Neurosensory Disorders
The nurse is reinforcing teaching about aspirin therapy with a client diagnosed with transient ischemic attacks (TIA). Which statement made by the client indicates understanding?
"Aspirin will help prevent me from having a stroke."
A client is scheduled for an electroencephalogram (EEG) after having a seizure for the first time. Which instruction does the nurse provide to the client as preparation for this test?
"Avoid stimulants and alcohol for 24 to 48 hours before the test."
A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client?
An isolation room close to the nurses' station
Identifying factors that trigger seizure activity could lead to which alteration in the child's environment or activities of daily living?
Avoid striped wallpaper and ceiling fans.
A quadriplegic client is prescribed baclofen, 5 mg by mouth three times daily. The client asks what is the indication for baclofen. How would the nurse respond?
Baclofen is indicated when there are muscle spasms with paraplegia or quadriplegia from spinal cord lesions.
A client experienced a stroke that damaged the hypothalamus and was admitted to an acute unit. Which body function would the nurse anticipate that the client has problems with and assess as needed?
Body temperature control
The nurse is performing a mental status examination on a client diagnosed with a subdural hematoma. This test assesses which of the following functions?
Cerebral function
The nurse is scheduled to administer an otic medication. Which action should the nurse perform first?
Check and verify the proper client's name.
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?
Edrophonium
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
A client who sustained a closed head injury in a skating accident pulls out his feeding tube, I.V. catheter, and indwelling urinary catheter. To ensure this client's safety, a physician prescribes restraints. Which action should a nurse take when using restraints?
Fasten the restraint to the bed frame using a quick-release knot.
A client is admitted with Ménière's disease. Which instruction should the nurse reinforce in client teaching?
Get up slowly, turning the entire body.
A client with cerebrovascular accident (CVA) is admitted with receptive aphasia. Which action by the nurse is appropriate?
Give the client simple and slow instructions.
When contributing to the development of an education session on glaucoma for the community, which statement would the nurse emphasize?
Glaucoma can be painless with loss of peripheral vision.
The nurse is assisting a client with cerebrovascular accident (CVA) with feeding. Which nursing action(s) promote(s) safety when feeding the client? Select all that apply.
Have the client in a sitting position. Elevate the head of the bed. Check the mouth after feeding.
The nurse is caring for a client who is blind. Which is the best way for the nurse to assist with ambulation?
Have the client take the nurse's arm, with the nurse walking slightly ahead of the client.
A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings should the nurse notify the physician of because they indicate spasm or occlusion of a cerebral vessel by a clot?
Hemiplegia, seizures, and decreased level of consciousness (LOC)
The nurse educator presents an in-service on how to formulate a nursing diagnosis of Risk for imbalanced body temperature for a client who suffers a stroke after surgery. The expected outcomes incorporate assessment of the client's temperature to detect abnormalities. The educator will include in the lecture that the thermoregulatory centers are located in which part of the brain?
Hypothalamus
A client comes to the emergency department after hitting his or her head in a motor vehicle collision. The client is alert and oriented. Which nursing intervention should be done first?
Immobilize the client's head and neck.
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?
Ineffective breathing pattern
What is the function of cerebrospinal fluid (CSF)?
It cushions the brain and spinal cord.
A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough violently. What should the nurse do?
Make sure a tonsil suction device is readily available while providing mouth care.
A client who experienced a severe stroke develops a fever and a cough that produces thick, yellow sputum. A nurse observes sediment in the client's urine in the indwelling urinary catheter tubing. Based on these findings, which action should the nurse take?
Notify a physician of the findings.
A client with breast cancer reports back pain and difficulty moving her legs. Which nursing intervention is most appropriate?
Notify the health care provider.
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
Notify the physician.
The nurse is observing pupillary responses from a client. Which method should the nurse use to evaluate pupil accommodation?
Observe for pupil constriction and convergence while focusing on an object coming toward the client
A client is admitted to the emergency department with a suspected overdose of an unknown drug. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation.
Which method should the nurse use to properly instill eardrops in an adult client with otitis externa?
Pull the pinna up and back.
A nurse is preparing a client with suspected herniated nucleus pulposus (HNP) for myelography. Which nursing intervention should the nurse perform before the test?
Question the client about allergy to iodine
When assisting with the education of the family of a client with C4 quadriplegia on how to perform tracheostomy suctioning, which instruction should the nurse be sure to include?
Suction for 10 to 15 seconds at a time.
A client is receiving pilocarpine eye drops. Which statement made by the client shows correct understanding of the medication?
The medication will help decrease pressure in my eyes.
A client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière's disease. When reviewing this client's chart, the nurse expects to find which signs and symptoms?
Vertigo, tinnitus, and hearing loss
A 58-year-old client complaining of difficulty driving at night states that the "lights bother my eyes." The client wears corrective glasses. The nurse would expect the physician to have the client increase his or her intake of which vitamin because the client is experiencing a deficiency in this vitamin?
Vitamin A
The nurse is discussing the purpose of an electroencephalogram with the family of a client who has massive cerebral hemorrhage and loss of consciousness. Which response by the nurse would be the most accurate in describing what the test measures?
activity of the brain
A nurse is collecting data on an 8-month-old for signs of neurologic deficit and increased intracranial pressure (ICP). Which finding should the nurse expect to observe?
altered level of consciousness
Which hormone deficiency should the nurse suspect as the underlying cause of diabetes insipidus in a postoperative craniotomy client?
antidiuretic hormone (ADH)
The nurse is caring for a child with eningitis receiving IV fluids. What condition should the nurse monitor for closely?
cerebral edema
A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:
demonstrate eyedrop instillation.
A client with a stroke in evolution and a history of coronary artery disease is brought to the medical-surgical floor. The client's medications include heparin and isosorbide. The nurse should monitor the client for which condition?
hypotension
A client admitted to the hospital with a subarachnoid hemorrhage (SAH) reports severe headache, nuchal rigidity, and projectile vomiting. The nurse suspects that lumbar puncture (LP) may be contraindicated due to which circumstance?
increased intracranial pressure (ICP)
A client with a spinal cord injury has a neurogenic bladder. When planning for discharge, the nurse anticipates that the client will need which procedure or program?
intermittent catheterization
When obtaining the health history from a client with retinal detachment, the nurse expects the client to report:
light flashes and floaters in front of the eye.
A graduate nurse, working in a long-term facility, is caring for a client who has hearing loss. When observing the graduate, the nurse mentor would intervene if which action is taken by the graduate?
moves around and multitasks when speaking
The nurse is working with the client who is experiencing right-sided weakness secondary to a thrombotic stroke. Where is the best area to place personal hygiene items?
on the overbed table on the left side
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. The client has questions about the paralysis. What information will the nurse tell the client about the paralysis?
"The paralysis caused by this disease is temporary."
A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair. How should the nurse intervene first?
Assist the client to a side-lying position on the floor, and protect her with linens.
The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in a room set at a comfortable temperature.
A nurse is reinforcing education about glaucoma to a newly diagnosed client. Which statement made by the nurse indicates further teaching is needed?
"It is one of the diseases that does not affect children under the age of 3."
The parent of a child with a history of closed-head injury asks the nurse why the child would begin having seizures without warning. Which response by the nurse is the most accurate?
"It's not unusual to develop seizures after a head injury because of brain trauma."
A client with paraplegia must perform intermittent catheterization of the bladder. Which instruction should be given?
Clean the meatus with soap and water.
A nurse is caring for a client who meets brain-death criteria. Which nursing intervention is most appropriate at this time?
Notify the organ donor association.
The nurse is watching the health care provider check reflexes during a physical assessment. The RN illicits a positive Babinski reflex. The nurse is aware that this reflex is characterized by what?
dorsiflexion of the great toe with fanning of the other toes
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
electromyography (EMG).
The nurse is making assignments for the day. Which of the following tasks can be safely assigned to unlicensed assistive personnel (UAP)?
measuring the intake of a client with multiple sclerosis
A client is admitted to an acute care facility with a diagnosis of stroke. The nursing student is reviewing the client's history. Which history findings noted will the student report as risk factors for stroke? Select all that apply.
obesity smoking ½ pack of cigarettes a day hypertension
The nurse is caring for a client who underwent a stapedectomy. Which position would have the greatest benefit for prevention of complications and promotion of comfort?
on the unaffected side
The clinic nurse is working with a client with dysuria who is prescribed phenazopyridine. The nurse will reinforce the client to expect urine that is what?
orange
A client at the eye clinic is newly diagnosed with glaucoma. What should the nurse inform the client might occur if administration of the medication is not closely adhered to?
permanent vision loss
A nurse is educating the parents of a 1-year-old infant with otitis media. Which statement regarding predisposing factors for otitis media would be most accurate for the nurse to make?
"Eustachian tubes are short, wide, and straight and lie in a horizontal plane."
A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. Which nursing diagnosis takes highest priority in this client's plan of care?
Risk for injury
A client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from the ears and nose. Which nursing intervention is appropriate?
checking the fluid for glucose with a dipstick
A client is admitted with retinal detachment. Which sign or symptom would the nurse anticipate during data collection?
flashing lights and floaters
A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint?
"I'm sorry you haven't been bathed. I'm available to bathe you now."
The nurse is reinforcing education to a parent of a child with cerebral palsy. Which statement indicates that the education has been successful?
"My child will need continual therapy to maintain functioning."
A client with a mild concussion reports a headache. When offered acetaminophen, the client asks for a stronger pain medication. Which response by the nurse is appropriate?
"Opioids are avoided after a head injury because they may hide a worsening condition."
A client with Parkinson disease tells the nurse of plans to take St. John's wort for depression in addition to the prescribed carbidopa-levodopa. What is the nurse's best response?
"St. John's wort can cause a toxic reaction with the Parkinsonian drugs."
A hospitalized child is to receive 75 mg of acetaminophen for fever control. How much will the nurse administer if the acetaminophen concentration is 40 mg per 0.4 ml? Record your answer using two decimal places.
0.75
A client who's receiving phenytoin to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?
10 to 20 mcg/ml
The physician orders measurement of the serum acetaminophen level of a client admitted with a suspected overdose of this drug. To ensure an accurate result, the nurse should wait how long after acetaminophen ingestion before drawing the blood sample?
4 hours
The health care provider prescribed t-PA, a thrombolytic agent. The order is for 0.9 mg/kg over 1 hour. The client weighs 110 lb (50 kg). What is the total dose in milligrams the client will receive? Record your answer using a whole number.
45
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. When reviewing the client's chart, the nurse expects to find which documentation that confirms the client has Myasthenia gravis?
A positive edrophonium (Tensilon) test
What should the nurse do when administering pilocarpine?
Apply pressure on the inner canthus to prevent systemic absorption.
A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first?
Advise the client to discard the drug because it may have undergone chemical changes or become contaminated
The neurologic unit has identified a 30% occurrence of pressure ulcers in clients admitted with the diagnosis of stroke. Which of the following actions should be included in the unit's performance improvement plan?
Creating a spreadsheet on which nursing staff should document repositioning of clients admitted with a stroke
A nurse is caring for a client who has a history of epilepsy. After the client experiences a generalized tonic-clonic seizure, what is the priority nursing action?
Check the client's vital signs and remove restrictive clothing.
The nurse is reviewing the medical record for a client in a long-term care facility. The nurse notes an entry by the primary care physician indicating the client is colorblind. The nurse understands this condition results from a problem with which structure(s) of the eye?
Cones
A client is admitted into a medical unit confused and agitated. Which nursing measure should the nurse implement first to keep the client safe?
Encourage family, friends, or a sitter to stay with the client.
The nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?
Establishing an intermittent catheterization routine every 4 hours
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway, attends to the client's immediate needs, and then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, the examination must be brief but will include which nursing intervention?
Evaluation of the corneal reflex response
The nurse is caring for a client with stroke in evolution. Which nursing intervention is priority?
Have tracheal suction available at all times.
A client was admitted with an injury to the occipital lobe. Which nursing action should the nurse perform?
Monitor client for visual disturbances.
Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?
Risk for injury related to vertigo
The nurse is reinforcing instruction with a female client regarding collection of a urine culture. Which instruction will the nurse include?
Separate the labia, one at a time clean from front to back with the three wipes provided in the kit, and then start to void in the toilet. Stop voiding, then continue to void into the sterile container
A client has a diagnosis of stroke versus transient ischemic attack (TIA). Which statement demonstrates the difference between a TIA and a stroke?
TIAs typically resolve in 24 hours.
The parent of a child with a ventriculoperitoneal shunt calls the nurse saying that the child has a temperature of 101.2° F (38.4° C), a blood pressure of 108/68 mm Hg, and a pulse of 100 beats/minute. The child is lethargic and vomited the night before. Other children in the family have had similar symptoms. Which nursing intervention is most appropriate?
Tell the parent to bring the child to the primary health care provider's office.
A client who is paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?
The client uses a mirror to inspect skin.
An infant is diagnosed with an ear infection. The mother asks why children experience more ear infections than adults. The nurse explains the differences in anatomy. Identify the portion of the infant's ear that allows fluid to stagnate and act as a medium for bacteria.
The eustachian tube in an infant is shorter and wider than in an adult or older child. It also slants horizontally. Because of these anatomical features, nasopharyngeal secretions can enter the middle ear more easily, stagnate, and cause infections.
The nurse is working on a surgical floor. The nurse must logroll a client following a:
The nurse is caring for a client with stroke in evolution. Which nursing intervention is priority?
A client accidentally splashes chemicals into his 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 client was admitted with a diagnosis of meningitis, and the nurse is providing hygiene care. Which infection control measures should the nurse implement when caring for the client? Select all that apply.
Wear gloves. Wear gown. Wear mask. Wash hands.
Which client would be most at risk for secondary Parkinson disease caused by pharmacotherapy?
a 30-year-old client with schizophrenia taking chlorpromazine
A nurse performs a neurologic data collection on a client reporting headache and dizziness. Which data collection technique helps determine the motor function of cranial nerve VII?
asking the client to frown, smile, and raise the eyebrows
One hour after receiving pyridostigmine, a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the health care provider and prepares to administer which medication?
atropine
A client recovering from a spinal cord injury has a great deal of spasticity. What medication administered by the nurse may be used to control spasticity?
baclofen
The nurse is reinforcing education for the family of a child with seizures. When should the nurse inform them to call emergency medical services in the event of a seizure?
continuous vomiting for 30 minutes after the seizure
Which nursing data should be given the highest priority for a child with clinical findings related to tubercular meningitis?
signs of increased intracranial pressure (ICP)
The nurse is caring for a post-op client following the removal of right cataract. What is the best position for the client after surgery?
supine
A client has a cervical spinal cord injury at the level of C5. Which condition would the nurse anticipate during the acute phase?
the need for mechanical ventilation
The nurse is gathering data from a client with Ménière disease. Which symptom does the nurse relate to the disease process?
tinnitus
A client with new-onset seizures of unknown cause is started on phenytoin, 750 mg IV now and 100 mg P.O. t.i.d. Which statement best describes the purpose of the loading dose?
to more quickly attain therapeutic levels
A 1-year-old child is brought to the emergency department with a mild respiratory infection and a temperature of 101.3° F (38.5° C). Otitis media is diagnosed. Which sign would the nurse also expect to find?
tugging on the ears
A nurse working on a surgical floor observes an unlicensed assistive personnel (UAP) completing assigned tasks. Which situation requires the nurse to intervene?
turning a client who is 24 hours post-op laminectomy
A client at the eye clinic reports difficulty seeing at night. Which nutritional deficiency should the nurse be sure the client is monitored for?
vitamin A