Neurosensory

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

A nurse is caring for a client who begins to have a generalized tonic clonic seizure while lying in bed. Which of the following actions should the nurse take? A. Insert an oral airway B. Turn the client onto a side C. Restrict movements of the client's limbs D. Place a pillow under the client's head

B. Turn the client onto a side

A nurse is preparing a client for an electroencephalogram (EEG). Which of the following pieces of information should the nurse share with the client? A. Expect the test to take about 3 hr B. You will begin by lying still with your eyes closed C. You'll sleep for the duration of the procedure D. Expect some mild electrical shocks during the test

B. You will begin by lying still with your eyes closed RATIONALE: A- takes 45min-2hr

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 minutes, 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

A nurse is assessing a client who recently experiences 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

A nurse is planning care for a client following 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)

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching? A. Place a warm compress on your forehead B. Darken the lights C. Light a scented candle D. Drink a caffeinated beverage

B. Darken the lights RATIONALE: D- Caffeine can TRIGGER migraines

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? A. Visualizing the eardrum before irrigating B. Instilling 50mL of fluid with each irrigation C. Using firm, continuous pressure while irrigating D. Warming the irrigation fluid to at least 98F

B. Instilling 50mL of fluid with each irrigation RATIONALE: Use no more than 5-10mL to decrease chance of stimulating the vestibular nerve (would result in N/V, & dizziness)

A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a flash of light followed by a curtain across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? A. Glaucoma B. Retinal detachment C. Macular degeneration D. Cataracts

B. Retinal detachment

A nurse is walking along the unit when she sees smoke coming from the central supply room. After activating the fire alarm, which of the following actions should the nurse take? A. Place unused equipment between the fire doors B. Turn off sources of oxygen near the fire C. Place rolled blankets at the base of the fire D. Keep the doors to the unit and client rooms open

B. Turn off sources of oxygen near the fire RATIONALE: D- keep doors CLOSED

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

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 RATIONALE: hypothalamus regulates body temperature A- language and speech comprehension B- higher functions of the brain C- motor control and learning

A nurse is reviewing the medical history of a client who has presbyopia. Which of the following activities should the nurse expect the client to have difficulty? A. Finding the bathroom in the dark B. Driving at night C. Seeing numbers on highway signs D. Reading the newspaper

D. Reading the newspaper RATIONALE: presbyopia= can't see near objects and develops with aging

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 ICP? A. Widened pulse pressure B. Tachycardia C. Periorbital edema D. Decrease in UO

A. Widened pulse pressure RATIONALE: Other manifestations include pupil changes, change in LOC and N/V

A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client? A. The client cannot name simple objects or formulate sentences of phrases B. The client has difficulty articulating correctly due to muscle weakness of the mouth and tongue C. The client is unable to understand words or sentences she hears D. The client speaks words that substitute for those she intends to say

C. The client is unable to understand words or sentences she hears

A nurse is caring for a client who has Meniere's disease. The nurse should identify that Meniere's disease affects which structure of the ear? A. Eustachian tube B. Cochlea C. Perichondrium D. Eardrum

B. Cochlea RATIONALE: Meniere'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 assessing a client who was admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment the nurse should perform to determine the client's neurological status? A. Vital signs B. Body posture C. Level of consciousness D. Examination of pupils

C. Level of consciousness

A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions? A. Trendelenburg B. Prone C. Semi-Fowler's D. Sims'

C. Semi-Fowler's RATIONALE: This position permits blood flow to the brain while allowing venous drainage to decrease postoperative risk of increased ICP

A nurse is assessing a client who has a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth CN (CN VIII)? A. Dizziness and hearing loss B. Weakness of a side of the tongue C. Facial drooping and asymmetrical smile D. Loss of the same visual field in both eyes

A. Dizziness and hearing loss RATIONALE: This reflects alterations in the vestibulocochlear area B- CN XII C- CN VII D- CN II

A nurse is assessing an older adult client for physiological changes that can occur with age. Which of the following findings should the nurse expect? A. Increased saliva production B. Decreased sense of taste C. Increased sense of smell D. Decreased chest wall rigidity

B. Decreased sense of taste

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? A. Elevated glucose B. Elevated protein C. Presence of RBCs D. Presence of D-dimer

B. Elevated protein RATIONALE: A- DECREASED

A home health nurse is interviewing the adult child of a client who has Alzheimer's disease. The child is the client's sole caregiver and reports feeling fatigued and overwhelmed. Which of the following referrals should the nurse make for the caregiver? A. Attorney B. Physical therapy C. Respite care D. Occupational therapy

C. Respite care

A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard EEG. Which of the following instructions should the nurse include in the teaching? A. Remain NPO 6-8hr prior to the EEG B. Take a sedative the night prior to the EEG C. Thoroughly shampoo her hair prior to the EEG D. Sleep for at least 8hr during the night prior to the test

C. Thoroughly shampoo her hair prior to the EEG RATIONALE: A- eat regularly B- avoid because it can depress CNS functioning and can alter results D- needs to be sleep deprived prior to the EEG to increase the likelihood of recording seizure activity

A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching? A. High-pitched sound heard in the ear B. Intermittent rapid eye movement C. Itching of the external canal D. Feeling of fullness in the ear

D. Feeling of fullness in the ear RATIONALE: Other manifestations include ear pain, cracking sound when yawning or swallowing, and mild dizziness

A nurse in the ED has assessed a client's airway, breathing and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? A. Question the client's coworkers about the mechanism of injury B. Check the client's pupils for equality and reaction to light C. Measure the client's alertness using the Glasgow Coma Scale D. Immobilize the clients cervical spine

D. Immobilize the clients cervical spine

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 RATIONALE: This is to reduce confusion B- noises can increase anxiety; environment should be quiet to reduce stress and promote rest

A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following actions should the nurse take? A. Place a vest restraint on the client to protect others in the environment B. Provide a variety of routines to keep the client from getting bored C. Explain to the client that episodes of anxiety will decrease over time D. Redirect the client to a different activity with a small group of people

D. Redirect the client to a different activity with a small group of people

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 RATIONALE: A- FUROSEMIDE can cause this B- NSAIDs (e.g. ASA) can cause this

A nurse is providing preoperative teaching for a client who will undergo laser assisted 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 surgery D. Expect complete healing and clear vision in about a week

A. You might need glasses after the surgery RATIONALE: overcorrection or under-correction of refractive errors is possible

A nurse is teaching a client about CT scanning of the brain. Which of the following teaching points should the nurse include? A. You'll have to lie still on a very long, narrow table during the test B. You should be able to sit up during the test if you need a break C. You'll have many tiny electrodes placed on your scalp during the test D. You should expect the test to take less than an hour

A. You'll have to lie still on a very long, narrow table during the test RATIONALE: D- with newer CT scanners, each set of head scans (usually 1 or 2) takes <5min

A nurse is providing teaching to the family of a client who has a new diagnosis of ALS. Which of the following is an early manifestation of ALS? A. Sensory dysfunction B. Weakness of the distal extremities C. Decreased vision D. Altered temperature regulation

B. Weakness of the distal extremities RATIONALE: ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain & spinal cord, causing muscle wasting, spasticity, and eventually paralysis. Other early manifestations include: speech problems, swallowing problems, breathing difficulty A. ALS does not affect the sensory nervous system C. ALS does not cause vision changes D. Does not affect the autonomic nervous system or temp regulation

A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? A. You can expect your vision to return immediately after the procedure B. You should avoid reading for 1 week C. You can remove eye shields when you're sleeping D. You should not lift objects that weight more than 25lb

B. You should avoid reading for 1 week RATIONALE: Avoid reading and any activity that can cause rapid movement of the eye because of the risk for detached retina A- several weeks C- wear eye shields for 2-6 wks after surgery while sleeping D- no more than 20lbs

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 RATIONALE: Report immediately A- bruising behind the ears and lower jaw from trauma of a skull fracture B- result of facial trauma, not increased ICP D- CSF leak

A nurse is caring for a client during the first 72hr 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 degrees 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 degrees 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 degrees with the client in a neutral midline position RATIONALE: This helps prevent an increase in intracranial pressure, which is a major risk factor for complications in the first 72hr following a CVA

A nurse is assessing a client who has increased intracranial pressure and has received IV mannitol. Which of the following findings indicates a therapeutic effect of this medication? A. Decreased blood glucose B. Decreased brochospasms C. Increased UO D. Increased temperature

C. Increased UO RATIONALE: Osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys; increased UO and decreased intracranial pressure are therapeutic effects of this medication

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching? A. Dry the ear canal with a cotton swab after swimming B. Apply an ice pack to the ear to relieve pain C. Instill a diluted alcohol solution into the ear after swimming D. Irrigate the ear with cool tap water to clean

C. Instill a diluted alcohol solution into the ear after swimming RATIONALE: B- warm/moist towel or heating pad at the lowest setting to the ear to reduce pain D- WARM tap water (cool water can cause nausea/dizziness)

A nurse in an acute facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? A. Metered-dose inhaler B. Continuous passive motion machine C. Oral nasal suction equipment D. External defibrillator

C. Oral nasal suction equipment RATIONALE: MG causes muscle weakness due to autoimmune disease that affects the acetylcholine receptors (watch for respiratory distress)

A nurse is caring for a client who has a closed TBI 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 CSF C. Rigid skull containing cranial contents D. Brain herniated into the brainstem

C. Rigid skull containing cranial contents RATIONALE: The client's rigid skull prevents expansion

A nurse is providing teaching to a client who is scheduled for an electroencephalogram in the morning. Which of the following pieces of information should the nurse share? A. You'll feel some mild electrical sensations like static electricity during the procedure B. Do not eat or drink anything except water after midnight C. Shampoo your hair before the procedure and don't use any styling products afterwards D. It's common to have temporary short-term memory loss after the procedure

C. Shampoo your hair before the procedure and don't use any styling products afterwards RATIONALE: For the electrodes to stick, must be free of oil & hair care products

A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect? A. Tonic clonic seizures B. Report of a severe headache C. Weakness of the lower extremities D. Decreased level of consciousness

C. Weakness of the lower extremities RATIONALE: Guillain-Barre syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves; characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities and can advance to the upper extremities A, ,B & C= not characteristics

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 headache

D. Report of headache RATIONALE: Autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic spinal cord injury about T6. It 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 caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? A. Spasticity of the left foot B. Negative babinski reflex C. Ocular hypertension D. Right-sided hemiplegia

D. Right-sided hemiplegia

A nurse is providing teaching to a client who has a new diagnosis of MG. Which of the following pieces of information should the nurse include? A. Use enemas to treat constipation caused by daily medications B. Take a hot bath when muscles ache C. Eat a low-calorie diet D. Set an alarm to ensure medication dosages are taken on time

D. Set an alarm to ensure medication dosages are taken on time

A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600mL/hr. The nurse suspects the client has manifestations of diabetes insipidus. Which of the following lab values should hte nurse plan to assess for DI? A. BUN B. Blood glucose C. Urine ketones D. Specific gravity

D. Specific gravity RATIONALE: A LOW specific gravity of 1.001-1.003 is a manifestation of DI

What is the patient teaching for Meniere's disease?

-Avoid caffeine -Avoid alcohol -Avoid smoking -Restrict salt intake -Distribute fluid evenly throughout the day

What are the s/s of a TBI?

-Decreased LOC -Cushing's triad (systolic hypertension, bradycardia, irregular breathing) -Confusion -HA -Pupil abnormalities -N/V -Seizures -Abnormal posturing -Ataxia (loss of balance) -Muscle weakness

What is the treatment for a TBI?

-Mannitol to decreased ICP -Hypertonic NaCl -Pentobarbitol to induce coma and decrease metabolic demands -Anticonvulsants to prevent & tx seizures -Opioid analgesics

What is the difference between open and closed angle glaucoma?

-Open: GRADUAL increase in IOP -Closed: SUDDEN increase in IOP (angle between iris and sclera closes completely)

What is the difference between a primary and secondary TBI?

-Primary: Acceleration or deceleration injury results in shearing, injury/destruction of brain tissue and/or hemorrhage -Secondary: Reactive processes that occur AFTER initial injury that causes further damage to brain tissue

What is the emergency care for a TBI?

-Stabilize the c-spine -Maintain patent airway

What are the s/s of Meniere's disease?

-Tinnitus -UNILATERAL sensorineural hearing loss -Vertigo -Vomiting -Balance issues

What are the S/S of closed-angle glaucoma?

1. Severe eye pain 2. Severe HA 3. N/V 4. Blurred vision 5. Halos around lights 6. Reddened sclera Normal IOP 10-21

What is the Cushing's triad a/w a TBI?

1. SysTolic HTN 2. Bradycardia 3. Irregular breathing

A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate CN involvement? A. Dysphagia B. Positive Babinski sign C. Decreased deep tendon reflexes D. Ataxia

A. Dysphagia RATIONALE: Can result from damage to GN IX (glossopharyngeal) or X (vagus)

A nurse in the ED is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse assess first? A. A client who is difficult to arouse and unable to respond to questions B. A client who has slurred speech and exhibits anger C. A client who reports nausea and vomiting D. A client who is uncooperative and has uncoordinated movements

A. A client who is difficult to arouse and unable to respond to questions

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 RATIONALE: To increase the client's understanding of the conversation D- need to use the same words when repeating a statement to reduce confusion

A nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. Which of the following statements by the client indicates an understanding of the teaching? A. An aura is a sensory warning that a seizure is imminent B. An aura is a continuous seizure in which seizures occur in rapid succession C. An aura is a period of sleepiness following the seizure D. An aura is a brief loss of consciousness accompanied by staring

A. An aura is a sensory warning that a seizure is imminent

A nurse is providing teaching to a client who has a new diagnosis of MS. The client asks the nurse about the usual course of MS. Which of the following responses should the nurse make? A. Each client is different; we cannot predict what will happen B. I can see that you are worried, but it's too soon to predict what will happen C. Acute episodes are usually following by remissions, which can vary in duration D. It's too early to think about the future; let's focus on the present and take each day as it comes

C. Acute episodes are usually following by remissions, which can vary in duration

A nurse is providing teaching to a client who has a new diagnosis of Meniere'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 RATIONALE: Meniere's affects balance and hearing; characterized by vertigo, hearing loss and tinnitus

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? A. Occipital B. Temporal C. Frontal D. Limbic

C. Frontal RATIONALE: A- vision B- hearing D- memory & learning

A nurse is 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

A nurse is preparing a client for an electroencephalogram (EEG). When the client asks the nurse what this test does, which of the following responses should the nurse provide? A. An EEG measures the electric signals to your brain from hearing sight and touch B. An EEG measures the electrical activity in your muscles C. An EEG identifies the magnetic fields produced by electrical activity in your brain D. An EEG records the electrical activity in your brain cells

D. An EEG records the electrical activity in your brain cells RATIONALE: Used to identify various problems, including seizure disorders, sleep disorders, inflammation, bleeding, and migraine HA's

A nurse is reviewing the medical history of a client who is scheduled for an MRI examination of the cervical vertebra. Which of the following pieces of information in the client's history is a C/I 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 RATIONALE: Also clients who have cerebral aneurysm clips or internal defibrillators

What is the treatment for Meniere's disease?

No cure, supportive tx -Antihistamines -Anticholinergics -Antiemetics -Diuretics

What reflex may not be evident in a patient with cataracts?

Red reflex

What is the nursing care for a TBI to decrease ICP?

Reduce hypercarbia (too much Co2) by hyperventilating pts -AVOID suctioning -HOB ≥ 30° -Head needs to be midline

What is a patient at risk for if they have had a previous TIA (transient ischemic attack)?

Stroke/Cerebrovascular Accident (CVA)

How many weeks following cataract surgery will best vision occur?

~4-6 weeks post surgery

Following cataract surgery, patients may not lift up to how many pounds?

≥10 lbs

A nurse is providing teaching about degenerative complications to the partner of a client who has a new diagnosis of Parkinson's disease. Which of the following manifestations is the priority? A. Dysphagia B. Emotional lability C. Impaired speech D. Self-care dependency

A. Dysphagia

A nurse in a rehab center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? A. Reduced left-sided motor function B. Difficulty with speech C. Impulsive behavior D. Neglect of the left side of the body

B. Difficulty with speech RATIONALE: C- this can occur from w RIGHT sided stroke

What type of vision loss does macular degeneration cause?

Central

A nurse is providing discharge teaching to a client who had a transient ischemic attack (TIA). Which of the following instructions should the nurse include? A. Reduce dietary sodium B. Decrease dietary potassium C. Restrict intake of insoluble fiber D. Limit alcohol intake to < or = 3 servings per day

A. Reduce dietary sodium RATIONALE: Most common causes of TIA are atherosclerotic plaque in the carotid arteries and hypertension B- increase C- Increase D- no more than 2/day for men and 1/day for women

During a neurological assessment, a nurse asks the client to name all of his children, their ages, and their birth dates. Which of the following types of memory is the nurse testing? A. Remote B. Sensory C. Immediate D. Recall

A. Remote RATIONALE: Remote AKA long-term memory B- stimuli from environment C- e.g., giving the client a 3-step command and observing for completion of all 3 steps D- recent activities like how they got to the facility, etc.

A nurse is preparing to test the function of cranial nerve X. Which of the following procedures should the nurse use? A. Have the client open his mouth and say, "ahh" B. Ask the client to identify the scent of coffee C. Use a tongue blade to provoke the gag reflex D. Have the client smile and raise his eye brows

A. Have the client open his mouth and say, "ahh" RATIONALE: CN X= vagus, which has both sensory and motor functions. The palate and the uvula should move upward in response. The nurse should also assess the client's voice quality for hoarseness B- CN 1, olfactory C- CN IX, glossopharyngeal D- CN VII, facial

A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a positive Romberg test, indicating which of the following alterations? A. Cerebellar dysfunction B. Occipital lobe dysfunction C. Increased intraocular pressure D. Macular degeneration

A. Cerebellar dysfunction

A nurse is caring for a client who had a cerebrovascular accident (CVA). The client appears alert and engaged during a visit, but does not respond verbally to questions. The nurse should document this as which of the following alterations? A. Expressive aphasia B. Dysarthria C. Receptive aphasia D. Dysphagia

A. Expressive aphasia RATIONALE: understands speech fine but has difficulty speaking and writing; this typically occurs as a result of a lesion at Broca's area of the frontal lobe B- slurred speech C- can't understand

A nurse is caring for a client who has a hearing impairment. Which of the following actions should the nurse take when communicating with the client? A. Face the client when speaking B. Speak in a loud voice C. Use a normal rate when speaking D. Avoid hand motions

A. Face the client when speaking

A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect? A. Swelling behind the effected ear B. Facial drooping on the affected side C. Nystagmus on the effected side D. Pearly gray color of the affected eardrum

A. Swelling behind the effected ear RATIONALE: D- this is a healthy eardrum; a red, thick eardrum would be a manifestation of mastoiditis

A nurse is caring for a client who has a TBI and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? A. The client rigidly extends his arms B The client internally flexes his wrists C. The client curls into a fetal position D. The client internally rotates his legs

A. The client rigidly extends his arms RATIONALE: Decerebrate posturing indicates a severe brain stem injury & late neurological decline B- Decorticate C- not a manifestation D- Decorticate

A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? A. The client's ability to clear oral secretions B. The client's ability to communicate verbally C. The client's ability to move all extremities D. The client's ability to remain continent of urine

A. The client's ability to clear oral secretions

A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased ICP. Which of the following indicates that the medication is having a therapeutic effect? A. The client's serum osmolarity is 310 mOsm/L B. The client's pupils are dilated C. The client's heart rate is 56/mi n D. The client is restless

A. The client's serum osmolarity is 310 mOsm/L RATIONALE: Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue; a serum osmo of 310 is desired. A decrease in cerebral edema should result in a decreased in ICP

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? SATA A. Place the client in respiratory isolation B. Monitor vital signs every 2hr C. Assess neurological status every 4hr D. Maintain the client in modified trendelenburg position E. Keep the client's room darkened

B. Monitor vital signs every 2hr C. Assess neurological status every 4hr E. Keep the client's room darkened RATIONALE: A- STANDARD precautions D- they are at an increased risk for increased intracranial pressure, therefore the nurse should maintain the HOB 30-45 degrees

A nurse is caring for a client who has received sedation. When the nurse applies nailbed pressure, the client withdraws his hand. The nurse should document this response as indicating which of the following? A. Confusion B. Arousal C. Orientation D. Attention

B. Arousal RATIONALE: responsiveness to sensory stimulation

A nurse is preparing an older adult client who had a transient ischemic attacks (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 RATIONALE: The most common cause of TIA are atherosclerotic plaque and HTN

A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations following by 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

A nurse in an ED 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

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? A. Pupils nonreactive to light B. Opacity visible behind the pupil C. White circle around the outside border of the iris D. Increased intraocular pressure

B. Opacity visible behind the pupil RATIONALE: C- this is arcus senilis

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next? A. Administer nifedipine B. Place the client in a high fowler's position C. Check for urinary retention D. Check for fecal impaction

B. Place the client in a high fowler's position RATIONALE: to decrease the clients BP and reduce risk of end-organ damage from the sudden rise in BP

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? A. Reorient the client B. Protect the client's head C. Loosen constrictive clothing D. Turn the client onto his side

B. Protect the client's head

A nurse is caring for a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor? A. Understanding speech B. Respiratory effort C. Decision making ability D. Temperature control

B. Respiratory effort RATIONALE: A- frontal C- frontal D- hypothalamus

A nurse responds to a call from an assistive personnel that a client just had a seizure and is unconscious. Which of the following assessments is the nurse's priority? A. Measure the client's vital signs B. Perform a neurological examination C. Check airway patency D. Assess the client for injuries

C. Check airway patency

A nurse is preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affects the manner in which the nurse will prepare the client for the scan? A. No food or fluids consumed for 4 hr B. Difficulty recalling recent events C. Development of hives when eating shrimp D. Paresthesia's in both hands

C. Development of hives when eating shrimp RATIONALE: related to contrast media

A nurse is caring for a client who has an impairment of CN II. Which of the following actions should the nurse perform to promote the client's safety? A. Initiate seizure precautions B. Ensure the client receives a soft diet C. Provide an obstacle free path for ambulation D. Instruct the client to use lukewarm water when showering

C. Provide an obstacle free path for ambulation RATIONALE: CN II= optic A- none of the CN's affect seizure activity B- CN IX, glossopharyngeal

An emergency room nurse is assessing a client who has a new TBI. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurses priority? A. Monitor urinary output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure precautions

C. Provide supplemental oxygen

During a neurological assessment, a nurse asks how the client arrived at the appointment and with whom. Which of the following types of memory is the nurse testing? A. Remote B. Immediate C. Recall D. Past

C. Recall RATIONALE: B- immediate would be NEW memory (tell the client to say back 3 unrelated words)

A nurse is triaging client's during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixated, dilated pupils? A. Red tag B. Yellow tag C. Green tag D. Black tag

D. Black tag RATIONALE: Black= not expected to live and will be allowed to die naturally A- Red= life threatening injuries but high possibility of survival once stabilized B- Yellow= major injuries that are not yet life threatening C- Green= minor injuries that are not life threatening and don't need immediate attention

A nurse is teaching a client who has a new diagnosis of POAG. Which of the following pieces of information should the nurse include in the teaching? SATA 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

D. Driving can be dangerous due to the loss of peripheral vision E. Laser surgery can help reestablish the flow of aqueous humor RATIONALE: Presbyopia is a decrease in near vision that occurs after age 40 and is not related to POAG. Vision loss from POAG does NOT improve with glasses

A nurse is teaching a client who has myopia about laser assisted in situ keratomileusis (LASIK) surgery. Which of the following is an adverse effect of LASIK surgery? A. Eyelid twitching B. Photosensitivity C. Intraocular hemorrhage D. Dry eyes

D. Dry eyes

A nurse is caring for a client who has had repeated middle ear infections. The client reports that the provider said the infections are due to an obstruction of the structure that connects the middle ear to the throat. The nurse should identify that the provider was referring to which of the following structures? A. Oval window B. Auricle C. Tympanic membrane D. Eustachian tube

D. Eustachian tube RATIONALE: The eustachian tube connects the middle ear to the throat and allows equalization of pressure and drainage of fluids from the middle ear to the throat C- Tympanic membrane, often referred to as the eardrum, separates the external ear from the middle ear