GI/ NEUROLOGY

A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?

B. Dilated pupils

An acute care nurse receives shift report for a client with increased intracranial pressure and is told the client demonstrates decorticate posturing. Which of the following should the nurse expect to observe upon assessment of this client?

Plantar flexion of the legs

An older adult client in a long-term care facility had a cerebrovascular accident (CVA) 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

A reddened area over the sacrum

An emergency room nurse is caring for a client following an automobile crash. Upon assessment the nurse observes bleeding from the client's nose. Which of the following interventions is appropriate?

Allow the drainage to drip onto a sterile gauze pad.

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm/Hg. Which assessment should the nurse recognize as a late sign of ICP? (Select all that apply.)

Bradycardia Nonreactive dilated pupils Widened pulse pressure

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Brudzinski sign

A nurse is caring for a client following surgical treatment for a brain tumor near the hypothalamus. For which of the following is the client at risk?

Inability to regulate body temperature

.A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

C. Open the airway using a jaw-thrust maneuver. D. Determine effectiveness of ventilator efforts. B. Establish IV access. A. Perform a Glasgow Coma Scale assessment. E. Remove clothing for a thorough assessment.

A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following is an appropriate response by the nurse?

Incorporate nonverbal cues in the conversation.

A nurse is collaborating on care for a client following a cerebrovascular accident (CVA). Which of the following should be addressed by an occupational therapist?

Completing self-care

.The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior?

Confusion

A client has increased intracranial pressure following a closed-head injury. The nurse should recognize which of the following interventions as contraindicated for this client?

Cough and deep breathe

A nurse is caring for a client who is 6 days postoperative following a craniotomy for removal of an intracerebral aneurysm. The client has been transferred from the ICU to the PACU. The nurse should assess the client for early signs of increased intracranial pressure (ICP) when the client states

Could you get me a bowl? I feel nauseated.

A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If the client manifests increased intracranial pressure, which of the following findings should the nurse expect? (Select all that apply)

Violent headache Slurred speech Projectile vomiting Rapid loss of consciousness

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). The nurse should know that which of the following client findings supports this suspicion?

Diplopia.

A nurse is planning care for a client who has a decreased level of consciousness from bacterial meningitis. The client is receiving continuous nourishment via gastrostomy tube (G-tube) feedings due to an inability to swallow. Which of the following is the priority action by the nurse?

Elevate the head of the client's bed 30° to 45

A nurse is caring for a client at a rehabilitation center 3 weeks after a cerebrovascular accident (CVA). Because the client's CVA affected the left side of the brain, which of the following goals should the nurse anticipate including in the client's rehabilitation program?

Establish the ability to communicate effectively.

A nurse is admitting a client who has bacterial meningitis. The nurse notes during the physical examination that the client cannot extend his leg when his hip is flexed so that his thigh rests on his abdomen. The nurse should document this as which of the following?

Kernig's sign

An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. When performing a neurological examination, which of following is the most reliable indicator of cerebral status?

LOC

A nurse creates a plan of care for a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is within normal limits?

Pushes the painful stimulus away

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following statements indicates the nurse understands the rationale for using this solution?

Reduce edema of the brain

A client is recovering from a cerebrovascular accident (CVA). Which of the following information should the nurse include when teaching family members about repositioning? (Select all that apply.)

Remove pillows prior to repositioning. Elevate the bed to waist height. Stand with feet wide apart. Face the direction of movement when positioning the client.

A nurse is caring for a client who has just had an evacuation of a subdural hematoma following a head injury. Which of the following is the nurse's highest priority assessment?

Respiratory status

A nurse admits a client who has a concussion for overnight observation. Alert and oriented on admission, the client reports a headache along with neck pain and generalized muscle aches. The nurse knows that a manifestation considered an early indication of increased intracranial pressure (ICP) is

lethargy.

A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate finding by the nurse?

Severe headache

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?

Shivering

A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

Supplements via nasogastric tube

A client has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement to prevent foot-drop?

Support the right foot in dorsiflexion with a footboard.

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). To determine if the client is experiencing pain, the nurse should use

a self-report pain rating scale

A nurse is monitoring a client who is at risk for increased intracranial pressure. While assessing the client's cranial nerves, the nurse should check the function of cranial nerve III by

checking pupillary response to light

A nurse is caring for a client who has hemianopsia following a cerebrovascular accident (CVA). The nurse should document an improvement in this condition when the nurse observes that the client

eats items from both sides of her lunch tray

to promote reduction of intracranial pressure the nurse should:

elevate the head of the bed 15-30