Neurosensory

The long-term care nurse is caring for a client newly diagnosed with macular degeneration. Which client statement would support this diagnosis? 1. "I have been seeing small flashes of light." 2. "I have trouble threading my sewing needle; I have to hold it at arm's length." 3. "I notice that my peripheral vision is becoming worse." 4. "I see a blurry spot in the middle of the page when I read."

4

The nurse receives the change of shift report for assigned clients at 7 AM. Which client should the nurse assess first? 1. Client with change in level of consciousness who fell in the nursing home 2. Client with chronic headaches who is scheduled for an MRI at 9 AM 3. Client with chronic obstructive pulmonary disease (COPD) and pulse oximeter reading of 90% 4. Client with heart failure and 3+ pitting edema of the lower extremities

1

A client is admitted to the hospital with an exacerbation of myasthenia gravis. What are the appropriate nursing actions? Select all that apply. 1. Administer an anticholinesterase drug AC 2. Anticipate a need for an anticholinergic drug 3. Develop a bladder training schedule 4. Encourage semi-solid food consumption 5. Teach the necessity for annual flu vaccination

1,4,5

A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye. The conjunctiva is erythematous and the client reports a burning sensation. What is the priority action? 1. Analgesic oral medication 2. Copious eye irrigation 3. Cover with an eye patch 4. Snellen eye acuity test

2

The emergency department nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury. Which assessment finding is consistent with injury to the occipital lobe? 1. Decreased rate and depth of respirations 2. Deficits in visual perception 3. Expressive aphasia 4. Inability to recognize touch

2

A nurse is speaking with the parent of a school-aged child who was newly diagnosed with myopia. Which statements by the parent support this diagnosis? Select all that apply. 1. "My child closes one eye to read." 2. "My child gets headaches frequently." 3. "My child is doing poorly in math." 4. "My child's eyes blink often." 5. "My child's eyes seem red most of the time."

2,3,4

The nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes. Which cranial nerves is the nurse assessing? Select all that apply. 1. II 2. III 3. IV 4. V 5. VI

2,3,5

A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency? 1. "I am very tired, and it's hard for me to keep my eyes open." 2. "I don't feel good, and I want to be seen." 3. "I have not taken my blood pressure medicine in over a week." 4. "I have the worst headache I've ever had in my life."

4

The nurse receives the assigned clients for today on a neurology unit. The nurse should check on which client first? 1. Client with history of head injury whose Glasgow Coma Scale (GCS) changes from 13 to 14 2. Client with history of myasthenia gravis who had ptosis in the evening 3. Client with history of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension 4. Client with history of transverse myelitis with 2+ bilateral lower extremity muscle strength

3

The nurse is caring for a client who has homonymous hemianopsia following an acute stroke. Which nursing diagnosis is the most appropriate for this client? 1. Risk for ineffective airway maintenance 2. Risk for knowledge deficit 3. Risk for poor fluid intake 4. Risk for self-neglect

4

A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? 1. Administer atropine for bradycardia 2. Administer nifedipine for hypertension 3. Have CT scan performed to rule out an intracranial bleed 4. Perform hourly neurologic checks with Glasgow coma scale (GCS)

3

The nurse is triaging clients at an ophthalmology clinic. Which client report would most likely indicate a serious pathology that should be given priority? 1. "I'm having trouble reading the small print on a distant object." 2. "It's as if a curtain is crossing my field of vision today." 3. "I've been noticing lately that my central vision is blurry." 4. "I've had yellow discharge from my eye for the past week."

2

A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen. At 02:00 AM, the client appears to be sleeping. Which action should the nurse take? 1. Arouse the client and ask what the current month is 2. Document "relief apparently obtained" and recheck at 03:00 AM 3. Let the client sleep but verify respiratory rate 4. Wake the client up and check for paresthesia

1

A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? Select all that apply. 1. Apply a patch to the right eye at night 2. Avoid driving 3. Chew on the left side 4. Maintain meticulous oral hygiene 5. Use a cane on the left side

1,3,4

The nurse is caring for a client with Bell's palsy. The nurse most likely expects which finding(s) on assessment? Select all that apply. 1. Change in lacrimation on the affected side 2. Electric shock-like pain in the lips and gums 3. Flattening of the nasolabial fold 4. Inability to smile symmetrically 5. Severe facial pain along the cheekbone

1,3,4

A client sustained a concussion after falling off a ladder. What are essential instructions for the nurse to provide when the client is discharged from the hospital? Select all that apply. 1. Client should abstain from alcohol 2. Client should remain awake all night 3. Client should return if having difficulty walking 4. Responsible adult should be taught neurological examination 5. Responsible adult should stay with the client

1,3,5

The nurse is caring for a client who had a stroke 2 weeks ago and has receptive aphasia.The nurse is trying to get the client to follow simple commands regarding activities of daily living (ADL).Which nursing interventions should be included in the plan of care? Select all that apply. 1. Ask simple questions that require "yes" or "no" answers 2. If the client becomes frustrated, seek a different care provider to complete ADL 3. Perform ADL for the client until the goal of each activity is understood 4. Show the client gestures or pictures of ADL (shower, toilet, and toothbrush) 5. Speak slowly but loudly while looking directly at the client

1,4

A client comes to the emergency department with ischemic stroke symptoms that started 7 hours ago. The client's current blood pressure is 202/108 mm Hg. What priority action related to blood pressure should the nurse implement? 1. Assess the National Institutes of Health stroke scale 2. Document the current findings 3. Request a prescription for IV blood pressure medication 4. Request a prescription for IV antiseizure medication

2

The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is most concerning and requires a nursing response? 1. Consumes 600 mL liquid over 4 hours 2. Insertion site dressing saturated with clear fluid 3. Observed lying in the right-sided Sim's position 4. Reports a headache rated 6/10

2

The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply. 1. Asymmetrical pupillary constriction 2. Brief loss of consciousness 3. Headache 4. Loss of vision 5. Retrograde amnesia

2,3,5

A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated."Which action by the nurse is themostappropriate? 1. Document the amount of emesis 2. Lower the head of the bed 3. Notify the health care provider (HCP) 4. Offer anti-nausea medication

3

A client with a middle cerebral artery stroke exhibits the ability to understand and follow some commands but is unable to respond to questions with appropriate word choices. The nurse documents this type of communication deficit as which of the following? 1. Aphasia 2. Dysarthria 3. Dysphagia 4. Dysphasia

4

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do? 1. Bend at the waist 2. Keep the feet close together 3. Pivot on the foot proximal to the chair 4. Use a transfer belt

4

The nurse is caring for a client with absence seizures. The unlicensed assistive personnel (UAP) asks if the client will "shake and jerk" when having a seizure. Which response from the nurse is the most helpful? 1. "No, absence seizures can look like daydreaming or staring off into space." 2. "No, you are wrong.Don't worry about that." 3. "Yes, so please let me know if you see the client do that." 4. "You don't have to monitor the client for seizures."

1

Nausea and vomiting in which client is of greatest concern to the nurse? 1. Client postoperative ophthalmic surgery 2. Client receiving chemotherapy 3. Client with Ménière disease 4. Client with severe gastroenteritis

1

The neurological unit staff is composed of an experienced registered nurse (RN), a new graduate RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which are appropriate assignments for the charge nurse to give to the new graduate RN? Select all that apply. 1. Client with multiple sclerosis who has ataxia and is awaiting discharge placement 2. Discharge a client who had a stroke to the rehabilitation unit 3. New admission with Guillain-Barré syndrome with paralysis to the thigh 4. New admission with head injury and Glasgow Coma Scale (GCS) score of 8 5. Provide initial teaching for a client beginning prednisone therapy

1,2,5

The nurse is assessing a newly admitted client on a neurological inpatient unit. Which assessment findings are abnormal and require follow-up by the nurse? Select all that apply. 1. Cannot touch chin to chest 2. Eyes roll in opposite direction when turning head side to side 3. Muscle strength of lower extremities is 3/5 4. Pupils are 8 mm in diameter 5. Toes point downward when noxious stimuli are applied to the sole

1,3,4

The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? Select all that apply. 1. Call for help 2. Hold down the client's arms 3. Insert a tongue depressor to move the tongue 4. Prepare for suctioning 5. Turn the client on the side

1,4,5

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include? 1. Belief that the current surroundings are a racetrack 2. GCS score was "11" one hour ago 3. Recent vital signs show blood pressure of 120/80 mm Hg and pulse of 82/min 4. Reported allergy to penicillin and vancomycin

2

A college football player is brought to the emergency department after an accidental, forceful helmet-to-helmet collision with another running football player. Which of the following presenting signs/symptoms is most concerning and needs to be followed up by the nurse? 1. Continually oozing epistaxis 2. "Hairnet" across vision 3. One episode of coffee-ground emesis 4. Temporal headache

2

A nurse is assessing a 58-year-old client with blurred vision and reduced visual fields. Which manifestation is of most concern to the nurse? 1. Difficulty adjusting to dimmed lights 2. Extreme eye pain 3. Gradual loss of peripheral vision 4. Opaque appearance of lens

2

A nurse is completing discharge teaching to the parent of a child who is postoperative following a tonsillectomy. Which finding should be reported as a priority? 1. Ear pain 2. Frequent swallowing 3. Low-grade fever 4. Objectionable mouth odor

2

An elderly client with dementia frequently exhibits sundowning behavior while living in a community-based residential facility. When the nurse finds the client wandering at night, which of the following statements is most appropriate? 1. "Don't you know it's not morning yet?" 2. "It's time to get back to bed now." 3. "You might fall if you wander in the dark." 4. "You should not leave your room without assistance."

2

The nurse is caring for a client with a history of headaches. The client has talked to the nurse, smiled at guests, and maintained stable vital signs. The nurse notes the following changes in the client's status. Which assessment finding is critical to report to the health care provider (HCP)? 1. Blood pressure 136/88 mm Hg 2. Flat affect and drowsiness 3. Poor appetite 4. Respiratory rate 12/min

2

A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action? 1. Determine onset of symptoms 2. Ensure that the client has 2 large-bore intravenous (IV) lines 3. Maintain patent airway 4. Prepare for head CT scan

3

A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what action first? 1. Check for Kernig's and Brudzinski's signs 2. Establish IV access 3. Place the client on droplet precautions 4. Prepare the client for lumbar puncture

3

The clinic nurse is assessing a previously healthy 60-year-old client when the client says, "My hand has been shaking when I try to cut food.I did some research online. Could I have Parkinson's disease?" Which response from the nurse is the most helpful? 1. "It can't be Parkinson's disease because you aren't old enough." 2. "Make sure you tell the physician about your concerns." 3. "Parkinson's disease does not cause that kind of hand shaking." 4. "Tell me more about your symptoms. When did they start?"

4

The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? 1. "I will ask the health care provider to explain the consequences of your procedure." 2. "This is a common complication that will require you to have a hearing test every year." 3. "This is a common complication; your health care provider will order a consult for the speech pathologist." 4. "This is the reason you are using a special swallowing technique when you eat and drink."

4

A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? Select all that apply. 1. Identify the number "8" traced on the palm 2. Shrug the shoulders against resistance 3. Swallow water 4. Touch each finger of one hand to the hand's thumb 5. Walk heel-to-toe

4,5

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A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident.Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock? 1. Apical heart rate 48/min 2. Blood pressure 186/92 mm Hg 3. Cool, clammy skin 4. Temperature 100 F (37.7 C) tympanic

1

A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-contrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain? 1. Expressive speech, vision 2. Light touch, hearing 3. Sense of position, graphesthesia 4. Weber tuning fork test, cranial nerve I

1

The nurse is making follow-up phone calls to clients who had cataract surgery with intraocular lens implantation the previous day. The nurse receives which client report that requires priority intervention? 1. Blurry vision in the affected eye 2. Constipation 3. Itching in the affected eye 4. Sleeping on 2 pillows at night

2

A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform? Select all that apply. 1. Administer an analgesic as needed 2. Determine if there is bladder distention 3. Measure the client's blood pressure 4. Place the client in the Sims' position 5. Remove constrictive clothing

2,3,5

The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a headache. The nurse documents the confusion and headache as which phase of the client's seizure activity? 1. Aural phase 2. Ictal phase 3. Postictal phase 4. Prodromal phase

3

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? 1. Auscultate breath sounds to assess for crackles 2. Monitor for >50 mL/hr urine output 3. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15 4. Press over the tibia to assess for pitting edema

1

The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse? 1. "Half of my vision looks like it's being blocked by a curtain." 2. "I have to use reading glasses to see small print." 3. "My vision seems cloudy and I notice a lot of glare." 4. "The colors don't seem as bright as they used to."

1

The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves. The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding? 1. A tongue blade is used to touch the client's pharynx; gag reflex is absent 2. Only one side of the mouth moves when the client is asked to smile and frown 3. The absence of light touch and pain sensation on the left side of the client's face 4. When the client shrugs against resistance, the left shoulder is weaker than the right

1

The nurse is planning care for a client being admitted with newly diagnosed quadriplegia (tetraplegia). Which intervention will the nurse prioritize? 1. Assess vital capacity and tidal volume once per shift and PRN 2. Perform passive range of motion exercises on affected joints every 4 hours 3. Provide time during each shift for the client to express feelings 4. Turn the client every 2 hours throughout the day and night

1

The nurse is planning care for a client experiencing an acute attack of Meniere disease. Which action is a high priorityto include in the plan of care? 1. Initiate fall precautions 2. Keep the emesis basin at bedside 3. Provide a quiet environment 4. Start intravenous fluids

1

An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP goes back to assist the client with a shower, the client curses at and tries to hit the UAP. Which of the following is the most appropriate response by the registered nurse? Click on the exhibit button for additional information. Exhibit: Vital signs Temperature 98.7 F (37.05 C) Blood pressure 110/64 mm Hg Pulse 92/min Respirations 22/min Oxygen saturation 90% on room air 1. "I need to assess the client." 2. "It sounds like the client is not satisfied with the care provided. I'll see if we can make the client more comfortable." 3. "Just leave the client alone now and try again later." 4. "The client probably has dementia and is under a lot of stress with the change of environment."

1

The home health nurse teaches an elderly client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching? 1. "I have to remember to raise my chin slightly upward when I swallow." 2. "I have to remember to swallow 2 times before taking another bite of food." 3. "I should avoid taking over-the-counter cold medications when I'm sick." 4. "I should sit upright for at least 30-40 minutes after I eat."

1

The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions? 1. "I have a leftover prescription at home I can use if I have pain." 2. "I will cancel the wine tasting I have planned for this weekend." 3. "I will have someone drive me home and will take a couple of days off work." 4. "I will have someone stay with me and make sure I am okay."

1

The nurse is caring for a female young adult newly diagnosed with epilepsy and treated with phenytoin. Which of the following should the nurse include in client teaching?Select all that apply. 1. Avoid excess caffeine 2. Do not stop antiepileptic medicine abruptly 3. Do not use oral contraceptives for birth control 4. Go to an emergency department if a seizure occurs 5. Wear MedicAlert® identification

1,2,3,5

The emergency department nurse is assessing a client brought in after a car accident in which the client's head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? Select all that apply. 1. Breath smells of alcohol 2. Client disoriented to place 3. Client reports eyes burning 4. History of multiple sclerosis 5. Point tenderness over spine

1,2,5

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate? 1. Give the antihypertensive medication 2. Monitor the blood pressure 3. Notify the health care provider 4. Question the prescription

2

The nurse is preparing for the admission of a 9-year-old client with new-onset tonic-clonic seizures. It is important for the nurse to ensure that what is in the room? Select all that apply. 1. Oral bite prevention device 2. Oxygen delivery system 3. Padding on the bed siderails 4. Soft arm and leg restraints 5. Suction equipment

2,3,5

A client with a history of headaches is scheduled for a lumbar puncture to assess the cerebrospinal fluid pressure. The nurse is preparing the client for the procedure. Which statement by the client indicates a need for further teaching by the nurse? 1. "I may feel a sharp pain that shoots to my leg, but it should pass soon." 2. "I will go to the bathroom and try to urinate before the procedure." 3. "I will need to lie on my stomach during the procedure." 4. "The physician will insert a needle between the bones in my lower spine."

3

The health care provider prescribes a multivitamin regimen that includes thiamine for a client with a history of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose? 1. To lower the blood alcohol level 2. To prevent gross tremors 3. To prevent Wernicke encephalopathy 4. To treat seizures related to acute alcohol withdrawal

3

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing carepriorityfor this client? 1. Diaphoresis with facial flushing 2. Hypoactive or absent bowel sounds 3. Inability to cough or lift the head 4. Warm, tender, and swollen leg

3

Which consultation is appropriate for the nurse to advocate in a client who has had a stroke (brain attack)? Select all that apply. 1. Occupational therapy to help the client learn proper technique for a walker 2. Physical therapy to help with the client's dressing skills 3. Speech therapy when the client coughs during a meal 4. Social services when the client has no funds for medications 5. Wound care nurse when a yellow wound is present on the knee

3,4,5

The nurse is assessing the cranial nerves and begins testing the facial nerve (cranial nerve VII). Which direction should the nurse give the client to test this cranial nerve? 1. "Close your eyes and identify this smell." 2. "Follow my finger with your eyes without moving your head." 3. "Look straight ahead and let me know when you can see my finger." 4. "Raise your eyebrows, smile, and frown."

4

The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse? 1. "I will raise the head of the bed so it is easier to see the television." 2. "I will turn down the lights when I leave." 3. "Let me move your belongings closer so you can reach them." 4. "You should do deep breathing and coughing exercises."

4

The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? 1. History of Bell's palsy with unilateral facial droop and drooling 2. History of multiple sclerosis and reporting recent blurred vision 3. Reports unilateral facial pain when consuming hot foods 4. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14

4

A client with stroke symptoms has a blood pressure of 240/124 mm Hg. The nurse prepares the prescribed nicardipine intravenous (IV) infusion solution correctly to yield 0.1 mg/mL. The nurse then administers the initial prescription to infuse at 5 mg/hr by setting the infusion pump at 50 mL/hr. What is the nurse's priority action at this time? 1. Assess hourly urinary output 2. Increase pump setting to correct administration rate to 100 mL/hr 3. Keep systolic blood pressure above 170 mm Hg 4. Monitor for a widening QT interval

3