immune/Neuro Q's

Family members of a client who had a brain attack (cerebrovascular accident, CVA) ask why the client cries easily and without provocation. How does the nurse explain the client's behavior?

Has little control over this behavior

When assessing a client, the nurse identifies that the client has weakness of some of the muscles of the body. What should the nurse document in the medical record when describing weakness in the area indicated in the shaded portion of the

Hemiparesis

During an assessment, the nurse shines a light into the client's eyes and observes that the pupil remains dilated. Which cranial nerve (CN) does the nurse suspect to be affected?

CN III

A client reports buzzing in the ear for the past 5 days and a decreased ability to hear sounds. After interacting with the client, the nurse finds that the client is receiving long-term aminoglycoside therapy. Which cranial nerve should the nurse suspect to be affected?

CN VIII

Which radiologic study is used to obtain radiographic images of the client's brain for three-dimensional intracranial contents

CT

Which test is used to diagnose diseases of the vestibular system?

Caloric test stimulus

Upon assessment, the nurse finds the following (see image). The nurse will prepare the client for which type of surgery?

Cataract removal

Which part of the client's brain primarily regulates muscle functioning and coordinates movement?

Cerebellum

A client with a head injury has a fixed, dilated right pupil, responds only to painful stimuli, and exhibits flexion (decorticate) posturing. What should the nurse conclude from these clinical findings?

Cerebral compression

A client comes into the emergency room (ER) after hitting his head while playing basketball. He is alert and oriented. Which is a priority nursing intervention?

Immobilize the client's head and neck

A nurse should plan to maintain a client who has experienced a subarachnoid hemorrhage in what position?

In bed with the head of the bed elevated

The nurse is caring for a client who has a tumor of the cerebellum. What is the client most likely to exhibit?

Inability to execute smooth movements

When completing a neurologic assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion?

Inability to stand with feet together when eyes are closed

A nurse is caring for a client who just has had surgery on the ear. The nurse should assess for which early indicator of potential damage to the motor branch of the facial nerve?

Inability to wrinkle the forehead

The nurse is teaching a client with multiple sclerosis methods to reduce fatigue. Which statement indicates an understanding of the education?

Rest in an air-conditioned room.

A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse will best elicit information that supports this diagnosis?

"Have you experienced an infection recently?"

While caring for a client who had an accident, the nurse suspects injury to the frontal lobe. Which statements by the client may support the nurse's conclusion? Select all that apply.

"I am unable to move my eyes." "I am unable to concentrate on anything."

When preparing a client for discharge after a laminectomy, the nurse evaluates that further health teaching is necessary when the client makes which statement?

"I should spend most of the day sitting in a straight-back chair."

Which client eye movement does the superior oblique muscle control?

pulls the eye down

A nurse begins planning for the discharge of a client who had a brain attack (cerebrovascular accident, CVA) with residual hemiparesis and hemianopsia. Which information should the nurse include in the discharge teaching plan for this client?

safe environment

Which area of the client's cerebral lobe is linked to Wernicke's area of speech?

temporal lobe

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?

yellow

The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes associated with aging. Which statement made by the coworker indicates the nurse needs to intervene?

"Clients with decreased sensory perception of touch should be carefully monitored for infection."

On the first postoperative evening after a lumbar laminectomy, a client states, "My feet are as numb as they were before the operation." Which is the nurse's best response?

"Continue to let me know how you feel. It often takes time before this feeling subsides."

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record?

"Exhibits a positive Babinski sign"

A nurse performs preoperative teaching for a client who is to have cataract surgery. Which is most important for the nurse to include concerning what the client should do after surgery?

Avoid bending from the waist

A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase?

Avoiding flexion or hyperextension of the spine

While performing a visual system assessment, the nurse observes that the client has a misalignment of the right eye. The client reports to the nurse, "I am having double vision." What may be the cause of this condition?

Abnormalities of extraocular muscle actions

A nurse providing care in a hospital witnesses a client's spouse shaking the client vigorously because the client has had an episode of incontinence. Because of the suspicion of physical abuse, legally the nurse should discuss the concerns with which party?

Adult Protective Services

A client is going for a magnetic resonance imaging (MRI). What should the nurse ascertain before taking the client to the procedure?

All metal, such as jewelry and hair ornaments, has been removed.

A client asks for information about glaucoma. How should the nurse explain glaucoma to the client?

An increase in the pressure within the eyeball

The nurse assesses a client's eyes and notices that the pupils are unequal in size and constricted. What condition would be found in the client's medical record?

Anisocoria

While making rounds, the nurse finds a client lying on the floor next to a wheelchair. The client states, "I was trying to get back to bed and slipped." What should be the nurse's initial action?

Arrange for the client to be examined by the in-house healthcare provider.

The spouse of a client who had a cerebrovascular accident (also known as a "brain attack") seems unable to accept the concept that the client must be encouraged to participate in self-care. What is the best response by the nurse?

Ask the spouse for assistance in planning those activities most helpful to the client.

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care?

Aspiration

Which condition is associated with unevenly curved surfaces of the client's cornea?

Astigmatism

A client who sustained a severe head injury remains unconscious. During the client's assessment, the nurse observes bleeding from the left ear and rhinorrhea. What injury does the nurse conclude that drainage from the ear and nose indicates?

Basilar fracture

A nurse is caring for a client with expressive aphasia. Which action should the nurse include when planning for the long-term care of this client?

Begin helping the client to write.

A client has inflammation of the facial nerve, causing facial paralysis on one side. Which diagnosis will the nurse most likely observe written in the medical record?

Bell palsy

Which beta-adrenergic blocker is prescribed to clients with glaucoma?

Betaxolol

Which prostaglandin agonist is used in the treatment of clients with glaucoma?

Bimatoprost

A client has a craniotomy for a meningioma. For which response should the nurse assess the client in the postanesthesia care unit?

Blurred vision

Which anatomical area in the brain regulates a client's verbal expression?

Broca's area

Following a motor vehicle accident a client reports seeing frequent flashes of light. Which condition should the nurse be prepared to address?

Detached retina

The primary healthcare provider is performing a procedure (see image) on a client. What is the purpose of the examination as shown in the given figure?

Determine intraocular pressure

Which part of the brain contains the client's "central switchboard" of the central nervous system?

Diencephalon

A client has had a carotid endarterectomy. To monitor for the complication of cranial nerve dysfunction, the nurse assesses the client for which finding?

Difficulty swallowing

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify?

Difficulty swallowing saliva

A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed?

Effectiveness of respiratory exchange and ability to swallow

After sustaining a head trauma, a client reports hearing ringing noises. Which area should the nurse assess further?

Eighth cranial nerve (vestibulocochlear)

The family members of a client with the diagnosis of cerebrovascular accident (CVA, also known as "brain attack") express concern that the client often becomes uncontrollably tearful during their visits. What should the nurse include in a response?

Emotional lability is associated with brain trauma.

A nurse is caring for an older adult with a history of recent memory loss. Which action should the nurse take?

Employ electronic devices that provide alerts

A nurse may find that for optimum nutrition a client with a cerebrovascular accident (also known as "brain attack") needs assistance with eating. What should the nurse do?

Encourage the client to participate in the feeding process.

A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. Which information should the nurse share with the family?

Encourage the client to speak while allowing time to respond.

A college athlete sustained a complete transection of the spinal cord while practicing on a trampoline. The healthcare provider explains that return of function to the lower extremities is not likely to occur. Two weeks later, the client verbalizes the need to get out of the hospital to practice for an upcoming tournament. Which is the nurse's most appropriate conclusion about the client's statement?

Exhibiting denial

A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed with a seizure disorder. Which is most important for the nurse to include in a teaching program?

Explain ways to prevent physical trauma from occurring during a seizure.

A client is to have a parotidectomy to remove a cancerous lesion. Which postoperative complication that may be permanent should the nurse monitor in this client?

Facial nerve dysfunction

An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action?

Interview the client without the presence of family members.

Which is a clinical manifestation of a cluster headache?

Ipsilateral tearing of the eye

Which statement indicates a nurse has a correct understanding about trigeminal autonomic cephalalgia (cluster headaches)?

It is caused by an overactive hypothalamus.

A client who is legally blind is admitted to the hospital for surgery. Which nursing action is most appropriate when caring for this client?

Keep the furniture in the same location in the room.

A client has surgery for the creation of burr holes after sustaining head trauma. Which early clinical manifestation of meningeal irritation does the nurse assess in the client?

Kernig sign

The caretaker of a client who sustained a head injury reports to the nurse that the client always says that food tastes unappealingly bland even though the food is good. Which area of the brain may the nurse suspect to be affected in the client?

Parietal lobe

Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia?

Paroxysmal hypertension and bradycardia

An older adult who was in a motor vehicle collision is brought to the emergency department via ambulance. The client exhibits a decreased level of consciousness, and the nurse identifies serosanguineous drainage from the client's left ear. Which action should the nurse take?

Place a sterile pad over the external ear.

What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke?

Place objects within the visual field.

A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first?

Place the head and neck in alignment.

The nurse uses which principles of body mechanics when caring for immobilized clients?

Placing the feet apart to increase the stability of the body

A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client's rehabilitation?

Position the client to prevent contractures.

The nurse is caring for a client who underwent surgery for a brain tumor. On assessment, the nurse suspects meningitis in the client. Which finding would help confirm the nurse's suspicion?

Positive Kernig sign

A client is having a tonic-clonic seizure. Which is a priority nursing action?

Prevent injury

While setting up a client's food tray, the nurse identifies tremoring of the hand when it lies in the client's lap. The tremor disappears when the client reaches for silverware. What type of tremor should the nurse document in the client's medical record?

Resting Tremors

An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine has the most risk for developing a pressure ulcer?

Sacrum

A client with myasthenia gravis has increased difficulty swallowing. Which action will the nurse take to prevent the aspiration of food?

Schedule meals with the peak effect of an anticholinesterase muscle stimulant.

A debilitated older client with glaucoma who places great value on independence is being prepared for discharge from the hospital. To promote independence, what should the nurse encourage the client to do?

Self-administer the eye medications using appropriate technique

A nurse identifies that a client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, what term does the nurse use to document this gait?

Shuffling

A client has a diskectomy and fusion for a herniated nucleus pulposus. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. What should the nurses assisting with the ambulation have the client do?

Sit on the edge of the bed so they can hold the client upright.

A nurse is caring for an anxious, fearful client. Which client response indicates sympathetic nervous system control?

Skin pallor

A client is admitted to the hospital for observation after an accident. The client is oriented to person, place, and time, and vital signs are within normal ranges. When performing an assessment, the nurse observes a clear, watery drainage oozing from the client's ear. What should be the nurse's first action?

Test the fluid for glucose and apply a sterile dressing.

A client with a diagnosis of polyarteritis nodosa asks the nurse for information about this disorder. What information should the nurse include in the response?

The disorder is considered one of hypersensitivity, and the exact cause is unknown.

Haloperidol 100 mg intramuscularly (IM) stat has been prescribed for a client who is battered and agitated after a street brawl. What does the nurse conclude after reviewing the prescription?

The dose is more than recommended

While conducting an eye examination, the ophthalmologist shines a light into the client's pupil and observes that there is a slow recovery of the pupil size. Which muscular atrophy is responsible for this condition?

The iris dilator muscle

During a health fair, the nurse takes an adult's blood pressure, and it is 200/120 mm Hg. The nurse should base the next nursing intervention on what understanding?

There is an increased risk for having a cerebrovascular accident (brain attack).

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply.

These seizures increase the risk of injuries due to fall. These seizures are most resistant to drug therapy.

What is the middle layer of the eyeball?

Uveal tract

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which laboratory result should the nurse check?

decreased urine output

Which lobe of the cerebrum includes the client's Broca's speech center

frontal lobe

Which structure is a component of the auditory ossicles?

malleus

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours?

prevention of pressure ulcers

A client is diagnosed with myasthenia gravis. Which response does the nurse expect the client to demonstrate?

Fluctuating weakness of muscles innervated by the cranial nerves

What is the function of a client's cranial nerve VI?

Movement of the eye with lateral rectus muscles

A nurse is caring for a client with Bell palsy. Which goal is priority?

Preventing corneal damage

Which beta-adrenergic blocker is used to reduce a client's intraocular pressure?

Timolol

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" Which is the nurse's best response?

"The prognosis is variable; most individuals experience remissions and exacerbations."

How is the brachioradialis reflex elicited

By striking the radius 3 to 5 cm above the wrist

A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" What is the nurse's best response?

"Pain is not a characteristic symptom of this condition."

A client exhibits blurred and double vision and muscular weakness, and diagnostic tests are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respond?

"That must have really shocked you. Tell me what the healthcare provider told you about it."

A healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing objective for the client during the diagnostic phase?

"The client will maintain present muscle strength."

A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure?

"Were you aware of anything different or unusual just before your seizure began?"

What is the maximum amount of time the nurse should allow an older adult with a cerebrovascular accident (also known as "brain attack") to remain in one position?

1-2 hours

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?

6

A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan which intervention?

Space activities throughout the day.

The nurse is caring for a client who reports excessive tearing. Which disorders does the nurse suspect could be responsible for the client's condition? Select all that apply.

Chalazion Entropion Conjunctivitis

A 62-year-old client reports to the nurse, "My eyes don't feel right and I have a gritty and sandy sensation in my eyes." What condition might this client have?

Changes in tear composition

A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority?

Checking that a bag-valve mask is available during the transfer

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. Which diagnostic test result will the nurse check for confirmation of this diagnosis?

Computed tomography

A young man who sustained a spinal cord injury at the cervical level expresses concern about sexual functioning. What should the nurse do when counseling this client?

Consider that the client most likely will be able to have reflex penile erections.

A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse explains that the chief aim of treatment is to meet which goal?

Control the intraocular pressure

Which function of a client's eyes ensures formation of a single image of close objects being seen?

Convergence

The primary healthcare provider has prescribed convex lens for a client to improve vision. Which physiologic process will be corrected?

Convergence of images behind the retina

A client is awaiting surgery for a herniated lumbar nucleus pulposus. The nurse's teaching should include that the pain will most likely increase if the client performs which action?

Coughs excessively

Which type of cranial surgery involves opening the cranium and removing the bone flap?

Craniotomy

Which factors can trigger a client's migraine attacks? Select all that apply.

Fatigue Sleep disturbances Hormones

What clinical finding does the nurse expect when assessing a client with myasthenia gravis?

Fluctuating weakness of muscles innervated by the cranial nerves

Which antiinfective agent may lead to blindness if not used correctly by the client in prescribed amounts?

Gentamicin

A registered nurse assesses a client's electronic medical record (EMR) and observes increased blood pressure, severe myopia, and blood glucose levels. Which type of eye disorder will the nurse most likely observe written in the EMR?

Glaucoma

Which gerontologic assessment findings of the auditory system are related to the inner ear? Select all that apply.

Hair cell degeneration Reduced blood supply to the cochlea Less effective vestibular apparatus in the semicircular canals

Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care?

Increased intracranial pressure

The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure?

Increased restlessness

Which muscle helps in moving the eye diagonally downward towards the middle of the head? Select all that apply

Inferior rectus muscle Medial rectus muscle

An adult client is brought to the emergency department by a friend who states, "We were all partying at a club, and all of a sudden my friend collapsed." Vital signs revealed a temperature of 99.2° F, pulse of 152, respiratory rate of 32, blood pressure of 163/92. After performing a physical assessment and collecting a health history from the client, what action should the nurse take next?

Inform the healthcare provider of the client's status and prepare to start an intravenous (IV) line.

The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve VII. What will the nurse observe upon assessment?

Inhibition of tear production

A nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which behavior indicates understanding about the nursing team's responsibility in relation to pressure ulcers?

Inspecting the skin daily

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence?

Institute measures to prevent constipation.

A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reports back pain and an inability to move the legs. Which action should the nurse take first?

Leave the individual lying on the back with instructions not to move, and seek additional help

Which structure helps to bend light rays and allow them to fall onto the retina?

Lens

A client is diagnosed with the genetic disorder osteogenesis imperfecta. Which condition can be anticipated in the client at an age of 30?

Loss of auditory acuity

A nurse obtains the nursing history from a client who has open-angle (chronic) glaucoma. The nurse anticipates that the client will report which finding during the history?

Loss of peripheral vision

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

Lowered level of consciousness

A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client?

Maintain airway

A nurse is caring for a client who is admitted to the hospital with a severe head injury. Which action is priority?

Maintain respiratory exchange and ventilation.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Space activities throughout the day.

Which is the priority assessment for the client with Guillain-Barré syndrome with rapidly ascending paralysis?

Monitor resp status

A client goes to the primary healthcare provider because of fatigue, double vision, and muscle weakness. A diagnosis of myasthenia gravis is suspected. When collecting a health history, the nurse expects the client to report which information?

Muscle weakness improving after a period of rest

After assessing a client's vision, the nurse observes the client has difficulty seeing objects that are far away. Which condition does the nurse suspect the client is experiencing?

Myopia

Which condition is characterized with an involuntary and rapid twitching of the client's eyeball?

Nystagmus

A client is admitted to the hospital for cranial surgery. What does the nurse include in the preoperative plan of care?

Obtaining the client's consent for shaving the head

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision?

Optic nerve inflammation

Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk?

Pain radiating to the hip and leg

Which clinical indicator does a nurse identify when assessing a client with hemiplegia

Paralysis of one side of the body

Which type of nerve helps the client's pupil constrict?

Parasympathetic-motor

After a cerebrovascular accident (also known as brain attack) a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected?

Parietal

A client has sensorineural hearing loss. Which finding in the client's history will alert the nurse to the most likely cause of the sensorineural hearing loss?

Prolonged exposure to noise

While walking in the hall, a hospitalized client has a tonic-clonic seizure. To protect the client during the seizure, what should the nurse do?

Protect the client's head from injury.

A client with myasthenia gravis experiences generalized weakness. What is most important when planning this client's nursing care?

Providing frequent rest periods

A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)?

Pulse 50 bpm and BP 140/60 mm Hg

A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity?

Push-ups to strengthen arm muscles

The nurse assists the healthcare provider in performing a lumbar puncture. When pressure is placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is expected to increase. Which sign should the nurse expect the healthcare provider to document?

Queckenstedt

A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first

Raise the head of the bed

A client is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. The nurse explains to the client that the diagnosis of myasthenia gravis is confirmed if the administration of Tensilon produces which response?

Rapid but brief symptomatic improvement

After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis?

Redness of the eardrum

A client is diagnosed as having expressive aphasia. Which type of impairment does the nurse expect the client to exhibit?

Speaking and writing

A client is admitted to the emergency department with head and chest injuries sustained in a motor vehicle accident. What clinical findings indicate that the client is responding to medical intervention and is ready to be transferred from the emergency department to a critical care unit?

Stable vital signs and pain

A client with a 5-year history of myasthenia gravis is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. Which assessment finding should the nurse expect the client to report?

Strength decreases with repeated muscle use

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm?

Sudden severe headache

A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission?

Swimming

A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed, and an anticholinergic medication is prescribed. The nurse is planning care with the client and spouse. What instruction is the priority?

Take the medication according to a specific schedule.

A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question?

Teach isometric exercises

A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include?

Teaching the client to use head movements to scan the left field of vision

The spouse of a client who had a brain attack (cerebrovascular accident) tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. What is the nurse's best response?

This behavior is a common response over which the client has very little control.

Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a cerebrovascular accident (CVA, also known as "brain attack")?

Transient ischemic attacks (TIAs)

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level?

Using Wong's "Pain Faces"

Which cranial nerve is responsible for the client's equilibrium?

Vestibulocochlear

Which drug will most likely cause the client's eyelids to itch and eyes to burn as side effects?

Vidarabine

A nurse is caring for a client with a brain tumor in the occipital lobe. What clinical indicator does the nurse expect to identify when assessing the client?

Visual hallucinations

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure?

Widening pulse pressure

A young adult who is unconscious after an accident is brought to the emergency department. The client's pupils are equal and responsive to light. As part of the neurologic assessment, the nurse applies a painful stimulus to the client's left lower leg. Which is an expected response in a healthy adult?

Withdrawing the leg

A client is hospitalized with head trauma. Which imaging test should the nurse anticipate being prescribed by the primary healthcare provider to rule out a cervical spine fracture?

X-rays

A nurse is interviewing a client with a tentative diagnosis of Parkinson disease. What should the nurse expect the client to report about how the onset of symptoms occurred?

gradually

A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation?

physical therapy