the tongue. Which cranial nerve might have been injured in this client?

Cranial nerve VII

Which reflex is the nurse testing when using a dull object to stroke from the lateral sole of a client's foot upward to the great toe?

Babinski

After an earthquake that has caused mass casualties, which color tag would be given to the client with a massive head injury who does not respond to stimulation and cannot breathe independently?

Black tag

Which physiological response is the likely cause of a client developing hydrocephalus 2 weeks after cranial surgery for a ruptured cerebral aneurysm?

Blocked absorption of fluid from the arachnoid space

A client with a head injury has a computed tomography (CT) scan that shows a subdural hematoma. How would the nurse interpret this finding?

Blood between the dura mater and the arachnoid layer

A client who had a cerebrovascular accident reports feeling lightheaded and dizzy when moving from a lying to a standing position. Which information would the nurse include when explaining the cause of these symptoms?

Blood pooling in the lower extremities

During a follow-up visit, the nurse finds increased intracranial pressure in a client who has undergone nasal hypophysectomy for hyperpituitarism. Which action taken by the client is responsible for this condition?

Blowing the nose and sneezing

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? Select all that apply. One, some, or all responses may be correct.

Bradycardia, hypotension, urinary retention

Which factor contributes to skeletal calcium loss by a client who has paraplegia?

Decreased weight bearing

Which client condition requires a medium priority of care according to the National Institutes of Health Stroke Scale (NIHSS) score?

Facial palsy score of 1

Which skin care parent education would the nurse provide to the parents of an infant with spina bifida?

Frequent diaper changes with cleansing are needed

Which finding indicates a complication of the labor process in a client with a history of T5 spinal cord injury?

Increased blood pressure

Which procedure may benefit the client who was in a traffic accident, is choking, and may have a spinal cord injury?

Performing a jaw-thrust maneuver

Which nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke?

Place objects within the visual field

Which intervention would the nurse perform first for a client with a spinal cord injury who is experiencing autonomic dysreflexia?

Place the client in sitting position.

Which intervention would the nurse perform first for the client admitted with a closed head injury and increased intracranial pressure (ICP)?

Place the head and neck in neutral alignment

An infant has noncommunicating hydrocephalus, and a ventriculoperitoneal shunt is inserted. Which nursing intervention would the nurse implement for the infant during the initial postoperative period?

Place the infant flat with the head on the unaffected side

A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client's rehabilitation?

Position the client to prevent contractures.

Which device would the nurse use to prevent footdrop for a client on bed rest after a cerebrovascular accident?

Splints

The nurse is caring for a client 1 week after the client experienced a spinal cord injury at the T3 level. Which short-term goal is appropriate in planning care for this client?

The client will carry out personal hygiene activities.

Which explanation would the nurse provide family members who ask the meaning of their loved one's diagnosis of "paraplegia" after experiencing a spinal cord injury?

The client's lower extremities are paralyzed

The nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be effective for this client?

The plan is formulated and implemented early in the client's care

Which prehospital care intervention is the priority for the client with heatstroke?

Withholding food or liquid to the victim

When providing care for a client with paraplegia secondary to a spinal cord injury, which potential complication may occur early during the recovery period?

bladder control

A client reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as a heat stroke?

increased heart rate

Which item in the plan of care for a client with paraplegia would the nurse question?

instruct the client to do active leg exercises.

The nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation?

pain

After a cerebrovascular accident (CVA, also known as "brain attack"), a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. The nurse would conclude the CVA affected which lobe of the brain

parietal

Which level of care is the nurse providing when preparing to discharge a client who is learning to walk again after a stroke to a rehabilitation center?

tertiary care

Which nursing action is a priority for a client with a spinal cord injury who has developed sudden autonomic dysreflexia?

to place in a sitting position

The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem?

urinary tract infections

Which triage level would the nurse assign to the 60-year-old client is admitted with a head injury after a disaster?

Urgent

Which intervention and rationale would the nurse plan for a client admitted to the hospital with a right-sided brain attack (cerebrovascular accident)?

Use a hand roll and support the left arm on a pillow to prevent contractures

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit?

Validating availability of a bag-valve-mask during the transfer

Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring? Select all that apply. One, some, or all responses may be correct.

Wearing a medical alert bracelet Initiating bleeding precautions Refraining from estrogen therapy Obtaining routine prothrombin times Notifying providers of anticoagulation

The nurse was assessing an older adult client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. Which would be the approximate stroke volume?

70 ml

A client who sustains a stroke has a loss of proprioception and fine touch. Which artery would the nurse suspect is damaged?

Anterior cerebral

The emergency department received a client who was a passenger in an automobile collision, with rhinorrhea and bleeding from their ear. Having sustained a basilar head injury, which interventions would the nurse anticipate as the initial focus of this client's care?

Antimicrobial administration

The client taking intravenous coagulant medications for a bleeding disorder suddenly develops an embolic stroke as a result of medication overdose. Which actions by the hospital management does the Leapfrog Group suggest? Select all that apply. One, some, or all responses may be correct.

Apologize to the client and family. Waive all costs directly related to the adverse effect. Report the adverse event to The Joint Commission.

Which is the priority nursing action for a client admitted to the hospital in a coma after having a stroke?

Maintain an open airway.

To prevent the development of plantar flexion, which action would the nurse implement, when providing care for a client who sustained a cerebrovascular accident (CVA, also known as a "brain attack") 2 days ago?

Maintain the feet at right angles to the legs

Which action is the priority for a client who is admitted to the hospital with a severe head injury?

Maintain ventilation

Which care plan would the nurse implement for a 1-month-old infant with hydrocephalus scheduled to have surgery for the insertion of a ventriculoperitoneal shunt?

Maintaining a satisfactory comfort level to limit crying

Which goal is a priority for a client who is unconscious after a cerebrovascular accident?

Maintaining the airway

Which condition would the nurse suspect in an emergency department client with C8 tetraplegia, blood pressure of 80/40 mm Hg, pulse of 48 beats per minute, and respiratory rate (RR) of 18 breaths per minute?

Neurogenic shock

Two weeks after sustaining a spinal cord injury, a client begins vomiting thick, coffee-ground material and appears restless and apprehensive. Which is the most important initial nursing action?

Prepare for insertion of a nasogastric tube

When assessing a client with a diagnosed "brain attack" (cerebrovascular accident [CVA]), the nurse evaluated the baseline vital signs of pulse rate of 78 beats per minute (bpm) and a blood pressure (BP) of 120/80 mm Hg. Which changes in the baseline vital signs indicate an increasing intracranial pressure (ICP)?

Pulse 50 bpm and BP 140/60 mm Hg

The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for hydrocephalus are taught about postoperative positioning that helps prevent pressure on the valve site. Which statement indicates that they understand the teaching?

The flat left side-lying position is the safest position for our baby

Which rationale explains why the nurse would monitor a client who has a spinal cord injury at the T2 level for signs of autonomic hyperreflexia (autonomic dysreflexia)?

The injury is above the sixth thoracic vertebra.

The body temperature of a client with heatstroke is above 104°F (40°C). Which is the priority order the nurse would use for cooling the client so that breathing and circulation are not impaired?

The nurse will take off the client's clothing. The nurse would place ice packs on the neck, axillae, chest, and groin. The nurse would immerse the victim in cold water. The nurse would fan the client rapidly to aid in cooling by evaporation.

Which education would the nurse provide the parents of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus?

The shunt may need to be replaced as the child grows older.

The nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Which statement explains the nurse's rational?

There is damage above the sixth thoracic vertebra.

After a head injury, a client reports hearing ringing noises. Which area would the nurse assess further?

Eighth cranial nerve (vestibulocochlear)

The nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. Which is the initial nursing action?

Immobilizing the child's spine to limit additional injury

The nurse is providing care to a client. Which nursing action has the highest priority when the nurse is moving a client with a neck and spinal cord injury during the assessment process?

Implementing the logrolling technique

A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which areas of paralysis would the nurse expect to find upon assessment? Select all that apply. One, some, or all responses may be correct.

Left leg Left arm Left side of face

A client who recently experienced a brain attack (cerebrovascular accident [CVA]) and has limited mobility reports constipation. Which is most important for the nurse to determine when collecting information about the constipation?

Length of time this problem has existed

Which is the priority nursing intervention for a client admitted to the hospital with a brain attack (cerebrovascular accident)?

Monitoring for increased intracranial pressure

After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. Which specific range-of-motion exercise would the nurse teach the client?

Opposition

Which clinical assessment would the nurse perform to evaluate the effectiveness of a shunt for an infant with hydrocephalus?

Palpating the anterior fontanel

A client who had a cerebrovascular accident (CVA, also known as a "brain attack") begins to eat lunch. Which client behavior indicates the client may be experiencing left hemianopsia?

The client ignores the food on the left side of the tray when eating

Which assessment finding reflects increased intracranial pressure (ICP)?

Unequal pupil size

A 50-year-old client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse inquired about the client's feelings, the spouse responded. Which communication strategy would the nurse use to address this behavior?

Acknowledge the spouse, but look at the client for a response.

A client who sustained a cerebrovascular accident (CVA, also known as a "brain attack") becomes incontinent of feces. Which nursing intervention is most important for supporting the success of the client's bowel training program?

Adhere to a definite time for attempted evacuations

Which action would the nurse include when preparing a toddler with the diagnosis of hydrocephalus for a computed tomography scan?

Administering the prescribed sedative

After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide. Which instruction will the nurse give the client regarding nutrition?

Eat more dark green, leafy vegetables such as spinach.

Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is rising. Which complication would the nurse plan to address?

Increased intracranial pressure

When the nurse tries to bathe a young client with a spinal cord injury who has an incontinence episode he says, "Leave me alone. Having you care for me is worse than lying in this mess." Which response is the best?

During the bath, I'll start teaching you about bowel training."

An older client experiences a cerebrovascular accident (CVA) with right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. Which abilities would the nurse explain will be affected?

Speaking preferences aloud

Which position would the nurse select for an infant with hydrocephalus?

Supine, with the head elevated about 45 degrees

Which intervention would the disaster management team nurse perform for the survivors of an explosion who developed heat stroke?

Apply ice packs on the client's scalp

Which nursing intervention would the nurse perform immediately for the client with a head injury and a Glasgow Coma Scale score of 9?

Stabilize the cervical spine

A client has had a recent brain attack (cerebrovascular accident/stroke). Which preventative would the nurse anticipate will be prescribed daily to avoid straining due to constipation?

Stool softener

Which position would the nurse use for an infant after the insertion of a ventriculoperitoneal shunt for hydrocephalus

Supine on the unaffected side

The nurse is caring for a client who has a traumatic brain injury with increased intracranial pressure. Which health care provider prescription would the nurse question?

Teach isometric exercises

A client who had a cerebrovascular accident leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. Which nursing action would the client's plan of care include?

Teaching the client to use head movement to scan the left field of vision

Which explanation would the nurse provide to a client about transient ischemic attacks (TIAs)?

Temporary episodes of neurological dysfunction

A client who sustained a head injury reports bland taste of food. Upon examination, the nurse finds that there is loss of taste perception from the anterior two-thirds region of the tongue. Which origin of the brain is associated with the involved nerve?

Inferior pons

A client has increased intracranial pressure and is unconscious with a heart rate of 60 beats/min, respirations 16 breaths/min, and blood pressure 142/64 mm Hg. The nurse reviews the treatment plan and questions which prescription?

Morphine

A young man who sustained a spinal cord injury at the cervical level expresses concern about future sexual functioning. Which action would the nurse take?

Explain to the client that he likely will be able to have reflex penile erections

The nurse is assessing a client who has a head injury. Which movement of the client's arm after the nurse applies nailbed pressure would cause the most concern?

Extending

The nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked. Which finding would the nurse document?

Exhibits a positive Babinski sign

A child loses consciousness a few days after a traumatic head injury that resulted in a subdural hematoma. While assessing extraocular movements, the nurse notes that the child is displaying the oculocephalic reflex. Which would the nurse conclude about the presence of the oculocephalic reflex in an unconscious child?

Expected

An older adult client is admitted to the health care facility following a stroke. Which action is correct when the client's cousin asks to see the client's health record?

Explain that medical health records are confidential

In which order would the nurse caring for a client suffering from heatstroke provide emergency interventions?

Ensure a patent airway. Remove the client from the hot environment. Remove the client's clothing Pour or spray cold water on the client's body and scalp. Fan the client with newspapers or whatever is available. Place ice in cloth or bags and position the packs on the client's scalp Emergency care should be provided to the client with heatstroke to restore thermoregulation. First the nurse would ensure a patent airway. Then the nurse would remove the client from the hot environment into air conditioning or shade and remove his or her clothing. Then the nurse would pour or spray cold water on the client's body and scalp. The client should be fanned with newspapers or whatever is available. This should be followed by placing ice in cloth or bags and positioning the packs on the client's scalp.

The parents of a toddler with a right ventriculoperitoneal (VP) shunt for the treatment of hydrocephalus are taught about postoperative positioning. The nurse concludes that they understand the teaching when they state that they will place the toddler in which position?

Flat on the left side with the head and back supported

Which clinical manifestations would the nurse identify as indicators suggesting a client has urinary retention and overflow after sustaining a cerebrovascular accident (CVA, also known as a "brain attack")? Select all that apply. One, some, or all responses may be correct.

Frequent voiding Suprapubic distention

Which assessments would the nurse include in a focused assessment for a client who has sustained a head injury? Select all that apply. One, some, or all responses may be correct.

HR, pulse pressure, LOC, oral cavity inspection

When using the Glasgow Coma Scale, which consideration would the nurse make when evaluating a 3-year-old child with a head injury?

He or she may not respond to strangers asking questions

A client is admitted with a head injury and has large amounts of clear, colorless urine draining from the urinary catheter. Which physiological response is possibly causing the increased urine output?

Inadequate antidiuretic hormone (ADH) secretion

A client diagnosed with a transient ischemic attack (TIA) related to hypertension is discharged with a prescription of hydrochlorothiazide. Which instruction would the nurse include when teaching about this medication?

Increase the intake of potassium-rich foods."

Which action is likely to help prevent pressure injuries for a client who has paraplegia?

Inspecting the skin every day

Which nursing intervention would the nurse implement for an infant during the first 24 hours after surgery to place a ventriculoperitoneal shunt for hydrocephalus?

Monitoring for increasing intracranial pressure

Which nursing care would the nurse provide for an infant the first 24 hours after surgical placement of a ventriculoperitoneal shunt for hydrocephalus?

Monitoring the infant for increasing intracranial pressure