NEURO Prep U - Study Guide

Which goal is a priority for a client who has undergone surgery for retinal detachment?`

Prevent an increase in intraocular pressure.

When assessing the client with Parkinson's disease, the nurse should observe the client for:

a stiff, masklike facial expression.

When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for:

aspiration

A client who has Ménière's disease is experiencing an acute attack of vertigo. The nurse should:

darken the client's room and provide a quiet environment.

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition?

decrease in level of consciousness (LOC)

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for:

sudden, severe hypertension

A nurse is caring for a client declared brain dead following a motor vehicle accident. When the nurse enters the client's room, his spouse and family are talking with friends about the possibility of organ donation. Which statement by the nurse reflects an ethical practice dilemma?

"If you're thinking about organ donation, my sister is waiting for a kidney transplant. She'd be an excellent recipient. I can give you her phone number."

Three years ago, a client was diagnosed with multiple sclerosis. He now presents with lower extremity weakness and heaviness. During the admission process, the client presents his advance directive that states he doesn't want intubation, mechanical ventilation, or tube feedings, should his condition deteriorate. How should the nurse respond?

"It's important for us to have this information. You should review the document with your physician at every admission."

A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The healthcare provider calls and asks for a report on the client's condition. Based on the documentation below, how would the nurse respond?

"The client's ICP remains elevated."

It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client:

"You will need to hold your head very still during the examination."

A client is scheduled to undergo cerebral angiography to allow for examination of the cerebral arteries. Place the following interventions in the order in which the nurse would perform them. All options must be used.

1.Encourage the client to verbalize questions about the procedure with nurse and health care provider. 2.Make sure the client has signed an informed consent form. 3.Confirm no allergies to iodine, seafood, or radiopaque dyes. 4.Administer antianxiety medication if ordered. 5.Maintain the affected extremity in straight alignment for 6 hours as ordered.

A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?

Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer?

Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply.

Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?

Declining level of consciousness (LOC)

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with chin resting on flexed knees

A client has been injured in a snowmobile accident and is airlifted to the trauma center with a neck injury. The nurse needs to implement which of the following interventions if the injury is at the C4 level? Select all that apply.

Mechanical ventilation to prevent hypoxemia and hypercapnia Assessment of level and extent of paralysis

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate?

Meningeal irritation

Which action is contraindicated for a client with seizure precautions?

assessing the client's oral temperature with a glass thermometer

A client returns from a myelogram, for which an iodized oil was used. The nurse should include which instruction in the plan of care?

assessment of lower extremity movement and sensation

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:

demonstrate eyedrop instillation.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness.

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the client's first response to pain will be to:

escape the source of pain.

The nurse should instruct the client with low back pain to avoid:

exceeding the prescribed exercise program.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. The nurse should:

explain how to overcome a freezing gait by telling the client to march in place.

A client has had a cerebrovascular accident (CVA) which has affected the left side of the client's brain. The nurse should assess the client for:

expressive aphasia.

The client with a lumbar laminectomy asks to be turned onto the side. The nurse should:

get another nurse to help logroll the client into position.

A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage?

head of the bed elevated to 30 degrees with the client's head in a neutral position

The son of an older adult reports that his father increasingly just "stares off into space" in the last several months, but then eagerly smiles and nods once the son can get his attention. The nurse should assess the client further for:

hearing loss

After an eye examination, a client is diagnosed with open-angle glaucoma. The physician orders pilocarpine ophthalmic solution, 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by:

instilling one drop of pilocarpine 0.25% into both eyes four times daily.

After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which postoperative complication?

intraocular hemorrhage

The nurse is assessing an infant diagnosed with bacterial meningitis. The nurse should ask the parent if the infant has which symptoms? Select all that apply.

poor feeding vomiting fever

A nurse is caring for a client with severe depression. The client reports changes in appetite and sleep pattern and has lost her job because of the effects of her depression. The client has two young children at home and states, "I just wish things could be like they were. I feel so helpless that I can't even get out of bed in the morning." The physician has ordered electroconvulsive therapy (ECT) for the client in addition to her current antidepressant medications. A nurse evaluates the ECT therapy as effective when the client:

sleeps through the night, eats 80% of her meals, and is out of bed.

An older adult has vertigo accompanied with tinnitus as the result of Ménière's disease. The nurse should instruct the client to restrict which dietary element?

sodium

A nurse is monitoring a client for adverse reactions to atropine eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?

tachycardia

The nurse assesses for euphoria in a client with multiple sclerosis, looking for what characteristic clinical manifestation?

an exaggerated sense of well-being

A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a corticosteroid ointment, one-half inch in the lower conjunctival sac four times a day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent:

increased intraocular pressure (IOP).

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:

the rehabilitation plan will be guided by it.

The best method to remove cerumen from a client's ear involves:

irrigating the ear gently.

A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plans the client's nursing care with the understanding that acute angle-closure glaucoma:

is a medical emergency that can rapidly lead to blindness.

A nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy.

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate?

limiting fluid intake to 1,000 mL/day

Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure?

loss of consciousness, body stiffening, and violent muscle contractions

The client with Ménière's disease is instructed to modify his diet. The nurse should explain that the most frequently recommended diet modification for Ménière's disease is:

low sodium

After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eyedrops. The expected outcome of applying pressure is that the pressure:

prevents the medication from entering the tear duct.

The primary goal in the plan of care for the client after cataract removal surgery is to:

promote safety at home.

A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client?

"You are in the hosipital. You were in an accident and unconscious."

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?

"Assume a reclining or flat position."

Which statement indicates the client understands the expected course of Ménière's disease?`

"Control of the episodes is usually possible, but a cure is not yet available."

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?

"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."

As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability?

"I can participate in sexual activity but might not experience orgasm."

The nurse is teaching a young woman about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client states:

"I will use one of the barrier methods of contraception."

After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in the legs, and calls the nurse in excitement to report the leg movement. Which response by the nurse would be the most accurate?

"The movements occur from muscle reflexes that cannot be initiated or controlled by the brain."

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate an understanding of the instructions? Select all that apply.

"If brushing my teeth is too painful, I'll try to rinse my mouth instead." "I'll try to chew my food on the unaffected side." "Drinking fluids at room temperature should reduce pain."

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why am I unable to stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior?

"Reviewing your losses is a way to help you work through your grief and loss."

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin. Client teaching about this drug should include which instruction?

"Schedule follow-up visits with your physician for blood tests."

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

"The paralysis caused by this disease is temporary."

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time he's admitted to the intensive care unit (ICU) for aggressive treatment. She's meeting with the team to develop a change strategy using indicators. Which statement by a team member indicates a need for further teaching regarding performance management?

"We can discipline the ED staff for not getting the clients to the ICU fast enough."

A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client reports a headache. The mother questions pain medication for home. Which response by the nurse is most appropriate?

"Your child has a mild concussion; acetaminophen can be given."

The parent of a child who is taking an antibiotic for bilateral otitis media tells the nurse that they have stopped the medicine since the child is better and are saving the rest of the medication to use the next time the child gets sick. What should the nurse tell the parent?

"Your child needs all of the medicine so that the infection clears."

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.

1.Ease the client to the floor. 2.Maintain a patent airway. 3.Obtain vital signs. 4.Record the seizure activity observed.

When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of:

10 to 20 mm Hg

A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?

15

A client has just undergone a lumbar puncture (LP). Which finding should the nurse immediately report to the health care provider (HCP)?

A moderate amount of serous fluid was noted on the lumbar dressing.

A child with meningitis is to receive 1,000 mL of dextrose 5% in normal saline over 12 hours. At what rate in milliliters per hour should the nurse set the pump? Round your answer to the nearest whole number.

83

The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure and monitors the blood pressure for signs of widening pulse pressure. The client's current blood pressure is 170/80 mm Hg. What is the client's pulse pressure? Record your answer using a whole number.

90

Which of the following clients requires increased sensory stimulation to prevent sensory deprivation?

A 65-year-old client who has employment-induced presbycusis and advanced glaucoma

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 bpm; and respiratory rate of 30 shallow breaths/min. What should the nurse do first?

Activate the Rapid Response Team (RRT).

Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?

Activity is resumed gradually; the client can resume usual activities in 5 to 6 weeks.

The client with glaucoma is scheduled for a hip replacement. Which prescription would require clarification before the nurse carries it out?

Administer atropine sulfate.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

Alternatively patch one eye every 2 hours.

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?

An isolation room three doors from the nurses' station

What should a nurse do when administering pilocarpine?

Apply pressure on the inner canthus to prevent systemic absorption.

The nurse is preparing to administer propranolol to a client for control of migraine headaches. The client also has a prescription for sumatriptan as needed for a headache. The client's pulse rate is 56 bpm. What should the nurse do next?

Assess blood pressure.

Following a scleral buckling, what should the nurse instruct the client to do during the postoperative period?

Assess for eye drainage.

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?

Attaching braces or splints to each foot and leg

During a facility disaster drill, an "injured client" presents to the emergency department with complaints of dry mouth, inability to focus his vision, and double vision. A nurse notes that the client has an unsteady gait and appears to be very weak. The client states, "My arms and legs feel like they just can't move." A nurse suspects the client may be a victim of bioterrorism with:

Botulism

A nurse is documenting a health assessment when the client states having problems with balance, as well as, fine and gross motor function. When collaborating with the health team, in which area on the illustration of the brain would the nurse highlight as an area of concern?

CLICK IN MIDDLE OF CEREBELLUM

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?

Decreased acetylcholine level

A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests?

EEG, blood cultures, and neuroimaging studies

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

The nurse is caring for a client with a subdural hematoma. Which of the following is the priority outcome?

Ensure airway patency and optimal oxygen levels and protect from injury.

When completing a nursing assessment on a client admitted with a neck injury, which of the following findings would indicate an incomplete spinal cord injury (SCI)?

Evidence of voluntary motor and sensory function below the level of injury

The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which intervention should the nurse consider?

Thicken all liquids before offering to the client.

A nurse is caring for a client who's had surgery to repair a hip fracture. The client says his left hand and arm are numb and he can't move the extremity. The nurse contacts the physician, who suspects brachioplexus nerve damage. What additional priority assessment does the nurse need?

Function of the client's left hand before the operation

Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which body system?

GI

A client with glaucoma is to receive 3 gtt of acetazolamide in the left eye. What should the nurse do?

Have the client look up while the nurse administers the eyedrops.

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Helicopod

The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring?

I&O

When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis?

Improved muscle strength after I.V. administration of edrophonium chloride.

The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which of the following nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions?

Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?

Increase the frequency of client observation.

A physician diagnoses a client with myasthenia gravis, and orders pyridostigmine, 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition should lead the nurse to question this drug order?

Intestinal obstruction

A client with a new diagnosis of myasthenia gravis asks, "What is happening to me?" What would be the most appropriate response by the nurse?

It is a chronic disease in which there is a disturbance in nerve transmission to the muscle, resulting in fatigue and muscle weakness.

A physician orders diazepam, 10 mg I.V., for a client experiencing status epilepticus. Which statement about I.V. diazepam is true?

It should be administered no faster than 5 mg/minute in an adult.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

Keeping the client in one position to decrease bleeding

A parent of a child with a moderate head injury asks the nurse, "How will you know if my child is getting worse?" The nurse should tell the parents that best indicator of the child's brain function is:

LOC

Which is the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury?

Leg girth

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume

A new ancillary staff member is assisting the nurse with a client diagnosed with Parkinson's disease. The client needs assistance with eating but doesn't require thickened liquids to aid swallowing. Which instruction should the nurse give the ancillary staff member about eating assistance?

Make sure the client is sitting with the head of bed elevated to 90 degrees.

A nurse is providing discharge instructions on phenytoin to a female client with tonic-clonic seizure disorder. Which instructions would the nurse include? Select all that apply

Monitor for skin rash. Perform good oral hygiene, including daily brushing and flossing. Receive necessary periodic blood work. Report any problems with walking or coordination, slurred speech, or nausea.

The nurse has administered mannitol IV. Which is a priority assessment for the nurse to make after administering this drug?

Monitor urine output.

Which of the following nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

What assessment findings would the nurse expect to find with a client with progressive myasthenia gravis?

Muscle weakness, difficulty swallowing, double vision, and difficulty speaking

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?

Risk for injury related to vertigo

A client who has Ménière's disease reports having frequent attacks of vertigo. The nurse should include which information in the client's teaching plan? Select all that apply.

Sit down if dizzy. Consider using a cane to maintain balance during an attack. Avoid bright lights if they make the symptoms worse.

A client is scheduled for surgery is confused and shows signs of dementia. The nurse should ask which person to sign the consent for the client?

Spouse

A client has been hospitalized with a diagnosis of myasthenia gravis. A friend is visiting the client during lunch. The nurse enters the room after the client recovered from choking on lunch. What should the nurse do next?

Tell the client to swallow when her chin is tipped down on her chest.

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?

Test the nasal drainage for glucose.

After 5 days of hospitalization, a client who is receiving morphine sulfate for pain control asks for pain medication with increasing frequency and exhibits increased anxiety and restlessness. The vital signs are within normal ranges. What is a possible cause of this behavior?

The client has developed tolerance to the dose of morphine.

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment?

To prevent vision loss

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?

Trigeminal neuralgia

The nurse is caring for a client with a diagnosis of cerebrovascular accident (CVA) with left-sided hemiparesis. What would be important nursing measures in the acute phase of care? Select all that apply.

Turn and position every 2 hours. Perform passive range of motion on the affected side. Support the affected side with pillows.

The client with a head injury receives mannitol during surgery to help decrease intracranial pressure. Which finding indicates that the drug is having the desired effect?

Urine output increases.

A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention?

Urine retention or incontinence

Which is the most effective way for a nurse to assess for posterior nasal bleeding in a client who has had nasal surgery?

Use a penlight to inspect the back of the pharynx for bleeding.

An adult client has bacterial conjunctivitis. What should the nurse teach the client to do? Select all that apply.

Wash the hands after touching the eyes. Use warm saline soaks four times per day to remove crusting. Avoid touching the eyes. Apply topical antibiotic without touching the tip of the tube to the eye.

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)?

Wrap the hands in soft "mitten" restraints.

The nurse should inform a client with Ménière's disease that before an attack of the disease, the client may experience:

a feeling of inner ear fullness.

A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client? The client will:

actively participate in the rehabilitation process as appropriate.

When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated?

asking the client to speak louder when tired

A history of which factors will complicate the recovery from a concussion? Select all that apply.

attention deficit/hyperactivity disorder (ADHD) depression migraines previous concussion

A client with alcohol dependency has peripheral neuropathy. The nurse should develop a teaching plan that emphasizes:

avoiding use of an electric blanket.

After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which activity would be contraindicated?

bending over the sink to wash the face

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called:

conductive hearing loss.

A client is color blind. The nurse understands that this client has a problem with:

cones

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:

cranial nerves IX and X.

An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, then take him to the emergency department of a nearby hospital, where he receives emergency care for corneal injury. The physician orders dexamethasone, two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate, 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. The nurse knows that dexamethasone exerts its therapeutic effect by:

decreasing leukocyte infiltration at the site of ocular inflammation.

The nurse should assess clients with chronic open-angle glaucoma (COAG) for:

decreasing peripheral vision.

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

dysfunction in the brain stem.

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?

even unlabored respirations

A nurse on a rehabilitation unit is caring for a client who sustained a head injury in a motor vehicle accident. She notes that the client has become restless and agitated during therapy; previous documentation described the client as cooperative during therapy sessions. The nurse's priority action should be to:

gather assessment data and notify the physician of the change in the client's status.

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness

Which nursing diagnosis takes the highest priority for a client with parkinsonian crisis?

ineffective airway clearance

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?

inner ear

The primary nursing goal for a client with myasthenia gravis is to:

maintain respiratory function.

A short time after cataract surgery, the client has nausea. The nurse should first:

medicate the client with an antiemetic, as prescribed.

A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which of the following?

meningitis

A nurse is monitoring a client for adverse reactions to dantrolene. Which adverse reaction is most common?

muscle weakness

A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the health care provider (HCP) immediately?

new onset of footdrop

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. The nurse should:

notify the health care provider (HCP).

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

occipital

Following nasal surgery, the client has packing in the nose. The nurse should:

perform frequent mouth care.

A client is experiencing autonomic dysreflexia. The nurse should first:

place the client in Fowler's position.

Which action is not appropriate when providing oral hygiene for a client who has had a stroke?

placing the client on the back with a small pillow under the head

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction?

pulling up the client under the left shoulder when getting the client out of bed to a chair

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon's eyes and Battle's sign.

The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. The nurse should:

readminister the residual to the client and continue with the feeding.

A client uses timolol maleate eyedrops. The expected outcome of this drug is to control glaucoma by:

reducing aqueous humor formation.

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

respiratory acidosis

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in an air-conditioned room.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

risk for injury

A client tells the nurse about the vision being blurred and hazy throughout the entire day. The nurse should recommend that the client:

schedule an appointment with an ophthalmologist.

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?

semi-Folwer's

After the client returns from surgery for a deviated nasal septum, the nurse should place the client in what position?

semi-Fowler's

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:

she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

Which respiratory pattern indicates increasing intracranial pressure in the brain stem?

slow, irregular respirations

Which action would not be appropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a ruptured disc?

starting an IV line at keep-open rate

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent?

succinylcholine

A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside?

suction machine with catheters

The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document:

the client's hand-grasp strength is equal.

Sodium polystyrene sulfonate is prescribed for a client following crush injury. The drug is effective if:

the serum potassium is 4.0 mEq/L (4.0 mmol/L).

Which goal is the most realistic for a client diagnosed with Parkinson's disease?

to maintain optimal body function

The nurse is to check a client's gag reflex. The most effective technique for testing the gag reflex is to:

touch the back of the client's throat with a tongue blade.

Which is an initial sign of Parkinson's disease?

tremor

A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by:

turning the client's head suddenly while holding the eyelids open.

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?

unequal pupil size

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences.

One day after cataract surgery the client is having discomfort from bright light. The nurse should advise the client to:

use sunglasses that wrap around the side of the face when in bright light.

A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to:

wander