ch.40 prep u med surg

A client is diagnosed with an intracerebral tumor. The nurse knows that the diagnosis may include which of the following? Select all that apply.

Astrocytoma Ependymoma Medulloblastoma

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?

Initiate seizure precautions.

A client diagnosed with a brain tumor is exhibiting focal symptoms. Which assessment findings are the nurse likely to note? Select all that apply.

Muscle weakness Sensory loss Aphasia Visual changes

A gerontologic nurse is advocating for diagnostic testing of an 81-year-old client who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults?

The effects of brain tumors are often attributed to the cognitive effects of aging.

A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase?

preventing further neurologic damage

A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team?

spouse

A client has left-sided hemiplegia as the result of a brain attack (cerebrovascular accident). While being dressed, the client states in a disgusted tone of voice, "I feel like a 2-year-old. I can't even get dressed by myself." What is the nurse's best response?

"It's hard to feel dependent on others."

The nurse caring for a client with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?

15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days

During a Tensilon test to determine if a client has myasthenia gravis, the client reports cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium.

The nurse is discharging a client home after surgery for trigeminal neuralgia. What advice should the nurse provide to this client in order to reduce the risk of injury?

Avoid rubbing the eye on the affected side of the face.

A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment?

Decreased muscle spasms in the lower extremities

A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. Which nursing action(s) would best address the report of headache? Select all that apply.

Dimming the lights Limiting noise

A client with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this client?

EEG

A 25-year-old client with brain metastases is considering life expectancy after their most recent meeting with the oncologist. Since the client is not receiving treatment for the brain metastases, what is the nurse's priority action?

Ensuring that the client receives adequate palliative care

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.

A client with paralysis is disturbed by spontaneous erections. Which nursing action may help the client?

Explain that it may occur when the bladder is full.

The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication?

Falls

The nurse is assessing an older adult who is experiencing a new onset of weakness, fatigue, and musculoskeletal pain. Which information in the client's health history will the nurse identify to help determine the reason for the client's new symptoms?

History of polio in 1955

A client has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The client has just exhibited seizure activity for the first time. What is the nurse's priority response to this event?

Implement precautions to ensure the client's safety.

A nurse is providing care to a client who has been diagnosed with metastatic brain cancer. When developing the client's plan of care, which outcome would the nurse most likely identify?

Improved quality of life

The nurse in an extended care facility is planning the daily activities of a client with post-polio syndrome. The nurse recognizes the client will best benefit from physical therapy when it is scheduled at what time?

In the morning

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 they have 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

While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the clients' cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action?

Inform the surgeon of the possibility of a dural leak.

A family member of a client diagnosed with Huntington disease calls the clinic. The family member is requesting help from the Huntington Disease Society of America. What kind of help can this client and family receive from this organization? Select all that apply.

Information about this disease Referrals Public education

The nurse is providing postoperative care for a client who just underwent surgery to remove a metastatic intramedullary tumor. On postoperative day 3, the client states, "I am really looking forward to going running again, it had become too difficult because of the loss of feeling in my feet." Which should the nurse address in the client's care plan?

Knowledge deficit

A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment?

Loss of hearing, tinnitus, and vertigo

A 73-year-old client comes to the clinic reporting weakness and loss of sensation in the feet and legs. Assessment of the client shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this client?

Many symptoms can be the result of normal aging process.

The nurse is caring for a client who has muscular dystrophy. When planning assistance with the client's ADLs, what goal should the nurse prioritize?

Maximizing the client's level of function

The nurse educator is facilitating a class on neurological function with a group of nursing students. When discussing problems that can result from growing brain tumors, the nurse educator should include that clients can experience which neurologic deficits even after surgical resection? Select all that apply.

Paralysis Incontinence Aphasia

A client diagnosed with myasthenia gravis (MG) has developed dysphagia due to cranial nerve dysfunction. Which nursing action(s) will the nurse consequently perform? Select all that apply.

Position the client upright during feeding. Teach the client to flex their neck when swallowing.

A client diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this client most likely has?

Relapsing-remitting (RR)

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions?

Renal

The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest?

Resting in an air-conditioned room whenever possible

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 diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response?

Symptom improvement that lasts a few weeks after TPE ceases

A neurologic deficit is best defined as a deficit of the:

central and peripheral nervous systems with decreased, impaired, or absent functioning.

A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?

immediately