Neuro

A nurse is collecting data from a school age child who is undergoing a neurological assessment following a head injury. The nurse should document gross incoordination when walking as which of the following findings? 1. tremors 2. ataxia 3. dystonia 4. rigidity

Ataxia; demonstrates ataxia when he shows gross incoordination movements, which might get worse when he closes his eyes.

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? 1. monitor for elevated blood pressure 2. provide analgesia for headaches 3. prevent bladder distention 4. elevate the client's head

Prevent bladder distention; autonomic dysreflexia can occur in clients who have a spinal cord injury at or above T-6. Triggers include bladder distention, insertion of rectal suppository, enemas, or sudden change in position.

A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? 1. walk with leg braces and crutches 2. drive an electric wheelchair with hand-control device 3. drive an electric wheelchair with a chin-control device 4. propel a wheelchair equipped with knobs on the wheels

Propel a wheelchair equipped with knobs on the wheels; an injury at C8 has full use of shoulders and arms but will experience hand weakness. Knobs on the wheels will help the client use the wheelchair more effectively.

A nurse is caring for a client following a lumbar puncture. Which of the following actions should the nurse take? (SATA) 1. provide oral fluids 2. monitor for nausea 3. maintain fetal position 4. check LOC 5. check sensation in the toes

Provide oral fluids, Monitor for nausea, Check LOC, Check sensation in the toes; nausea is a possible manifestation of increased ICP. The nurse should also monitor for photophobia, headache, or drainage or redness from the puncture site.

Order of actions to take when your client has a tonic-clonic seizure:

Remain with client and call for help --> Position client in lateral or side-lying position --> Check the client from head to toe for injuries --> reorient and reassure the client

A nurse is reinforcing teaching with a client who is diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? 1. take medication 45 before eating 2. expect diaphoresis as side effect 3. if dose is missed, wait until next scheduled dose to take medication 4. treat nasal rhinitis with OTC antihistamine

Take medication 45 minutes before eating; allows medication to work and limit difficulty chewing and swallowing. Diapheresis is a cholinergic crisis and is an emergency. Should have strict medication schedule. Contact provider before taking any OTC medication. Antihistamines may worsen symptoms.

A client's family asks the nurse what the term paraplegia means. Which of the following responses should the nurse make? 1. "He is unable to move his lower body and legs." 2. "He cannot move anything from the neck down." 3. "His lower body and legs are extremely weak." 4. "He has temporarily lost motor and sensory functions below the waist."

"He is unable to move his lower body and legs"; a client who has a lumbar fracture and complete spinal cord transection has paraplegia.

A nurse is reinforcing teaching with a client who is scheduled for a CT scan of the head with contrast. Which of the following statements by the client should the nurse identify as understanding of the teaching? 1. "I can take medication up to 2 hours before the procedure" 2. "I will expect the procedure to last about 15 minutes" 3. "I will not eat or drink 4 hours after the procedure" 4. "I will feel a coolness or chills when the dye is injected"

"I can take medication up to 2 hours before the procedure"; procedure lasts 30-90 minutes. NPO 4-8 hours prior to procedure. May feel warmth and flushing as dye is injected.

A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate the pressure is increasing. The nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? 1. observing for facial asymmetry 2. checking pupillary responses to light 3. eliciting the gag reflex 4. testing visual acuity

Checking pupillary responses to light; CNIII is the oculomotor nerve. Indications for increased ICP: lethargy, decreased consciousness, tachypnea, hypertension, bradycardia, bounding pulse, changes in pupils (sluggish, dilation of one or both)

A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg. Which of the following therapeutic outcomes should the nurse monitor for? 1. improved speech patterns 2. increased bladder function 3. decreased tremors 4. diminished drooling

Decreased tremors; this is an MAO-B inhibitor. It improves motor function by decreasing tremors, rigidity, and bradykinesia.

A nurse is reinforcing teaching with a client who is taking Benztropine to treat Parkinson's. The nurse should instruct the client to report which of the following findings as an adverse effect? 1. excessive salvation 2. difficulty voiding 3. diarrhea 4. slow pulse

Difficulty voiding; indicates urinary retention

A nurse is collecting data from a client who is 6 days post craniotomy. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1. decreased pedal pulses 2. hypertension 3. peripheral edema 4. diarrhea

Hypertension; early manifestation if increased ICP. Other manifestations are restlessness, headache, change in LOC. These manifestations should be reported.

Which should be included in the teaching as manifestations seen in the moderate stage of Alzheimer's disease? (SATA) - Inability to find commonly used items - Inability to perform common tasks - Exhibits wandering behaviors - Difficulty remembering how to swallow - Inability to recognize family members

Inability to perform common tasks, Exhibits wandering behavior.

A nurse is collecting data from a client following surgery for a brain tumor near the hypothalamus. For which of the following findings should the nurse monitor the client because of the risks of surgery on this area of the brain? 1. inability to regulate body temperature 2. bradycardia 3. visual disturbances 4. inability to perceive sound

Inability to regulate body temperature; the hypothalamus controls body temperature, fluid balance, some emotions (pleasure, fear), sleep, and appetite.

A nurse is caring for a client who has Alzheimer's disease and is confused. Which of the following actions should the nurse take? 1. keep the television on 2. hang abstract pictures on the walls 3. keep familiar personal items in client's room 4. encourage bright lighting in the room

Keep familiar personal items in client's room; helps the client reminisce. Should not be overstimulated.

A nurse is collecting data from a client who has an epidural hematoma. Which of the following manifestations should the nurse expect? 1. lucid period followed by rapid loss of consciousness after injury occurs 2. headache and drowsiness 24-48 hours after injury occurs 3. neurological deficits that appear up to 2 weeks after injury occurred 4. slowed thinking and confusion developing up to several months after injury occurred

Lucid period followed by rapid loss of consciousness after injury occurs; ultimately deteriorates to coma.

A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (SATA) - Muscle distortion - Pain behind ear - Hearing loss _ Facial twitching - Impaired taste

Muscle distortion, Pain behind the ear, Impaired taste.

A nurse is collecting data from an adult client who has meningococcal meningitis. Which of the following findings should the nurse expect? 1. petechial rash on chest and extremities 2. tachycardia 3. negative kernig's sign 4. mild headache

Petechial rash on the chest and extremities; other manifestations are bradycardia r/t increased ICP, positive Kernig's sign, severe and persistent headache made worse by moving client's head and neck.

A nurse is caring for a client who is unconscious and has lost the corneal reflex. Which of the following actions should the nurse take? 1. keep the client's room darkened 2. place a patch over the eye 3. apply a warm saline compress to the eye 4. cleanse the eye with mild soap

Place a patch over the eye; prevents dryness and irritation.

A nurse collecting data from a client who have increased ICP is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect? 1. extension of the extremities 2. pronation of the hands 3. plantar flexion of the legs 4. external rotation of the lower extremities

Plantar flexion of the legs; internal rather than external rotation of the lower extremities is an indicator of decorticate posturing.

A nurse is caring for a client who has a psinal cord injury. The nurse suspects that the client has autonomic dysreflexia. Which of the following actions should the nurse take first? 1. check the client for fecal impaction 2. ensure the room temperature is warm 3. check the client's bladder for distention 4. raise the head of the bed

Raise the head of the bed; use the ABC approach by placing the client in a sitting position or raising the head of the bed to a 45 degree angle to lower blood pressure.

A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor? 1. respiratory difficulty 2. confusion 3. increased ICP 4. joint pain

Respiratory difficulty; progressive weakness of diaphragmatic and intercostal muscles can cause respiratory distress. MG affects neuromuscular transmission of neurological impulses to the voluntary muscles.

A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately? 1. sudden sleepiness 2. diplopia 3. headache 4. slight ataxia

Sudden sleepiness; this client is unstable due to increased ICP. Diplopia can indicate injury to the optic tract, but it is not a priority finding.

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect? 1. the client requires total nursing care 2. the client is alert and oriented 3. the client is in a deep coma 4. the client has a stable neurological status

The client requires total nursing care. A patient in a deep coma will have a score of 3.

A nurse is collecting data from a client who has meningitis. When passively flexing the client's neck, the nurse notes an involuntary flexion of both legs. Which of the following conditions is the client displaying? 1. Kernig's sign 2. Nuchal rigidity 3. Brudzinski's sign 4. Bradykinesia

Brudzinski's sign; manifested by hips and knees flexing when neck is flexed, which is a common sign of meningitis.

A nurse is assisting with care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (SATA) 1. encourage fluid intake 2. monitor puncture site for hematoma 3. insert urinary catheter 4. elevate head of bed 5. apply cervical collar

Encourage fluid intake, Monitor for hematoma; fluid intake to replace CSF that was removed during procedure and reduce risk for headache. The client should remain flat in bed for 1 hour or more to reduce risk for a headache

A nurse is contributing to the plan of care for a client who is having headaches following the administration of a spinal anesthetic during surgery. Which of the following interventions should the nurse include in the plan of care? 1. encourage increased intake of fluids 2. encourage increased physical activity 3. maintain the client in high fowlers 4. apply an ice bag at the injection site of the spinal anesthetic

Encourage increased intake of fluids; keep the client flat, decrease physical activity, increase oral fluid intake to promote increased ICP to relieve spinal headaches.

A nurse is contributing to the plan of care for a client following a lumbar puncture. Which of the following interventions should the nurse include? 1. Provide a low-sodium diet 2. change the client's dressing q12h 3. place the client in high-fowlers 4. encourage oral fluids

Encourage oral fluids; to replace fluid the client loses during the test, the nurse should encourage oral fluid intake possible up to 3,000 mL in 24 hours.

A nurse is assisting with the plan of care for a client who is 1 day postop following spinal fusion. Which of the following interventions should the nurse include in the plan? 1. log roll client q2h 2. assist client to sit upright in chair for 4 hours at a time 3. expect clear drainage on the spinal dressing 4. elevated the client's legs when he is lying on his side

Log roll the client q2h; keep spinal column aligned, prevent pressure sores, monitor incision site. Clear drainage could indicate cerebrospinal fluid leak and should be reported.

A nurse is collecting data as part of a neurological exam of a client who is receiving treatment for head trauma. Which of the following observations will give the nurse information about the function of the third cranial nerve? 1. Instruct client to look up and down without moving his head 2. observe client's ability to smile and frown 3. evaluate client's pupillary reaction to light 4. ask client to shrug his shoulders against passive resistance

Instruct client to look up and down without moving his head; observes extraocular eye movements as part of evaluation of oculomotor nerve.

While performing a neurological exam, which of the following findings is the earliest indicator of the client's cerebral status? 1. pupil response 2. deep tendon reflexes 3. muscle strength 4. level of consciousness

Level of consciousness

A nurse is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse should identify that which of the following factors can cause a myasthenic crisis? 1. developing a respiratory infection 2. taking too much prescribed medication 3. insufficient sleep 4. insufficient exercise

Developing a respiratory infection; r/t not taking or taking too little of the prescribed medication. Surgery and pregnancy are also triggers.

A nurse is caring for a client who has been place in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take? 1. Elevate the foot of the bed 2. Elevated the head of the bed 3. Apply a pelvic girdle 4. Place the client in supine position

Elevate the head of the bed

A nurse is contributing to the plan of care for a client who has increased ICP following a closed-head injury. Which of the following interventions should the nurse recommend? 1. have the client perform huff coughing hourly 2. elevate the head of the bed 3. place pillows under the client's knees 4. encourage liberal fluid intake

Elevate the head of the bed; neutral position with elevated HOB promotes venous drainage from the brain. Fluid intake should be limited to reduce cerebral edema.

A nurse is collecting data from a client who was involved in a motor-vehicle crash. Which of the following techniques should the nurse use to test for corneal reflexes? 1. examine the eye with a penlight 2. instill drops of dye into the eye 3. visualize the red reflex of the eye 4. lightly touch the eye with a wisp of cotton

Lightly touch the eye with a wisp of cotton; corneal reflexes result from the loss of the ability to blink, due to a head injury or stroke.