Med Surge Chap 64 Neuro Point Questions

A patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective?

"I need to allow my arms and hands to support my body weight."

A 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?

"The paralysis caused by this disease is temporary."

A nurse is teaching a client who was recently diagnosed with myasthenia gravis. Which statement should the nurse include in her teaching?

"This disease doesn't cause sensory impairment."

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

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

A female client has been achieving significant improvements in her ADLs since beginning rehabilitation after a brain hemorrhage. The nurse must observe and assess the client's ability to perform ADLs to determine the client's level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize?

Appraising the family's involvement in the client's ADLs

A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?

Cerebellar abscess

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following?

Client does not reach the toilet before experiencing voiding

The rehabilitation nurse is caring for a 25-year-old client who suffered extensive injuries in a motorcycle accident. During each interaction with the client, what action should the nurse perform most frequently?

Evaluate the client's positioning

The nurse is working with a rehabilitation client who has a deficit in mobility following a skiing accident. The nurse knows that preparation for ambulation is extremely important. What nursing action will best provide the foundation of preparation for ambulation?

Helping the client perform frequent exercise

Which is the most common cause of acute encephalitis in the United States?

Herpes Simplex Virus

Which is the primary vector of arthropod-borne viral encephalitis in North America?

Mosquitos

Which of the following is considered a central nervous system (CNS) disorder?

Multiple Sclerosis

The nurse is assisting a patient in assuming a side-lying position. What intervention would be best for the nurse to provide?

Place the uppermost hip slightly forward in a position of slight abduction

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?

Practice meticulous hygiene measures

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Stage 2 Pressure Ulcer

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?

Trochanter roll

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:

advance both crutches

The diagnosis of multiple sclerosis is based on which test?

an MRI

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to:

document the condition of the client's skin

Ischial Tuberosity

sit bones

Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply.

stage 3 and 4

The nurse is volunteering for a Red Cross blood drive and is taking the history of potential donors. Which volunteer would the nurse know will not be allowed to donate blood?

A donor who was in college in England for 1 year

An adult client's current goals of rehabilitation focus primarily on self-care. What is a priority when teaching a client who has self-care deficits in ADLs?

To provide an optimal learning environment with minimal distractions

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:

complications