Quiz for adn 235 ati

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

Add gesture when speaking with the client

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, dislates pupils?

Black tag

An 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 clients should the nurse assess first?

A client who is difficult to arouse and is unable to response to questions

A nurse in a rehabilitation 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?

Difficulty with speech Rationale: 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 has a closed traumatic brain injury and is experiencing increased intercranial pressure. This increased intercranial pressure is due to which of the following?

Digit skull containing cranial contents

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

Dysphagia. This can occur as a result of CN IX or X damage

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

Dysphagia. This can occur as a result of CN IX or X damage

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

Elevated protein

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

Elevated protein levels

A nurse is caring for a client who has experience aphasia following a stroke. the nurse should identify that the stroke affected which of the following lobes of the clients brain?

Frontal

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 clients brain?

Frontal lobe

A nurse is preparing to test the function of the cranial nerve 10. Which of the following assessment procedures should the nurse use?

Have the client open his mouth and say "aah"

A nurse names 3 obiects 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 min, the nurse asks the client to name the objects. The nurse is using this strategy to test which type of memory?

Immediate memory

A nurse in the emergency department has assessed a clients airway, breathing and circulation following a head injury from a fall at work. Which of the following action is the priority for the nurse to perform next?

Immobilize the clients cervical spine

The nurse is providing teaching to a family of a client who has stage two Alzheimer's disease. Which of the following pieces of information should the nurse include in the teaching?

Limit the choices offered to the client

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?

Place the patient in a high-fowler's position

A 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 flexión of the feet. Which of the following actions is the nurse priority?

Provide supplemental oxygen

An emergency room nurse is assessing a client who has 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 nurse priority?

Provide supplemental oxygen

During a neurological assessment, a nurse asked how the client arrived at the appointment and with whom. Which of the following types of memory is the nurse testing?

Recall

during a neurological assessment, a nurse asks who the client arrived at the appointment in with Home which of the following types of memory is the nurse testing?

Recall

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

During a neurological assessment, a nurse asked the client to name all of his children, their ages, and their birthdates. Which of the following types of memory is the nurse testing?

Remote

A nurse is assessing a client who has a A nurse is assessing a client who has a high thoracic spinal core injury. The nurse should identify that which of the following findings as a manifestation of autonomic dysreflexia ?

Report of a headache

A nurse is assessing a client who has a high thoracic spinal cord injury. The nurse should identify which of the following findings acid manifestation of autonomic dysreflexia?

Report of a headache

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

Ridges skull containing cranial Contant

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 Rationale: 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 assessing a client who has sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?

Widened pulse pressure Rationale: A widening of pulse pressure, the difference between the systolic and diastolic pressure, is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting.

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

You'll begin by lying still with your eyes closed

A nurse is assessing a client who sustain a recent heading injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressures?

Widened pulse pressure Pupil changes(dilation) Change in level of consciousness, nausea and vomiting

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?

B. Protect the client's head

A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicate the client is experiencing increased intracranial pressure?

Dilated pupils

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

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

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

The client's ability to clear oral secretions