Neuro

A 21-year-old female client takes clonazepam (Klonopin). What should the nurse ask this client about? Select all that apply. 1. Seizure activity 2. Pregnancy status 3. Alcohol use 4. Cigarette smoking 5. Intake of caffeine and sugary drinks

1, 2, 3 1. Seizure activity 2. Pregnancy status 3. Alcohol use Rationale: The nurse should assess the number and type of seizures the client has experienced since starting clonazepam monotherapy for seizures. The nurse should also determine if the client might be pregnant because clonazepam crosses the placental barrier. The should also ask about the client's use of alcohol because alcohol potentiates the action of clonazepam. Although the nurse may want to check on the client's diet or use of cigarettes for health maintenance and promotion, such information is not specifically related to clonazepam therapy.

Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP) when caring for a client with a thrombotic stroke who has residual left-sided weakness? Select all that apply. 1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active range-of-motion (ROM) exercises 4. Assessing the the extremities for redness and edema 5. Setting up meal trays and assisting with feeding 6. Using a lift to assist the client up to a bedside chair

1, 2, 3, 5, 6 1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active range-of-motion (ROM) exercises 5. Setting up meal trays and assisting with feeding 6. Using a lift to assist the client to a bedside chair Rationale: An experienced UAP would know how to reposition the client, reapply compression boots, and feed a client, and would remind the client to perform activities the client has been taught to perform. UAPs are also trained to use a client lift to get clients into or out of bed. Assessing for redness and swelling (signs of deep vein thrombosis) requires additional education and skill, appropriate to the professional nurse.

Which pressure point area(s) should the nurse monitor for for an unconscious client positioned on the left side? Select all that apply. 1. Ankles 2. Ear 3. Greater trochanter 4. Heels 5. Occiput 6. Sacrum 7. Shoulders

1, 2, 3, 7 1. Ankles 2. Ear 3. Greater trochanter 7. Shoulders Rationale: Pressure points in the side-lying position include the ears, shoulders, ribs, greater trochanter, medial or lateral condyles, and ankles. The sacrum, occiput, and heels are pressure point areas affected in the supine position.

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? Select all that apply. 1. Placing a pillow in the axilla so the arm is away from the body 2. Inserting a pillow under the slightly flexed arm, so the hand is higher than the elbow 3. Immobilizing the extremity in a sling 4. Positioning a hand cone in the hand so the fingers are barely flexed 5. Keeping the arm at the side using a pillow

1, 2, 4 1. Placing a pillow in the axilla so the arm is away from the body 2. Inserting a pillow under the slightly flexed arm, so the hand in higher than the elbow 4. Positioning a hand cone in the hand so the fingers are barely flexed Rationale: Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly fixed arm so the can is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures.

The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void? Select all that apply. 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 3. Initiating intermittent straight catheterization 4. Tapping the bladder to stimulate the detrusor muscle 5. Reminding the client to void in a urinal every hour while awake

1, 2, 4, 5 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 4. Tapping the bladder to stimulate the detrusor muscle 5. Reminding the client to void in a urinal every hour while awake Rationale: All of the strategies except straight catheterization may stimulate voiding in clients with a spinal cord injury (SCI). Intermittent bladder catheterization can be used to empty the client's bladder, but it will not stimulate voiding. To use a urinal, the client must have bladder control, which is often absent after SCI. In addition, every hour while awake would be too often and ignore the bladder filling at night.

A 23-year-old client with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be BEST to assign to an LPN/LVN whom the nurse is supervising? Select all that apply. 1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin 200 mg PO three times a day 3. Teaching the client about the need for frequent tooth brushing and flossing 4. Developing a discharge plan that includes referral to the Epilepsy Foundation 5. Assessing for adverse effects caused by new antiseizure medications 6. Turning the client to his or her side to avoid aspiration

1, 2, 6 1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin 200 mg PO three times a day 6. Turning the client to his or her side to avoid aspiration Rationale: Any nursing staff member who is involved in caring for the client should observe for the onset and duration of seizures (although a more detailed assessment of seizure activity should be done by the RN). Administration of medications is included in LPN/LVN education and scope of practice. Turning the client on his or her side to avoid aspiration is certainly within the scope of practice for an LPN/LVN. Teaching, discharge planning, and assessment for adverse effects of new medications are complex activities that require RN-level education and scope of practice.

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies should the nurse include in the teaching plan? Select all that apply. 1. Maintaining an upright position while eating 2. Restricting the diet to liquids until swallowing improves 3. Introducing foods on the unaffected side of the mouth 4. Keeping distractions at a minimum 5. Cutting food into large pieces of finger food

1, 3, 4 1. Maintaining an upright position while eating 3. Introducing foods on the unaffected side of the mouth 4. Keeping distractions at a minimum Rationale: A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided. Large pieces of food could cause choking; the food should be cute into bite-sized pieces.

When communicating with a client who has aphasia, which of the following are helpful? Select all that apply. 1. Present one thought at a time 2. Avoid writing messages 3. Speak with normal volume 4. Make use of gestures 5. Encourage pointing to the needed object

1, 3, 4, 5 1. Present one thought at a time 3. Speak with normal volume 4. Make use of gestures 5. Encouraging pointing to the needed object Rationale: The goal of communicating with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating.

A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN/LVN? Select all that apply. 1. Checking the client's sin for pressure from the device 2. Assessing the client's neurologic status for changes 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 5. Developing the nursing plan of care for the client 6. Administering oral medications as ordered

1, 3, 4, 6 1. Checking the client's skin for pressure from the device 3. Observing the halo insertion for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 6. Administering oral medications as ordered Rationale: Checking and observing for signs of pressure or infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Administering oral drugs is within the scope of practice for an LPN/LVN. Neurologic examination and care plan development require additional education and skill appropriate to the professional RN.

The nurse on the neurologic acute unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? Select all that apply. 1. When did you first experience the headache symptoms? 2. Who is the Mayor of Cleveland? 3. What is your health care provider's name? 4. What year and month is this? 5. What is your parents' address? 6. What is the name of this health care facility?

1, 3, 4, 6 1. When did you first experience the headache symptoms? 3. What is your health care provider's name? 4. What year and month is this? 6. What is the name of this health care facility? Rationale: After determining alertness in a client, the next step is to evaluate orientation. When the client's attention is engaged, ask him or her questions to determine orientation. Varying the sequence of questioning on repeated assessments prevents the client from memorizing the answers. Responses that indicate orientation include the ability to answer questions about person, place, and time by asking for information such as the client's ability to relate the onset of symptoms, the name of his or her health care provider or nurse, the year and month, his or her address, and the name of the referring physician or health care agency. Asking about mayors' names or parents' address may be inappropriate to assess orientation.

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the MOST critical for the nurse to monitor? Select all that apply. 1. Systolic blood pressure 2. Urine output 3. Breath sounds 4. Cerebral perfusion pressure 5. Level of pain

1, 4 1. Systolic blood pressure 4. Cerebral perfusion pressure Rationale: The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.

When evaluating an arterial blood gas report from a client with a subdural hematoma who had surgery and is now on a ventilator, the nurse notes the PaCO2 is 30 mmHg. The ventilator settings are: TV 400, respiration rate 24, FiO2 100%. What should the nurse do FIRST? 1. Ask the respiratory technician to decrease the respiration rate on the ventilator to 18. 2. Position the client with the head of the bed elevated. 3. Continue to monitor the client. 4. Inform the charge nurse of the results of the report.

1. Ask the respiratory technician to decrease the respiration rate on the ventilator to 18. Rationale: CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP by dilated cerebral vessels. Since the client's PaCO2 level is normal (35-45 mmHg), paging the respiratory technician to change the respiration rate is an appropriate action. Elevating the head of the client's bed is contraindicated with this client's condition: that would lower blood pressure and care of these patients involves maintenance of a flat position in the bed for 24 hours after surgery. Continuing to monitor the client is inappropriate because the PaCO2 level is normal and the respiratory technician needs to adjust the hyperventilation setting to normal on the ventilator since the lab indicates that PaCO2 is normal. Informing the charge nurse about the change in ventilator settings is not necessary at this time because this is expected care for this client.

The nurse is assessing a client in the postictal phase of a generalized tonic-clonic seizure. The nurse should determine if the client has: 1. Drowsiness 2. Inability to move 3. Parasthesia 4. Hypotension

1. Drowsiness Rationale: The nurse should expect a client in the postictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron firing and tonic-clonic motor response. An inability to move a muscle part is not expected after a tonic-clonic seizure because a lack of motor function would be related to complication, such as a lesion, tumor, or stroke, in the correlating brain tissue. A change in the sensation would not be expected because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part of the central nervous system. Hypotension is not typically a problem after a seizure.

The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student requires that the nurse intervene MOST rapidly? 1. Entering the room without putting on a protective mask and gown 2. Instructing the family that visits are restricted to 10 minutes 3. Giving the client a warm blanket when he says he feels cold 4. Checking the client's pupil response to light every 30 minutes

1. Entering the room without putting on a protective mask and gown Rationale: Meningococcal meningitis is spread through contact with respiratory secretions, so use of a mask and gown is required to prevent transmission of the infection to staff members or other clients. The other actions may or may not be appropriate. The presence of a family member at the bedside may decrease client confusion and agitation. Clients with hyperthermia frequently 199 report feeling chilled, but warming the client is not an appropriate intervention. Checking the pupils' response to light is appropriate but is not needed every 30 minutes and is uncomfortable for a client with photophobia.

An unconscious Client with multiple injuries arrives in the emergency department. Which nursing intervention receives the HIGHEST priority? 1. Establishing an airway 2. Replacing blood loss 3. Stopping bleeding from open wounds 4. Checking for a neck fracture

1. Establishing an airway Rationale: The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless a client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.

A 22-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a PRIMARY cause of tonic-clonic seizures in adults older than age 20? 1. Head trauma 2. Electrolyte imbalance 3. Congenital defect 4. Epilepsy

1. Head trauma Rationale: Trauma is one of the primary causes of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neospasms, withdrawal from drugs and alcohol, and vascular disease. Given the history of head injury, electrolyte imbalance is not the cause of the seizure. There is no information to indicate that the seizure is related to a congenital defect. Epilepsy is usually diagnosed in younger clients.

The RN is supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene? 1. Instructing the client to sit up straight and the client responds with a puzzled expression 2. Moving the client's food tray to the right side of his over-the-bed table 3. Assisting the client with passive range-of-motion (ROM) exercises 4. Combing the hair on the left side of the client's head when the client always combs his hair on the right side

1. Instructing the client to sit up straight and the client responds with a puzzled expression Rationale: Clients with right cerebral hemisphere stroke often manifest neglect syndrome. They lean to the left and, when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse needs to remind the student of this phenomenon and discuss the appropriate interventions.

What is the PRIORITY nursing concern for a client experiencing a migraine headache? 1. Pain 2. Anxiety 3. Hopelessness 4. Risk for brain injury

1. Pain Rationale: The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other problems are accurate, but none of them is as urgent as the issue of pain, which is often incapacitating.

Which of the following nursing measures is NOT appropriate when providing oral hygiene for a client who has had a stroke? 1. Placing the client on the back with a small pillow under the head 2. Keeping portable suctioning equipment at the bedside 3. Opening the client's mouth with a padded tongue blade 4. Cleaning the client's mouth and teeth with a toothbrush

1. Placing the client on the back with a small pillow under the head Rationale: A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive receive oral care, including brushing with a toothbrush.

A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client? 1. Position the client sitting up in bed before he or she is fed. 2. Check the client's gag and swallowing reflexes. 3. Feed the client quickly because there are three times more clients to feed. 4. Suction the client's secretions between bites of food.

1. Position the client sitting up in bed before he or she is fed. Rationale: Positioning the client in a sitting position decreases the risk of aspiration. The UAP is not trained to assess gag or swallowing reflexes. The client should not be rushed during feeding. A client who needs suctioning performed between bites of food is not handling secretions and is at risk for aspiration. Such a client should be assessed further before feeding.

Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem? 1. Slow, irregular respirations 2. Rapid, shallow respirations 3. Asymmetric chest excursion 4. Nasal flaring

1. Slow, irregular respirations Rationale: Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic os respiratory distress or hypoxia.

The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IV push every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns the nurse the MOST? 1. The client no longer recognizes family members. 2. The blood glucose level is 234 mg/mL (13 mmol/L). 3. The client reports a continuing headache. 4. The daily weight has increased 2.2 lb (1 kg).

1. The client no longer recognizes family members. Rationale: The inability to recognize family members is a new neurologic deficit for this client and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the health care provider immediately so that treatment can be initiated. The continuing headache also indicates that the ICP may be elevated but is not a new problem. The glucose elevation and weight gain are common adverse effects of dexamethasone that may require treatment but are not emergencies.

The client has a sustained increased intracranial pressure (ICP) of 20 mmHg. Which client position would be the MOST appropriate? 1. The head of the bed elevated 30 to 45 degrees 2. Trendelenburg's position 3. Left Sims' position 4. The head elevated on two pillows

1. The head of the bed elevated 30 to 45 degrees Rationale: The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 30 to 45 degrees to drain he venous sinuses and thus decrease the ICP. Trendelenburg's position places the client's head lower than the body, which would increase ICP. Sims' position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP.

In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because: 1. The rehabilitation plan will be guided by it. 2. Functional status before the stroke will help predict outcomes. 3. It will help the client recognize physical limitations. 4. The client can be expected to regain most functional status.

1. The rehabilitation plan will be guided by it. Rationale: The primary reason for the nursing assessment of a client's functional status before and after a stroke is to guide the plan. The assessment does not help to predict how far the rehabilitation tam can help the client to recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status is not a motivating factor.

Which nursing action will be implemented FIRST if a client has a generalized tonic-clonic seizure? 1. Turn the client to one side. 2. Give lorazepam 2 mg IV. 3. Administer oxygen via nonrebreather mask. 4. Assess the client's level of consciousness.

1. Turn the client to one side. Rationale: The priority action during a generalized tonic-clonic seizure is to protect the airway by turning the client to one side to prevent aspiration. Administering lorazepam should be the next action because it will act rapidly to control the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea, which cannot be corrected by oxygen administration. Checking level of consciousness is not appropriate during the seizure because generalized tonic-clonic seizures are associated with a loss of consciousness.

A client is at risk for increased intracranial pressure (ICP). Which of the following would be a PRIORITY for the nurse to monitor? 1. Unequal pupil size 2. Decreasing systolic blood pressure 3. Tachycardia 4. Decreasing body temperature

1. Unequal pupil size Rationale: Increasing ICO causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increased the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his wife to the hospital to deliver their child. 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. 1. Find a television so the client can view the football game. 2. Determine if the client's pupils are equal and react to light. 3. Ask the client if he has a headache. 4. Arrange for the client to be with his wife and baby. 5. Administer a sedative.

2, 3 2. Determine if the client's pupils are equal and react to light. 3. Ask the client is he has a headache. Rationale: The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle critical manifestations of increased ICP. At this time, it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP.

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. 1. Encourage the client to cough to expectorate secretions. 2. Elevate the HOB 15 to 30 degrees. 3. Contact the health care provider if ICP is greater than 20 mmHg. 4. Monitor the neurologic status using the Glasgow Coma Scale. 5. Stimulate the client with active range-of-motion exercises.

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

The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicated that the client understands how to the take drugs? Select all that apply. 1. "The drug's action peaks in 2 hours." 2. "Maximum dosage is not achieved until 3 to 4 days after starting the medication." 3. "Effects of the drug continue for 4 to 5 days after discontinuing the medication." 4. "Protamine sulfate is the antidote for warfarin." 5. "I should have my blood levels tested periodically."

2, 3, 5 2. "Maximum dosage is not achieved until 3 to 4 days after starting the medication." 3. "Effects of the drug continue for 4 to 5 days after discontinuing the medication." 5. "I should have my blood levels tested periodically." Rationale: The maximum dosage of warfarin sodium (Coumadin) is not acheived until 3 to 4 days after starting the medication, and the effects of the drug continue for 4 to 5 days after discontinuing the medication. The should should have blood levels tested periodically to make sure that the desired level is maintained. Warfarin has a peak action of 9 hours. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.

Which statement by a client with a seizure disorder taking topiramate (Topamax) indicated the client has understood the nurse's instruction? 1. "I will take the medicine before going to bed." 2. "I will drink six to eight glasses of water a day." 3. "I will eat plenty of fresh fruits." 4. "I will take the medicine with a meal or snack."

2. "I will drink six to eight glasses of water a day." Rationale: Toxic effects of topiramate (Topamax) include nephrolithiasis, and clients are encouraged to drink six to eight glasses of water a day to dilute the urine and flush the renal tubule to avoid stone formation. Topiramate is taken in divided doses because it produces drowsiness. Although eating fresh fruits is desirable from a nutritional standpoint, this is not related to the topiramate. The drug does not have to be taken with meals.

Which client should the charge nurse assign to a new graduate RN who is orientating to the neurologic unit? 1. A 28-year-old newly admitted client with a spinal cord injury 2. A 67-year-old client who had a stroke 3 days ago and has left-sided weakness 3. An 85-year-old client with dementia who is to be transferred to long-term care today 4. A 54-year-old client with Parkinson disease who needs assistance with bathing

2. A 67-year-old client who had a stroke 3 days ago and has left-sided weakness Rationale: The new graduate RN who is on orientation to the unit should be assigned to care for clients with stable, noncomplex conditions, such as the client with stroke. The task of helping the client with Parkinson disease to bathe is best delegated to the unlicensed assistive personnel (UAP). The client being transferred to the nursing home, and the newly admitted client with spinal cord injury should be assigned to experienced nurses.

Which client should the charge nurse assign to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? 1. A 34-year-old client with newly diagnosed multiple sclerosis (MS) 2. A 68-year-old client with chronic amyotrophic lateral sclerosis (ALS) 3. A 56-year-old client with Guillain-Barre syndrome (GBS) in respiratory distress 4. A 25-year-old client admitted with a C4-level spinal cord injury (SCI)

2. A 68-year-old client with chronic amyotrophic lateral sclerosis (ALS) Rationale: The traveling nurse is relatively new to neurologic nursing and should be assigned clients whose condition is stable and not complex, such as the client with chronic ALS. The newly-diagnosed client with MS will need a lot of teaching and support. The client with respiratory distress will need frequent assessments and may need to be transferred to the intensive care unit. The client with a C4-level SCI is at risk for respiratory arrest. All three of these clients should be assigned to nurses experienced in neurologic nursing care.

A client who has had seizures asks the nurse about being able to drive because of the seizures. Which response by the nurse is BEST? 1. A person with a history of seizures can drive only during daytime hours. 2. A person with evidence that the seizures are under medical control can drive. 3. A person with evidence that seizures occur no more often than every 12 months can drive. 4. A person with a history of seizures can drive if he or she carries a medical identification card.

2. A person with evidence that the seizures are under medical control can drive. Rationale: Specific motor vehicle regulations and restrictions for people who experience seizures vary locally. Most commonly, evidence is that the seizures are under medical control is required before the person is given permission to drive. Time of day is not a consideration when determining driving restrictions related to seizures. The amount of time a person has been seizure-free is a consideration for lifting driving restrictions; however, the time frame is usually 2 years. It is recommended, not required that a person who is subject to seizures carry a card or wear an ID bracelet describing the illness to facilitate quick identification in the event of an emergency.

A client with a spinal cord injury (SCI) reports a sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/95 mmHg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take FIRST? 1. Administer the ordered acetaminophen. 2. Check the Foley tubing for kinks or obstruction. 3. Adjust the temperature in the client's room. 4. Notify the health care provider about the change in status.

2. Check the Foley tubing for kinks or obstruction. Rationale: The client's signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, and fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful because too cool a temperature in the room may contribute to the problem. Acetaminophen will not decrease the autonomic dysreflexia that is causing the client's headache. Notifying the health care provider may be necessary if nursing actions do not resolve symptoms.

The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) when providing nursing care for a client with a spinal cord injury? 1. Assessing the client's respiratory status every 4 hours 2. Checking and recording the client's vital signs every 4 hours 3. Monitoring the client's nutritional status, including calorie counts 4. Instructing the client how to turn, cough, and breathe deeply every 2 hours

2. Checking and recording the client's vital signs every 4 hours Rationale: The UAP's training and education covers measuring and recording vital signs. The UAP may help with turning and repositioning the client and may remind the client to cough and deep breathe, but he or she does not teach the client how to perform these actions. Assessing and monitoring clients require additional education and are appropriate to the scope of practice of professional nurses.

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will: 1. Have a preference for foods high in salt. 2. Eat food on only half of the plate. 3. Forget the names of foods. 4. Not be able to swallow liquids.

2. Eat food on only half of the plate. Rationale: Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of the plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods is a sign of aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.

In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is CONTRAINDICATED when positioning the client? 1. Keeping the client flat on one side or the other 2. Elevating the head of the bed to 30 degrees 3. Logrolling or turning as a unit when turning 4. Keeping the neck in a neutral position

2. Elevating the head of the bed to 30 degrees Rationale: Elevating the head of the bed to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down into the brain stem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite the incision, if not contraindicated by the ICP, is used for supratentorial craniotomies.

The nurse has just admitted a client bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6 F (39.2 C) orally. Which prescribed intervention should be implemented first? 1. Administer codeine 15 mg orally for the client's headache. 2. Infuse ceftriaxone 2000 mg IV to treat the infection. 3. Give acetaminophen 650 mg orally to reduce the fever. 4. Give furosemide 40 mg IV to decrease intracranial pressure.

2. Infuse ceftriaxone 2000 mg IV to treat the infection. Rationale: Bacterial meningitis is a medical emergency, and antibiotics are administered even before the diagnosis is confirmed (after specimens have been collected for culture). The other interventions will also help to reduce central nervous system stimulation and irritation and should be implemented as soon as possible but are not as important as starting antibiotic therapy.

The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring? 1. Muscle relaxation 2. Intake and output 3. Widening of the pulse pressure 4. Pupil dilation

2. Intake and output Rationale: After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.

Which of the following should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin (Neurontin)? 1. Take all the medication until it is gone. 2. Notify the physician if vision changes occur. 3. Store gabapentin in the refrigerator. 4. Take gabapentin with an antacid to protect against ulcers.

2. Notify the physician if vision changes occur. Rationale: Gabapentin (Neurontin) may impair vision. Changes in vision, concentration, or coordination should be reported to the physician. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to be stored at room temperature and out of direct light. It should not be taken with antacids.

A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should: 1. Count the rate to be sure that ventilations are deep enough to be sufficient. 2. Notify the physician of the client's breathing pattern. 3. Increase the rate of ventilation. 4. Increase the tidal volume on the ventilator.

2. Notify the physician of the client's breathing pattern. Rationale: Cluster breathing consists of irregular breaths followed by periods of apnea on an irregular basis. A lesion in in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the physician immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen and the depth of breathing is assisted by the ventilator. The health care provider will determine changes in the ventilator settings.

What is a PRIORITY nursing assessment in the first 24 hours after administration of the client with a thrombolytic stroke? 1. Cholesterol level 2. Pupil size and pupillary response 3. Bowel sounds 4. Echocardiogram

2. Pupil size and pupillary response Rationale: It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased ICP. An echocardiogram is not needed for the client with a thrombotic stroke without heart palpitations.

The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN? 1. Completing the admission assessment 2. Setting up oxygen and suction equipment 3. Placing a padded tongue blade at the bedside 4. Padding the side rails before the client arrives

2. Setting up oxygen and suction equipment Rationale: The LPN/LVN scope of practice includes setting up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins.

Which of the following techniques is NOT appropriate when the nurse changes a client's position in bed if the client has hemiparalysis? 1. Rolling the client onto the side 2. Sliding the client to move up in bed 3. Lifting the client when moving the client up in bed 4. Having the client help lift off the bed using a trapeze

2. Sliding the client to move up in bed Rationale: Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and the limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to self and the client. Having the client help lift off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown.

When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge to the client not to stop the drug suddenly because: 1. Physical dependency on the drug develops over time 2. Status epilepticus may develop 3. A hypoglycemic reaction Heart block is likely to develop

2. Status epilepticus may develop Rationale: Anticonvulsant drug therapy should never be stopped suddenly; doing so can lead to life-threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. Phenytoin has antiarrhythmic properties, and discontinuation does not cause heart block.

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's BEST interpretation of this finding? 1. The client's condition is improving. 2. The client's condition is deteriorating. 3. The client will need intubation and mechanical ventilation. 4. The client's medication regime will need adjustments.

2. The client's condition is deteriorating. Rationale: The GCS is used in many acute care settings to establish baseline data in these areas: eye opening, motor response, and verbal response. The client is assigned a numeric score for each of these areas. The lower the score, the lower the client's neurologic function. A decrease of 2 or more points in the Glasgow Coma Scale score total is clinically significant and should be communicated to the health care provider immediately.

A client who recently stated taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of GREATEST concern? 1. The gums appear enlarged and inflamed. 2. The white blood cell count is 2300/mm3. 3. The client sometimes forgets to take the phenytoin until the afternoon. 4. The client wants to renew her driver's license in the next month.

2. The white blood cell count is 2300/mm3. Rationale: Leukopenia is a serious adverse effect of phenytoin therapy and would require discontinuation of the medication. The other data indicate a need for further assessment or client teaching but will not require a change in medical treatment for the seizures.

A 70-year-old client with alcoholism who has become lethargic, confused, and incontinent during the week is admitted to the emergency department. His wife tells the nurse that he fell down the stairs about a month ago but that, "he didn't have a scratch afterward." Which collaborative interventions will the nurse implement FIRST? 1. Place the client on the hospital alcohol withdrawal protocol. 2. Transport the client to the radiology department for a computed tomography (CT) scan. 3. Make the referral to the social services department. 4. Give the client phenytoin 100 mg PO.

2. Transport the client to the radiology department for a computed tomography (CT) scan. Rationale: The client's history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the client to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward diagnosis and treatment of any intracranial lesion.

For the client who is experiencing expressive aphasia, which nursing intervention is MOST helpful in promoting communication? 1. Speaking loudly and slowly 2. Using a "picture board" for the client to point to pictures 3. Writing directions so the client can read them 4. Speaking in short sentences

2. Using a "picture board" for the client to point to pictures Rationale: Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. Which nursing intervention protects the client without increasing the intracranial pressure (ICP)? 1. Plave in a jacket restraint 2. Wrap the hands in soft "mitten" restraints 3. Tuck the draw sheet and hands under the drawsheet. 4. Apply a wrist restraint to each arm

2. Wrap the hands in soft "mitten" restraints Rationale: It is best for the client to wear mitts to help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the drawsheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.

The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's BEST response? 1. "Your wife was not admitted within the time frame that alteplase is usually given." 2. "This drug is used primarily for clients who experience an acute heart attack." 3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." 4. "Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase."

3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." Rationale: Alteplase is a clot buster. In a client who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug, such as alteplase, dissolves the clot and can cause more bleeding in the brain. The other statements about the use of alteplase are accurate but are not pertinent to this client's diagnosis.

Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit? 1. A 26-year-old client with a basilar skull fracture who has clear drainage coming out of the nose. 2. A 42-year-old client admitted 48 hours ago with a headache and a diagnosis of a ruptured berry aneurysm. 3. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic due. 4. A 65-year-old client with an astrocytoma who has just returned to the unit after undergoing a craniotomy

3. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic due. Rationale: Of the clients listed, the client with bacterial meningitis is in the most stable condition and likely the least complex. An RN from the medical unit would be familiar with administering IV antibiotics. The other clients require assessments and care from RNs more experienced in caring for clients with neurologic diagnoses.

The client will have an electroencephalogram (EEG) in the morning. The nurse should instruct the client to have which of the following for breakfast? 1. No food or fluids 2. Only coffee or tea, if needed 3. A full breakfast without coffee, tea, or energy drinks 4. A liquid breakfast of fruit juice, oatmeal, or smoothie

3. A full breakfast without coffee, tea, or energy drinks Rationale: Beverages containing caffeine, such as coffee, tea, cola, and energy drinks, are withheld before an EEG because of the stimulating effects of the caffeine on brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee. The client does not need to be on a liquid diet or NPO.

The nurse is teaching a client to recognize an aura. The nurse should instruct the client to note: 1. A postictal state of amnesia. 2. A hallucination that occurs during a seizure. 3. A symptom that occurs just before a seizure. 4. A feeling of relaxation as the seizures begins to subside.

3. A symptom that occurs just before a seizure. Rationale: An aura is a premonition of an impending seizure. Auras usually are of a sensory nature; some may be of a psychic nature. Evaluating an aura may be helpful to identify the area of the brain from which the seizure originates. Auras occur before a seizure not during or after (postictal). They are not similar to hallucinations or amnesia or related to relaxation.

A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will: 1. Exhibit no further episodes of short-term memory loss 2. Be able to return to his construction job in 3 weeks 3. Actively participate in the rehabilitation process as appropriate 4. Be emotionally stable and display preinjury personality traits

3. Actively participate in the rehabilitation process as appropriate Rationale: Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. Family members and significant others will need long-term support to help them cope with the changes that have occurred in the client.

What is the PRIORITY nursing intervention is the postictal phase of a seizure? 1. Reorient the client to time, person, and place 2. Determine the client's level of sleepiness 3. Assess the client's breathing pattern 4. Position the client comfortably

3. Assess the client's breathing pattern Rationale: A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

Which of the following is CONTRAINDICATED for a client with seizure precautions? 1. Encouraging him to perform his own personal hygiene 2. Allowing him to wear his own clothing 3. Assessing his oral temperature with a glass thermometer 4. Encouraging him to be out of bed

3. Assessing his oral temperature with a glass thermometer Rationale: Temperatures are not assessed orally with a glass thermometer because the thermometer could break and cause injury if a seizure occurred. The client can perform personal hygiene. There is no clinical reason to discourage the client from wearing his own clothes. As long as there are no other limitations, the client should be encouraged to be out of bed.

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the BEST technique for the nurse to instruct family members to try when the client experiences a crying episode? 1. Sit quietly with the client until the episode is over. 2. Ignore the behavior. 3. Attempt to divert the client's attention. 4. Tell the client that this behavior is unacceptable.

3. Attempt to divert the client's attention. Rationale: A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate.

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Temperature.

3. Blood pressure. Rationale: Control of blood pressure is critical during the first 24 hours after after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.

The nurse is assessing the level of consciousness in a client with head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. The nurse should: 1. Attempt to rouse the client. 2. Reposition the client with the extremities in normal alignment. 3. Chart the client's level of consciousness as coma. 4. Notify the physician.

3. Chart the client's level of consciousness as coma. Rationale: The client has a score of 6 (eye opening to pain = 2; verbal response, incomprehensible sounds = 2; best motor response, abnormal extension = 2); a score less than 7 is indicative of coma. While the nurse should continue to speak to the client, at this time the client will not be able to be aroused. The nurse should continue to provide skin care and appropriate alignment but the client will continue to have a motor response of limb extension. It is not necessary to notify the physician as this assessment does not represent a significant change in neurological status.

After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Documenting the seizure 2. Performing neurologic checks 3. Checking the client's vital signs 4. Restraining the client for protection

3. Checking the client's vital signs Rationale: Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary to prevent injury.

The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's BEST action? 1. Perform a complete neurologic assessment. 2. Assess the cranial nerve functions. 3. Contact the Rapid Response Team. 4. Reassess the client in 30 minutes.

3. Contact the Rapid Response Team. Rationale: A change in the level of consciousness and orientation is the earliest and most reliable indication that central neurologic function has declined. If a decline occurs, contact the Rapid Response Team or health care provider immediately. The nurse should also perform a focused assessment to determine if there are any other changes.

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? 1. Deep breathing 2. Turning 3. Coughing 4. Passive range-of-motion (ROM) exercices

3. Coughing Rationale: Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.

The nurse is preparing a nursing care plan for a client with a spinal cord injury (SCI) for whom problems of decreased mobility and inability to perform activities of daily living (ADLs) have been identified. The client tells the nurse, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing concern takes PRIORITY? 1. Risk for injury 2. Decreased nutrition 3. Difficulty with coping 4. Impairment of body image

3. Difficulty with coping Rationale: The client's statement indicates difficulty with coping in adjusting to the limitations of the injury and the need for additional counseling, teaching, and support. The other three nursing problems may be appropriate for a client with SCI but are not related to the client's statement.

What is the expected outcome of thrombolytic drug therapy for stroke? 1. Increased vascular permeability 2. Vasoconstriction 3. Dissolved emboli 4. Prevention of hemorrhage

3. Dissolved emboli Rationale: Thrombolytic agents are used for clients with a thrombotic stroke to dissolve emboli, this reestablishing cerebral perfusion, cause vasoconstriction, or prevent further hemorrhage.

Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mmHg? 1. Give the client a warming blanket. 2. Administer low-dose barbiturates. 3. Encourage the client to hyperventilate. 4. Restrict fluids.

3. Encourage the client to hyperventilate. Rationale: A normal ICP is 15 mmHg or less for 15 to 30 seconds or longer. Hyperventilation cause vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mmHg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases the ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mmHg.

Which clinical manifestation is a typical reaction to long-term phenytoin sodium (Dilantin) therapy? 1. Weight gain 2. Insomnia 3. Excessive growth of the gum tissue 4. Deteriorating eyesight

3. Excessive growth of the gum tissue Rationale: A common adverse effect of long-term phenytoin therapy is an overgrowth of gingival tissues. Problems may be minimized with good oral hygiene, but in some cases, overgrown tissue must be removed surgically. Phenytoin does not cause weight gain, insomnia, or deteriorating eyesight.

What should the nurse do FIRST when a client with a head injury begins to have clear drainage from the nose? 1. Compress the nares. 2. Tilt the head back. 3. Give the client tissues to collect the fluid. 4. Administer an antihistamine for postnasal drip.

3. Give the client tissues to collect the fluid. Rationale: The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.

A client arrives to the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should FIRST: 1. Ask what medications the client is taking. 2. Complete a history and health assessment. 3. Identify the time of onset of the stroke. 4. Determine if the client is scheduled for any surgical procedures.

3. Identify the time of onset of the stroke. Rationale: Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. After attempting to reorient the client, the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, the nurse should FIRST: 1. Ask the family to stay with the client. 2. Contact the physician and request a prescription for soft wrist restraints. 3. Increase the frequency of client observation. 4. Administer a sedative.

3. Increase the frequency of client observation. Rationale: The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses' station if possible and/or delegating the nursing assistant to check on the client more frequently. If the family is able to 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 the 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 potentiate the problems.

A nursing assistant is providing care to a client with left-sided paralysis. Which of the following actions by the nursing assistant requires the nurse to provide further instruction? 1. Providing passive range-of-motion exercises to the left extremities during the bed bath 2. Elevating the foot of the bed to reduce edema 3. Pulling up the client under the left shoulder when getting the client out of bed to a chair 4. Putting high top tennis shoes on the client after bathing

3. Pulling up the client under the left shoulder when getting the client our of bed to a chair Rationale: Pulling the client up under the arm can cause shoulder displacement. A belt around the waist should be used to move the client. Passive range-of-motion exercises prevents contractures and atrophy. Raising the foot of the bed assists in venous return to reduce edema. High top tennis shoes are used to prevent foot drop.

The client is scheduled to receive phenytoin (Dilantin) through a nasogastric tube (NGT) and has tube-feeding supplement running continuously. The head of the bed is elevated to 30 degrees. Prior to administering the medication, the nurse should: 1. Elevate the head of the bed to 60 degrees. 2. Draw blood to determine the Dilantin level after giving the morning dose in order to determine if client has toxic blood level. 3. Stop the tube feeding 1 hour before giving Dilantin and hold tube feeding for 1 hour after giving Dilantin. 4. Flush the NGT with 150 mL of water before and after giving Dilantin.

3. Stop the tube feeing 1 hour before giving Dilantin and hold tube feeding for 1 hour after giving Dilantin. Rationale: In order for Dilantin to be properly absorbed and provide maximum benefit to the client, nutritional supplements must be stopped before and after delivery. The head of the bed is elevated to 30 degrees since this client has a tube feeding infusing it is not necessary to elevate the bed any further. Blood levels are usually drawn before giving a dose of Dilantin, not after. It is not necessary to flush with such a large amount of water before and after Dilantin.

A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene? 1. "You should avoid consumption of all forms of alcohol." 2. "Wear your medical alert bracelet at all times." 3. "Protect your loved one's airway during a seizure." 4. "It's OK to take over-the-counter medications."

4. "It's OK to take over-the-counter medications." Rationale: A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families.

A client with a head injury regains consciousness after several days. Which of the following nursing assessments is MOST appropriate as the client awakens? 1. "I'll get your family." 2. "Can you tell me your name and where you live?" 3. "I'll bet you're a little confused right now." 4. "You are in the hospital. You were in an accident and unconscious."

4. "You are in the hospital. You were in an accident and unconscious." Rationale: It is important to first explain where a client is to orient him or her to time, person, and place. Offering to get the family and asking questions to determine orientation are important, but the first comments should let the client know where he or she is and what has happened. It is useful to be empathetic to the client, but making a comment such as "I'll bet you're a little confused" is not helpful anf may cause anxiety.

It is the night before a client is to have a computerized tomography (CT) scan of the head without contrast. The nurse should tell the client: 1. "You must shampoo your hair tonight to remove all oil and dirt." 2. "You may drink fluids until midnight, but after that drink nothing until the scan is completed." 3. "You will have some hair shaved to attach the small electrode to your scalp." 4. "You will need to hold you head very still during the examination."

4. "You will need to hold your head very still during the examination." Rationale: The client will be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes. In some instances, food and fluids may be withheld for 4 to 6 hours before the procedure if a contrast medium is used because the radiopaque substance sometimes causes nausea. There is no special preparation for a CT scan, so a shampoo the night before is not required. The client may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT scan.

After the nurse receives the change-of-shift report at 7:00 AM, which client must the nurse assess FIRST? 1. A 23-year-old client with a migraine headache who reports severe nausea associated with retching 2. A 45-year-old client who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching 3. A 59-year-old client with Parkinson disease who will need a swallowing assessment before breakfast 4. A 63-year-old client with multiple sclerosis (MS) who has an oral temperature of 101.8 F (38.8 C) and flank pain

4. A 63-year-old client with multiple sclerosis (MS) who has an oral temperature of 101.8 F (38.8 C) and flank pain Rationale: Urinary tract infections (UTIs) are a frequent complication in clients with MS because of the effect of the disease on bladder function, and UTIs may lead to sepsis in these clients. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The health care provider should be notified immediately so that IV antibiotic therapy can be started quickly. The other clients should be assessed as soon as possible, but their needs are not as urgent as those of this client.

After receiving a change-of-shift report at 7:00 AM, the nurse should assess which of these clients FIRST? 1. A 23-year-old with a migraine headache who has severe nausea associated with retching 2. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching 3. A 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast 4. A 63-year-old with multiple sclerosis who has an oral temperature of 101.8 F and flank pain

4. A 63-year-old with multiple sclerosis who has an oral temperature of 101.8 F and flank pain Rationale: Urinary tract infections are a frequent complication in clients with multiple sclerosis because of the effect on bladder function; therefore, that client should be seen first by the nurse. The elevated temperature and flank pain suggest that this patient may have pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly. The other clients should be assessed soon, but do not have needs as urgent as this client.

Which intervention is MOST effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures? 1. Maintain the client on bed rest. 2. Administer butabarbital sodium 3. Close the door to the room to minimize stimulation 4. Administer carbamazepine (Tegretol) 200 mg PO, twice per day

4. Administer carbamazepine (Tegretol) 200 mg PO, twice per day Rationale: Carbamazepine (Tegretol) is an anticonvulsant that helps prevent further seizures. Bed rest, sedation (phenobarbital), and providing privacy do not minimize the risk of seizures.

Which of the following describes decerebrate posturing? 1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers 2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet 3. Supination of arms, dorsiflexion of the feet 4. Back arched, rigid extension of all four extemities

4. Back arched, rigid extension of all four extremities Rationale: Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and crebral hemispheres.

The nurse is assessing a client with increasing intracranial pressure (ICO). The nurse should notify the health care provider about which of the following changes to the client's condition? 1. Widening pulse pressure 2. Decrease in the pulse rate 3. Dilated, fixed pupils 4. Decrease in the level of consciousness

4. Decrease in the level of consciousness Rationale: A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in the LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? 1. Jerking in one extremity that spreads gradually to adjacent areas 2. Vacant staring and abruptly ceasing all activity 3. Facial grimaces, patting motions, and lip smacking 4. Loss of consciousness, body stiffening, and violent muscle contractions

4. Loss of consciousness, body stiffening, and violent muscle contractions Rationale: A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread. An absence seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking.

What nursing assessments should be documented at the beginning of the ictal phase of a seizure? 1. Heart rate, respirations, pulse oximeter, and blood pressure 2. Last dose of anticonvulsant and circumstances at the time 3. Type of visual, auditory, and olfactory aura the client experienced 4. Movement of the head and eyes and muscle rigidity

4. Movement of the head and eyes and muscle rigidity Rationale: During a seizure, the nurse should note movement of the client's head and eyes and muscle rigidity, especially when the seizure first begins, to obtain clues about the location of the trigger focus in the brain. Other important assessments would include noting the progression and duration of the seizure, respiratory status, loss of consciousness, pupil size, and incontinence of urine and stool. It is typically not possible to assess the client's pulse and blood pressure during a tonic-clonic seizure because the muscle contractions make assessment difficult to impossible. The last dose of anticonvulsants can be evaluated later. The nurse should focus on maintaining an open airway, preventing injury to the client, and assessing the onset and progression of the seizure to determine the type of brain activity involved. The type of aura should be assessed in the preictal phase of the seizure.

The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following? 1. The client's shoulders shrug against downward pressure of the examiner's hands. 2. The client's arm pulls up from a resting position against resistance. 3. The client's arm straightens out from a flexed position against resistance. 4. The client's hand-grasp strength is equal.

4. The client's hand-grasp strength is equal. Rationale: The correct motor function test for C8 is a hand-grasp check. The motor function for C4 to C5 is shoulders shrugging against downward pressure of the examiner's hands. The motor function check for C5 to C6 is an arm pulling up from a resting position against resistance. The motor function check for C7 is an arm straightening out from a flexed position against resistance.

A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the PRIMARY safety precaution to use? 1. Wear a patch over one eye 2. Place personal items on the sighted side 3. Lie in bed with the unaffected side toward the door 4. Turn the head from side to side when walking

4. Turn the head from side to side when walking Rationale: To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision. Personal items can be placed within sight and reach, but most accidents occur from tripping over items that cannot be seen. It may help the client to see the door, but walking presents the primary safety hazard.

A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mmHg when blood pressure (BP) is 120/60 mmHg?

80 mmHg Rationale: To obtain MAP, use this formula: MAP = [systolic BP + (2)diastolic BP]/3 MAP = [120 + (2)60]/3 MAP = 230/3=80

A client with a spinal cord injury at level C3 to C4 is being care for by the nurse in the emergency department (ED). What is the PRIORITY nursing assessment? 1. Determine the level at which the client has intact sensation. 2. Assess the level at which the client has retained mobility. 3. Check blood pressure and and pulse fo signs of spinal shock. 4. Monitor respiratory effort and oxygen saturation level.

4. Monitor respiratory effort and oxygen saturation level. Rationale: The first priority for the client with a spinal cord injury is assessing respiratory patterns and ensuring an adequate airway. A client with a high cervical injury is at risk for respiratory compromise because spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary but are not as high a priority.