neuro - HESI (evolve)
A nurse is counseling a client with amyotrophic lateral sclerosis (ALS) about management of this disorder. What important suggestion should the nurse make to the client? "Eye surgery may improve your vision." "Activities should be spaced throughout the day." "Opioids may be necessary for the pains in your legs." "Leg restraints will decrease the chance of physical injury."
"Activities should be spaced throughout the day."
When a disaster occurs, the nurse may have to first treat mass hysteria that is indicated by what response? Panic Coma Euphoria Depression
Panic
During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? These seizures are associated with amnesia. These seizures increase the risk of injuries due to fall. These seizures are most resistant to drug therapy. These seizures are preceded by perception of an offensive smell. These seizures cause one sided movement of extremities in the client.
These seizures increase the risk of injuries due to fall. These seizures are most resistant to drug therapy.
A client with quadriplegia is placed on a tilt table daily. The client asks why the angle of the head of the table is gradually increased. How should the nurse respond? It facilitates turning. This prevents pressure ulcers. It promotes hyperextension of the spine. This limits loss of calcium from the bones.
This limits loss of calcium from the bones.
A client has had a carotid endarterectomy. To monitor for the complication of cranial nerve dysfunction, the nurse assesses the client for which finding? Labored breathing Edema of the neck Difficulty in swallowing Alteration in blood pressure
difficulty in swallowing
A nurse is providing instructions to a client with glaucoma. Which statements made by the client indicate the nurse needs to intervene? "I should take stool softeners." "I can wear loose collar shirts." "I should refrain from sneezing and coughing." "I can lift objects that weigh more than 10 lbs (4.5 kg)." "I should keep my head in a dependent position."
"I can lift objects that weigh more than 10 lbs (4.5 kg)." "I should keep my head in a dependent position
The nurse is teaching a client about self-ear irrigation for cerumen removal at home. Which statements made by the client indicate the nurse needs to follow up? "I should fill the syringe with hot water." "I should use a designed ear syringe for wax removal." "I should decrease the pressure if I feel any ear pain." "I should use cotton to remove any extra water in my ear." "I should irrigate until at least a cup of solution has been washed out of my ear canal."
"I should fill the syringe with hot water." "I should use cotton to remove any extra water in my ear."
A registered nurse teaches a nursing student about cluster headaches. Which statement made by the nursing student indicates a need for further teaching? "Each episode of a cluster headache may last up to 3 hours." "Pupillary constriction occurs during the period of cluster headaches." "Pulsating pain is the characteristic type of pain that occurs in cluster headaches." "Cluster headaches occur for weeks to months followed by a period of remission."
"Pulsating pain is the characteristic type of pain that occurs in cluster headaches."
A nurse provides education to a client with myasthenia gravis about how to prevent myasthenic crisis. The nurse evaluates that the teaching is effective when the client makes which statement? "I'll take an antihistamine at the first sign of a cold." "I should skip a dose of pyridostigmine bromide (Mestinon) if it upsets my stomach." "We've told our daughter not to let her cold keep her from visiting us." "The healthcare provider may need to adjust the dosage of my medication if I'm more active."
"The healthcare provider may need to adjust the dosage of my medication if I'm more active."
The registered nurse (RN) is teaching an older adult with a hearing problem due to cerumen impaction. Which instructions should the nurse share with the client? "Nausea and vomiting are to be expected when you irrigate." "Wash the external ears daily with soap and water." "Use cool water to irrigate your ear." "Use 70 mL of irrigating fluid each time."
"Wash the external ears daily with soap and water."
A client who had a cerebrovascular accident (also known as a "brain attack") becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program? Using medication to induce elimination Adhering to a definite time for attempted evacuations Considering previous habits associated with defecation Timing of elimination to take advantage of the gastrocolic reflex
Adhering to a definite time for attempted evacuations
A client is going for a magnetic resonance imaging (MRI). What should the nurse ascertain before taking the client to the procedure? Scheduled medications have been given. All metal, such as jewelry and hair ornaments, has been removed. Adequate prehydration has been given. The client has emptied the bladder.
All metal, such as jewelry and hair ornaments, has been removed.
A client asks for information about glaucoma. How should the nurse explain glaucoma to the client? An increase in the pressure within the eyeball An opacity of the crystalline lens or its capsule A curvature of the cornea that becomes unequal A separation of the neural retina from the pigmented retina
An increase in the pressure within the eyeball
A client who has a history of seizures is scheduled for an arteriogram at 10:00 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9:00 AM. What should the nurse do? Omit the 9:00 AM dose of the drug. Give the same dosage of the drug rectally. Administer the drug with 30 mL of water at 9:00 AM. Ask the healthcare provider if the drug can be given intravenously.
Ask the healthcare provider if the drug can be given intravenously.
A male client with a brain attack (cerebrovascular accident) has regained control of bowel movements but still is incontinent of urine. To help reestablish bladder control, what should the nurse encourage the client to do? Assume a standing position for voiding. Void every four hours and attempt to hold urine between set times. Attempt to void more frequently in the afternoon than in the morning. Drink a minimum of 4 L of fluid daily and divide it equally among the hours while awake.
Assume a standing position for voiding.
The nurse is performing a neurologic assessment on a client and is completing the Glasgow Coma Scale (GCS). What components make up this assessment tool? Best verbal response Best pupillary response Best motor response Best eye-opening response
Best verbal response Best motor response Best eye-opening response
A nurse is evaluating sensory changes in a client whose spinal cord was severed at the level of T6 and T7. What does this evaluation process require? Client squeezing the nurse's hand Nurse monitoring the client's vital signs Client stating where the pinching sensation is felt Nurse observing the skin for color changes below the lesion
Client stating where the pinching sensation is felt
A 62-year-old client reports to the nurse, "My eyes don't feel right and I have a gritty and sandy sensation in my eyes." What condition might this client have? Retinal detachment Infection of the cornea Changes in tear composition Hemorrhage in the vitreous humor
Changes in tear composition
The primary healthcare provider has prescribed convex lens for a client to improve vision. Which physiologic process will be corrected? Constriction of the pupil Convergence of images behind the retina Descent of inverted images onto the retina Presence of an unevenly curved surface on the retina
Convergence of images behind the retina
Which cranial nerve damage may lead to a decrease in the client's olfactory acuity? Cranial nerve I Cranial nerve X Cranial nerve V Cranial nerve VIII
Cranial nerve I
While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which condition should the nurse record in the assessment findings? Decortication Pronator drift Babinski's sign Decerebration
Decerebration
Before performing a visual system assessment, the nurse observes that the client is dressed in an unusual color combination of clothes. The client's eye examination reveals changes in the retina. Which condition might this client have? Decrease in cones Retinal vascular changes Overall loss of photoreceptor cells Macular degeneration of the retina
Decrease in cones
A client is admitted to the hospital after sustaining a head injury. Which is the most reliable sign of increased intracranial pressure the nurse can monitor for? Rise in respiratory rate Narrowing of pulse pressure Decrease in the level of consciousness Increase in the diastolic blood pressure
Decrease in the level of consciousness
A client is admitted to the hospital with a diagnosis of myasthenia gravis. For which common early clinical finding should the nurse assess the client? Tearing Diplopia Nystagmus Exophthalmos
Diplopia
After sustaining a head trauma, a client reports hearing ringing noises. Which area should the nurse assess further? Frontal lobe Occipital lobe Sixth cranial nerve (abducens) Eighth cranial nerve (vestibulocochlear)
Eighth cranial nerve (vestibulocochlear)
A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. Which information should the nurse share with the family? Speak louder than usual during visits while looking directly at the client. Encourage the client to speak while allowing time to respond. Give positive reinforcement for correct communication. Tell the client to use the correct words when speaking.
Encourage the client to speak while allowing time to respond
The nurse is supporting cognitive ability in clients with Alzheimer disease. Which actions will the nurse take? Encouraging caregivers to support safe independence Using calendars, clocks, and pictures to support memory Providing a limited number of choices to support decision-making Quizzing the client regularly to assess orientation to person, place, and time Administering prescribed rivastigmine to the client with severe Alzheimer dementia
Encouraging caregivers to support safe independence Using calendars, clocks, and pictures to support memory Providing a limited number of choices to support decision-making
A client comes into the emergency room (ER) after hitting his head while playing basketball. He is alert and oriented. Which is a priority nursing intervention? Assess full range of motion (ROM) to determine extent of injuries. Call for an immediate head computed tomography (CT). Immobilize the client's head and neck. Open the airway with the head-tilt chin-lift maneuver.
Immobilize the client's head and neck.
A nurse is caring for a client with a tumor of the cerebellum. What clinical manifestation does the nurse expect the client to exhibit? Absence of the knee-jerk reflex Change in level of consciousness Inability to execute voluntary movements Inability to execute coordinated movements
Inability to execute coordinated movements
A nurse is assessing a client with Parkinson disease. Which assessment finding indicates the presence of bradykinesia? Intention tremor Muscle flaccidity Paralysis of the limbs Lack of spontaneous movement
Lack of spontaneous movement
A 65-year-old client tells the nurse, "I see some particles that float within my field of vision." What may be the cause of this condition? Opacities in the lens Dilator muscle atrophy Atrophy of nerve fibers Liquefaction and detachment of the vitreous membrane
Liquefaction and detachment of the vitreous membrane
A nurse obtains the nursing history from a client who has open-angle (chronic) glaucoma. The nurse anticipates that the client will report which finding during the history? Flashes of light Sensitivity to light Seeing floating specks Loss of peripheral vision
Loss of peripheral vision
An older client is diagnosed with Alzheimer disease. For which clinical manifestations should the nurse assess the client? Loss of recent memory Focused attention span Perceptual disturbances Willingness to accept change Difficulty learning something new
Loss of recent memory Perceptual disturbances Difficulty learning something new
During the immediate posttrauma period after injury to the frontal lobe of the brain, the nurse places a client in what position? Supine Side-lying Low-Fowler Trendelenburg
Low-Fowler
A client sustains a vertebral fracture at the T1 level and is admitted to the emergency department. During a detailed neurologic assessment, the nurse expects to identify which clinical manifestation? Difficulty breathing Inability to move the lower arms Normal biceps reflexes in the arms Loss of pain sensation in the hands
Normal biceps reflexes in the arms
A client who had an infratentorial craniotomy is admitted to the intensive care unit after discharge from the postanesthesia care unit. Frequent assessments reveal that the client's intracranial pressure is increasing. What should the nurse do first? Notify the healthcare provider. Elevate the head of the bed. Reduce the flow rate of intravenous (IV) fluid. Administer the next dose of osmotic diuretic early.
Notify the healthcare provider.
A client has experienced an episode of myasthenic crisis. Upon review of the client history by the nurse, which finding will most likely be a precipitating factor of the myasthenic crisis? Getting too little exercise Taking excess medication Omitting doses of medication Increasing intake of fatty foods
Omitting doses of medication
A client is admitted to the hospital with numbness of the hands and feet, which has progressed upward and now involves the arms, legs, and lower trunk. The client tells the nurse that approximately two weeks ago, the client experienced 48 hours of chills, fever, and upper respiratory congestion. A tentative diagnosis of Guillain-Barré syndrome is made. The nurse assesses for what major clinical manifestations of the syndrome? Ptosis and dysphagia Paresthesias and paralysis Atrophy and fasciculations Muscle weakness and drooling
Paresthesias and paralysis
After a cerebrovascular accident (also known as brain attack) a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected? Frontal Parietal Occipital Temporal
Parietal
A client is diagnosed with hyperopia and has insufficient corneal thickness for a LASIK flap. Which surgical procedure should the nurse anticipate being most likely performed by the primary healthcare provider in this condition? Phakic intraocular lens Refractive intraocular lens Photorefractive keratectomy (PRK) Laser-assisted in situ keratomileusis (LASIK)
Photorefractive keratectomy (PRK)
A client is diagnosed with stage 3 of Parkinson disease. Which clinical manifestations are found in the client? Akinesia Masklike face Postural instability Unilateral limb involvement Increased gait disturbances
Postural instability Increased gait disturbances
The nurse is caring for a client who underwent a contrast-based cerebral angiography. Which nursing interventions will be beneficial after the procedure? Provide oral or intravenous fluids Encourage deep or moderate sedation Maintain pressure dressing at the injection site Evaluate kidney function 24 hours after the test Have the client ambulate immediately after the procedure
Provide oral or intravenous fluids Maintain pressure dressing at the injection site Evaluate kidney function 24 hours after the test
Which client eye movement does the superior oblique muscle control? Pulls the eye upward Pulls the eye downward Turns the eye towards the nose Turns the eye towards the side of the head
Pulls the eye downward
A client is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. The nurse explains to the client that the diagnosis of myasthenia gravis is confirmed if the administration of Tensilon produces which response? Brief exaggeration of symptoms Prolonged symptomatic improvement Rapid but brief symptomatic improvement Symptomatic improvement of only the ptosis
Rapid but brief symptomatic improvement
In caring for the client with burr holes for a subdural hematoma postoperatively on day 2, the nurse notes the client has an increased temperature to 101.3 F° (38.5° C). What does the nurse understand about this reaction? This is a normal assessment for the client with a subdural hematoma. This is a normal reaction day 2 postoperatively, and the nurse will administer acetaminophen as prescribed by the healthcare provider. Because the client has burr holes, this is not an accurate measurement. The client is exhibiting signs of an infection, and the healthcare provider needs to be notified.
The client is exhibiting signs of an infection, and the healthcare provider needs to be notified.
A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? Resting tremors Flattened affect Muscle flaccidity Tonic-clonic seizures Slow voluntary movements
Resting tremors Flattened affect Slow voluntary movements
A client reports a severe, sharp, stabbing headache and intense pain in and around the eye that lasts for up to 1 hour. History reveals that the client had similar episodes of headaches previously which lasted for ten weeks. What other symptoms may be manifested by the client? . Vertigo Rhinorrhea Lacrimation Phonophobia Pupillary constriction
Rhinorrhea Lacrimation Pupillary constriction
A client is scheduled for a labyrinthectomy to treat Meniere syndrome. Which expected outcome of the procedure should be included in preoperative teaching? Absence of pain Decreased cerumen Loss of sense of smell Permanent irreversible deafness
Permanent irreversible deafness
Which factors can trigger a client's migraine attacks? Fatigue Vertigo Aphasia Sleep problems Tingling sensations Hormonal fluctuations
Fatigue Sleep problems Hormonal fluctuations
After surgery to repair a retinal detachment, an older adult client is transferred to the postanesthesia care unit with the affected eye patched. During the first four hours after surgery, the nurse should plan to notify the primary healthcare provider if the client reports which information? Has not voided Cannot open the eye Cannot remember the date Has sharp pain in the affected eye
Has sharp pain in the affected eye
A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex. Which position does the nurse recognize is the most appropriate for this client postoperatively? Semi-Fowler with knee gatch elevated Flat on one side with the neck maintained in alignment with a small pillow Head of the bed elevated 30 to 45 degrees with the neck in neutral alignment Head of the bed elevated 20 degrees with the head turned to the operative side
Head of the bed elevated 30 to 45 degrees with the neck in neutral alignment
A client has a history of diabetes mellitus. After assessing the client, the primary healthcare provider confirms damage to the sensory limb of the bladder spinal reflex arc. Which clinical manifestations could confirm this condition? Incomplete voiding Overdistention of bladder Lack of control on micturition Infrequent voiding of large residual volumes
Infrequent voiding of large residual volumes
When performing a neurologic check on a client with a head injury, the nurse identifies a diminished corneal reflex in the left eye. What does appropriate nursing care for a client with an absent corneal reflex include? Irrigating the eye routinely Instilling artificial tears frequently Checking the corneal reflex every hour Taping the eyelids open during the day
Instilling artificial tears frequently
A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure? Maintaining the client in the supine position for several hours Encouraging the client to ambulate every hour for at least 6 hours Keeping the client in the Trendelenburg position for at least 2 hours Placing the client in the high-Fowler position immediately after the procedure
Maintaining the client in the supine position for several hours
Which muscle helps in moving the eye diagonally downward towards the middle of the head? Lateral rectus muscle Medial rectus muscle Inferior rectus muscle Inferior oblique muscle Superior oblique muscle
Medial rectus muscle Inferior rectus muscle
What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma? Monitor the client for signs of brain injury. Check for hemorrhaging from the oral and nasal cavities. Elevate the foot of the bed if the client develops symptoms of shock. Observe for clinical indicators of decreased intracranial pressure and temperature.
Monitor the client for signs of brain injury.
A client comes into the emergency department with neurologic deficits after falling off a ladder. Which client assessment will the nurse perform for the Glasgow Coma Scale? Breathing patterns Deep tendon reflexes Eye accommodation to light Motor response to verbal commands
Motor response to verbal commands
What is the function of a client's cranial nerve VI? Movement of the eye with levator muscle Movement of the eye with lateral rectus muscles Movement of the eye with medial rectus muscles Movement of the eye with superior oblique muscles
Movement of the eye with lateral rectus muscles
Bed rest is prescribed after a client's cerebrovascular accident (CVA, "brain attack") results in right hemiplegia. Which exercises should the nurse incorporate into the client's plan of care 24 hours after the brain attack? Passive range-of-motion exercises Active exercises of the extremities Light weight-lifting exercises of the right side Isotonic exercises that will capitalize on returning muscle function
Passive range-of-motion exercises
A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment? The injury results in loss of the reflex arc. The injury is above the sixth thoracic vertebra. There has been a partial transection of the cord. There is a flaccid paralysis of the lower extremities.
The injury is above the sixth thoracic vertebra.
