PassPoint - Neurosensory Disorders

A client preparing to undergo a lumbar puncture states they don't think they will be able to get comfortable with their knees drawn up to the abdomen and the chin touching their chest. The client asks if they can lie on their left side. Which statement is the best response by the nurse?

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."

The nurse is providing information to the parents of a child newly diagnosed with juvenile arthritis. Which statements by the parents indicate understanding of the teaching? Select all that apply.

"I help my child perform daily range-of-motion exercises." "I give my child NSAIDs three times a day." "I apply heat pads to the joints when my child is having pain."

A client with multiple sclerosis (MS) is receiving discharge instructions from the nurse. Which statement by the client indicates that more instruction is required?

"I will walk with my feet close together."

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."

Friends come to visit a client admitted with new-onset ischemic stroke. The stroke has caused aphasia and right-sided weakness. The client has an advance directive and an identified healthcare power of attorney. The friends ask the nurse about the client's condition. How should the nurse respond?

"I'm not at liberty to discuss their condition with you. You'll have to speak to the client's power of attorney if you'd like information."

The nurse is providing medication teaching for a client who has been prescribed carbamazepine for a seizure disorder. What client statement would indicate that additional instruction is required?

"If I have a seizure, I should take two tablets immediately."

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about past activities. In tears, one day they ask the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior?

"Reviewing your losses is a way to help you work through your grief and loss."

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."

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time that client is admitted to the intensive care unit (ICU) for aggressive treatment. The nurse meets with the team to develop a change strategy based on indicators. Which statement by a team member shows a need for further teaching regarding performance management?

"We can discipline the ED staff for not getting the clients to the ICU fast enough."

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 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 receives a physician's order to administer 1,000 mL of intravenous (I.V.) 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

A client with a head injury is being monitored for increased intracranial pressure (ICP). The client's blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore their cerebral perfusion pressure (CPP) is

52 mm Hg.

A client with glaucoma is scheduled for a hip replacement. Which prescription would require clarification before the nurse carries it out?

Administer atropine sulfate.

The nurse working on a neurological unit is assigned a client with spinal cord injury. Which nursing actions can the nurse delegate to the nursing student on the unit? Select all that apply.

Administer oral medication to decrease muscle spasticity. Provide pin care.

A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first?

Administer oxygen.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

Alternatively patch one eye every 2 hours.

A nurse is caring for a client who has returned to their room after a carotid endarterectomy. Which action should the nurse take first?

Ask the client if they have trouble breathing.

A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer?

Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU.

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.

Following a scleral buckling, what should the nurse instruct the client to do during the postoperative period?

Assess for eye for drainage.

The nurse is planning care for a client in the postictal phase of a seizure. What action should the nurse take first?

Assess the client's breathing pattern.

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.

The nurse is assessing motor strength in a client with a head injury. Which is the best way to determine motor strength for this client?

Compare equality of hand grasps.

A 24-year-old client, diagnosed with acute osteomyelitis in the left leg, has acute pain in the leg that intensifies on movement. The client has a temperature of 101°F (38.3°C) and a reddened, warm area in the midcalf region over the shaft of the tibia. Based on this information, what should the nurse do?

Develop a plan for pain management.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?

Explain how to overcome a freezing gait by telling the client to march in place.

A nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement?

Give the medication before meals with a small amount of food.

A client complains that they experience pain and numbness in the fingers when typing on a computer keyboard. Which action will help the nurse assess for Phalen's sign?

Having the client hold both wrists in acute flexion with the dorsal surfaces touching for 60 seconds

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.

What is the function of cerebrospinal fluid (CSF)?

It cushions the brain and spinal cord.

A short time after cataract surgery, a client has nausea. What should the nurse do first?

Medicate the client with an antiemetic, as prescribed.

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.

A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. Which assessment finding should the nurse anticipate?

Muscle contraction is palpable and visible.

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).

A client has a plaster cast applied to the lower extremity that is still wet to touch. In which way should the nurse move the casted limb to elevate it on a pillow?

Place the palms on both sides of the cast.

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.

The nurse is instructing a client about postoperative care following cataract removal. What position should the nurse teach the client to use?

Remain in a semi-Fowler position.

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?

Risk for injury related to vertigo

A client who has glaucoma has been prescribed timolol eye drops. The nurse should give which instructions about the administration of the eye drops?

The medication may cause some transient eye discomfort.

The nurse is caring for a client with a diagnosis of cerebrovascular accident (CVA) with left-sided hemiparesis. What would be important nursing measures in the acute phase of care? Select all that apply.

Turn and position every 2 hours. Perform passive range of motion on the affected side. Support the affected side with pillows.

One day after cataract surgery, the client is having discomfort from bright light. What should the nurse advise the client to do?

Use sunglasses that wrap around the side of the face when in bright light.

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing?

XII

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by

a positive edrophonium test.

The nurse is instructing an unlicensed assistive personnel (UAP) on how to correctly position a client who has had a recent total hip replacement. In which position should the nurse tell the UAP to place the affected leg when the client is lying on the nonoperative side?

abduction and extension

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

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 recovering from Guillain Barré syndrome states, "I'm nervous that this disease will come back." Which nursing diagnoses is most suggested by this comment?

anxiety

The nurse is admitting a client diagnosed with multiple sclerosis (MS). Which medication would the nurse expect to find on the client's record?

baclofen

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with

body temperature control.

The nurse is assessing a client who has had an internal fixation and hip pinning. Which nursing measure will likely decrease the risk for a surgical wound infection in this client?

changing the surgical dressings using sterile technique

The nurse is teaching a client who has had cataract surgery how to decrease intraocular pressure. What should the nurse instruct the client to avoid?

coughing

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.

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 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 with Parkinson's disease needs assistance with eating but does not require thickened liquids to aid swallowing. For what action by the unlicensed assistive personnel should the nurse intervene?

elevating the head of the client's bed to 45 degrees

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 and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an

evaluation of the corneal reflex response.

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?

generalized

A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage?

head of the bed elevated to 30 degrees

The adult child of an older adult reports that their parent just "stares off into space" more and more in the last several months but then eagerly smiles and nods once the son can get their attention. What additional assessment should the nurse make to better understand the client's behavior?

hearing loss

To promote early and efficient ambulation for a client after an above-the-knee amputation, the nurse is aware that the leg will need to be positioned in which way?

in functional alignment

The nurse is administering eye drops to a client with glaucoma. Which technique is correct for instilling the eye drops?

in the lower conjunctival sac

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 notes that a client has kyphosis and generalized muscle atrophy. Which problem is a priority when the nurse develops a nursing plan of care?

ineffective coughing and deep breathing

After an eye examination, a client is diagnosed with open-angle glaucoma. The physician orders pilocarpine ophthalmic solution, 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by

instilling one drop of pilocarpine 0.25% into both eyes four times daily.

What is the best method to remove cerumen from a client's ear?

irrigating the ear gently

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 is in the ictal phase of a generalized tonic-clonic seizure. Which finding is expected?

loss of consciousness, body stiffening, and violent muscle contractions

A physician is assessing a client's ear and notes excess bone formation around the oval window. Which additional assessment finding should the nurse anticipate?

low-frequency hearing loss

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

lung auscultation and measurement of vital capacity and tidal volume

The nurse is teaching the family of a client with dysphagia about decreasing the risk for aspiration while eating. Which measure(s) should the nurse include in the teaching plan? Select all that apply.

maintaining an upright position while eating introducing foods on the unaffected side of the mouth keeping distractions to a minimum

A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which condition?

meningitis

What assessment findings would the nurse expect in a client with progressive myasthenia gravis?

muscle weakness, difficulty swallowing, double vision, and difficulty speaking

A nurse is assessing a client's extraocular eye movements as part of evaluating neurological functioning. Which cranial nerve status is documented? Select all that apply.

oculomotor (III). trochlear (IV). abducens (VI).

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.

padding the side rails setting up suction keeping the client side lying

The client comes to the clinic reporting activity restriction and sexual dysfunction. Tests are completed and a diagnosis of L5-S1 herniated disk impinging on the right nerve root is made by the healthcare provider. What assessment findings should the nurse expect to note?

pain radiating down the right leg

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.

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP indicates that the nurse should provide further instruction?

pulling up the client under the left shoulder when getting the client out of bed to a chair

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.

A client with multiple sclerosis (MS) lives with their daughter and 3-year-old granddaughter. The daughter asks the nurse what they can do at home to help the client. Which measure would be most beneficial?

regular exercise

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

rising blood pressure and bradycardia

Which is the best positioning for a client who has a fractured spine as a result of a diving accident?

supine with the head midline

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to

support the joint where the tendon is being tested.

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

A client with suspected myasthenia gravis is scheduled for a edrophonium test. The nurse identifies which test finding that most likely indicates a positive test result?

temporary muscle improvement

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

The nurse is assessing a client with Parkinson disease. Which is an initial sign of Parkinson disease?

tremor

A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place them closer to the nurses' station because of their tendency to

wander

The nurse is discharging a client who had a fish hook embedded in their eye. The fish hook was removed surgically in the emergency department, but the client currently has no vision in that eye. The surgeon has informed the client that a corneal transplant may restore some vision but the surgery cannot be performed for 6 to 8 weeks and only if no infection occurs. What information should the nurse include in the discharge teaching plan?

washing hands carefully to keep the area clean and decrease risk for infection