Adult health 10# prepu doc

A client you are caring for experiences a seizure. What would be a priority nursing action? -

Protect the client from injury.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?-

Risk for injury

The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord?

Second lumbar vertebrae

Which nursing technique best allows the client with slight expressive aphasia to communicate his feelings about using adaptive equipment in public? -

Sit beside the client and patiently assist in interpreting communication

The nurse is caring for a stuporous client in the intensive care unit. Which assessment finding is documented to reflect an improvement in the client's level of consciousness? -

Somnolent

The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm? -

The stimulation can increase intracranial pressure (ICP) or trigger a seizure

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with a spinal cord injury?

Traction with weights and pulleys

Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy? -

Use ophthalmic lubricant to protect the eye.

The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?-

VIII

The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client? -

Vector bites

The nurse caring for a client diagnosed with Guillain-Barré syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurse's communication with the client should reflect the possibility of what sign or symptom of the disease?

Vocal paralysis

A client is prescribed sumatriptan (Imitrex) for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?

"I use this to prevent migraines"

A client, with a recent closed head injury, began experiencing partial (focal) seizures and asks the nurse to explain why this is happening. Which is the best response from the nurse? -

"It is not uncommon for seizure activity to occur after head trauma"

client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding a cerebral aneurysm? -

"Your physician wants to evaluate the location and condition of the aneurysm."

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? -

"my children are at greater risk to develop this disease"

What phase of a neurologic deficit begins when the client's condition is stabilized?

- Recovery

Which of the following Glasgow Coma Scale scores indicates coma?-

7

A client with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?-

Absence of reflexes along with flaccid extremities

The nurse is completing a neurological assessment and uses the whisper test to assess which cranial nerve? -

Acoustic

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?

Burr holes

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? -

Call the health care provider immediately.

A client is prescribed warfarin. Client teaching has included instructions to avoid a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to avoid? -

Cereals, soybeans, and spinach

The physician's office nurse is caring for a client who has a history of cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? -

Cerebral angiography

A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headaches are caused by which of the following? -

Cerebral spinal fluid leakage at the puncture site

Which is the earliest sign of increasing intracranial pressure?

Change in level of consciousness

Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of muscular body area? - Computed tomography (CT)

Computed tomography (CT)

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful? -

Conception is not impaired; the birth process is determined by the physician

The nurse is caring for a client with dysphagia. Which instruction to the family is most important? -

Do not open/crush a medication in a capsule

What would the nurse do to best assist the client in increasing peristalsis and encouraging defecation after suffering from a neurologic deficit? -

Help the client go to the bathroom at a particular time each day

The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?

Herniation occurs through the foramen magnum

The nurse administers a medication that stimulates the parasympathetic nervous system (PNS). What manifestations would indicate the medication is having the desired effect? -

Hyperactive bowel sounds, increased saliva production, constricted pupils

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test?

Inform the client that he will not experience any electrical shock

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

- Body temperature

Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome?

-3 hours

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?

-Autonomic dysreflexia

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

-Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

-High in protein and low in carbohydrate

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

-Keeping the client in one position to decrease bleeding

While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak?-

18 to 36 hours

The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated? -

Antihistamine

The emergency department nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered level of consciousness. Following a skull X-ray, the patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture?-

Battle's sign

The nurse is assisting in the discharge process where a female, paralyzed client is returning home with her husband and two children. Which of the following prescription classifications, used prior to hospitalization, is most important to relate to the physician when discharging?

Birth control pills

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? -

Damage to the nerves that facilitate vision and hearing

Stimulation of the sympathetic nervous system results in all of the following except -

Decreased rate of cellular metabolism

nurse's most appropriate action? -

Document successful completion of the assessment

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?-

Ecchymosis over the mastoid

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important post procedure nursing intervention should be performed to ensure the client's maximum comfort?

Encourage the client to drink liberal amounts of fluids

Which is a nonmodifiable risk factor for ischemic stroke?

Gender

The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure?-

IV diazepam

A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client?

Identify and avoid factors that precipitate or intensify an attack

The nurse is caring for a client who requires bone surgery to remove bone fragments and fuse the vertebrae with bone from which location?

Iliac crest

You are caring for a client with an inoperable brain tumor. What is a major threat to this client? -

Increased ICP.

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 reflect which complication? -

Increased intracranial pressure (ICP)

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? -

Left-sided cerebrovascular accident (CVA)

Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

Lethargy. (decreased level of consciousness is one of the earliest signs of increased ICP)

A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action?

Migraine often coincide with menstrual cycle

The client is switched to a different dose of carbidopa-levodopa (Sinemet). Which nursing assessment is primary during this time of medication change? -

Monitor vital sign fluctuation

The nurse is working on a neurosurgical unit. Which of the following nursing interventions are included in the plan of care following spinal surgery? Select all that apply.

Monitor vital signs, intake and output, coughing and deep breathings, neurovascular assessment of the lower extremity, dressing assessment

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? -

Nausea

You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? -

Neurologic examination.

When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit response from cranial nerve VII? -

Observe for a facial movement symmetry, such as a smile.

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste? -

Parasympathetic

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture? -

Position the client flat for at least 3 hours.

A client has undergone a lumbar puncture for a neurological assessment. The client is put under the post-procedure care of a nurse. Which important post-procedure nursing interventions should be performed to ensure maximum comfort for the client? -

Position the client flat for at least three hours or as directed by the physician. Encourage liberal fluid intake for the client

Which basic of client care, occuring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident? -

Prevention of joint contractures

A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? -

Semisolid food with thick liquids

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? -

Shivering

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?-

Side-lying, to facilitate drainage of oral secretions

A home health nurse is assisting the wheelchair-dependent, post-cerebrovascular accident client in transition from the rehabilitative center to home. Which of the following concerns would the nurse address first when assessing the client's home? -

Steps to the front door

A client has begun to experience post-operative pain and the client's heart rate has increased from 72 beats per minute to 96 beats per minutes. The nurse should attribute this change to the effect of -

Stimulation of beta1 receptors in the sympathetic nervous system

Which condition occurs when blood collects between the dura mater and arachnoid membrane?-

Subdural hematoma

Which nursing assessment finding is most indicative of a hemorrhagic stroke? -

Sudden onset of breathing alterations

client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? -

Suicidal ideations

The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?

Sympathetic nervous system

The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care? -

The client who played soccer in college

Which client goal, established by the nurse, is most important as the nurse plans for a seizure client in the home setting?

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

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?-

The day the patient has the stroke

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders? - The first thoracic vertebrae

The first thoracic vertebrae

The nurse is working in an outpatient studies unit administering neurologic tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. The nurse is most correct to state which?

The paste is removed with standard shampoo

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. -

Unequal pupils, pinpoint pupils, absence of pupillary response

A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA?

Unilateral ptosis -A client with a TIA may experience impaired muscle coordination or paralysis on one side.

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest over night. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following? -

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? -

"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."

The client is undergoing chronic stress and is experiencing negative health effects. What type of drug could this client receive to reduce the autonomic nervous response?

- A drug that reduces sympathetic response, a drug that increases parasympathetic response, a drug that reduces central nervous system response

A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment to include which of the following?

- Anticoagulant therapy

You are caring for a client who has had intracranial surgery and is being discharged home. What instructions would you give the client besides instructions on the medication?

- Expect sensory changes, such as hearing a clicking sound, around the bone flap

The nurse is assessing a client's ability to detect sensation in the upper extremity. Which nursing actions would be appropriate?

- Place a warm cotton ball on the arm, a gentle pinch using the fingers, drag the alcohol pad over the skin, the client with the pads of the finger

A client has been prescribed a medication that antagonizes the beta receptors of the sympathetic nervous system. What assessment finding should the nurse attribute to the effects of this medication?

- The client's blood pressure is decreased

Which of the following goals is the priority in the care planning of a client with cerebrovascular accident (CVA) who is being transferred to a rehabilitation unit?

- To prevent contractures and joint deformities

A nursing instructor is teaching the senior class about clients with neurologic disorders. The instructor tells the students that these clients are at risk of disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. What nursing intervention helps prevent plantar flexion?

- Use of a footboard

A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client?

-Safety

A client's family is trying to understand the client's diagnosis of an acute subdural hematoma. The nurse would best explain the condition by stating that a subdural hematoma is:

-a result of venous bleeding into the space below the dura.

Following the use of a thrombolytic agent in the management of cerebrovascular accident (CVA) client, which is the priority nursing assessment? -

Blood pressure

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? -

Brain CT scan or MRI

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?-

Loosen the client's restrictive clothing.

A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster to be used to restore functioning. The nurse knows that successful use of TPA in a client with CVA requires which of the following? Select all that apply. -

Presence of an ischemic stroke, administer within 3 hours of onset of symptoms.

Which of the following, if left untreated, can lead to an ischemic stroke?

-Atrial fibrillation

The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate to the nurse that the client is in a semi-comatose state? - A score of 9

A score of 9

The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious stating, "What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain." The nurse is most correct to turn the teaching to which surgical procedure?

A spinal fusion

A 76-year-old male client is brought to the clinic hy his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerosis plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain. Select all that apply? -

Balloon angioplasty, carotid endarterectomy

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?

Cerebrospinal fluid is cloudy in nature.

While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind his right eye, which is red and tearing. What type of headache would you suspect this client of having? -

Cluster

Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply.

Elevated systolic blood pressure, wide pulse pressure

A client, who was adopted at birth, recently discovers that Huntington's disease is prevalent in the biological family history. How can the nurse best assist the client in dealing with personal fears? -

Encourage the client to verbalize fears

An emergency department nurse is admitting a client brought in by paramedics after falling from a tree stand. The client has fractured vertebrae at T3 and T4. The nurse knows the client is in the acute phase of neurologic deficit. What should the nurse know about the medical management of this client? -

Goal is to stabilize the client and prevent further neurologic damage

A 58-year-old client has scheduled a sick visit to the physician's office, stating symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and identifies potential causes of the pain. Which area of the drawing would the nurse emphasize? -

Nucleus pulposus

The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? -

Observing the client's response to painful stimulus.

Which of the following occupations are anticipated to improve the functioning of a client with a neurologic deficit? Select all that apply. -

Occupational therapist, Speech therapist, neurologist, physical therapist

A critical care nurse is documenting her assessment of a client she is caring for. The client is status post resection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean? -

The client is not responding to stimuli.

The nurse is talking with the mother of a client who is diagnosed with a traumatic brain injury. The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction , made by the nurse, is most correct? -

The client may be experiencing a change in affect due to the brain injury."

The nurse is talking with a newly paralyzed client and his wife. The wife is trying to raise the client's spirits and begins talking about the possibility of them having a baby. When the wife is alone, which instruction is essential?

There is reduced ability for your husband to be able to father children

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? -Maintenance of a patent airway

Which of the following actions would be the first priority? -Maintenance of a patent airway

Which interventions are appropriate for a client with increased intracranial pressure (ICP) Select all that apply. -

administering prescribed antipyretics, maintaining aseptic technique with an intraventricular catheter, frequent oral care

The initial sign of increasing intracranial pressure (ICP) includes

decreased level of consciousness

List the common causes of autonomic dysreflexia.

stress, full bladder, abdominal distention, impacted feces, skin pressure or breakdown. overstretched muscles, sex, delivery, sunburn, infection on toe, hot or cold, decongestants.

A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions?-

Applying a protective eye shield at night

A client is admitted for scheduled gamma-knife radiosurgery, in the treatment of a brain tumor. Which nursing measure is primary in the postsurgical care of this client? -

Assess neurological findings

The nurse is performing a neurologic assessment of a client whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)? -

Assess the client's eye opening and response to stimuli.

A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?

Avoid heavy lifting (

A client with atrial fibrillation is placed on Coumadin to reduce the potential of developing a cerebrovascular accident (CVA). The international normalized ratio (INR) is 1.5. What does this finding indicate to the nurse? -

Coumadin will be increased (Ideally, the INR will be therapeutic at 2.0 to 3.0. Because the level is low, the nurse can anticipate an increase in Coumadin dosage.

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? -

Drooping eyelids

A mother brings her 6-year-old to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's best response be? -

"A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."

The client with Guillain-Barre syndrome is scheduled for plasmapheresis and is questioning how this process works. Which of the following statements by the nurse best describes plasmapheresis in the management of this syndrome? -

"Antibodies that triggered the autoimmune response are removed from your blood".

The home care nurse is evaluating a post-cerebrovascular accident (CVA) client 1 week after returning to the home from a rehabilitation setting. Which of the following statements, made by the client, most concerns the nurse?

"My spouse goes to work in the morning and leaves my lunch at my bed stand."

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? -

"TIA is a warning sign. Let's talk about lowering your risks."

The nurse is assessing the client's mental status. Which question will the nurse include in the assessment? -

"Who is the president of the united states?"

Which is a sympathetic effect of the nervous system?

- Dilated pupils

The client with hemiplegia is at risk for impaired walking. Which nursing intervention would best assist this client in preventing complications associated with lower extremity impairment?

- Use of high-top tennis shoes throughout the day

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? -

-Pulse and blood pressure

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

-Subdural

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client?

-The client should be approached on the side where visual perception is intact.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?-

Administer a stool softener

The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is the priority nursing action? -

Administer medications at exact intervals ordered.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners

A patient who has sustained a basal skull fracture is admitted to the neurological unit. The nurse should know that the patient should be observed for:

Bleeding from the ears

The nurse is caring for a post-lumbar puncture client experiencing an intense headache. The physician is notified and arriving to assess the client. If the physician chooses aggressive treatment, which nursing action is anticipated? -

Drawing venous fluid to perform a blood patch

The nurse is performing an assessment for a patient in the clinic with Parkinson's disease. The nurse determines that the patient's voice has changed since the last visit and is now more difficult to understand. How should the nurse document this finding? -

Dysphonia

The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/or leaking of cerebrospinal fluid? -

Halo sign (to detect any CSF drainage, the nurse looks for a halo sign)

One defining characteristic of a complex partial seizure versus a simple partial seizure is the presence of which of the following?

Impaired consciousness

A client is brought to the emergency department (ED) by family members who tell the triage nurse that the client doesn't recognize them. The client is diagnosed with a neurologic deficit. What other conditions are considered neurologic deficits? - Select all that apply -

Impaired speech, abnormal bladder elimination, paralysis

A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition?-

Impaired verbal communication

What is the resulting physiologic effect when the parasympathetic nervous system is stimulated?-

Increased GI motility

The nurse is caring for a client with Guillain-Barre syndrome. Which assessment finding would indicate the need for oral suctioning? - Increased pulse rate, adventitious breath sounds (an increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance.

Increased pulse rate, adventitious breath sounds

The nurse is caring for a 55-year-old client on a rehabilitated unit following a cerebrovascular accident (CVA). The nurse is instructing on range of motion exercises when the client begins to cry. The client states she has always taken care of the family and does not want to be a burden. Which nursing diagnosis would the nurse add to the plan of care?

Ineffective role performance related to inability to function in family role

The nurse is caring for a client with paraplegia in the acute care setting. The client's last bowel movement was 4 days ago. Which nursing action is best to assist the client in accomplishing the goal of an enema? -

Instill the enema slowly (1 to 2 oz at a time) followed by a waiting period

A family member comes to the clinic to talk to the nurse who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain. common deficits include what? Select all that apply

Left-sided hemiplegia, tendency to distractibility, neglect of objects and people on the left side

The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment? - Loss of voluntary control of movement

Loss of voluntary control of movement

A client presents to the emergency department status post-seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? -

Lumbar puncture

Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease? -

Maintaining a safe environment

Which of the following assessment tools should the nurse use to perform a neurologic assessment?

Mini-mental status examination

A field hockey coach was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic testing, it was determined that the client suffered a skull fracture with moderate symptoms. What would the nurse anticipate the nursing care plan to include? Select all that apply-

Monitor for a halo sign. Prepare for the possibility of a seizure.

When a nurse is caring for a client diagnosed with a neurologic deficit who has begun responding to those around him, what therapy should the nurse suggest to strengthen the muscles that are under voluntary control? -

Occupational therapy

A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken? -

Perform a vision field assessment

The nurse is providing care to a client with neurologic problems and notices that the client is experiencing penile erection. Which nursing reaction is correct? -

Perform duties professionally and explain that spontaneous erections are unpreDICtable

When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms?

Perform stretching exercises and frequent position change-

A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of TPA in a client with CVA requires which of the following? Select all that apply.

Presence of an ischemic stroke Administer within 3 hours of onset of symptoms.

The nurse caring for a client in the chronic phase of neurologic deficit knows that nursing management focus on what?

Preventing physical and psychological complications

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?

Raise the head of the bed and place the patient in a sitting position.

The nurse is caring for a client with neurologic deficits who is interested in implementing a bowel training program. Which of the following does the nurse identify as the first step?

Recording bowel movements

The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply. - Red wine, menstruation

Red wine, menstruation

A nurse is preparing a client for lumbar puncture. The client has heard about post-procedure lumbar puncture headaches and asks the nurse how to avoid having one. The nurse tells the client that these headaches can be avoided by doing which of the following after the procedure? -

Remain prone for 2 to 3 hours."

A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse?-

Reorient the client while gently holding their arms.

A nurse is caring for a client with a cerebral aneurysm. Which nursing interventions would be most useful to the nurse to avoid bleeding in the brain? Select all that apply.-

Report changes in neurologic status as soon as a worsening trend is identified. Maintain the head of the bed at 30 degrees. Avoid any activities that cause a Valsalva maneuver.

A client with a neurologic deficit has been admitted to your unit. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Which of the following actions should the nurse perform immediately?

Report the change to the physician

A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following?-

Respiratory function

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:

Right-sided paralysis.

A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring?-

Riluzole

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? -

Seizure was 1 minute in duration including tonic-clonic event

The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered?

Select all that apply. - Anticonvulsants, analgesics, antibiotics

A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure?

Select all that apply.- Turn the client to the side, Provide verbal reassurance.

The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, "What do you want?" Which level of consciousness should the nurse document?

Somnolent

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?-

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first?

The client with a basilar fracture

A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse?

The client's medications include warfarin (Coumadin)

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? -

The client's vital signs are temperature, 100.9 F, heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in -

Thought content

A client receives a diagnosis of concussion. While speaking with the client, the nurse learns that this is the client's third head injury. This information is of particular significance because it puts the client at risk for:-

Traumatic encephalopathy

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? -

Turn the client to side-lying position

The nurse is assessing the client's pupils following a sports injury. Which assessment findings indicate a neurologic concern? Select all that apply. -

Unequal pupils, pinpoint pupils, absence of pupillary response

The nurse is instructing the client on how to perform Crede's maneuver. In which situation is this maneuver helpful? -

When a client is attempting to empty the bladder

Sympathetic stimulation of the heart causes:

an increased rate and force of myocardial contraction

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:-

complications.

A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to-

decrease the potential for brain damage.

A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of

increased intracranial pressure (ICP)

Which of the following would the nurse include in the rationale for the nursing intervention to maintain body alignment? Select all that apply. -

maintaining body alignment prevents contractures, maintaining body alignment decreases pain

A 13 year old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. What assessment finding would rule out discharging the client?-

the clients speech is slurred

A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA? -

unilateral ptosis.

A client is status post-CVA with significant residual effects. When did this client begin the recovery phase of the neurologic deficit?-

upon stabilization

A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy?

- Anticipate the need for endotracheal intubation

A nurse is working in a neurologist's office. The physician orders a Romberg test. Which nursing action is correct?

- Have the client close his eyes and stand erect

A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure?-A dysrhythmia in the nerve cells in one section of the brain

-A dysrhythmia in the nerve cells in one section of the brain

The nurse and physician are viewing a brain scan, which indicates bleeding at the point of impact to the skull and edema on the opposite side. The client is sleeping but can be aroused. The client has no memory of the accident. The nurse provides all details to the next shift and is most accurate to report which type of injury?

- Contrecoup injury.

Which nursing intervention is most helpful when addressing the priority nursing diagnosis of impaired physical mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field?

- Ensure a clutter-free walkway

A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing the nursing care of this client?

- Grade V on the Hunt-Hess Scale

A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client?

- Hopelessness

The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of the highest priority?

- Include client in planning of care and setting of goals

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

-Monitoring the patency of an indwelling urinary catheter

The family nurse practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

- Moving the head and chin toward the chest

A client is receiving baclofen (Lioresal) for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following?

- Muscle spasm.

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? -

- Neurovascular system

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

- Paresthesia

The nurse is doing an initial assessment in a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in the client's deficit?

- Parietal-occipital area

The nurse is caring for a client following intracranial surgery. In the plan of care, the nurse states to remove anti embolism stockings. What would the nurse do to accurately complete this intervention?

- Remove the anti embolism stocking briefly every 8 hours

The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline (Eldepryl) with carbidopa-levodopa (Sinemet) to the medication regimen should result in which purpose?

- Slows the progression of the disease

When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data?

- When, if any, was your last narcotic use?

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in mid stride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? -

Absence seizure

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)

Administering a stool softener as ordered

When managing CSF drainage, which instructions should the nurse give a client with a skull fracture? Select all that apply.

Allow it to flow freely onto porous gauze. -Avoid tightly plugging the orifice.

A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches?

Relaxes muscles

The nurse is caring for a client newly diagnosed with multiple sclerosis. The client indicates that there is so much to understand at one tie. The client indicates understanding that there is a disruption in the covering of the axons but does not remember what the covering is called. Which nursing action is correct.

- Tell the client that the covering is called myelin and you can discuss at the next meeting.

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?

- The client grasps the affected arm at the wrist and raises it

The nurse received a report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

- The client has cerebral spinal fluid

The client is waiting in a triage area to learn the medical status of his family following a motor vehicle accident. The client is pacing, taking deep breaths, and wringing the hands. Considering the effects in the body systems, what effects does the nurse anticipate in the liver?

- The liver will convert glycogen to glucose for immediate use

The nurse is caring for a client in the emergency department with diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to client the client's face and torso. For which action, made by the nurse aide, would the nurse provide further instruction? - The nurse aide moved the client's head to clean behind the ears.

- The nurse aide moved the client's head to clean behind the ears.

The nurse is assisting a client, with a right-sided brain infarction, to transfer from the wheelchair to the bed. Which is the best placement of the wheelchair to facilitate this transfer?

- Wheelchair placed on right side of the bed facing the foot

During the course of performing a lumbar puncture, the anesthesiologist observes slight muscle twitching in his patient's lower limbs. This evoked reaction suggests the spinal needle stimulated one or more of the components of the cauda equina. Which of the following is the correct composition of the causa equina? -

- anterior and posterior roots of lumbar, sacral, and coccygeal spinal nerves plus the filum terminale.

The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?

-80

The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication?

-Autonomic dysfunction

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication?

-Bleeding

While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?

-Confusion

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for?

-Dyskinesia

A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease?

-Elevated protein levels in the CSF

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

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?

-Gingival hyperplasia

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?

-To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow

When using pharmacologic aids to assist with bowel training, which aid would the nurse anticipate to be used first? - A glycerin suppository

A glycerin suppository

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? -

Elevate the head of the bed

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? -

Epidural hematoma

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?

-Uneven, labored respirations

A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following?-

-Watchful waiting and close monitoring

Which are characteristics of autonomic dysreflexia?

-severe hypertension, slow heart rate, pounding headache, sweating

A client with MS has been admitted to the hospital following an acute exacerbation. When planning the client's care, the nurse addresses the need to enhance the client's bladder control. What aspect of nursing care is most likely to meet this goal?-

Establish a timed voiding schedule.

The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client? -

Explaining hospice care and services.

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool?-

Glasgow Coma Scale

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? - Mannitol

Mannitol

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse is correct to instruct on the action of which system? -

Sympathetic nervous system

The nurse is caring for clients on a neurologic floor. Which client goal is most appropriate for the acute phase of neurologic injury? -

The client's vital signs will stabilize returning to baseline

A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse? -

The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures."

A physician orders a lumbar puncture (spinal tap) for his 43-year-old female patient in order to obtain a sample of cerebrospinal fluid (CSF). He explains to her that this procedure will be done in the lower back, between the spinous processes of the L3 and L4 vertebrae. What is the best reason for performing the lumbar puncture at this location?

The medullary cone ends at or above the L3 level

A client with increased intracranial pressure is receiving mannitol (Osmitrol) via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment? -

Urine output is increased

A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way?

-Weakness starting in the muscles supplied by the cranial nerves

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?

-acute

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. What is the origin of the client's symptoms?

-impaired cerebral circulation

A client who was involved in a motor vehicle collision is brought to the emergency department. After examination and diagnostics, the neurosurgeon diagnoses an epidural hematoma and orders that the client be prepared for surgery. In preparing the client for surgery, which would be the least likely nursing intervention?

-preoperative sedation

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? -

3

A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client?-

Reduce hypertension and high blood cholesterol

You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?

- Ischemic

A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility?

- Keep the client hydrated.

The nurse is caring for a client in the neurologic intensive care unit. The nurse is noting from the assessment findings that the client is lacking a connection because motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit?

- Medulla oblongata

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply.

Positioning the patient on his or her side with head flexed forward, Providing for privacy, Loosening constrictive clothing

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have?

-Grade 3 concussion

You are caring for an 82-year-old client who needs bladder training. You know that bladder training is difficult for older adult clients with neurologic deficits because of what?

Relaxation of the internal bladder sphincter

The nurse accompanies the health care provider into the client's room and remains after the client is told he has cancer and a poor prognosis. The client's respirations become rapid and deep, his pupils dilate, and he appears diaphoretic. What type of response is the nurse witnessing?

Sympathetic nervous system (SNS) response-

The nurse is caring for a client with a spinal cord injury leaving paralysis. When planning care related to the musculoskeletal system, which considerations are important? Select all that apply.

- Bone demineralization, contractures, spasticity, limited range of motion

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

- Bradycardia and hypertension

An older client complains of constant headache. A physical examination shows papilledema. What my the symptoms indicate in this client?

- Brain tumor

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. -

- Cloudy cerebral spinal fluid, purpura of the hands and feet

The nurse is describing the differing functions of the sympathetic nervous system (SNS) and parasympathetic nervous system to a client. The nurse has explained how the SNS is associated with a "fight-or-flight" reaction. How should the nurse describe the characteristics of the parasympathetic nervous system? -

"rest and digest"

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?

- Edema of the head with bruising of the mastoid process

The nurse is caring for a client with tetraplegia following a motor vehicle accident. A family member of the client states, "I know there is grief associated with the loss of independence, but how do i help my loved one to move past that?" The nurse is most helpful to say which of the following?

- "Grief is a normal process. Let's discuss offering support throughout the process."

A female client undergoes a scheduled electroencephalogram (EEG). Which of the following post-procedure activities should the nurse carry out for the client?

- Allow the client to rest and shampoo the client's hair.

The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse describes hospice care? -

"Clients and families are the focus of hospice care."

You suspect that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? select all that apply. -

- Bladder distension, poikilothermia, no perspiration below the level of injury

Parasympathetic stimulation causes the release of nitrous oxide from the endothelium of blood vessels. Which of the following results from this release?

- Relaxation of vascular smooth muscle

The nurse is providing diet-related advice to a client who experienced a cerebrovascular accident (CVA). The client wants to minimize his volume of food and yet meet all nutritional requirements. To control the volume of food intake, the nurse should suggest that the client consume:-

-thickened commercial beverages and fortified cooked cereals.

The Glasgow Coma scale is a common screening tool used for patients with a head injury. During the physical exam, the nurse documents that the patient is able to spontaneously open her eyes, obey verbal commands, and is oriented. The nurse records the highest score of -

15

The nurse is caring for a client with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used?

A cervical collar

The client is undergoing chronic stress and is experiencing negative health effects. What type of drug could this client receive to reduce the autonomic nervous response? -

A drug that reduces sympathetic response, a drug that increases parasympathetic response, a drug that reduces central nervous system response

A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes? -

A unit of fresh frozen plasma is infusing

A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of cell transplantation therapy. Which early outcome of treatment is anticipated?

Cell transplantation therapy allows the replacement of nerve cells that are damaged

The critical care nurse is giving report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has a LOC of 6. What does a LOC score of 6 in a client indicate? -

Comatose

An eldery client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client?

Drooling from the side of the mouth

Bell palsy is a disorder of which cranial nerve?-

Facial (VII)

The nurse is caring for a client with deteriorating neurologic status. The nurse Is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? -

Flaccidity

You are the nurse caring for a client with Guillain-Barre syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should you keep always ready at the bedside? -

Intubation tray and suction apparatus

A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of:

Leakage of cerebrospinal fluid (CSF)

The nurse is instructing the paralyzed client on a method to stimulate the relaxation of the urinary sphincter aiding in urinary elimination. Which instruction would be correct? -

Lightly massage or tap the skin above the pubic area.

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Monitoring is needed as rapid neurologic deterioration may occur. (The nurse identifies that the CT scan suggests an epidural hematoma

The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? -

Observe for any signs of behavioral changes

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? -

Occipital

Which of the following would the nurse recognize as being the least likely reason for the procedure shown in the accompanying image?-To

To confirm a skull fracture

A video fluoroscopy has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened. Which of the following is the priority nursing diagnosis for this client?

impaired swallowing

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?-

increased ICP

A client is brought to the ED by her family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?-

making openings in the skull