ATI NEURO Questions #2

A nurse is caring for a client who has aphasia following a stroke. A family member ask the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate? A. "Incorporate nonverbal cues in the conversation." B. "Ask multiple choice questions as part of the conversation." C. "Use a higher-pitched tone of voice when speaking." D. "Use simple, child-like statements when speaking."

A. "Incorporate nonverbal cues in the conversation."

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? A. Decreased level of consciousness B. Tachypnea C. Bilateral weakness of extremities D. Hypotension

A. Decreased level of consciousness

A nurse at a rehabilitation center is planning care for a client who has a left hemispheric cerebral accident CVA three weeks ago. Which of the following goals should the nurse include in the clients rehabilitation program? A. Establish the ability to communicate effectively. B. Compensate for loss of depth perception C. Learn to control impulsive behavior. D. Improve left-side motor function.

A. Establish the ability to communicate effectively.

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take? A. Speak to the client about one idea at a time B. Ask the client to multi-task. C. Limit questions to yes and no answers D. Focus on a single form of communication.

A. Speak to the client about one idea at a time

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? Select all that apply. A. Loosen restrictive clothing B. Insert a bite stick into the client's mouth. C. Place the client into a supine position. D. Place a pillow under the client's head. E. Apply restraints.

A. Loosen restrictive clothing D. Place a pillow under the client's head.

A nurse working on a medical unit is caring for a client who is prescribe seizure precautions. Which of the following intervention should the nurse include in the client's plan of care? A. Obtain IV access. B. Keep the lights on when the client is sleeping. C. Place the client's bed in the high position. D. Keep a padded tongue blade available at the client's bedside.

A. Obtain IV access.

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following intervention should the nurse include? Select all that apply A. Provide a suction setup at the bedside. B. Elevate the side rails near the head when the client is in bed. C. Place the bed in the lowest position. D. Keep an oxygen setup at the bedside. E. Furnish restraints at the bedside.

A. Provide a suction setup at the bedside. B. Elevate the side rails near the head when the client is in bed. C. Place the bed in the lowest position. D. Keep an oxygen setup at the bedside.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? A. Provide client supervision B. Limit client physical activity. C. Speak loudly to the client. D. Leave the television on continuously.

A. Provide client supervision

-A nurse is assessing a client who has a score of six on the Glasgow coma scale. The nurse should expect which of the following outcomes based on the score? A. The client needs total nursing care. B. The client is alert and oriented. C. The client is in a deep coma D. Indicates stable neurologic status

A. The client needs total nursing care.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Turn the client's head to the side. B. Check the client's motor strength. C. Loosen the clothing around the client's waist. D. Document the time the seizure began.

A. Turn the client's head to the side.

A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. Which of the following statements should the nurse include in the teaching? A. "Take this medication with an antacid to reduce gastric irritation." B. "You may experience drowsiness while taking this medication." C. "You should take this medication with meals." D. "You may continue to breastfeed while taking this medication."

B. "You may experience drowsiness while taking this medication."

A nurse is caring for a client who has an intracranial pressure ICP reading of 40 mmHg. Which of the following findings should the nurse identify as a late sign of ICP? Select all that apply. A. Confusion B. Bradycardia C. Hypotension D. Nonreactive dilated pupils E. Slurred speech

B. Bradycardia D. Nonreactive dilated pupils

A nurse is teaching a client who is taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects? A. Excess salivation B. Difficulty voiding C. Diarrhea D. Slow pulse

B. Difficulty voiding

A nurse is implementing precautions for a client who has a cerebral aneurysm. Which of the following nursing intervention should the nurse implement? A. Allow bathroom privileges B. Encourage exhaling through mouth during defecation. C. Allow natural sunlight in the room. D. Encourage visitation from family and friends.

B. Encourage exhaling through mouth during defecation.

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? A. Gradual onset of several hours B. Manifestations preceded by a severe headache C. Maintains consciousness D. History of neurologic deficits lasting less than 1 hr

B. Manifestations preceded by a severe headache RATIONALE = A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke.

A nurse is caring for a client who has an intracranial aneurysms and requires aneurysm precautions. Which of the following intervention should the nurse take? A. Place the client in protective isolation. B. Minimize environmental stimuli. C. Elevate the head of the client's bed 45° D. Limit the client's ambulation to once a day.

B. Minimize environmental stimuli.

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate? A. Observe for the presence of Kernig's sign. B. Perform a Romberg's test. C. Check the function of cranial nerve V. D. Inspect for the presence of clubbing.

B. Perform a Romberg's test.

A nurse enters a client's room and find him on the floor in the clinic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? A. Insert a padded tongue blade into the client's mouth. B. Place a pillow under the client's head. C. Gently restrain the client's extremities. D. Apply a face mask for oxygen administration.

B. Place a pillow under the client's head.

A nurse enters a clients room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? A. Insert a tongue blade in the client's mouth. B. Place the client on his side. C. Hold the client's arms and legs from moving D. Place the client back in bed.

B. Place the client on his side.

A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor which of the following complications? A. Bradycardia B. Pulmonary embolism C. Peripheral vascular disease D. Hypertension

B. Pulmonary embolism

A nurse is shopping and finds a woman who has collapsed with right sided weakness and slurred speech. Which of the following actions should the nurse take? A. Provide the client with water to test the gag reflex B. Perform carotid massage. C. Notify emergency management services D. Drive the client to the nearest medical facility.

C. Notify emergency management services

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestation should the nurse expect? A. Pruritus B. Hypertension C. Bradykinesia D. Xerostomia

C. Bradykinesia

A nurse who is off-dutty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take? A. Obtain the telephone number of the client's provider B. Find a location for the client to sit. C. Call emergency services D. Drive the client to the nearest emergency department.

C. Call emergency services

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? A. Provide a nonskid mat to alleviate plate movement. B. Encourage the client to use his right hand when feeding himself. C. Remind the client to look for food on the left side of the tray. D. Encourage the use of the wide grip utensils.

C. Remind the client to look for food on the left side of the tray.

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? A. Perform passive range of motion on each extremity. B. Monitor the client's electrolyte levels. C. Suction saliva from the client's mouth. D. Record the client's intake and output.

C. Suction saliva from the client's mouth.

A nurse is caring for a client who is scheduled to have a MRI scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? A. "An MRI scan is not distorted by movement, so you do not have to lie still." B. "An MRI scan is a short procedure and should take no longer than 30 minutes." C. "The MRI contrast dye contains iodine and can cause your skin to itch." D. "An MRI scan is very noisy, and you will be allowed to wear earplugs whil

D. "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."

A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? A. Delay in disease progression B. Improved bladder function C. Relief of depression D. Decreased tremors

D. Decreased tremors

A nurse is presenting discharge instructions to a client who has multiple sclerosis MS. The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? A. "Wear an eye patch on the right eye at all times." B. "Plan to relax in a hot tub spa each day." C. "Engage in a vigorous exercise program." D. Implement a schedule to include periods of rest

D. Implement a schedule to include periods of rest

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure ICP? A. Tachycardia B. Amnesia C. Hypotension D. Restlessness

D. Restlessness

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow coma scale score of 3 for eye opening, 5 for verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? A. The client can follow simple motor commands. B. The client is unable to make vocal sound. C. The client is unconscious. D. The client opens his eyes when spoken to.

D. The client opens his eyes when spoken to.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident CVA. Which of the following parameters should the nurse he is first in order to assess the clients pain level? A. pulse and blood pressure findings B. behavioral indicators and effect C. scheduled treatments and client illness D. a self-report pain rating scale

D. a self-report pain rating scale

A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following information should the nurse include in the teaching? A. "Syncope episodes may occur when taking this medication." B. "This medication may cause tachycardia." C. "You should administer the medication each morning." D. "You will need to monitor for constipation."

A. "Syncope episodes may occur when taking this medication."

A nurse is modifying the diet have a client who has Parkinson's disease and it's prescribed Selegiline, an MAOI. Which of the following foods should the nurse eliminate? A. Fresh fish B. Cheddar cheese C. Cherries D. Chicken

B. Cheddar cheese

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations and function should the nurse expect? A. Difficulty reading B. Inability to recognize his family members C. Right hemiparesis D. Aphasia

B. Inability to recognize his family members

A nurse is caring for a client who has increased intracranial pressure. Which of the following intervention should the nurse take? A. Teach controlled coughing and deep breathing. B. Provide a brightly lit environment. C. Elevate the head of the bed 20°. D. Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day.

C. Elevate the head of the bed 20°.

A nurse is instructing a clients family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instruction should the nurse include? A. Encourage brief exercise before meals to promote appetite B. Place food in the affected side of the mouth. C. Encourage the client to take small bites. D. Place the client with the head reclined back to facilitate swallowing.

C. Encourage the client to take small bites.

A nurse is monitoring a client who has a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? A. Hypotension B. Tachycardia C. Irritability D. Tinnitus

C. Irritability

A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take? A. Elevate the head of bed to 45° B. Administer a cleansing enema. C. Place the client in a room near the nurses' station. D. Maintain the client on absolute bed rest.

D. Maintain the client on absolute bed rest.

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instruction should the nurse include in the teaching? A. "Insert a padded tongue blade into the client's mouth." B. "Restrain the client." C. "Place the client on his back." D. Move objects away from the client."

D. Move objects away from the client."