NCLEX 10000- Neurosensory

A client with an inoperable brain tumor is brought to the hospital because the family can no longer care for the client at home. As the nurse provides care for the client, family members express their disappointment at not being able care for him/her at home as the client wished, since he/she did not want to die in the hospital. Which response by the nurse is best?

"Have you explored hospice care? I can ask the case manager to discuss this care option with you, if you're interested."

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin. Client teaching about this drug should include which instruction?

"Schedule follow-up visits with your physician for blood tests."

The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client:

Keep active, use stress reduction strategies, and avoid fatigue."

Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?

Activity is resumed gradually; the client can resume usual activities in 5 to 6 weeks.

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with chin resting on flexed knees

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

Alteration in level of consciousness (LOC)

Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin?

Notify the health care provider (HCP) if vision changes occur.

A client with Tourette syndrome is seen in an outpatient clinic. The client has multiple tics occurring several times per day. The nurse notices that the client has a difficult time completing tasks such as activities of daily living (ADLs). In which of the following ways can the nurse best help this client?

Break down tasks into small achievable steps

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?

Risk for injury related to vertigo

When assessing a client who has had spinal anesthesia, which finding is expected?

Sensation returns to the toes first and then progresses to the perineal area.

Which is the best positioning for a client who has a fractured spine as a result of a diving accident?

Supine with the head midline

A client who has glaucoma has been prescribed timolol eyedrops. The nurse should give which instructions about the administration of the eyedrops?

The medication may cause some transient eye discomfort.

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply.

The physician was correct to stop resuscitation efforts. By calling a code blue, the nurse disregarded the client's advance directives and DNR order.

The nurse is teaching a young woman about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client states:

I will use one of the barrier methods of contraception."

Which is not a typical clinical manifestation of multiple sclerosis (MS)?

sudden bursts of energy

When determining how to administer analgesics to a client who has been receiving opiates for pain relief administered by injection, the nurse should consider using patient-controlled analgesia since it is more effective because:

the client will control the amount of pain medication administered.

The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document:

the client's hand-grasp strength is equal.

The client with a hearing aid does not seem to be able to hear the nurse. The nurse should first:

check the hearing aid's placement.

For a neurologically injured client, the nurse should assess motor strength by:

comparing equality of hand grasps.

The client with a lumbar laminectomy asks to be turned onto the side. The nurse should:

get another nurse to help logroll the client into position.

Which is an expected outcome for a client with Parkinson's disease who has had a pallidotomy?

improved functional ability

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report:

light flashes and floaters in front of the eye.

A short time after cataract surgery, the client has nausea. The nurse should first:

medicate the client with an antiemetic, as prescribed.

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction?

pulling up the client under the left shoulder when getting the client out of bed to a chair

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?

"Avoid stimulants and alcohol for 24 to 48 hours before the test."

A client with a history of painful, continuous muscle spasms has been ordered diazepam, 2 mg P.O. twice daily. The client states the medication is so effective he wants to continue using it long term. Which response by the nurse is most appropriate?

"Diazepam isn't intended for long-term use because of issues relating to addiction."

A nurse is giving discharge teaching to a client with an eye injury. Which statement about preventing eye injuries should the nurse include?

"Direct all spray nozzles away from your face before spraying."

Which measure would be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery?

Apply ice compresses.

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?

Avoid hot baths and showers."

A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

Call the physician immediately.

Which statement indicates the client understands the expected course of Ménière's disease?

Control of the episodes is usually possible, but a cure is not yet available."

A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test?

Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

Which of the following nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma?

Disorientation, increasing blood pressure, bradycardia, and bradypnea

A client with Parkinson's disease needs a long time to complete morning care, but becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation?

Praise the client for the desire to be independent and give extra time and encouragement.

Which goal is a priority for a client who has undergone surgery for retinal detachment?

Prevent an increase in intraocular pressure.

The nurse is completing a neurologic assessment on a client who has been admitted with a contusion to the brain. Which of the following findings would warrant further action?

Pupils are equal and sluggish in reaction to light.

A client is scheduled for a prostatectomy, and the anesthetist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthetist's instructions. Why does the client require special positioning for this type of anesthesia?

To prevent cerebrospinal fluid (CSF) leakage

A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client reports a headache. The mother questions pain medication for home. Which response by the nurse is most appropriate?

Your child has a mild concussion; acetaminophen can be given."

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

a positive edrophonium test.

The nurse is teaching a client to recognize an aura. The nurse should instruct the client to note:

a symptom that occurs just before a seizure.

A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client? The client will:

actively participate in the rehabilitation process as appropriate.

When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated?

asking the client to speak louder when tired

A client returns from surgery after a submucosal resection with nasal packing in place. The nurse should first:

assess the degree of airway obstruction.

Which action is contraindicated for a client with seizure precautions?

assessing the client's oral temperature with a glass thermometer

After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which activity would be contraindicated?

bending over the sink to wash the face

A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction?

"I don't really need to sign anything. I'm depending on my physician to tell my family what to do if something bad happens."

The client with a cataract tells the nurse about being afraid of being awake during eye surgery. Which response by the nurse would be the most appropriate?

"What is it that disturbs you about the idea of being awake?"

A nurse is preparing to administer phenytoin to a 99-lb (45 kg) client with a seizure disorder. The medication administration record documents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin should be administered in the first dose? Record your answer as a whole number.

75

A child with meningitis is to receive 1,000 mL of dextrose 5% in normal saline over 12 hours. At what rate in milliliters per hour should the nurse set the pump? Round your answer to the nearest whole number.

83

A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse?

Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment.

A health care provider (HCP) has prescribed carbidopa-levodopa four times per day for a client with Parkinson's disease. The client wants "to end it all now that the Parkinson's disease has progressed." What should the nurse do? Select all that apply.

Contact the HCP before administering the carbidopa-levodopa. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. Determine if the client is at risk for suicide.

A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests?

EEG, blood cultures, and neuroimaging studies

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?

Establish a regular voiding schedule.

The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which of the following nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions?

Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital

The client with retinal detachment in the right eye is extremely apprehensive and tells the nurse, "I am afraid of going blind. It would be so hard to live that way." What factor should the nurse consider before responding to this statement?

Optimism is justified because surgical treatment has a 90% to 95% success rate.

When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

elevate the head of the bed 90 degrees during meals.

The nurse is administering eyedrops to a client with glaucoma. Which is a correct technique for instilling the eyedrops? The eyedrops are placed:

in the lower conjunctival sac.

The best method to remove cerumen from a client's ear involves:

irrigating the ear gently.

A nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy.

Which action is not appropriate when providing oral hygiene for a client who has had a stroke?

placing the client on the back with a small pillow under the head

Which goal is the most realistic for a client diagnosed with Parkinson's disease?

to maintain optimal body function

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

30-degree head elevation

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?

Administering a stool softener as ordered

A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first?

Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.

An elderly client has suffered a cerebrovascular accident (CVA). The right side of the client's face has visible ptosis. The nurse would be alert to which of the following?

Dysphagia

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.

Ease the client to the floor. Maintain a patent airway. Obtain vital signs. Record the seizure activity observed.

Because of symptoms experienced after a cerebrovascular accident (CVA), the nurse discovers that a client needs assistance using utensils while eating. What would the nurse do to support this activity of care?

Encourage participation in the feeding process to the best of the client's abilities.

A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?

Establishing an intermittent catheterization routine every 4 hours

The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions should be included in the client's care plan? Select all that apply.

Furnish the client's environment with familiar possessions. Assist the client with activities of daily living (ADLs) as necessary. Assign tasks in simple steps.

A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness (LOC)

A physician orders diazepam, 10 mg I.V., for a client experiencing status epilepticus. Which statement about I.V. diazepam is true?

It should be administered no faster than 5 mg/minute in an adult.

A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which of the following?

Meningitis

A nurse is administering dexamethasone 4 mg I.V. to a client diagnosed with a brain tumor. The nursing assistant informs the nurse that the client's fingerstick glucose level is 240 mg/dl (13.32 mmol/L). A sliding insulin scale hasn't been ordered. How should the nurse intervene?

Notify the physician of the fingerstick glucose level, inquire about insulin therapy, and ask whether the dexamethasone should be administered.

The nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use?

Remain in a semi-Fowler's position.

A registered nurse (RN) and licensed practical nurse (LPN) are administering medications on the neurologic floor. The LPN prepares to administer phenytoin to a client with a history of seizures. As the LPN walks into the room, she hands the medication to a nursing assistant. The LPN asks the nursing assistant to give the client the medication after completing the client's morning care. What should the registered nurse do?

Remind the LPN that she must administer the medications herself.

A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first?

The client admitted after a head injury in a motor vehicle who reports nausea

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?

The stroke may have impacted the body's thermoregulation centers.

A client comes to the clinic for an ophthalmologic screening, which will include measurement of intraocular pressure (IOP) with a tonometer. Which statement about this procedure is true?

The tonometer will register the force required to indent or flatten the corneal apex.

A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, "How does glaucoma damage my eyesight?" The nurse's reply should be based on the knowledge that COAG:

causes increased intraocular pressure.

A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when she:

documents medications after administration.

A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:

electromyography (EMG).

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:

evaluation of the corneal reflex response.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. The nurse should:

explain how to overcome a freezing gait by telling the client to march in place.

A client has had a cerebrovascular accident (CVA) which has affected the left side of the client's brain. The nurse should assess the client for:

expressive aphasia.

A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage?

head of the bed elevated to 30 degrees with the client's head in a neutral position

After an eye examination, a client is diagnosed with open-angle glaucoma. The physician orders pilocarpine ophthalmic solution, 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:

instilling one drop of pilocarpine 0.25% into both eyes four times daily.

The nurse is teaching a husband how to care for his wife with Alzheimer's disease at home. The nurse should instruct the husband to:

keep a consistent schedule.

The client with Ménière's disease is instructed to modify his diet. The nurse should explain that the most frequently recommended diet modification for Ménière's disease is:

low sodium.

A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy?

muscle rigidity

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial?

regular exercise

A physician has ordered home health and physical therapy for an older adult who will be discharged home following an acute stroke. The nurse's discharge teaching should include instructions about:

reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns.

A client tells the nurse about the vision being blurred and hazy throughout the entire day. The nurse should recommend that the client:

schedule an appointment with an ophthalmologist.

An older adult has vertigo accompanied with tinnitus as the result of Ménière's disease. The nurse should instruct the client to restrict which dietary element?

sodium

A client is scheduled for surgery is confused and shows signs of dementia. The nurse should ask which person to sign the consent for the client?

spouse

The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate?

the head of the bed elevated 15 to 20 degrees

Friends come to visit a client admitted with new-onset ischemic stroke. The stroke has caused aphasia and right-sided weakness. The client has an advance directive and an identified health care power of attorney. The friends ask the nurse about the client's condition. How should the nurse respond?

"I'm not at liberty to discuss his condition with you. You'll have to speak to his power of attorney if you'd like information."

The nurse observes that the client with multiple sclerosis looks untidy and sad. The client suddenly says, "I cannot even find the strength to comb my hair," and bursts into tears. Which response by the nurse is best?

"Tell me more about how you are feeling."

A 70-year-old, previously well client asks the nurse, "I notice I have tremors. Is this just normal for my age?" What should the nurse tell the client?

"You should report this to the health care provider because it may indicate a problem."

A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac catheterization that involved a femoral puncture. The client is reminded to keep his leg straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is responsible for three other clients who underwent cardiac catheterization. What's the best step the nurse can take?

Ask the staffing coordinator to assign a nursing assistant to sit with the client.

The nurse is caring for a client with a subdural hematoma. Which of the following is the priority outcome?

Ensure airway patency and optimal oxygen levels and protect from injury.

The nurse is assessing a client with a head injury. On admission, the pupils were equal; now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What would this change in neurologic status of the client suggest to the nurse?

Increased intracranial pressure

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene, 25 mg P.O. daily. Which assessment finding indicates the medication is effective?

Reduced muscle spasticity

A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse?

Risk for caregiver role strain related to increased client care needs

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury

The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which intervention should the nurse consider?

Thicken all liquids before offering to the client.

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time he's admitted to the intensive care unit (ICU) for aggressive treatment. She's meeting with the team to develop a change strategy using indicators. Which statement by a team member indicates a need for further teaching regarding performance management?

We can discipline the ED staff for not getting the clients to the ICU fast enough."

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

carefully move the client to a flat surface and turn him on his side.

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent:

contractures.

A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plans the client's nursing care with the understanding that acute angle-closure glaucoma:

is a medical emergency that can rapidly lead to blindness.

The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:

monitor the temperature of the bathwater.

A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should:

ncorporate the client's toileting schedule into the pattern of his wandering.

A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the health care provider (HCP) immediately?

new onset of footdrop

A client has short-term memory loss. To help the client cope with memory loss, the nurse should: You Selected:

place a single-date calendar where the client can view it.

A client with a ruptured intervertebral disc at L4-5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. The nurse interprets this finding as indicating:

postural deformity.

A nurse is caring for a client with severe depression. The client reports changes in appetite and sleep pattern and has lost her job because of the effects of her depression. The client has two young children at home and states, "I just wish things could be like they were. I feel so helpless that I can't even get out of bed in the morning." The physician has ordered electroconvulsive therapy (ECT) for the client in addition to her current antidepressant medications. A nurse evaluates the ECT therapy as effective when the client:

sleeps through the night, eats 80% of her meals, and is out of bed.

According to hospital policy, a nurse in charge of a neurologic floor must facilitate discharges during a disaster event so clients involved in the disaster can be admitted promptly. After quickly reviewing the client census, the nurse identifies five postoperative clients who may be ready for discharge. What should the nurse do next?

Assess each client, call the physician, and ask for discharge orders if appropriate.

A client who is in rehabilitation following a cerebrovascular accident (or brain attack) is experiencing total hemiplegia of the dominant right side. The nurse finds that the client needs assistance with eating to ensure optimum nutrition. Which of the following actions is most important for the nurse to take to facilitate rehabilitation with eating?

Assist the client in learning to eat with the left hand.

A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer?

Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU.

After 5 days of hospitalization, a client who is receiving morphine sulfate for pain control asks for pain medication with increasing frequency and exhibits increased anxiety and restlessness. The vital signs are within normal ranges. What is a possible cause of this behavior?

The client has developed tolerance to the dose of morphine.

As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability?

"I can participate in sexual activity but might not experience orgasm."

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply.

Elevate the head of the bed 15 to 20 degrees. Contact the health care provider (HCP) if ICP is greater than 15 mm Hg. Monitor neurologic status using the Glasgow Coma Scale.

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

Generalized

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why am I unable to stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior?

Reviewing your losses is a way to help you work through your grief and loss.

Sensorineural hearing loss results from which condition?

damage to the cochlear or vestibulocochlear nerve

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate?

limiting fluid intake to 1,000 mL/day

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon's eyes and Battle's sign.

In discharge planning after scleral buckling, the nurse should teach the client to avoid which activity during the early recovery period?

reading

When a nurse is assessing a client for pain, what finding is most significant? The client:

tells the nurse about experiencing pain.