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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?

"An aura is a sensory warning that a seizure is imminent" An aura is a sensory warning that a seizure is imminent. The aura can be similar to hallucination and involve any of the sense. The client can report hearing bells, seeing lights, or smelling an odor.

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching?

A TIA can proceed an ischemic stroke TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of TIA include loss of vision in an hour, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness.

A nurse in the emergency department 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 client should the nurse assess first?

A client who is difficult to arouse and unable to respond to questions A client who is difficult to arouse and is unable to respond to questions could have a decreased level of consciousness due to an alcohol intoxication level of 401 to 800 mg/dL or traumatic brain injury. The greatest risk to the client is the neurological sequelae of head trauma or death due to severe alcohol intoxication.

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take?

Add gestures when speaking with the client The nurse should use gestures when speaking with the client to increase the clients understanding of the conversation

A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed dilated pupils?

Black tag The nurse should assign a black tag, or a class IV label, to clients who are not expected to live and will be allowed to die naturally. Dilated pupils that are fixed or non-reactive to light are a poor prognostic sign, and indicate severely increased intracranial pressure. In a mass casualty situation, the overall goal is to provide life-saving treatment to the greatest number of people possible.

A nurse is preparing an older client who had a transient ischemic attack (TIA) for discharge. The nurse should teach the client how to monitor which of the following parameters at home?

Blood pressure A temporary disturbance of the blood supply to the brain causes a TIA, which is a brief alteration in neurological function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension. Therefore the client should track his BP regularly to promote hypertension management, and reduce the risk of another TIA or cerebrovascular accident

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?

Cerebellar dysfunction Cerebellar dysfunction causes a loss of position sense (proprioception), which results in a positive Romberg sign.

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 nurses priority?

Check airway patency The priority assessment, the nurse should make is to check the clients airway patency. The nurse should establish and maintain the clients airway to prevent respiratory arrest and hypoxia.

A nurse in an emergency department is assessing a client who sustained a fall off of the roof. Which of the following findings should the nurse identify as an indication of a basal skull fracture?

Clear fluid coming from the nares Cerebrospinal fluid manifests as clear fluid coming from the nares or ears, indicating a basilar skull fracture

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?

Darken the lights The nurse should instruct the client to lay down in a dark room to reduce migraine pain

A nurse is assessing an older client for physiological changes that can occur with age. Which of the following findings should the nurse expect?

Decreased sense of taste When assessing an older client, the nurse should expect a decreased sense of taste due to atrophy of the taste buds. This can increase the clients risk for port intake, resulting in less than optimal nutrition.

A nurse in a rehabilitation centers performing an assessment for a client who was recovering from the left hemisphere stroke. Which of the following findings should the nurse expect?

Difficulty with speech The left hemisphere of the brain is usually the dominant side and is responsible for language. This is always true for right, handed clients, and for the majority of left-handed clients. Since this client is recovering from a left hemisphere stroke, the nurse should anticipate that the client will have aphasia and require speech therapy to establish communication.

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?

Dilated pupils Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately.

A nurse is assessing a client who has a head injury with 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 cranial nerve (CN VIII)?

Dizziness and hearing loss Dizziness and hearing loss reflect alterations in the vestibulocochlear area, which CN VIII innervates?

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (SATA)

Driving can be dangerous due to the loss of peripheral vision Laser surgery can help reestablish the flow of aqueous humor Damage to the optic nerve that occurs secondary to increase intraocular pressure causes a decrease in peripheral vision and can lead to complete vision loss if not treated. Laser surgery can reopen the trabecular mesh work and widen the canal of Schlemm.

A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement?

Dysphagia Dysphasia (difficulty swallowing) can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (Vagus)

A nurse is reviewing the laboratory results of the lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?

Elevated protein An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include increased protein in the cerebral spinal fluid.

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?

Face the client when speaking Facing the client will allow the nurse to observe the nurse's facial expressions and to lip read during the communication process

A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?

Feeling of fullness in the ear A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations include ear pain, a cracking sound when yawning or swallowing, and mild dizziness.

The nurse is caring for a client who has expressive aphasia, follow me a stroke. The nurse should identify that the stroke affected which of the following lobes of the clients brain?

Frontal The nurse should identify that the posterior portion of the frontal lobe is responsible for the verbal expression of thoughts

A nurse is caring for a client who has had a cerebral lesion in develops hyperthermia. Which of the following areas of the clients brain is affected?

Hypothalamus The nurse should identify that the hypothalamus, located below the cerebrum of the brain, is responsible for the regulation of body temperature

A nurse names three 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 five minutes, the nurse asked the client to name the objects. The nurse is using the strategy to test what type of memory?

Immediate The nurse tests the clients immediate or new memory by following the three object protocol. A client without cognitive decline should be able to recall and named the three objects five minutes later.

A nurse in the emergency department has accessed the clients, airway, breathing and circulation (ABC) following a head injury from a far at work. Which of the following actions is the priority for the nurse to perform next?

Immobilize the clients cervical spine The greatest rest of this client is an injury from a cervical spine, dislocation and spinal cord compression following a traumatic head injury. Therefore, the priority action, the nurse should take after assessing the client's ABC is immobilizing the client snack with a cervical collar. The client who has a head trauma might also have damage to the cervical spine. This is an essential component of the initial stabilization of a client who has a head injury.

A nurse is assessing a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment?

Inability to locate eyeglasses Short-term memory loss is manifested by an inability to recall events or actions that just occurred, such as where the client recently placed her eyeglasses.

A charge nurse is observing a newly licensed nurse, irrigate, a clients ear, which is impacted with cerumen. Which of the following actions requires a charge nurse intervene?

Instilling 50 ML of fluid with each irrigation When irrigating a clients ear, the nurse should use no more than 5 to 10 ML of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear, which would result in nausea, vomiting, or dizziness. The nurse should stop irrigating if the client experiences, pain, nausea, vomiting, or dizziness

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?

Limited choices offered to the client Choices should be limited for a client who has stage II AD to reduce confusion and frustration.

A nurse is planning care for a client following a stroke. Which of the following intervention should the nurse identify as a priority in the clients plan of care?

Monitor the client for increased intracranial pressure (ICP) The greatest risk to this client is an injury from increased ICP, which can result in decreased cerebral perfusion and neurological injury. Therefore the priority intervention, the nurse should include in the plan of care is monitoring the client for increased ICP. Manifestations of increased ICP include a decreased level of consciousness and a change in pupils.

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)

Monitor vitals signs every 2 hours Assess neurological status every 4 hours Keep the clients room darkened The nurse should monitor the client's vital signs to assess for changes consistent with increased intracranial pressure. In addition, the nurse should monitor the client's neurological status at least every 4 hours or more frequently if the client's status indicates. The course of encephalitis is unpredictable, so the client should be monitored closely for any indications of deteriorating neurological functioning. The nurse should provide the client with a low-stimulation environment to promote comfort and decrease agitation.

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect?

Opacity visible behind the pupil With a cataract, the lens of the eye becomes thick and opaque behind the pupil when the nurse shines a light on the area.

A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following action should the nurse perform to promote the clients safety?

Provide an obstacle free path for ambulation Although, providing an obstacle, free path is a safety precaution for all clients, it is especially crucial for this client. Cranial nerve II is the optic nerve there for the client has at least some visual challenges and will need an obstacle free pass for ambulation.

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities, should the nurse expect the client to have difficulty?

Reading the newspaper. With presbyopia, the lens is unable to change shape to focus on near objects. Presbyopia develops with aging, beginning in middle age, and results from decreased elasticity of the lens.

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?

Recall To test recall or recent memory, the nurse should ask the client to provide details about how he arrived at the appointment and with whom. The nurse could also ask the client to name any healthcare providers he saw in the past few days.

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?

Report of a headache Autonomic dysreflexia is a neurological emergency that can occur in clients, who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia 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 brainstem injury. Which of the following physiological functions should the nurse monitor?

Respiratory effort The nurse should monitior respiratory effect bc the medulla in the brainstem controls the respiratory center.

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?

Respite care The nurse should make a referral for respite care for the caregiver. Respite care can provide needed relief for caregivers in an expedient, short-term arrangement.

A nurse is assessing a client who reports an acute visual disturbance that he described as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders?

Retinal detachment The retina is the thin layer of light sensitive tissue on the back of the wall of the eye. Retinal detachment is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). This increase in ICP is due to which of the following?

Rigid skull containing cranial contents The nurse should identify that the clients rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP.

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?

Sclerosis of the ossicles Otosclerosis is an overgrowth os tissue of the bones in the middle ear, which can cause tinnitus and conductive hearing loss. A stapdectomy is a surgical procedure by removing a portion of the stapes and inserting a prosthesis.

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?

Semi-Fowler's To prevent an increase in intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30 degrees. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure.

A nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis (MG). Which of the following pieces of information should the nurse include?

Set an alarm to ensure medication dosages are taken on time The nurse should instruct the client to take medication dosages on time to maintain a therapeutic blood level. Dosages should not be missed or postponed because this can cause an exacerbation of the disease.

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?

Severe eye pain Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headache, brown pain, and nausea and vomiting.

A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect?

Swelling behind the ear Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include swelling and pain behind the ear.

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?

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

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing blood sample?

The client rigidly extends his arms A client who exhibit a decerebrate posture rigidly extends and pronates the four extremities and externally rotates the wrists. Decerebrate posturing indicates a severe brain stem injury and late neurological decline.

A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect?

Weakness of the lower extremities Guillain-Barré syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities.

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 intracranial pressure?

Widened pulse pressure

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 a change in the clients neurological status?

level of consciousness

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?

right sided hemiplegia The nurse should expect right-sided hemiplegia following intracranial bleeding in the left hemisphere of the brain.

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?

" shampoo your hair before the procedure and don't use any styling products afterwards" An electroencephalogram (EEG) is a painless test that records, the electrical activity of the brain. For the test, the technician attaches electrodes to the scalp to record the tiny electrical charges released by nerve cells in the brain. For the electrodes to adhere to the scalp, the clients hair has to be clean and free of oils and hair care products.

The nurse is preparing a client for an electroencephalogram (EEG). Which of the following pieces of information should the nurse share with the client?

"You'll begin by lying still with your eyes closed." The client will have to lie still in a reclining chair or bed and keep her eyes closed for the initial recording

A nurse is teaching a client about computed tomography (CT) scan of the brain. Which of the following teaching points should the nurse include?

"You'll have to lie very still on a long, narrow table during the test" The nurse should inform the client that the test will require the client to lie very still on a long, narrow table. Movement during the test interferes with the quality of the films.

A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual cause of MS. Which of the following responses should the nurse make?

Acute episodes are usually followed by remissions, which can vary in duration This client is asking an information-seeking question, so the nurse should provide the client with factual information. The nurse should inform the client that MS is a chronic autoimmune disorder characterized by remissions and exacerbations, with exacerbations becoming more frequent and intense as the disease progresses.

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?

An EEG records, the electrical activity of your brain cells An EEG measures brain waves via multiple electrodes the technician will attach to the scalp. An EEG provides information the provider can use to identify various problems, including seizure disorders, sleep disorders, inflammation, bleeding, and migraine headaches.

A nurse is caring for a client who has received sedation. When the nurse applause, nail bed pressure, the nurse withdrawals his hand. The nurse should document this response as indicating, which of the following?

Arousal The nurse should document that the client is demonstrating some degree of arousal. Withdrawing the hand in response to nailbed pressure indicates responsiveness to sensory stimulation.

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?

Avoid sudden movements Meniere's disease is a disorder of the inner ear affecting balance and hearing. It is characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations.

lurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow pirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations?

Cheyne-Stokes Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.

A nurse is caring for a client who has Ménière's disease. The nurse should identify that Ménière's disease affects which structure of the ear?

Cochlea Ménière'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 preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affect the manner in which the nurse will prepare the client for the scan?

Development of hives when eating shrimp An allergy to shellfish is a contraindication for the use of contrast media during a CT scan. The nurse should inform the provider and explain to the client that this factor might alter how the technician performs the CT scan.

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?

Dry eyes LASIK surgery is a procedure that can correct nearsightedness, and astigmatism by changing the shape of the cornea. Adverse effects of LASIK surgery include dryness of the eyes and blurred vision.

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?

Dysphasia The nurse should apply the ABC priority setting framework, which emphasizes the basic core of human functioning, having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the bodies organs via the blood. An alteration in any of these areas can indicate a threat to life, and should be the nurses priority concern. When applying the ABC priority setting framework, that airway is the priority, because it must be open for oxygen exchange to occur. Breathing is the second priority framework, because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority because the Delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently, carrying oxygen to them. Therefore, dysphasia is the priority manifestation, because it can lead to aspiration.

A nurse is caring for a client during the first 72 hr following a cerebrovascular accident (CVA). Which of the following actions should the nurse take?

Elevate the head of the bed 25 to 30 degrees with the client in a midline position Elevating the head of the bed 25-30 degrees with the client's head in a neutral midline position helps prevent an increase in ICP. ICP is a major risk factor for complications in the first 72 hours following the onset of a CVA

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?

Eustachian tube The eustachian tube connects the middle ear to the throat and allows equalization of pressure and drainage of fluids from the middle ear into the throat.

A nurse is caring for a client who had a cerebrovascular accident (CVA). The cleint 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?

Expressive aphasia A client who has expressive aphasia understand speech, but has trouble speaking and writing. This occurs as a result of a lesion on Broc'as area of the frontal lobe.

A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse take?

Have the client open his mouth and say, "aah" The vagus or X nerve has both sensory and motor functions. To test the motor function, the nurse should have the client open his mouth and say "aah". The palate and uvula should move upward in response. The nurse should also assess the clients voice quality for hoarseness.

A nurse is providing discharge, teaching to a client who is postoperative following cataract surgery and has an intraocular lens placement. Which of the following statements by the client indicates an understanding of the instructions?

I will avoid bending over The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can create inter-ocular hemorrhage.

A nurse is assessing a client who has increased intracranial pressure and has received intravenous mannitol, which of the following findings, indicate a therapeutic effect of this medication?

Increased your an output Mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys. Increased urine output and decreased intracranial pressure for 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 instruction should the nurse include in the teaching?

Instill a diluted alcohol solution into the ear after swimming External otitis is an inflammation of the external auditory canal, often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling, diluted alcohol drops to decrease bacteria, and dry the external ear canal.

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the clients bedside?

Oral nasal suction equipment A client who has myasthenia gravis is at risk of aspiration due to progressive muscle weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an auto immune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral nasal suction equipment at the bedside in the event of aspiration or respiratory distress.

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C-5 spinal cord injury. After checking the clients, vital signs, which of the following action, should the nurse perform next?

Place the client in a high Fowlers position According to evidence based practice, the nurse should first place the client and a high Fowlers position to decrease the clients blood pressure and reduce the risk of end organ damage from the sudden rise in blood pressure

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 clients family to take which of the following actions first in the event of a seizure?

Protect the clients head The nurse should apply the safety and risk reduction priority setting framework, which is assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posting the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority, setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. This client is at greatest risk for injury from hitting his head; therefore the first action is to protect the clients head from injury.

An emergency room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the clients, arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurses priority?

Provide supplemental oxygen The first action, the nurse should take when using the airway breathing circulation. ABC approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical ventilation because the findings indicate decerebrate positioning, which is associated with brainstem injury, and can lead to brain herniation and death

A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following actions should the nurse take?

Redirect the client to a different activity with a small group of people The nurse should redirect the client to another activity to distract from the anxiety. The client should not be exposed to a large group because this provides too much stimulation and can increase anxiety.

A nurse is providing discharge, teaching to a client who has had a transient ischemic attack (TIA). Which of the following instructions should the nurse include?

Reduce dietary sodium A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations and neurological function. The most common causes are atherosclerotic plaque in the carotid, arteries and hypertension; therefore the client should limit sodium intake to help control, hypertension, and prevent future TIAs.

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?

Remote The nurse tests remote or long term memory by asking questions such as where and when the client was born, his age, when he graduated high school, and what the names, ages, and birth dates of his children are. The nurse can layer verify this information with the clients family or friends.

A nurse is assessing a client who reports vision loss. The client describes the loss is 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 disorder?

Retinal detachment A flash of light in a sudden loss of vision or manifestations of retinal detachment. Clients report the event of vision loss as sudden and painless

A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 ML/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory value should the nurse plan to obtain to assess for DI?

Specific gravity Diabetes insipidus is caused by damage to the hypothalamus, or the pituitary gland. As a result of cranial surgery, and infection, or a tumor. In this condition, an inadequate amount of antidiuretic hormone is released in results and polyuria. A low specific gravity, 1.001 (to 1.003) is a manifestation of diabetes insipidus.

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) of the cervical vertebra. Which of the following pieces of information in the clients history is a contraindication to this procedure?

The client has a pacemaker.

A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessment is the nurses priority?

The clients ability to clear oral secretions The first action, the nurse should take when, using the airway, breathing and circulation (ABC) approach to client care is to check the clients ability to clear secretions, in order to protect the airway, and reduce the risk of aspiration

A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates that the medication is having a therapeutic effect?

The clients serum osmolarity is 310 mOsm/L. Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the water tissue. A serum osmolarity is desired. A decrease in cerebral edema should result in a decrease in ICP.

A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching?

Thoroughly shampoo her hair prior to the EEG The nurse should instruct the client to thoroughly wash her hair prior to the EEG because hairsprays, oils, and other hair preparations interfere with recording results of the EEG.

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?

Turn off sources of oxygen near the fire. Oxygen fuels fire, so the nurse should turn off all sources of oxygen near the fire.

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?

Turn the client onto a side The nurse should turn the client onto a side to pretoect the cleint from aspiration.

A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following findings is an early manifestation of ALS?

Weakness of the distal extremities ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain and the spinal cord causing muscle wasting spasticity and eventually paralysis. Early manifestations of ALS include increasing muscle weakness, especially involving the distal arms and legs (hands and feet), speech, swallowing, and breathing.

A nurse is providing preoperative teaching for a client who will undergo laser assisted, in situ keratomileusis (LASIK) surgery. Which of the following pieces of information should the nurse include?

You might need glasses after the surgery Lasik is a type of refractive laser, eye surgery. The ophthalmologist performed to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, over correction or under correction of refractive errors is possible, so some clients will need prescription eyeglasses, despite having had Lasik surgery.

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?

You should avoid reading for 1 week. The client should avoid reading and any activity that can cause rapid movement of the eye because of the risk for detachment of the retina.