ATI_Med-Surg_Neuro System

A nurse is preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affect the manner in which the nurse will prepare the client for the scan? A. No food or fluid consumed for 4 hours B. Difficulty recalling recent events C. Developed hives when eating shrimp D. Parethesias in both hands

Developed hives when eating shrimp *An allergy to shellfish is a contraindication for the use of contrast media during a CT scan. The nurse should inform the provider and explain to the client that this factor might alter how the technician performs the CT scan

A nurse in a rehabilitation center is collecting data from a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? A. Reduced left-sided motor function B. Difficulty with speech C. Impulsive behavior D. Neglect of the left side of the body

Difficulty with speech *The left hemisphere of the braine is usually the dominant side and is responsible for language. This is always true for right-handed clients and for the majority of left-handed clients. Since this client is recovering from a left-hemisphere stroke, the nurse should anticipate that the client will have aphasia and require speech therapy to establish communication

A nurse is assisting with the care of a client during the first 72 hours following a cerebrovascular accident (CVA). Which of the following actions should the nurse take? A. Turn the client's head to the side and elevate the head of the bed to 60° B. Place the head of the bed flat with a pillow under the client's neck and feet C. Elevate the head of the bed by 25° to 30° with the client in a neutral midline position D. Position the client in a dorsal recumbent position with pillows under the head and knees

Elevate the head of the bed by 25° to 30° with the client in a neutral midline position *Elevating the head of the bed by 25° to 30° with the client's head in a neutral midline position helps prevent an increase an intracranial pressure. Increased pressure is a major risk factor for increased complications in the first 72 hours followings the onset of a CVA

A nurse is caring for a client who had a cerebrovascular accident (CVA). The client appears alert and engaged during the visit but does not respond verbally to questions. The nurse should document this finding as which of the following alterations? A. Expressive aphasia B. Dysarthria C. Receptive aphasia D. Dysphagia

Expresive aphasia *A client who has expressive aphasia understands speech but has difficulty speaking and writing. This typically occurs as a result of a lesion at Broca's area of the frontal lobe

A nurse is collecting data from a client who has increased intracranial pressure and has recieved intravenous mannitol. The nurse should identify that which of the following findings indicates a therapeutic effect of this medication? A. Decreased blood glucose B. Decreased bronchospams C. Increased urine output D. Increased temperature

Increased urine output *Mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid and inhibiting the reabsoroption of water and electrolytes in the kidneys. Increased urine output and decreased intracranial pressure are therapeutic effects of this medication

A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? A. Spasticity of the left foot B. Negative Babinski reflex C. Ocular hypertension D. Right-sided hemiplagia

Right-sided hemiplagia *The nurse should expect right-sided following intracranial bleeding in the left hemishphere of the brain

A nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. Which of the following items in the client's medical record should the nurse identify as a risk factor for tinnitus? A. Use of hydrochlorothiazide B. Chronic use of acetaminophen C. Allergic external otitis D. Sclerosis of the ossicles

Sclerosis of the ossicles *The nurse should identify that sclerosis of the ossicles, called otosclerosis, is an overgrowth of the tissues of the bones in the middle ear, which can cause tinnitus and conductive hearing loss. A stependectomy is a surgical procedure that corrects otosclerosis by removing a portion of the stapes and inserting a prosthesis

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. Which of the following items in the client's history is a contraindication to the procedure? A. The client has a new tattoo B. The client is unable to sit upright C. The client has a history of peripheral vascular disease D. The client has a pacemaker

The client has a pacemaker *An MRI uses strong magnets and radio waves that are evaluated using computer technology to view 3-dimensional images of the body. Since an MRI is magnetically generated, it is not indicated for use in the presence of certain medical implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures

A nurse is caring for a client who has receptive aphasia. Which of the following communication probens should the nurse expect to find when collecint data from this client? A. The client cannot name simple objects or formulate sentences or phrases B. The client has difficulty articulating correctly due to weakness of muscles of the mouth and tongue C. The client is unable to understand or sentences he hears D. The client sustitutes words in speech for those he intends to say

The client is unable to understand or sentences he hears *Clients who cannot understand words or sentences they hear have receptiive asphasia

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? A. The client rigidly extends his arms B. The client internally flexes his wrists C. The client internally rotates his legs D. The client curls in a fetal position

The client rigidly extends his arms *A client who exhibits a decerebrate posture rigidly extends and pronates his 4 extremities and externally rotates his wrists. Decerebrate posturing indicates severe brainstorm injury and late neurological decline

A nurse is assisting with the care of a client who has increased ICP. Which of the following findings should the nurse expect? A. Dilated pupils B. Hypotension C. Tachycardia D. Hypervenitilation

Dilated pupils *A client who has increased ICP can have dilated pupils as a result of herniation in the brain. The client can have hypertension and bradycardia as a result of the fluid volume in the brain increasing causing stress on the client's body. The client can have hypoxia as a result of pressure building in the client's brain against the client's arteries and veins

A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings is an indication the client is experiencing increased intracranial pressure? A. Battle's sign B. Perioribital edema C. Dilated pupils D. Halo sign

Dilated pupils *Dilated pupils can be an indication that intracranial pressure is increasing. This finding should be reported to the provider immediately

A nurse is collecting data from a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect? A. Swelling behind the affected ear B. Facial drooping on the affected side C. Nystagmus on the affected side D. Pearly gray color of the affected eardrum

Swelling behind the affected ear *Mastoidisitis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include swelling and pain behind the ear

A nurse is reinforcing teaching with a client who has a new diagnosis of multiple sclerosis (MS). The client ask the nurse about the usual course of MS. Which of the following responses should the nurse provide? A. "Each client is different. We cannot predict what will happen." B. "I can see what that you are worried, but it's too soon to predict what will happen." C. "Acute episodes are usually followed by remissions, which can last varying lengths of time." D. "It's too early to think about the future. Let's focus on the present and take each day at a time."

"Acute episodes are usually followed by remissions, which can last varying lengths of time." *This client is asking an information-seeking question, so the nurse should provide the client with factual information. The nurse should inform that MS is a chronic autoimmune disorder that is characterized by remissions and exacerbations, with exacerbations becoming more frequent and intense as the disease progresses

A nurse is assisting with preparing a client for an electroencephalogram (EEG). When the client asks the nurse what this test does, which of the following responses should the nurse make? A. "An EEG measures the electric signals to your brain from hearing, sight, and touch." B. "An EEG measures the electrical activity in your muscles." C. "An EEG identifies the magnetic fields produced by the electrical activity in your brain." D. "An EEG records the electrical activity of yor brain cells."

"An EEG records the electrical activity of yor brain cells." *An EEG measures brain waves via multiple electrodes attached to the scalp. An EEG provides information that the provider can use to identify various problems like seizure disorders, sleep disorders, inflammation, bleeding, and migraine headaches

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion devide after abdominal surgery. Which of the following client statements indicats that the client understands how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop after I use this device." D. "I will ask my son to push the dose button when I am sleeping."

"I should tell the nurse if the pain doesn't stop after I use this device." *PCA is a method of delivering pain medication through an electonic infusion device that allows the client to self-administer pain medication on an as-needed basis. If the client is not achieving adequate pain control, the nurse should be notified so a reevaluation of the client's pain managment plan can be done.

A nurse is reinforcing teaching with a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the teaching? A. "I will sleep on the affected side." B. "I will avoid bending over." C. "I will restrict caffeine in my diet." D. "I will take aspirin to relieve my pain."

"I will avoid bending over." *The nurse should instruct the client to avoid activities that can increase intraocular pressure such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can result in intraocular hemorrhage

A nurse is reinforcing teaching with a client who is scheduled for laser-assisted in situ keratomieusis (LASIK) surgery. Which of the following pieces of information should the nurse include? A. "Your procedure will only take 10 or 15 minutes for each eye." B. "You may drive home after the procedure." C. "This procedure is prescribed to treat farsightedness." D. "You will need to remain in the hospital overnight following the procedure."

"Your procedure will only take 10 or 15 minutes for each eye." *LASIK is a type of refractive laser eye surgery performed to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. The procedure typically takes 10 to 15 minutes per eye.

A nurse in an urgent care center is collecting data from a group of clients who all have an odor of alcohol on their breath and multpile injuries to the head and extremities. Which of the following clients should the nurse report first to the charge nurse? A. A client who is difficult to arouse and is unable to respond to questions B. A client who has slurred speech and exhibits anger C. A client who reports nausea and vomiting D. A client who is uncooperative and uncoordinated

A client who is difficult to arouse and is unable to respond to questions *The client who is difficult to arouse and is unable to respond to questions is the priority to report to the charge nurse. These findings might indicate a decreased level of consciousness due to an alcohol intoxication level of 401-800 mg percent or traumatic brain injury. The greatest risk to this client is neurological sequelae of head trauma or death due to severe alcohol intoxication

A nurse at a clinic is talking with a client who has cancer and takes extended-release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain/ A. Phantom limb pain B. Mixed pain C. Breakthrough pain D. Neuropathic pain

Breakthrough pain *Phantom limb pain is pain that is perceived to be initiated from a part of the body that is no longer present. *Mixed pain is a pain that is difficult to define, for conditions such as fibromyalgia. *Breakthrough pain is an acute exacerbation of pain beyond the level the client typically experiences. *Neuropathic pain sensations are described as burning, shppting, or pins and needles

A nurse is preparing to test the function of cranial nerve X for a client. Which of the following assessment procedures should the nurse use? A. Have the client open his mouth and say, "aah" B. Ask the client to identify the scent of coffee C. Use a tongue blade to provoke the gag reflex D. Have the client smile and raise his eyebrows

Have the client open his mouth and say, "aah" *The vagus or X nerve has both sensory and motor functions. To test the motor function, the nurse should have the client open his mouth and say "aah." The palate and the uvula should move upward in response. The nurse should also reassess the client's voice quality for hoarseness.

A nurse is reinforcing discharge teaching with the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions if a seizure occurs? A. Reorient the client B. Protect the client's head C. Loosen constrictive clothing D. Turn the client on his side

Protect the client's head *This client is at greatest risk from an injury related to hitting his head; therefore, the nurse should first protect the client's head from injury

A nurse is assisting with the care of a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor? A. Understanding speech B. Respiratory effort C. Decision making D. Temperature control

Respiratory effort *The nurse should monitor the respiratory effort of a client who has an injury to the brainstem. The medulla in the brainstem controls the respiratory center

A home health nurse is interviewig the adult child of a client who has Alzheimer's disease. The child is the client's sole caregiver and reports feeling fatigued and overwhelmed. Which of the following referrals should the nurse make for the caregiver? A. Attorney B. Physical therapy C. Respire care D. Occupation therapy

Respite care *The nurse should make a referral for respite care for the caregiver. Respite care can provide needed relief for caregivers in an expedient, short-term manner

A nurse is collecting data from a client who has an acute visual disturbance, describing a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify that this client might have which of the following disorders? A. Cataracts B. Angle-closure glaucoma C. Retinal detachment D. Macular degeneration

Retinal detachment *The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. Retinal detachment is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or "curtain" over a part of the visual field

A nurse is caring for a client who has a closed head injury. The nurse should place the client in which of the following positions? A. Trendelenburg B. Prone C. Semi-Fowler's D. Sims'

Semi-Fowler's *To prevent an increase in intracranial pressure, the nurse should position the client with the head midline and the head of the bed elevated 30°. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure

A nurse is reinforcing teaching for a client who has a new diagnosis of myasthenia gravis (MG). Which of the following pieces of information should the nurse provide? A. Use enemas to treat constipation caused by daily medications B. Take a hot bath when muscles ache C. Eat a low-calorie diet D. Set an alarm to ensure medication dosages are taken on time

Set an alarm to ensure medication dosages are taken on time *The nurse should instruct the client to take medication dosages on time to maintain a therapeutic blood level. Dosages should not be missed or postponed because this can cause an exacerbation of th disease

A nurse is collecting data from a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? A. Multiple floaters B. Flashes of light in front of the eye C. Severe eye pain D. Double vision

Severe eye pain *Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include a report of halos around lights, blurred vision, headaches, brow pain, and nausea and vomiting

A nurse is collecting data from a client with recent head trauma who has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to monitor for DI? A. Blood urea nitrogen (BUN) B. Blood glucose C. Urine ketones D. Specific gravity

Specific gravity *Diabetes Insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, infection, or a tumor. In this conditionm an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus

A nurse is collecting data from a client who is recovering from a recent stroke. Which of the following data is the nurse's priority to collect? A. The client's ability to clear oral secretions B. The client's ability to communicate verbally C. The client's ability to move all extremities D. The client's ability to remain continent of urine

The client's ability to clear oral secretions *The first action the nurse should take when using the airways, breathing, and circulation (ABC) approach to client care is to check the client's ability to clear secretions in order to protect the airway and reduce the risk of aspiration

A nurse is collecting data from a client who has a closed head injury and is receiving mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates the medication is having a therapeutic effect? A. The client's urine output is 250 mL/hr B. The client's pupils are dilated C. The client's heart rate is 56/min D. The client is restless

The client's urine output is 250 mL/hr *Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water from the brain tissue. An increased urine output is desired. A decrease in cerebal edema should result in a decrease in ICP

A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A. The vaccine is indicated to reduce the risk of respiratory infection B. The vaccine is administered in a series of four doses C. The vaccine is recommended for adolescents before starting college D. The vaccine is initially given at 2 months of age

The vaccine is recommended for adolescents before starting college *The pneumococcal vaccine is primarily indicated to reduce the risk of respiratory infection. However, it also reduces the risk of CNS infection *The HIB vaccine is administered to infants in a series of four doses *The meningococcal vaccine is recommended for adolescents prior to starting college due to the increased risk for infection in communal living facilities *The initial dose of the HIB vaccine is recommended for infants at 2 months of age

A nurse is reinforcing teaching with a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching? A. Remain NPO for 6 to 8 hours prior to the EEG B. Take a sedative on the night prior to the EEG C. Thoroughly shampoo the hair prior to the EEG D. Take an additional dose of anticonvulsant medication 30 minutes prior to the EEG

Thoroughly shampoo the hair prior to the EEG *The nurse should instruct the client to wash the hair thoroughly prior to the EEG because hairsprays, oils, and other hair preparations interfere with recording results of the EEG

A nurse is reinforcing teaching with a client about treatment options for profound sensorineural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implants? A. Transmits impulses directly to auditory nerve endings B. Conducts sound waves through the mastoid bone to the cochlea C. Amplifies sounds through the tympanic membrane to the inner ear D. Creates a new pathway for sound waves through a prosthetic stapes

Transmits impulses directly to auditory nerve endings *Cochlear implants directly stimulate nerve endings in the cochlea

A nurse is collecting data from a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect? A. Tonic-clonic seizures B. Report of a severe headache C. Weakness of the lower extremities D. Decreased level of consciousness

Weakness of the lower extremities *Guillain-Barre syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities and sometimes advancing to the upper extremities

A nurse is reinforcing teaching about auras with a client who has a new diagnosis of simple partial seizures. Which of the following statements by the client indicates an understanding of the teaching? A. "An aura is a sensory warning that a seizure is imminent." B. "An aura is a continuous seizure in which seizures occur in rapid succession." C. "An aura is a period of sleepiness following the seizure." D. "An aura is a brief loss of consciousness accompanied by staring."

"An aura is a sensory warning that a seizure is imminent." *An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or smelling an odor

A nurse is reinforcing teaching with a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following intstructions should the nurse include in the teaching? A. "Place a warm compress on your forehead." B. "Darken the lights." C. "Light a scented candle." D. "Drink a caffeinated beverage."

"Darken the lights." *The nurse should instruct the client to lie down in a dark room to reduce migraine pain

A nurse is reinforcing teaching to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure." B. "Try to stay awake most of the night prior to the procedure." C. "The procedure will take approximately 15 minutes." D. "You will need to lie flat for 4 hours after the procedure."

"Try to stay awake most of the night prior to the procedure." *Instruct the client to wah their hair on the morning of the procedure to remove oils, gels, and sprays, which can affect the EEG readings. Instruct the client remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity. Instruct the client that the procedure will take approximately 1 hr. Instruct the client that normal activity can resume immediately following the procedure

A nurse is reinforcing discharge teaching with a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? A. "You can expect your vision to return immediately after the procedure." B. "You should expect to see flashing lights in front of the affected eye after the procedure." C. "You can remove your eye shields when you're sleeping." D. "You should not lift objects that weigh more than 25 pounds."

"You should expect to see flashing lights in front of the affected eye after the procedure." *The client should expect to see flashing lights in front of the affected eye for several weeks following the procedure.

A nurse is assisting with preparing a client for an electroencephalogram (EEG). Which of the following directions should the nurse provide to the client? A. "Expect the test to take about 3 hours." B. "You'll begin by lying still with your eyes closed." C. "You'll sleep for the duration of the procedure." D. "Expect some mild electrical shocks during the test."

"You'll begin by lying still with your eyes closed." *The client will have to lie still in a reclining chair or bed and keep the eyes closed for the initial recording

A nurse is caring for a patient who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (select all that apply) A. Use the Glasgow Coma Scale when collecting data on the client B. Assist the client to a supine positon C. Administer the client to a supine position D. Encourage the client to increase fluid intake E. Instruct the client to perform deep breathing and coughing exercises

1. Assist the client to a supine positon 2. Administer the client to a supine position 3. Encourage the client to increase fluid intake *The Glasgow coma scale is used to determine the client's level of consciousness and is not necessary following a lumbar puncture *Assist the client to a supine position, which can relieve a headache following a lumbar puncture *Administer an opioid medication for a client's report of headache pain *Encourage an increased fluid intake to maintain a positive fluid balance *Coughing can increase ICP, which can result in an increase in the client's headache

A nurse is monitoring a client who is experiencing opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (Select all that apply) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

1. Bradypnea 2. Orthostatic hypotension 3. Nausea *Urinary retention, Constipation, Respiratory depression, (which causes respiratory rates to drop to dangerously low levels), Dizziness or lightheadedness when chaning positions, nausea, and vomiting are common adverse effects of opioid analgesia

A nurse is checking for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions shouold the nurse take when performing this technique? (select all that apply) A. Place client in supine position B. Flex client's hip and knee C. Place hands behind the client's neck D. Bend client's head toward chest E. Straighten the client's flexed leg at the knee

1. Place client in supine position 2. Place hands behind the client's neck 3. Bend client's head toward chest *Place the client in supine position, place the hands behind the client's neck, and bend the client's head toward the chest when checking for Brudzniski's sign. Flex the client's hip and knee and straighten th client's flexed leg at the knee when checking for Kernig's signs

A nurse is caring for a client who has a seizure disorder. The client tells the nurse, "I am about to have a seizure." Which of the following actions should the nurse plan to implement? (Select all that apply) A. Provide privacy B. Ease the client to the floor if standing C. Move furniture away from the client D. Loosen the client's clothing E. Protect the client's head with padding F. Restrain the client

1. Provide privacy 2. Ease the client to the floor if standing 3. Move furniture away from the client 4. Loosen the client's clothing 5. Protect the client's head with padding *Implement privacy to minimize the client's embarrassment. Ease the client to the floor to prevent falling and injury. Move the furniture away from the client to prevent injury. Loosen the client's clothing to minimize restriction of movement. Protect the client's head from injury by placing the client's head in a lap or using a pillow or blanket under the head during a seizure. Do not restrain the client. Restraint can increase the client's risk for injury or more seizure activity

A nurse is collecting data from a client who has encephalitis due to West Nile virus. Which of the following findings should the nurse expect? (select all that apply) A. Unilateral weakness B. Stiff neck C. Photophobia D. Epigastric pain E. Lethargy

1. Stiff neck 2. Photophobia 3. Lethargy *Encephalitis is acute inflammation of the brain; therefore, the nurse should expect neurological manifestations such as stiff neck, photophobia, and lethargy, which can progress to a coma

A nurse is reinforcing teaching with a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching? A. Avoid bearing down B. Increase caffeine intake C. Avoid sudden movements D. Increase sodium intake

Avoid sudden movements *Meniere's disease is a disorder of the inner ear affecting balance and hearing that is characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase these manifestations

A nurse responds to a call from an assistive personnel that a client has had a seizure and is unconscious. Which of the following data should the nurse collect first? A. Measure the client's vital signs B. Perform a neurological examination C. Check airway patency D. Check the client for injuries

Check airway patency *Using the ABC approach, the nurse should check the client's airway patency and establish and maintain the client's airway to prevent respiratory arres and hypoxia

A nurse is collecting data from a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. This client is experiencing which of the following types of respirations? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul

Cheyne-Stokes *Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths, followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death

A nurse in an urgent care clinic is collecting data from a client who sustained a fall. Which of the following findings should the nurse identify as an indication of skull fracture? A. Report of a severe headache B. Clear fluid coming from the nares C. Brief change in level of cosciousness D. Bleeding from the top of the scalp

Clear fluid coming from the nares *The nurse should identify cerebrospinal fluid coming from the nares or ears as an indication of a skill fracture

A nurse is caring for a client who has Meniere's disease. The nurse should identify that Meniere's disease affects which structure of the ear? A. Eustachiah tube B. Cochlea C. Perichondrium D. Eardrum

Cochlea *Meniere's is a disease of the inner ear in which excess fluid distorts the innter ear canal system. This distortion decreases hearing via dilation of the cochlear duct, leading to vertigo from damage to the vestibular system

A nurse is collecting data from a client who has a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eight cranial nerve (CN VIII)? A. Dizziness and hearing loss B. Weakness of a side of the tongue C. Facial droop and asymmetrical smile D. Loss of the same visual field in both eyes

Dizziness and hearing loss *Dizziness and hearing loss reflect alterations in the vestibulocochlear area, which CN VIII innervates

A nurse is collecting data from a client who has a brain tumor. Which of the following findings indicates cranial nerve involvement? A. Dysphagia B. Positive Babinski sign C. Decreased deep-tendon reflexes D. Ataxia

Dysphagia *Dysphagia (difficulty swallowing) can occur as a result of damage to cranial nerve IX (glossopharyngeal) or X (vagus). The cranial nerves primarily innervate the face, neck , and a few organs

A nurse is reinforcing teaching about degenerative complications with the parter of a client who has a new diagnosis of Parkinson's disease. Which of the following manifestations is the priority? A. Dysphagia B. Emotional lability C. Impaired speech D. Self-care dependency

Dysphagia *Dysphagia is the priority manifestation for this client because it can lead to aspiration

A nurse is collecting on a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens their eyes when spoken to, speaks incoherently, and moves their extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 =11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8

E3 + V4 + M4 =11 *E2 represents eyes opening secondary to pain, V3 represents verbal response with words spoken inappropriately, and M5 represents motor response to pain with a local reaction *E3 represents opening eyes secondary to voice stimulation, V4 represents verbal conversation that is incoherent and disoriented, and M4 represents motor response as a general withdrawal to pain *E4 represents eyes opening spontaneously, V5 represents verbal conversation as coherent and oriented, and M6 indicates a client is able to follow commands *E2 represents eyes opening secondary to pain, V2 represents verbal response by the client making sounds but speaking no words, and M4 is a motor response with a general withdrawal to pain

A nurse is reinforcing teaching with a class of new parent about otitis media. Which of the following manifestations should the nurse include in the teaching? A. High-pitched sound heard in the ear B. Intermittent rapid eye movement C. Itching om the external ear D. Feeling of fullness in the ear

Feeling of fullness in the ear *A client who has otitis media can develop a feeling of fullness in the ear. Other manifestation can include ear pain, a cracking sound when yawning or swallowing, and mild dizziness

A nurse is caring for a client who had a stroke and has espressive aphasia. The nurse should identify that the stroke affected whoch of the following lobes of the client's brain? A. Occipital B. Temporal C. Frontal D. Limbic

Frontal *The posterior portion of the frontal lobe is responsible for verbal expression of thoughts

A nurse is assisting with the care of a client who has a cerebral lesion and develops hyperthermia. The nurse should identify that which of the following areas of the brain is affected? A. Wernicke's area B. Cerebral cortex C. Basal ganglia D. Hypothalamus

Hypothalamus *The hypothalamus, located below the cerebrum, is responsible for the regulation of body temperature

A nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the client he will have to repeat them again in a few minutes. After 5 minutes, the nurse asks the client to name the objects. The nurse is using this strategy to test which type of memory? A. Remote B. Sensory C. Immediate D. Recall

Immediate *The nurse tests the client's immediate or new memory by following the 3-object protocol. A client without cognitive decline should be able to recall and name the 3 objects 5 minutes later

A nurse is assisting with caring for a client who has experienced a head injury from a fall at work . After checking the client's airway, breathing, circulation (ABC), which of the following actions is the priority for the nurse to perform? A. Question the client's coworkers about the mechanism of injury B. Check the client's pupils for equality and reaction to light C. Measure the client's alertness using the Glasgow Coma Scale D. Immobilize the client's cervical spine

Immobilize the client's cervical spine *The greatest risk to this client is an injury from a cervical spine dislocation and spinal cord compression following a traumatic head injury. Therefore, the priority action the nurse should take after assessing the client's ABC is to immobilize the client's neck with a cervical collar. A client who has head trauma might also have damage to the cervical spine. This is an essential component of the initial stabilization of a client who has a head injury

A nurse is monitoring a client who reports severe headache and a stiff neck. The nurse's data collection reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics B. Implement droplet precautions C. Initiate IV access D. Decrease bright lights

Implement droplet precautions *When using the urgent vs. nonurgent approach to care, the priority action is to initiate droplet precautions when meningitis is suspected to prevent spread of the disease to others

A nurse is collecting data from a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment? A. Inability to remember current age B. Inability to count backward C. Inability to locate eyeglasses D. Inablity to recall names of family members

Inability to locate eyeglasses

A nurse is collecting data from a client who is admitted to the facility for observation following a closed head injury. Which of the following data is the priority for the nurse to collect to detect a change in the client's neurological status? A. Vital signs B. Body posture C. Level of consciousness D. Examination of pupils

Level of consiousness *For this client, the priority data collection is level of consciousness. A change in the client's level of consciousness can be the first indication of a change in neurologic status

A nurse is reinforcing teaching with the family of a client who has stage 2 Alzheimer's disease (AD). Which of the following pieces of information should the nurse include in the teaching? A. Place abstract pictures on the wall in the client's room B. Provide music for the client using headphones C. Reorient the client to reality frequently D. Limit choices offered to the client

Limit choices offered to the client *Choices should be limited for the client who has stage 2 AD to reduce confusion and frustration

A nurse is collecting data from a client who has cataracts. Which of the following findings should the nurse expect? A. Pupils nonreactive to light B. Opacity visible behind the pupil C. White circle around the outside border of the iris D. Increased intraocular pressure

Opacity visible behind the pupil *With a cataract, the lens of the eye becomes thick and opaque with age. It appears as opacity behind the pupil when the nurse shines a light on it

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? A. Metered-dose inhaler B. Continuous passive motion machine C. External defibrillator pads D. Oral-nasal suction equipment

Oral-nasal suction equipment *This client who has myasthenia gravis is at risk of aspiration due to progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nurse suction equipment at the bedside in the event of aspiration or respiratory distress

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse take next? A. Administer nifedipine B. Place the client in a high-Fowler's position C. Check for urinary retention D. Check for a fecal impaction

Place the client in a high-Fowler's position *Accorcing to evidence-based practice, the nurse should first place the client in a high-Fowler's position to help decrease the client's blood pressure and reduce the risk of end-organ damage from the sudden rise in blood pressure

A nurse is caring for a client who has an impairment of cranial nerve II. The nurse should do which of the following to ensure the client's safety? A. Initiate seizure precautions B. Ensure the client receives a soft diet C. Provide an obstacle-free path for ambulation D. Instruct the client to use lukewarm water when showering

Provide an obstacle-free path for ambulation *Although providing an obstacle-free path is a safety precaution for all clients, it is especially crucial for this client. Cranial nerve II is the optic nerve; therefore, the client has at least some visual challenges. The nurse should make sure the client has an obstacle-free path for ambulation

During a neurological evaluation, a nurse asks how the client arrived at the appointment and with whom. Which of the following types of memory is the nurse testing? A. Remote B. Immediate C. Recall D. Past

Recall *To test recall or recent memory, the nurse should ask the client to provide details about how he arrived at the appointment and with whom. The nurse could also ask the client to name any health care providers he saw in the past few days

A nurse is caring for a client who has demential and is experiencing anxiety. Which of the following actions should the nurse take? A. Place a vest restraint on the client to protect others in the environment B. Provide a variety of routines to keep the client from getting bored C. Explain to the client that episodes of anxiety will decrease over time D. Redirect the client to a different activity with a small group of people

Redirect the client to a different activity with a small group of people *The nurse should redirect the client to another activity to distract from the anxiety. The client should not be exposed to large groups because this provides too much stimulation and can promote increased anxiety

A nurse is collecting data from a client who has high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. Flushing of the lower extremities B. Hypotension C. Tachycardia D. Report of a headache

Report of a headache

A nurse is collecting data from a client who reports vision loss that began with a "flash" or light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? A. Glaucoma B. Retinal detachment C. Macular degeneration D. Cataracts

Retinal detachment *A flash of light and sudden loss of vision are manifestations of retinal detachment. Clients report the even of vision loss as sudden and painless

A nurse is caring for a client who begins to have a generalized tonic-clonic seizure while lying in bed. Which of the following actions should the nurse take? A. Insert an oral airway B. Turn the client onto the side C. Restrict movement of the client's limb D. Place a pillow under the client's head

Turn the client onto the side *The nurse should turn the client onto the side to protect the client from aspiration

A nurse is caring for a client who is experiencing a seizure while in bed. Which of the following actions should the nurse take? A. Raise the head of the client's bed B. Restrain the client's arms and legs C. Turn the client's head to the side D. Insert a tongue blade into the client's mouth

Turn the client's head to the side *The nurse should turn the client's head to the side during the seizure. This prevents the client's airway from becoming obstructed and keeps the airway patent

A nurse is reinforcing teaching with the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following findings is an early manifestation of ALS? A. Sensory dysfunction B. Weakness of the distal extremities C. Decreased vision D. Altered temperature regulation

Weakness of the distal extremities *ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain and the spinal cord, causing muscle wasting, spasticity, and eventually paralysis. Early manifestations of ALS include increasing muscle weakness (especially involving the distal arms and legs), as well as impaired speech, swallowing, and breathing

A nurse is collecting data from a client following a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? A. Widened pulse pressure B. Tachycardia C. Periorbital edema D. Decreased urine output

Widened pulse pressure *A widening of the pulse pressure, which is the difference between the systolic and diastolic pressure, is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting

A nurse is assisting with triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils? A. red tag B. yellow tag C. green tag D. black tag

black tag *The nurse should assign a black tag or a class IV label to clients who are not expected to live and will be allowed to die naturally. Dilated pupils that are fixed or nonreactive to light are a poor prognostic sign and an indication or severely increased intracranial pressure.In a mass casualty situation, the overall goal is to provide lifesaving treatment to the greatest number of peopler possible

A nurse is reinforcing teaching with a client who is going to have an electroencephalogram (EEG) in the morning. Which of the following information should the nurse provide the client? A. "You'll feel some mild sensations like static electricity during the procedure." B. "Do not eat or drink anything except water after midnight." C. "Shampoo your hair before the procedure and don't use any styling products afterward." D. "A temporary short-term memory loss is common after the procedure."

"Shampoo your hair before the procedure and don't use any styling products afterward." *An EEG is a painless test that records the electrical activity of the brain. For the test, the technician attaches the electrodes to the scalp to record the tinry electrical charges release by nerve cells in the brain. In order for the electrodes to adhere to the scalp, the client's hair has to be clean and free of oil and hair-care products

A nurse is reinforcing teaching with a client about computed tomography (CT) scanning of the brain. Which of the following pieces of information should the nurse include? A. "You'll have to lie very still on a long, narrow table during the test." B. "You should be able to sit up during the test if you need a break." C. "You'll have many tiny electrodes placed on your scalp during the test." D. "You should expect the test to take at least an hour."

"You'll have to lie very still on a long, narrow table during the test." *The test will require the client to lie very still on a long, narrow table. Movement during the test interferes with the quality of the films

A nurse is caring for a client who has received sedation. When the nurse applies nailbed pressure, the client withdraws his hand. The nurse should document this response as indicating which of the following? A. Confusion B. Arousal C. Orientation D. Attention

Arousal *This client is demonstrating some degree of arousal. Withdrawing his hand in response to nailbed pressure indicates responsiveness to sensory stimulation

A nurse is collecting data from an older adult client for physiological changes that can occur with aging. Which of the following findings should the nurse expect? A. Increased saliva production B. Decreased sense of taste C. Increased sense of smell D. Decreased chest wall rigidity

Decreased sense of taste *A nurse collecting data from an older adult client should expect a decreased sense of taste due to atrophy of the taste bude. This can increase the client's risk for poor intake, resulting in less-than-optimal nutrition

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings is consistent with this diagnosis? A. Elevated glucose B. Elevated protein C. Presence of RBCss D. Presence of D-dimer

Elevated protein *An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. manifestations of bacterial meningitis include an increase in protein in cerebrospinal fluid

A nurse is caring for a client with a history of repeated middle ear infections. The client says. "My doctor told me these infections are due to an obstrcution of the structure that connects the middle ear to the throat." The nurse should identify that the provider is referring to which of the following structures? A. Oval window B. Auricle C. Tympanic membrane D. Eustachian tube

Eustachian tube *The eustachian tube connects the middle ear to the throat and allows equalization of pressure and drainage of fluids from the middle ear into the throat

A nurse is caring for a client who has a hearing impairment. Which of the following actions should the nurse take when communicating with the client? A. Face the client when speaking B. Speak in a loud voice C. Use a normal rate when speaking D. Avoid hand motions

Face the client when speaking *Facing the client will allow the client to observe the nurse's facial expressions and enable the client to lip read during the communication process

A nurse is reinforcing teaching with an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching? A. Dry the ear canal with a cotton swab after swimming B. Apply an ice pack to the ear to relieve pain C. Instill a diluted alcohol solution into the ear after swimming D. Irrigate the ear with cool tap water to clean

Instill a diluted alcohol solution into the ear after swimming *External otitis is inflammation of the external auditory canal. It is often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitits by instilling diluted alcohol drops to decrease bacteria and dry the external ear canal

A nurse is reinforcing teaching with a client who is preopertive for cataract surgery. The nurse should include in the teaching that which of the following is an adverse effect of cataract surgery? A. Eyelid twitching B. Photosensitivity C. Intraocular hemorrhage D. Dry eyes

Intraocular hemorrhage *Intraoculat hemorrhage is an adverse effect of cataract surgery. The client should immediately report manifestation of intraocular hemorrhage such as eye pain, brow pain, and decreased vision to the provider

A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse expect to administer? A. Ketorolac B. Ketamine C. Meperidine D. Methadone

Ketorolac *Ketorolac is in the NSAID category and is useful for anti-inflammatory effects in managing minor pain following a sprain *Ketamine is an anesthetic agent that is often used an an adjuvant medication for treating neuropathic pain. *Meperidine is not recommeded for regular use due to adverse effects of the medication *Methadone is effective for treating severe pain

A nurse is assisting with the plan of care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the plan of care? A. Prevent depression in the client B. Refer the client to occupational therapy C. Support the client's family D. Monitor the client for increased intracranial pressure (ICP)

Monitor the client for increased intracranial pressure (ICP) *The greatest risk to this client is an injury from increased ICP, which can result in decreased cerebral perfusion and neurological injury. Therefore, the priority intervention the nurse should include in the plan of care is to monitor the client for an increased ICP. Manifestations of increased ICP include decreased level of consciousness and change in pupils

A nurse is discussing data collection for pain with a newly licensed nurse. Which of the following information should the nurse include? A. Most clients exaggerate their level of pain B. Pain must have an identifiable source to justify the use of opioids C. Objective data are essential in collecting data about pain D. Pain is whatever the client says it is

Pain is whatever the client says it is *A misconception about pain is that clients exaggerate their pain level. Client can have pain without being able to identify the sourse.. Objective data is not always present when clients have pain. Pain is a subjective experience, and the client is the best source of information about it.

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty? A. Finding the bathroom in the dark B. Driving at night C. Seeing numbers on highway signs D. Reading the newspaper

Reading the newspaper *With presbyopia, the lens is unable to change shape to focus on objects close up. Presbyopia develops with aging, beginning in middle age, and results from the decreased elasticity of the lens

A nurse is reinforcing discharge teaching with a client who had a transient ischemic attach (TIA). Which of the following instructions should the nurse include? A. Reduce dietary sodium B. Decrease dietary potassium C. Restrict intake of soluble fiber D. Limit alcohol intake to 3 or fewer servings per day

Reduce dietary sodium *A temporary disturbance of the blood supply to the brain leads to TIAs, which are bried alterations in neurological function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should limit sodium intake to help control hypertension and prevent future TIAs

During a neurological evaluation, a nurse asks a client to name all of his children and state their ages and their birth dates. Which of the following types of memory is the nurse testing? A. Remote B. Sensory C. Immediate D. Recall

Remote *The nurse tests remote or long-term memory by asking questions such as where and when the client was born, what his age is, when he graduated high-school, and what the names, ages, and birth dates of his children are. The nurse can later verify this information with the client's family or friends

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). The nurse should identify that this elevated ICP is dues to which of the following? A. Decreased cerebral perfusion B. Leakage of cerebral spinal fluid C. Rigid skull containing cranial contents D. Brain herniation into the bloodstem

. Rigid skull containing cranial contents *The client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP

A nurse is contributing to the plan of care for a client who is scheduled for cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? (select all that apply) A. "I think I might be pregnant." B. "I take warfarin." C. "I take antihypertensive medication. D. "I am allergice to shrimp." E. "I ate a light breakfast this morning."

1. "I think I might be pregnant." 2. "I take warfarin." 3. "I am allergice to shrimp." 4. "I ate a light breakfast this morning." *Report the client's statement of possible pregnancy because the contrast media can place the fetus at risk. Report that the client is taking warfarin due to the potential for bleeding following angiography. There is no contraindication related to cerebral angiography for a client who is taking antihypertensive medication. Report a client's report of allergy to shrimp, which is a shellfish, due to a potential allergic reaction to the contrast media. Report a client's intake of food because the client should remain NPO prior to the procedure

A nurse is reinforcing teaching with a client who hasa diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (select all that apply) A. Lost vision can improve with eye drops B. Administer eye drops as needed for vision loss C. Glasses will be necessary to correct the accompanying presbyopia D. Driving can be dangerous due to the loss of peripheral vision E. Laser surgery can help reestablish the flow of aqueous humor

1. Driving can be dangerous due to the loss of peripheral vision 2. Laser surgery can help reestablish the flow of aqueous humor *Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can cause complete vision loss if not treated. Laser surgery can reoprt the trabecular meshworl and widen the canal of Schlemm

A nurse is contributing to the plan of care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? (select all that apply) A. Implement seizure precautions B. Perform neurologic checks four times a day C. Administer morphine for the report of neck and generalized pain D. Turn off room lights and television E. Monitor for impaired extraocular movements F. Encourage the client to cough frequently

1. Implement seizure precautions 2. Turn off room lights and television 3. Monitor for impaired extraocular movements *The client is at risk for seizures due to possible increased ICP. Therefore, implement seizure precautions to reduce the client's risk for injury *Perform a neurologic checks at least every 2 hr for a client who is at risk for increased ICP. *Avoid administering opioids to a client who is at risk for increased ICP. Opioids can mask changes in the client's level of consciousness *Turn off room lights and the television because they can increase neuron stimulation and cause a seizure when a client is at risk for increased ICP. *Monitor for impaired extraocular movements because this finding can indicate increased ICP *Instuct the client to avoid coughing because this action can causse increased ICP.

A nurse is contributing to the plan of care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (select all that apply) A. Monitor for bradycardia B. Provide an emesis basin at the bedside C. Administer antipyrectic medication D. Perform skin data collection E. Keep the head of the bed flat

1. Provide an emesis basin at the bedside 2. Administer antipyrectic medication 3. Perform skin data collection *Plan to monitor for tachycardia when a client has meningitis *Provide an emesis basis at the bedside because the client who has menigitis can have nausea and vomiting *Plan to adiminister antipyretic medication for fever to a client who has meningitis *Perform skin data collection to determine whether teh client has a red macular rash associated with meningococcal meningitis *Elevate the head of the client's bed 30° to promote venous drainage from the head and prevent increased ICP

A nurse is reinforcing teaching with a group of clients about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching? A. A TIA can cause irreversible hemiparesis B. A TIA can be the result of cerebral bleeding C. A TIA can cause cerebral edema D. A TIA can precede an ischemic stroke

A TIA can precede an ischemic stroke *TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include loss of vision in an eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? A. Add gestures when speaking with the client B. Ask open-ended questions C. Limit visitors to 3 at a time D. Use different words if the client does not understand a statement or question

Add gestures when speaking with the client *The nurse should use gestures when speaking to increase the client's understanding of the conversation

A nurse is reinforcing discharge teaching with a client who has a transient ischemic attack (TIA). The nurse should instruct the client to monitor which of the following parameters at home? A. Blood glucose B. Blood pressure C. Daily weight D. Sensation in the feet

Blood pressure *A temporary disturbance of the blood supply to the brain causes a TIA, which is a brief alteration in neurological function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should track BP regularly to promote hypertension management and reduce the risk of cerebrovascular accident

A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this findings as a positive Romberg test, indicating which of the following alterations? A. Cerebellar dysfunction B. Occipital lobe dysfunction C. Increased intraocular pressure D. Macular degeneration

Cerebellar dysfunction *Cerebellar dysfunction causes a loss of positional sense (proprioception), which results in a positive Romberg sign