Med surg neur
To encourage adequate nutritional intake for a female client with Alzheimer's disease, the nurse should: A. Stay with the client and encourage him to eat. B. Help the client fill out his menu. C. Give the client privacy during meals. D. Fill out the menu for the client.
A. Stay with the client and encourage him to eat.
The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? A. Tachycardia B. Increased salivation C. Hypotension D. Apnea
A. Tachycardia
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A. Time of onset of current stroke B. Complete physical and history C. Current medications D. Upcoming surgical procedures
A. Time of onset of current stroke
A male client with Bell's Palsy asks the nurse what has caused this problem. The nurse's response is based on an understanding that the cause is: A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem. B. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia. C. Primary genetic in origin, triggered by exposure to meningitis. D. Primarily genetic in origin, triggered by exposure to neurotoxins.
A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem.
A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of: A. Hypertension B. Heart failure C. Prosthetic valve replacement D. Chronic obstructive pulmonary disorder
C. Prosthetic valve replacement
A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? A. "You may have difficulty believing this, but the paralysis caused by this disease is temporary." B. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." C. "It must be hard to accept the permanency of your paralysis." D. "You'll first regain use of your legs and then your arms."
A. "You may have difficulty believing this, but the paralysis caused by this disease is temporary."
Which of the following values is considered normal for ICP? A. 0 to 15 mm Hg B. 25 mm Hg C. 35 to 45 mm Hg D. 120/80 mm Hg
A. 0 to 15 mm Hg
Emergency medical technicians transport a 27-year-old ironworker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag." Which intervention by the nurse has the highest priority? A. Assessing the left leg. B. Assessing the pupils. C. Placing the client in Trendelenburg's position. D. Assessing level of consciousness.
A. Assessing the left leg.
Which of the following symptoms would you expect to a client with a phenytoin level of 35 mg/dL? A. Ataxia B. Potassium deficit C. Neglect syndrome D. Tetraplegia
A. Ataxia
Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? A. Ataxia and confusion B. Sodium depletion C. Tonic-clonic seizure D. Urinary incontinence
A. Ataxia and confusion
If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: A. Body temperature control B. Balance and equilibrium C. Visual acuity D. Thinking and reasoning
A. Body temperature control
The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? A. Giving the client thin liquids. B. Thickening liquids to the consistency of oatmeal. C. Placing food on the unaffected side of the mouth. D. Allowing plenty of time for chewing and swallowing.
A. Giving the client thin liquids.
Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? A. Hemorrhagic skin rash B. Edema C. Cyanosis D. Dyspnea on exertion
A. Hemorrhagic skin rash
The nurse is working on a surgical floor. The nurse must log roll a male client following a: A. Laminectomy. B. Thoracotomy. C. Hemorrhoidectomy. D. Cystectomy.
A. Laminectomy.
When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: A. Light flashes and floaters in front of the eye. B. A recent driving accident while changing lanes. C. Headaches, nausea, and redness of the eyes. D. Frequent episodes of double vision.
A. Light flashes and floaters in front of the eye.
Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? A. Placing the client on the back with a small pillow under the head. B. Keeping portable suctioning equipment at the bedside. C. Opening the client's mouth with a padded tongue blade. D. Cleaning the client's mouth and teeth with a toothbrush.
A. Placing the client on the back with a small pillow under the head.
Which of the following assessment data indicated nuchal rigidity? A. Positive Kernig's sign B. Negative Brudzinski's sign C. Positive homan's sign D. Negative Kernig's sign
A. Positive Kernig's sign
The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? A. Side-lying, with legs pulled up and head bent down onto the chest. B. Side-lying, with a pillow under the hip. C. Prone, in a slight Trendelenburg's position. D. Prone, with a pillow under the abdomen.
A. Side-lying, with legs pulled up and head bent down onto the chest.
A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases. B. Pupils are 8 mm and nonreactive. C. Systolic blood pressure remains at 150 mm Hg. D. BUN and creatinine levels return to normal.
A. Urine output increases.
A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière's disease. When assessing this client, the nurse expects to note: A. Vertigo, tinnitus, and hearing loss. B. Vertigo, vomiting, and nystagmus. C. Vertigo, pain, and hearing impairment. D. Vertigo, blurred vision, and fever.
A. Vertigo, tinnitus, and hearing loss.
The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? A. Vision changes B. Absent deep tendon reflexes C. Tremors at rest D. Flaccid muscles
A. Vision changes
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: A. A negative Kernig's sign. B. A positive Brudzinski's sign. C. Absence of nuchal rigidity. D. A Glascow Coma Scale score of 15.
B. A positive Brudzinski's sign.
A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client's behavior. A. Is disoriented to person, place, and time. B. Affect is flat, with periods of emotional lability. C. Cannot recall what was eaten for breakfast today. D. Demonstrate inability to add and subtract; does not know who is the president.
B. Affect is flat, with periods of emotional lability.
A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? A. A private room down the hall from the nurses' station. B. An isolation room three doors from the nurses' station. C. A semi-private room with a 32-year-old client who has viral meningitis. D. A two-bedroom with a client who previously had bacterial meningitis.
B. An isolation room three doors from the nurses' station.
Which of the following pathologic processes is often associated with aseptic meningitis? A. Ischemic infarction of cerebral tissue. B. Childhood diseases of viral causation such as mumps. C. Brain abscesses caused by a variety of pyogenic organisms. D. Cerebral ventricular irritation from a traumatic brain injury.
B. Childhood diseases of viral causation such as mumps.
A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines which of the following results would verify the diagnosis? A. Cloudy CSF, decreased protein, and decreased glucose. B. Cloudy CSF, elevated protein, and decreased glucose. C. Clear CSF, elevated protein, and decreased glucose. D. Clear CSF, decreased pressure, and elevated protein.
B. Cloudy CSF, elevated protein, and decreased glucose.
A male client is color blind. The nurse understands that this client has a problem with: A. Rods. B. Cones. C. Lens. D. Aqueous humor.
B. Cones.
An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by: A. Increasing the exudative reaction of ocular tissue. B. Decreasing leukocyte infiltration at the site of ocular inflammation. C. Inhibiting the action of carbonic anhydrase. D. Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris.
B. Decreasing leukocyte infiltration at the site of ocular inflammation.
A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? A. Immobilize the neck before the client is moved onto a stretcher. B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. C. Place a cap on the client's head. D. Administer a sedative as ordered.
B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? A. Head midline B. Head turned to the side C. Neck in neutral position D. Head of bed elevated 30 to 45 degrees
B. Head turned to the side
Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam, if needed and prescribed? A. In 30 to 45 seconds B. In 10 to 15 minutes C. In 30 to 45 minutes D. In 1 to 2 hours
B. In 10 to 15 minutes
The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination D. Risk for injury
B. Ineffective airway clearance
A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Self-care deficit: Dressing/grooming
B. Ineffective breathing pattern
After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: A. Instilling one drop of pilocarpine 0.25% into both eyes daily. B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily. C. Instilling one drop of pilocarpine 0.25% into the right eye daily. D. Instilling one drop of pilocarpine 0.25% into the left eye four times daily.
B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily.
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? A. Vomiting continues. B. Intracranial pressure (ICP) is increased. C. The client needs mechanical ventilation. D. Blood is anticipated in the cerebrospinal fluid (CSF).
B. Intracranial pressure (ICP) is increased.
Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? A. Congenital anatomic abnormality of the meninges. B. Lack of acquired resistance to the various etiologic organisms. C. Occlusion or narrowing of the CSF pathway. D. Natural affinity of the CNS to certain pathogens.
B. Lack of acquired resistance to the various etiologic organisms.
When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? A. Bladder infection B. Middle ear infection C. Fractured clavicle D. Septic arthritis
B. Middle ear infection
The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Nail bed pressure C. Pressure on the orbital rim D. Squeezing of the sternocleidomastoid muscle
B. Nail bed pressure
After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? A. Give him a barbiturate. B. Place him on mechanical ventilation. C. Perform a lumbar puncture. D. Elevate the head of his bed.
C. Perform a lumbar puncture.
A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis? A. Anxiety B. Powerlessness C. Ineffective denial D. Risk for disuse syndrome
B. Powerlessness
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram
B. Pupil size and pupillary response
The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: A. Take a hot bath. B. Rest in an air-conditioned room. C. Increase the dose of muscle relaxants. D. Avoid naps during the day.
B. Rest in an air-conditioned room.
The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? A. Loosening restrictive clothing. B. Restraining the client's limbs. C. Removing the pillow and raising padded side rails. D. Positioning the client to the side, if possible, with the head flexed forward.
B. Restraining the client's limbs.
A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A. Abnormal flexion of the upper extremities and extension of the lower extremities. B. Rigid extension and pronation of the arms and legs. C. Rigid pronation of all extremities. D. Flaccid paralysis of all extremities.
B. Rigid extension and pronation of the arms and legs.
During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: A. Use the pointed end of the reflex hammer when striking the Achilles' tendon. B. Support the joint where the tendon is being tested. C. Tap the tendon slowly and softly. D. Hold the reflex hammer tightly.
B. Support the joint where the tendon is being tested.
The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: A. The client has complete bilateral paralysis of the arms and legs. B. The client has weakness on the right side of the body, including the face and tongue. C. The client has lost the ability to move the right arm but can walk independently. D. The client has lost the ability to move the right arm but can walk independently.
B. The client has weakness on the right side of the body, including the face and tongue.
A female client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? A. The client leaves the side rails down. B. The client uses a mirror to inspect the skin. C. The client repositions only after being reminded to do so. D. The client hangs the left arm over the side of the wheelchair.
B. The client uses a mirror to inspect the skin.
The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. A. Increased appetite B. Vomiting C. Polydipsia D. Lethargy E. Head tilt F. Increased pulse
B. Vomiting D. Lethargy E. Head tilt
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 mg/dl. B. A right-sided carotid bruit. C. A blood pressure of 220/120 mmHg. D. The presence of bronchogenic carcinoma.
C. A blood pressure of 220/120 mmHg.
A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: A. A cerebral lesion B. A temporal lesion C. An intact brainstem D. Brain death
C. An intact brainstem
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature
C. Blood pressure
The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? A. Cerebellar function B. Intellectual function C. Cerebral function D. Sensory function
C. Cerebral function
Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? A. Speaking to the client at a slower rate. B. Allowing plenty of time for the client to respond. C. Completing the sentences that the client cannot finish. D. Looking directly at the client during attempts at speech.
C. Completing the sentences that the client cannot finish.
What is the expected outcome of thrombolytic drug therapy? A. Increased vascular permeability B. Vasoconstriction C. Dissolved emboli D. Prevention of hemorrhage
C. Dissolved emboli
For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: A. Prevent respiratory alkalosis. B. Lower arterial pH. C. Promote carbon dioxide elimination. D. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.
C. Promote carbon dioxide elimination.
A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: A. Tolerate the pain. B. Decrease the perception of pain. C. Escape the source of pain. D. Divert attention from the source of pain.
C. Escape the source of pain.
A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half-circle. To document the client's gait, the nurse should use which term? A. Ataxic B. Dystrophic C. Helicopod D. Steppage
C. Helicopod
A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine? A. Ulcerative colitis B. Blood dyscrasia C. Intestinal obstruction D. Spinal cord injury
C. Intestinal obstruction
Nurse Mary witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway in this victim by using which method? A. Flexed position B. Head tilt-chin lift C. Jaw-thrust maneuver D. Modified head tilt-chin lift
C. Jaw-thrust maneuver
During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? A. Limiting conversation with the child. B. Allowing the child to play in the bathtub. C. Keeping extraneous noise to a minimum. D. Performing treatments quickly.
C. Keeping extraneous noise to a minimum.
A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? A. No precautions are required as long as antibiotics have been started. B. Maintain enteric precautions. C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics. D. Maintain neutropenic precautions.
C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.
A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? A. Diencephalon B. Medulla C. Midbrain D. Cortex
C. Midbrain
Nurse Marty is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? A. Excessive tearing B. Urine retention C. Muscle weakness D. Slurred speech
C. Muscle weakness
A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? A. Caucasian race B. Female sex C. Obesity D. Bronchial asthma
C. Obesity
A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: A. Getting too little exercise. B. Taking excess medication. C. Omitting doses of medication. D. Increasing intake of fatty foods.
C. Omitting doses of medication.
While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? A. Frontal B. Occipital C. Parietal D. Temporal
C. Parietal
A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? A. Giving the client full control over care decisions and restricting visitors. B. Providing positive feedback and encouraging active range of motion. C. Providing information, giving positive feedback and encouraging relaxation. D. Providing intravenously administered sedatives, reducing distractions and limiting visitors.
C. Providing information, giving positive feedback and encouraging relaxation.
A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? A. Loosen tight clothing or accessories B. Assess for any bladder distention C. Raise the head of the bed D. Administer antihypertensive
C. Raise the head of the bed
Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Large amounts of very dilute urine C. Restlessness and confusion D. Widened pulse pressure
C. Restlessness and confusion
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for A STAT computer tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consultation.
C. Schedule for A STAT computer tomography (CT) scan of the head.
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN? A. Complete admission assessment. B. Place a padded tongue blade at the bedside. C. Set up oxygen and suction equipment. D. Pad the side rails before the patient arrives.
C. Set up oxygen and suction equipment.
The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A. The assistant places a gait belt around the client's waist prior to ambulating. B. The assistant places the client on the back with the client's head to the side. C. The assistant places her hand under the client's right axilla to help him/her move up in bed. D. The assistant praises the client for attempting to perform ADL's independently.
C. The assistant places her hand under the client's right axilla to help him/her move up in bed.
A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A. To reduce intraocular pressure. B. To prevent acute tubular necrosis. C. To promote osmotic diuresis to decrease ICP. D. To draw water into the vascular system to increase blood pressure.
C. To promote osmotic diuresis to decrease ICP.
A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: A. Introducing ice water into the external auditory canal. B. Touching the cornea with a wisp of cotton. C. Turning the client's head suddenly while holding the eyelids open. D. Shining a bright light into the pupil.
C. Turning the client's head suddenly while holding the eyelids open.
Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal? A. More back pain than the first postoperative day. B. Paresthesia in the dermatomes near the wounds. C. Urine retention or incontinence. D. Temperature of 99.2° F (37.3° C).
C. Urine retention or incontinence.
A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? A. phenytoin (Dilantin) B. mannitol (Osmitrol) C. lidocaine (Xylocaine) D. furosemide (Lasix)
C. lidocaine (Xylocaine)
A male client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program. B. Keeping the linen wrinkle-free under the client. C. Preventing unnecessary pressure on the lower limbs. D. Limiting bladder catheterization to once every 12 hours.
D. Limiting bladder catheterization to once every 12 hours.
During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment evaluates: A. Cranial nerves I and II. B. Cranial nerves III and V. C. Cranial nerves VI and VIII. D. Cranial nerves IX and X.
D. Cranial nerves IX and X.
The nurse has given the male client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: A. Wrinkle the forehead, blow out the cheeks, and whistle. B. Massage the face with a gentle upward motion. C. Perform facial exercises. D. Exposure to cold and drafts.
D. Exposure to cold and drafts.
A client who had a stroke is seen bumping into things on the side and is having difficulty picking up the beginning of the next line of what he is reading. The client is experiencing which of the following conditions? A. Visual neglect B. Astigmatism C. Blepharitis D. Homonymous Hemianopsia
D. Homonymous Hemianopsia
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Pressure on the orbital rim C. Squeezing the sternocleidomastoid muscle D. Nail bed pressure
D. Nail bed pressure
A client is admitted with a diagnosis of Sturge-Weber syndrome. Which of the following information would you expect to find in this client? A. It is a dysfunction of the trigeminal nerve causing a severe sharp pain in the nose, lips, gums, or across the cheeks. B. It is a non-progressive neurological disorder of the seventh cranial nerve causing paralysis of one of the sides of the face. C. It is a rare degenerative brain disorder characterized by sudden development of progressive neurological and neuromuscular symptoms. D. It is a neurocutaneous disorder with angiomas causing abnormalities in the skin, brain, and eyes from birth
D. It is a neurocutaneous disorder with angiomas causing abnormalities in the skin, brain, and eyes from birth
A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? A. "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." B. "Try to ambulate independently after about 24 hours." C. "Shampoo your hair every day for ten (10) days to help prevent ear infection." D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
Which client would the nurse identify as being most at risk for experiencing a CVA? A. A 39-year-old pregnant female. B. A 67-year-old Caucasian male. C. An 84-year-old Japanese female. D. A 55-year-old African American male.
D. A 55-year-old African American male.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. A thrombolytic medication B. A beta-blocker medication C. An anti-hyperuricemic medication D. An oral anticoagulant medication
D. An oral anticoagulant medication
The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the physician immediately.
D. Call the physician immediately.
A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client's therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? A. Parasympathomimetic agent B. Sympatholytic agent C. Adrenergic blocker D. Cholinergic blocker
D. Cholinergic blocker
The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: A. Gets angry with family if they interrupt a task. B. Experiences bouts of depression and irritability. C. Has difficulty with using modified feeding utensils. D. Consistently uses adaptive equipment in dressing self.
D. Consistently uses adaptive equipment in dressing self.
While reviewing a client's chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? A. The client may be less sensitive to the effects of a neuromuscular blocking agent. B. Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage. C. Pancuronium shouldn't be used; succinylcholine may be used in a lower dosage. D. Pancuronium and succinylcholine both require cautious administration.
D. Pancuronium and succinylcholine both require cautious administration.
A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure the client to ensure client safety? A. Speak loudly to the client. B. Test the temperature of the shower water. C. Check the temperature of the food on the delivery tray. D. Provide a clear path for ambulation without obstacles.
D. Provide a clear path for ambulation without obstacles.
A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of: A. Seizures or trauma to the brain. B. Meningitis during the last five (5 years). C. Back injury or trauma to the spinal cord. D. Respiratory or gastrointestinal infection during the previous mont
D. Respiratory or gastrointestinal infection during the previous month
A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority for this client's plan of care? A. Disturbed sensory perception (visual) B. Self-care deficit: Dressing/grooming C. Impaired verbal communication D. Risk for injury
D. Risk for injury
A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: A. Is clear and tests negative for glucose. B. Is grossly bloody in appearance and has a pH of 6. C. Clumps together on the dressing and has a pH of 7. D. Separates into concentric rings and tests positive for glucose.
D. Separates into concentric rings and tests positive for glucose.
A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? A. Side-lying, with a pillow under the hip. B. Prone, with a pillow under the abdomen. C. Prone, in slight-Trendelenburg's position. D. Side-lying, with the legs, pulled up and head bent down onto the chest.
D. Side-lying, with the legs, pulled up and head bent down onto the chest.
A male client is having tonic-clonic seizures. What should the nurse do first? A. Elevate the head of the bed. B. Restrain the client's arms and legs. C. Place a tongue blade in the client's mouth. D. Take measures to prevent injury.
D. Take measures to prevent injury.
The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. The nurse tells the client that this is most effectively done by: A. Eating large, well-balanced meals. B. Doing muscle-strengthening exercises. C. Doing all chores early in the day while less fatigued. D. Taking medications on time to maintain therapeutic blood levels
D. Taking medications on time to maintain therapeutic blood levels
Problems with memory and learning would relate to which of the following lobes? A. Frontal B. Occipital C. Parietal D. Temporal
D. Temporal
A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), two (2) mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, Diazepam also is recommended for: A. Long-term treatment of epilepsy. B. Postoperative pain management of laminectomy clients. C. Postoperative pain management of diskectomy clients. D. Treatment of spasticity associated with spinal cord lesions.
D. Treatment of spasticity associated with spinal cord lesions.
Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except? A. acetaminophen (Tylenol) B. dexamethasone (Decadron) C. mannitol (Osmitrol) D. phenytoin (Dilantin) E. nitroglycerin (Nitrostat)
E. nitroglycerin (Nitrostat)
