** Neuro **

An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first?

establish an airway

The nurse is planning a bowel program for a client with multiple sclerosis. This would include:

A high-fiber diet "increases bulk, decreases constipation, designed for patients with MS"

The nurse is caring for a patient with a subdural hematoma. Which of the following is the usual cause of this condition?

A subdural hematoma occurs when there is an accumulation of blood UNDER the dura. It is slow forming due to its venous formation.

Nursing priority for a patient with Myesthenia Gravis?

Airway clearance

Parkinson's disease triad of symptoms?

Tremors, bradykinesia, rigidity

what is the action of a benzodiazepine in the treatment of seizures?

depresses the CNS which results in muscle relaxation and anticonvulsant activity

Parkinson's patient coughing while eating? Nursing intervention.?

thicken all liquids before offering to client

A client has suffered a CVA, what are some nursing interventions that will aid in recovery and prevent contractures?

turning patient every 2 hours, using a foot board and pillows, and encourage ROM exercises to all extremities

Realistic nursing goal with a client who has multiple sclerosis?

improved muscle strength

A client with multiple sclerosis is receiving baclofen. The nurse determines that the drug is effective when it produces which outcome? A.) Induces sleep B.) Stimulates the client's appetite C.) Reduces the urine bacterial count

A.) Induces sleep

A nurse is assisting the anesthetist in performing a lumbar puncture on a patient who is being tested for meningitis. What important factor should the nurse document before and after the procedure?

Ability to move all extremities

As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which would best describe the patient's inability to assess spatial position of his body? a. Agnosia b. Proprioception c. Apraxia d. Sensation

proprioception - perception or awareness of the position and movement of the body.

The nurse has established a goal to maintain intracranial pressure within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? 1. Encourage the client to cough to expectoratesecretions. 2. Elevate the head of the bed 15 to 30 degrees. 3. Contact the health care provider if ICP isgreater than 20 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale. 5. Stimulate the client with active range-of-motion exercises.

2, 3, 4 2. Elevate the head of the bed 15 to 30 degrees. 3. Contact the health care provider if ICP isgreater than 20 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale.The nurse should maintain ICP by elevating the head of the bed and monitoring neurologic status. An ICP greater than 20 mm Hg indicates increased ICP, and the nurse should notify the health care provider. Coughing and range-of-motionexercises will increase ICP and should be avoided in the early postoperative stage.

A client whose father died from Huntington's disease asks what his chances are that he will develop the disease. The nurse knows that the chances are???

50%

A primary nursing diagnosis for a client with Parkinson's disease is:

Alteration in safety

A client with a thoracic vertebrae injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the HOB which is the most appropriate nursing action?

Assessing the client for a distended bladder

A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his pregnant wife to the hospital. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next? (Select all that apply) A.) Arrange for the client to be with his wife and baby B.) Determine if the client's pupils are equal and react to light. C.) Find a television so the client can view the football game. D.) Administer a sedative E.) Ask the client if he has a headache

B.) Determine if the client's pupils are equal and react to light E.) Ask the client if he has a headache

A client with Parkinson's disease may experience constipation resulting from lack of exercise, medication side effects, or loss of saliva in the GI tract. Which of the following client statements regarding promotion of normal elimination would indicate a need for further teaching? A.) I should increase intake of fluid and dietary fiber B.) I should take a 2 hour nap each afternoon C.) I should use mild laxatives or stool softeners D.) I should establish a regular time for bowel movements.

B.) I should take a 2 hour nap each afternoon

The nurse is caring for a client who is confused about the time and place. The client has IV fluids infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first? a) Administer a sedative. b) Contact the physician and request an order for soft wrist restraints. c) Increase the frequency of client observation. d) Ask family members to stay with the client.

C.) Increase the frequency of client observation The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses' station if possible, delegating to the nursing assistant to check on the client more frequently, or both. If family members can stay with the client, that is an option but it is the nurse's responsibility, not the family's, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may actually exacerbate the problem.

A 24 year old client has been admitted to the emergency room. The physician suspects a head injury and a skull fracture. Cerebrospinal fluid leakage may occur. The nurse assesses for:

Clear fluid from the nose or ears

The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestations alerts the nurse to an adverse effect of this drug?

Epistaxis Plavix is an anti-platelet. Bleeding could indicate a severe effect.

A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)

Identify the time of onset of the stroke

A client is admitted to your unit with a diagnosis of brain tumor. He is awake and alert on admission, but later in the shift, he becomes hard to arouse. What other assessment findings makes you suspect increased intracranial pressure?

Increased blood pressure Pupils that don't respond to changes in light

when communicating with a client who has aphasia, which approaches are helpful?

Make use of gesture encourage pointing to the needed object speak with normal volume present one thought at a time

A nursing diagnosis related to alteration in nutrition is developed for a client with Parkinson's disease. The plan of care most appropriate to assist the client with nutrition is:

Place the client in an upright position

A client starts to have a seizure. It would be most important to:

Protect the head from injury and turn the head to the side.

A client with Parkinson's disease complains of "choking" when he swallows. Which intervention will improve the client's ability to swallow?

Providing semi-liquid foods when possible

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

Pupil size and Pupillary response

A client is admitted with a provisional diagnosis of Myasthenia Gravis. Which measures should the nurse include in the teaching plan for this patient?

Remember, it's normal to have times when you feel energetic and times when you feel exhausted. Daily changes in your energy level are common. Plan your daily activities around the times when you feel more energetic. These periods are usually in the morning or after a nap. You may have more weakness at the end of the day. Rest often throughout the day. Avoid strenuous exercise. Short walks spread out through the day will keep you fit without exhausting you. Do one thing at a time.

The nurse explains that the spinal cord extends from the brainstem to the level of which vertebrae?

Second lumbar

The nurse is doing discharge planning with a quadriplegic client. Which of the following instructions should be given to the client with an indwelling urinary catheter?

The tubing of the drainage bag should be inspected for kinks and twists frequently

Ergotamine tartate is prescribed for a client's migraine headaches. What is an expected outcome of the use of this drug?

aborting of the developing migraine

status elipticus

continuous seizure activity

A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider if there is a rapid change in which vital sign?

blood pressure

Postical stage of seizure?

determine the client's level of sleepiness

What is the expected outcome of thrombolytic drug therapy for stroke?

dissolved emboli

A client with a recent spinal cord injury is experiencing dysreflexia and is noted to have a BP of 240/110. The nurses initial response should be to:

elevate the head of bed to a 45 degree angle

The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which topic is most important to include in the plan?

maintaining a safe environment

A client with Parkinson's disease is prescribed levodopa therapy. Improvement in which area indicates effective therapy?

muscle rigidity