Neuro Med Surg Practice Questions
A client who was in a motor vehicle accident was admitted to the intensive care unit (ICU) with severe head trauma. What nursing interventions should the ICU nurse implement when caring for the client? (Select all that apply.) 1. Administering osmotic diuretics as prescribed 2. Hypooxygenating the client before suctioning 3. Encouraging the client to perform Valsalva's maneuver every 4 hours 4. Keeping the bed flat at all times 5. Reducing or eliminating noxious stimuli 6. Instituting seizure precautions
1. Administering osmotic diuretics as prescribed 5. Reducing or eliminating noxious stimuli 6. Instituting seizure precautions Because the client with severe head trauma is at risk for increased intracranial pressure (ICP), osmotic diuretics are administered to help reduce cerebral edema, seizure precautions are instituted, and safety measures — such as reducing noxious stimuli — should be instituted until normal neurologic status is restored. The client should be hyperoxygenated prior to suctioning, Valsalva's maneuver would increase ICP, and the head of the bed should be elevated to 30 degrees.
In assisting a client diagnosed with multiple sclerosis (MS), which topic would be important to include in client teaching? 1. Effect of stress and fatigue on symptoms 2. Need for small, frequent meals 3. Need for strenuous exercise 4. Positive effect of a high-protein diet
1. Effect of stress and fatigue on symptoms Studies have shown that stress and fatigue adversely affect the course of MS. The teaching plan needs to address these topics. Teaching stress-management techniques and helping the client adjust her schedule to ensure adequate rest are beneficial. Small, frequent feedings are not a priority for a client with MS. Vigorous exercise can lead to fatigue, possibly exacerbating the disease. Increased protein intake is not associated with MS treatment.
When teaching the client diagnosed with myasthenia gravis about anticholinesterase medications, which intervention should the nursing include in the discussion? 1. Giving instructions to take medication 30 minutes before eating meals 2. Explaining that atropine is used to determine a myasthenic or cholinergic crisis 3. Discussing the importance of tapering the dose when discontinuing this medication 4. Discussing the need to avoid exposure to ultraviolet rays of the sun with this medication
1. Giving instructions to take medication 30 minutes before eating meals Anticholinesterase agents inhibit the breakdown of acetylcholine, providing the client with more strength for activities such as eating. The medication should be taken daily at the same time to ensure maximum strength available for activity. Tensilon is used to determine the type of crisis. Atropine is the antidote for cholinergic crisis. Anticholinesterase medications are prescribed for life, and tapering is not suggested. Anticholinesterase medications do not cause photosensitivity.
Which position would be most appropriate for a client with right-sided paralysis after a stroke? 1. Side lying with hips slightly flexed and pillows in the axilla 2. Semi-Fowler's position, with hands tightly holding a washcloth 3. Supine with two large pillows under the head and a footboard 4. Prone for at least 2 hours with trochanter rolls and a footboard
1. Side lying with hips slightly flexed and pillows in the axilla For a client with right-sided paralysis after a stroke, the client should be placed on his side with the hips slightly flexed in as natural a position as possible and with pillows placed in the axillary area to prevent adduction. A semi-Fowler's position may cause too great a degree of hip flexion. Having the client's hands tightly holding a washcloth could lead to contractures. The supine position is avoided to minimize the risk of aspiration, and placing too many pillows under the head may interfere with breathing and pull the rest of the body out of alignment. Although the prone position should be used if possible, it should be used only for 15 to 30 minutes several times each day.
The client arrives at the emergency department, complaining of back spasms. The client states, "I have been taking 2 to 3 aspirin every 4 hours for the last week, and it hasn't helped my back." Since acetylsalicylic acid intoxication is suspected, the nurse would assess the client for which manifestation? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Photosensitivity
1. Tinnitus Rationale: Mild intoxication with acetylsalicylic acid is called salicylism and is experienced commonly when the daily dosage is higher than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation may occur, because salicylate stimulates the respiratory center. Fever may result, because salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. Options 2, 3, and 4 are not associated specifically with toxicity.
Which response by the nurse would be most appropriate for a client with aphasia who states, "I want a..." and then stops? 1. Waiting for the client to complete the sentence 2. Immediately showing the client various objects in the environment 3. Leaving the room and coming back later 4. Beginning naming objects the client could be referring to
1. Waiting for the client to complete the sentence The client with aphasia may need additional time to select the proper words when speaking. It is essential for the nurse to allow the client time to complete the sentence. Showing or naming various objectives and leaving the room are inappropriate responses. Actions such as these often lead to additional client frustration, anxiety, and feelings of low self-esteem.
The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? 1. "Alcohol is not contraindicated while taking this medication." 2. "Good oral hygiene is needed, including brushing and flossing." 3. "The medication dose may be self-adjusted, depending on side effects." 4. "The morning dose of the medication needs to be taken before a medication level is drawn."
2. "Good oral hygiene is needed, including brushing and flossing." Rationale: Typical antiseizure medication instructions include taking the prescribed daily dosage to keep the blood level of the medication constant and having a sample drawn for serum medication level determination before taking the morning dose. The client is taught not to stop the medication abruptly, to avoid alcohol, to check with a primary health care provider before taking over-the-counter medications, to avoid activities in which alertness and coordination are required until medication effects are known, to provide good oral hygiene, and to obtain regular dental care. The client needs to also wear a MedicAlert bracelet.
Which statement by the nurse would be appropriate when assisting a client with a neurologic disorder who has the nursing diagnosis of altered thought processes with self-care deficits? 1. "What would you like to do first: brush your teeth?" 2. "Where is your toothbrush?" 3. "When would you like to have your bath?" 4. "Do you want to brush your teeth or have me do it for you?"
2. "Where is your toothbrush?" Because the client has problems with altered thought and has self-care deficits, the nurse needs to make the decisions. Simple questions and directions are most appropriate. This client probably is not capable of making decisions at this time. Asking what the client wants to do first, when he would like to have his bath, or whether he wants to brush his own teeth or have the nurse do it for him require the client to make a decision. These types of questions are inappropriate in this situation.
When monitoring a client for early signs of increasing intracranial pressure, the nurse should be particularly alert for which assessment data? 1. Pupillary changes 2. Difficulty arousing the client 3. Decreasing blood pressure 4. Elevated temperature
2. Difficulty arousing the client The first sign of pressure on the reticular activating system in the brain stem is a decrease in responsiveness, evidenced by difficulty in arousing the client. Pupillary changes occur later. Systolic blood pressure increases, not decreases, with increased intracranial pressure. Temperature changes vary and may not be present even with severe decreases in responsiveness.
The nurse is caring for a client with cancer. Morphine has been prescribed for the client. Specific to this medication, which intervention would the nurse include in the plan of care while the client is taking this medication? 1. Monitor radial pulse. 2. Monitor bowel activity. 3. Monitor apical heart rate. 4. Monitor peripheral pulses.
2. Monitor bowel activity. While the client is taking morphine, the nurse would monitor vital signs and assess for hypotension and respiratory depression. The nurse would monitor respiratory status and initiate deep breathing and coughing exercises. In addition, the nurse monitors the effectiveness of the pain medication. The nurse also would increase fluid intake, palpate the bladder for urinary retention, auscultate bowel sounds, and monitor the pattern of daily bowel activity and stool consistency, because the medication causes constipation.
Oxycodone has been prescribed for a client to treat pain. Which side and adverse effects would the nurse monitor for? Select all that apply. 1. Diarrhea 2. Tremors 3. Drowsiness 4. Hypotension 5. Urinary frequency 6. Increased respiratory rate
2. Tremors 3. Drowsiness 4. Hypotension Rationale: Oxycodone is an opioid analgesic. Side and adverse effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors. These effects are potentially life-threatening and therefore are important for the client to be aware of so that they can be reported immediately if noticed.
Which statement describes the halo sign exhibited by a client with a head injury? 1. Presence of glucose in ear drainage 2. Cerebral artery dilation because of a weakness in the arterial wall 3 Cerebrospinal fluid (CSF) leakage of blood surrounded by a yellow stain 4. Temporary neurologic dysfunction from decreased cerebral blood supply
3 Cerebrospinal fluid (CSF) leakage of blood surrounded by a yellow stain A halo sign refers to the leakage of CSF that appears bloody and is surrounded by a yellow stain. The presence of glucose in ear drainage denotes otorrhea. Cerebral artery dilation because of a weakness in the arterial wall describes a cerebral aneurysm. Temporary neurologic dysfunction because of a decrease in cerebral blood supply refers to a transient ischemic attack.
Which statement would be included in the teaching plan for the client scheduled for a carotid angiography? 1. "You will receive general anesthesia before the needle is inserted." 2. "The test will take several hours to complete." 3. "You may feel a burning sensation when the contrast dye is injected." 4. "There are relatively few serious complications with this procedure."
3. "You may feel a burning sensation when the contrast dye is injected." Providing a client with information about expected sensations often helps decrease anxiety. The contrast medium commonly causes a burning sensation as it passes through the cerebral arteries. Clients rarely receive general anesthesia for angiography. The test usually takes less than an hour. Various serious complications, such as airway obstruction and vasospasm with sensory and motor deficits, may occur after an angiogram.
A client has sustained a severe head injury and damaged the prefrontal lobe. Which complication should the nurse expect to assess in the client? 1. Visual impairment 2. Swallowing difficulty 3. Impaired judgment 4. Hearing impairment
3. Impaired judgment A number of areas of the brain are involved in cognition and thinking, but damage to the prefrontal area usually results in impaired judgment and insight. Vision problems may occur with pathology in the occipital lobe or in the pituitary area (i.e., optic chiasm). Swallowing problems result from damage to cranial nerve IX in the brain stem. Hearing impairment commonly occurs with damage to cranial nerve VIII.
Which nursing intervention should the nurse implement for a client experiencing a tonic-clonic seizure? 1. Placing a tongue blade between the client's clenched teeth 2. Elevating the client's head at least 30 to 60 degrees 3. Protecting the extremities from contact with other objects 4. Firmly restraining the arms and legs alongside the body
3. Protecting the extremities from contact with other objects Because of the tonic-clonic motions, protecting the client by moving objects so that the arms and legs do not hit them and placing a soft object under the head are the most important immediate interventions. Trying to force a tongue blade or other object into the mouth may damage the teeth. Nothing is gained by elevating the client's head, because breathing will return to normal after the activity stops. Restraining movement may result in injury or stiffness after the seizure.
A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of this laboratory result? 1. Hypotension 2. Tachycardia 3. Slurred speech 4. No abnormal finding
3. Slurred speech Rationale: The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL, ataxia and slurred speech occur.
The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information would the nurse include in the teaching plan? 1. Pregnancy must be avoided while taking phenytoin. 2. The client may stop the medication if it is causing severe gastrointestinal effects. 3. There is the potential of decreased effectiveness of birth control pills while taking phenytoin. 4. There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together
3. There is the potential of decreased effectiveness of birth control pills while taking phenytoin. Rationale: Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options 1, 2, and 4 are inappropriate instructions. Pregnancy does not need to be "avoided" while taking phenytoin; however, because phenytoin may cause some risk to the fetus, consultation with the primary health care provider needs to be done if pregnancy is considered. Telling a client that there is an increased risk of thrombophlebitis is incorrect and inappropriate and could cause anxiety in the client. A client would not be instructed to stop antiseizure medication.
A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication? 1. Sodium level, 140 mEq/L (140 mmol/L) 2. Uric acid level, 4.0 mg/dL (240 mcmol/L) 3. White blood cell count, 3000 mm3 (3.0 °— 109/L) 4. Blood urea nitrogen level, 10 mg/dL (3.6 mmol/L)
3. White blood cell count, 3000 mm3 (3.0 °— 109/L) Rationale: Carbamazepine, classified as an antiseizure medication, is used to treat nerve pain. Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances, including thrombophlebitis and dysrhythmias; and dermatological effects. The low white blood cell count reflects agranulocytosis. The laboratory values in options 1, 2, and 4 are normal values.
After a stroke, which statement by the client indicates that teaching about passive range-of-motion (ROM) exercises has been successful? 1. "I do these exercises by myself with the supervision of the nurse." 2. "The nurse can help me do them if I have trouble doing them on my own." 3. "I should sit at the side of the bed to perform the exercises." 4. "The nurse performs the exercises without any help from me."
4. "The nurse performs the exercises without any help from me." Passive ROM exercises are defined as those performed by one person to the joints of a client, without any help from the client. The client's performance of the exercises is called active ROM. Performing the exercises by himself with some assistance if trouble is encountered is referred to assisted ROM. ROM exercises are usually done in bed but can be done anywhere.
A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? 1. No change in the condition 2. Complaints of muscle spasms 3. An improvement of the weakness 4. A temporary worsening of the condition
4. A temporary worsening of the condition Rationale: An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis. Muscle spasms are not associated with this test.
The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote would the nurse prepare for administration if prescribed? 1. Pentostatin 2. Auranofinterm-19 3. Fludarabine 4. Acetylcysteine
4. Acetylcysteine Rationale: The antidote for acetaminophen is acetylcysteine. The normal therapeutic serum level of acetaminophen is 10 to 20 mcg/mL. A toxic level is higher than 50 mcg/mL, and levels higher than 200 mcg/mL 4 hours after ingestion indicate that there is risk for liver damage. Auranofin is a gold preparation that may be used to treat rheumatoid arthritis. Pentostatin and fludarabine are antineoplastic agents.
A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication? 1. Sodium level of 140 mEq/L (140 mmol/L) 2. Platelet count of 400,000 mm3 (400 °— 109/L) 3. Prothrombin time of 12 seconds (12 seconds) 4. Direct bilirubin level of 2 mg/dL (34 mcmol/L)
4. Direct bilirubin level of 2 mg/dL (34 mcmol/L) Rationale: In adults, overdose of acetaminophen causes liver damage. The correct option is an indicator of liver function and is the only option that indicates an abnormal laboratory value. The normal direct bilirubin level is 0.1 to 0.3 mg/dL (1.7 to 5.1 mcmol/L). The normal sodium level is 135 to 145mEq/L (135 to 145 mmol/L). The normal prothrombin time is 11 to 12.5 seconds (11 to 12.5 seconds). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 Å~ 109/L).
Which intervention would have priority when providing emergency care to a client with a possible cervical spinal injury? 1. Monitoring vital signs every 5 minutes 2. Placing the neck in position of flexion 3. Checking to see if the client can move his toes 4. Immobilizing the head and spine in proper alignment
4. Immobilizing the head and spine in proper alignment The most important consideration when dealing with a client who has a possible cervical spinal injury is to immobilize the head and spine in alignment to prevent possible fractures or dislocated bone from damaging the spinal cord. Monitoring the client's vital signs is important but secondary to immobilization. Flexing the neck can cause spinal cord damage. Clients with suspected spinal injuries should avoid movement until spinal cord damage is ruled out.
Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? 1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements
4. Impaired voluntary movements Rationale: Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication
Which clinical manifestations would the nurse expect to assess in a client diagnosed with Guillain-Barré syndrome? 1. Headache and nuchal rigidity 2. Unilateral mouth drooping and pain 3. Severe fatigue and diplopia 4. Leg paresis and paresthesia
4. Leg paresis and paresthesia Common signs and symptoms of Guillain-Barré syndrome include leg paresis (usually the initial manifestation); motor weakness progressing to involve the entire peripheral nervous system, including respiratory muscles; and paresthesias. A client diagnosed with meningitis exhibits nuchal rigidity and complains of a headache. Unilateral mouth drooping and pain occur with Bell's palsy. Diplopia along with severe fatigue is seen in a client diagnosed with myasthenia gravis.
Which clinical manifestation would alert the nurse to the possibility of meningitis? 1. Unilateral mouth drooping 2. Post-activity muscle weakness 3. Impaired speech and swallowing 4. Nuchal rigidity
4. Nuchal rigidity Meningitis results in meningeal irritation. Signs of meningeal irritation include nuchal rigidity, positive Brudzinski's and Kernig's signs, exaggerated deep tendon reflexes, and opisthotonos. Unilateral mouth drooping suggests Bell's palsy. Muscle weakness, especially after activity, suggests myasthenia gravis. Impaired speech and swallowing may suggest amyotrophic lateral sclerosis or be the result of a stroke.
In which area would the nurse expect loss of motor control and sensation if the client experienced a spinal cord injury below the level of L4? 1. Below the mid-chest 2. Parts of the arms and hands 3. Legs and pelvis 4. Parts of the thighs and legs
4. Parts of the thighs and legs With a spinal cord injury below the level of L4, the client typically experiences loss of motor control and sensation in parts of the thighs and legs. Loss of motor control and sensation from below the mid-chest occurs in clients with a spinal cord injury below T6, but motor control and sensation are preserved in the arms and hands. Loss of motor control and sensation to parts of the arms and hands is seen in a client with injury below C8. With all these injuries, bowel and bladder control is lost.
A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following pieces of information should the nurse include? A. "You might need glasses after the surgery." B. "You may drive home after the procedure." C. "Continue to wear your contact lenses until the day of the surgery." D. "Expect complete healing and clear vision in about a week."
A. "You might need glasses after the surgery." LASIK is a type of refractive laser eye surgery that ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, overcorrection or undercorrection of refractive errors is possible, so some clients will need prescription eyeglasses despite having had LASIK surgery.
A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? A. Add gestures when speaking with the client B. Ask open-ended questions C. Limit visitors to 3 at a time D. Use different words if the client does not understand a statement
A. Add gestures when speaking with the client The nurse should use gestures when speaking with the client to increase the client's understanding of the conversation. Incorrect Answers:B. The nurse should ask questions that can be answered with "yes" or "no" to reduce the client's confusion. C. The nurse should limit visitors to 2 at a time to reduce the client's confusion. D. The nurse should use the same words when repeating a statement to reduce the client's confusion.
A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement? A. Dysphagia B. Positive Babinski sign C. Decreased deep-tendon reflexes D. Ataxia
A. Dysphagia Dysphagia (difficulty swallowing) can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus). Incorrect Answers:B. A positive Babinski sign (turning up of the toes on plantar stimulation) is associated with an upper motor neuron lesion. The cranial nerves primarily innervate the face, neck, and a few organs. C. Decreased deep-tendon reflexes indicate impairment in the electrical conduction of spinal nerves that interfere with reflex arcs. D. Ataxia (uncoordinated movements of the extremities) can indicate damage to the cerebellum or motor pathways.
A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? A. Widened pulse pressure B. Tachycardia C. Periorbital edema D. Decrease in urine output
A. Widened pulse pressure A widening of the pulse pressure (i.e. the difference between the systolic and diastolic pressure) is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting.
A nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions? A. "I will sleep on the affected side." B. "I will avoid bending over." C. "I will restrict caffeine in my diet." D. "I will take aspirin to relieve my pain."
B. "I will avoid bending over." The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can create intraocular hemorrhage.
A nurse is preparing an older adult client who had a transient ischemic attack (TIA) for discharge. The nurse should teach the client to monitor which of the following parameters at home? A. Blood glucose B. Blood pressure C. Daily weight D. Sensation in the feet
B. Blood pressure A temporary disturbance of the blood supply to the brain causes a TIA, which is a brief alteration in neurological function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should track his BP regularly to promote hypertension management and reduce the risk of another TIA or cerebrovascular accident.
A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul
B. Cheyne-Stokes Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.
A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nares C. Motor loss on one side of the body D. Bleeding from the top of the scalp
B. Clear fluid coming from the nares Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture. Incorrect Answers:A. Although a client who has a depressed fracture of the forehead might also have additional head trauma, this finding does not indicate a basilar skull fracture, which occurs at the base of the skull. C. Motor loss on one side of the body is an indication of an injury to the cerebral hemisphere. The motor dysfunction will be contralateral to the site of, which mean on the opposite side of, the injury, similar to the results of a stroke. Loss of motor function can also be an indication that injury has occurred to the spinal cord. D. Although a client who has bleeding from the scalp might also have additional head trauma, this finding does not indicate a basilar skull fracture.
A nurse is caring for a client who has Ménière's disease. The nurse should identify that Ménière's disease affects which structure of the ear? A. Eustachian tube B. Cochlea C. Perichondrium D. Eardrum
B. Cochlea Ménière's disease is a condition of the inner ear in which excess fluid distorts the inner ear canal system. This distortion decreases hearing via dilation of the cochlear duct, leading to vertigo from damage to the vestibular system.
A nurse is providing teaching to a client who has a new diagnosis of Menière's disease. Which of the following instructions should the nurse include in the teaching? A. Avoid bearing down B. Increase caffeine intake C. Avoid sudden movements D. Increase sodium intake
C. Avoid sudden movements Ménière's disease is a disorder of the inner ear affecting balance and hearing. It is characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations.
A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure? A. Battle's sign B. Periorbital edema C. Dilated pupils D. Halo sign
C. Dilated pupils Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately. Incorrect Answers:A. Battle's sign is bruising behind the ears and lower jaw that can occur from the trauma of a skull fracture. It does not indicate increased intracranial pressure. B. Periorbital edema is a result of facial trauma. It does not indicate increased intracranial pressure. D. A halo sign is a clear or yellow ring surrounding a spot of fluid or blood from the nose or ear. The ring indicates leakage of cerebral spinal fluid that can occur with a skull fracture. It does not indicate increased intracranial pressure.
A nurse is caring for a client during the first 72 hr following a cerebrovascular accident (CVA). Which of the following actions should the nurse take? A. Turn the client's head to the side with the head of the bed elevated 60° B. Place the head of the bed flat with pillows under the client's neck and feet C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position D. Position the client in a dorsal recumbent position with pillows under the head and knees
C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position Elevating the head of the bed 25° to 30° with the client's head in a neutral midline position helps prevent an increase in intracranial pressure. Increased intracranial pressure is a major risk factor for complications in the first 72 hours following the onset of a CVA.
A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.) A.Lost vision can improve with eye drops. B. Administer eye drops as needed for vision loss. C. Glasses will be necessary to correct the accompanying presbyopia. D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor.
C. Glasses will be necessary to correct the accompanying presbyopia. D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor. Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can lead to complete vision loss if not treated. Laser surgery can reopen the trabecular meshwork and widen the canal of Schlemm.
A nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the client he will have to repeat them again in a few minutes. After 5 min, the nurse asks the client to name the objects. The nurse is using this strategy to test which type of memory? A. Remote B. Sensory C. Immediate D. Recall
C. Immediate The nurse tests the client's immediate or new memory by following the 3-object protocol. A client without cognitive decline should be able to recall and name the 3 objects 5 minutes later. Incorrect Answers:A. The nurse tests remote or long-term memory by asking about information from the client's past that family or friends can verify later. B. Sensory memory is a momentary perception of some form of stimuli from the environment. Recalling 3 objects 5 minutes later does not test sensory memory. D. The nurse tests recall or recent memory by asking questions about recent activities that can be verified in the client's medical record, such as how the client got to the facility or the time of admission.
A nurse is assessing a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment? A. Inability to remember current age B. Inability to count backward C. Inability to locate eyeglasses D. Inability to recall names of family members
C. Inability to locate eyeglasses Short-term memory loss is manifested by an inability to recall events or actions that just occurred, such as where the client recently placed her eyeglasses.
A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). This increase in ICP is due to which of the following? A. Decreased cerebral perfusion B. Leakage of cerebral spinal fluid C. Rigid skull containing cranial contents D. Brain herniated into the brainstem
C. Rigid skull containing cranial contents The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP. Incorrect Answers:A. A decrease in cerebral perfusion is a result of increasing ICP, not the cause. This leads to brain tissue ischemia and edema, which can cause death if untreated. B. The leakage of cerebral spinal fluid occurs with a basilar skull fracture, which is an open traumatic injury rather than a closed traumatic injury. D. Brain herniation can occur as a result of untreated increased intracranial pressure and can lead to death. It is not a cause of increased intracranial pressure.
A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? A. Multiple floaters B. Flashes of light in front of the eye C. Severe eye pain D. Double vision
C. Severe eye pain Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headaches, brow pain, and nausea and vomiting.
Increased ICP signs A. abdominal pain and increased urination B. increased hunger and neuropathy C. increasing confusion, vomiting, sluggish pupils D. motor increases, no change in LOC
C. increasing confusion, vomiting, sluggish pupils
A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching? A. A TIA can cause irreversible hemiparesis. B. A TIA can be the result of cerebral bleeding. C. A TIA can cause cerebral edema. D. A TIA can precede an ischemic stroke.
D. A TIA can precede an ischemic stroke. TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include the loss of vision in an eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness.
A nurse is caring for a client who has a cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected? A. Wernicke's area B. Cerebral cortex C. Basal ganglia D. Hypothalamus
D. Hypothalamus The nurse should identify that the hypothalamus, located below the cerebrum of the brain, is responsible for the regulation of body temperature. Incorrect Answers:A. Wernicke's area is responsible for language and speech comprehension, not the regulation of body temperature B. The cerebral cortex is involved in complex thought processes and higher functions of the brain, not the regulation of body temperature. C. The basal ganglia are involved in a variety of functions, including motor control and learning, but not the regulation of body temperature.
A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease (AD). Which of the following pieces of information should the nurse include in the teaching? A. Place abstract pictures on the wall in the client's room B. Provide music for the client using headphones C. Reorient the client to reality frequently D. Limit choices offered to the client
D. Limit choices offered to the client Choices should be limited for a client who has stage II AD to reduce confusion and frustration.
A nurse is planning care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the client's plan of care? A. Prevent depression in the client B. Refer the client to occupational therapy C. Support the client's family D. Monitor the client for increased intracranial pressure (ICP)
D. Monitor the client for increased intracranial pressure (ICP) The greatest risk to this client is an injury from increased ICP, which can result in decreased cerebral perfusion and neurological injury. Therefore, the priority intervention the nurse should include in the plan of care is monitoring the client for increased ICP. Manifestations of increased ICP include a decreased level of consciousness and a change in pupils.
A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. Flushing of the lower extremities B. Hypotension C. Tachycardia D. Report of a headache
D. Report of a headache Autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.
A nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. Which of the following pieces of information in the client's medical record should the nurse identify as a risk factor for tinnitus? A. Use of hydrochlorothiazide B. Chronic use of acetaminophen C. Allergic external otitis D. Sclerosis of the ossicles
D. Sclerosis of the ossicles Sclerosis of the ossicles, called otosclerosis, is an overgrowth of the tissue of the bones in the middle ear, which can cause tinnitus and conductive hearing loss. A stapedectomy is a surgical procedure that corrects otosclerosis by removing a portion of the stapes and inserting a prosthesis.
A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI? A. Blood urea nitrogen (BUN) B. Blood glucose C. Urine ketones D. Specific gravity
D. Specific gravity Diabetes insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, an infection, or a tumor. In this condition, an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus.
A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. Which of the following pieces of information in the client's history is a contraindication to this procedure? A. The client has a new tattoo. B. The client is unable to sit upright. C. The client has a history of peripheral vascular disease. D. The client has a pacemaker.
D. The client has a pacemaker. An MRI uses strong magnets and radio waves that are evaluated using computer technology to view 3-dimensional images of the body. Since an MRI is magnetically generated, it is not indicated for use in the presence of certain medical implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures.
