Neurosensory Disorders
A client with an inoperable brain tumor is brought to the hospital because the family can no longer care for him at home. As the nurse provides care for the client, family members express their disappointment at not being able to care for him at home as he wished. Which response by the nurse is best? 1. "I understand; I take care of clients like this every day and don't know how you could do it at home." 2. "Have you explored hospice care? I can ask the case manager to discuss this care option with you, if you're interested." 3. "It's OK to bring the client back to the hospital to die." 4. "Having a family member with a terminal illness is very difficult."
2. "Have you explored hospice care? I can ask the case manager to discuss this care option with you, if you're interested." RATIONALE: The nurse should ask the family members if they've explored hospice care. Hospice care offers many resources that enable the family to successfully care for the client at home. The other options don't address the family's concerns.
After a motor vehicle accident, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? 1. Flat 2. Supine, with the head of the bed elevated 30 degrees 3. Flat, except for logrolling as needed 4. A head elevation of 90 degrees to prevent cerebral swelling
3. Flat, except for logrolling as needed RATIONALES: When caring for a client with a possible cervical spinal injury who's wearing a cervical collar, the nurse must keep the client flat to decrease mobilization and prevent further injury to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.
The nurse on the neurologic unit must provide care for four clients who require different levels of care. Which client should the nurse assist first with morning care? 1. A client who requires a complete bed bath and must be transported to physical therapy on a stretcher 2. A client who requires minimal bathing assistance and ambulates with a walker independently 3. A client who is confused since suffering a stroke 1 week ago 4. A client who suffered a stroke and is paralyzed of the left side of his body
2. A client who requires minimal bathing assistance and ambulates with a walker independently RATIONALES: The nurse should determine which client requires minimal assistance and then attend to that client first. The client who ambulates with a walker requires the least assistance. After attending to him, the nurse should distribute her time among those who require more care.
Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium), 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed? 1. In 30 to 45 seconds 2. In 10 to 15 minutes 3. In 30 to 45 minutes 4. In 1 to 2 hours
2. In 10 to 15 minutes RATIONALES: When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn't exceed 100 mg in 24 hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose can't be repeated in 30 to 45 seconds because the first dose wouldn't have been administered completely by that time. Waiting longer than 15 minutes to repeat the dose would increase the client's risk of complications associated with status epilepticus.
The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first? 1. Sit with the client for a few minutes. 2. Administer an analgesic. 3. Inform the nurse-manager. 4. Call the physician immediately.
4. Call the physician immediately. RATIONALES: The headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse-manager isn't necessary.
A client is hospitalized with Guillain-Barré syndrome. Which data collection finding is most significant? 1. Warm, dry skin 2. Urine output of 40 ml/hour 3. Soft, nondistended abdomen 4. Even, unlabored respirations
4. Even, unlabored respirations RATIONALES: A characteristic feature of Guillain-Barré syndrome is ascending weakness, which usually begins in the legs and progresses upward to the trunk, arms, and face. Respiratory muscle weakness is a particularly dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore, although all of the options are pertinent assessment data, those related to respiratory function and status are most significant.
A client experienced a right frontal stroke that left him with short-term memory loss and lack of impulse control. The nurse caring for the client on the previous shift identified him at high risk for falls. While making rounds to begin the shift, a nurse notices the client lying on the floor. The nurse assesses the client and notes no injuries. How should the nurse follow up this incident? 1. Report the previous shift for failing to follow the fall risk protocol. 2. Complete and incident report placing responsibility for the fall on the previous shift. 3. Do nothing because the client wasn't injured by the fall. 4. Notify the physician, then document the location of the fall, physician notification, any injury, necessary follow-up, and any changes in the care plan needed as a result of the fall.
4. Notify the physician, then document the location of the fall, physician notification, any injury, necessary follow-up, and any changes in the care plan needed as a result of the fall. RATIONALE: The nurse should notify the physician, then document the facts related to the fall, such as the location of the fall, physician notification, injury if any, necessary follow-up, and any changes in the care plan that occurred as a result of the fall. The nurse shouldn't include any information that places blame on the other care members. The fall must be reported even if the client doesn't suffer an injury.
The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure. She monitors his blood pressure for signs of widening pulse pressure. His current blood pressure is 170/80 mm Hg. What is the client's pulse pressure?
90 RATIONALES: Pulse pressure is the difference between the systolic blood pressure and the diastolic blood pressure. For this client, pulse pressure is 170 − 80 = 90.
