dyammic quizzes, neurosensory

A nurse is reinforcing teaching with a client who is scheduled for laser-assisted in situ keratomileusis (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." 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 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 The nurse should use gestures when speaking to increase the client's understanding of the conversation.

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 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 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" 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 assess the client's voice quality for hoarseness.

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

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 The first action the nurse should take when using the airway, 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 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 instructions should the nurse include in the teaching?

B. "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 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?

B. "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 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?

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

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 a skull fracture?

B. Clear fluid coming from the nares The nurse should identify cerebrospinal fluid coming from the nares or ears as an indication of a skull fracture.

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?

B. 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 buds. This can increase the client's risk for poor intake, resulting in less-than-optimal nutrition.

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 first if a seizure occurs?

B. Protect the client's head The nurse should apply the safety and risk reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. 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 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?

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

A nurse is reinforcing teaching with a client who has a new diagnosis of Menière's disease. Which of the following instructions should the nurse include in the teaching?

C. Avoid sudden movements Ménière'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 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?

C. 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 reinforcing teaching with an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching?

C. 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 otitis by instilling diluted alcohol drops to decrease bacteria and dry the external ear canal.

A nurse is reinforcing teaching with a client who is preoperative for cataract surgery. The nurse should include in the teaching that which of the following is an adverse effect of cataract surgery?

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

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?

C. 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 collecting data from a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect?

C. Weakness of the lower extremities Guillain-Barré 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 with a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?

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

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?

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

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?

D. 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 caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect?

D. Right-sided hemiplegia The nurse should expect right-sided hemiplegia following intracranial bleeding in the left hemisphere of the brain.