ATI Med-Surg Neurosensory Quiz

A nurse is collecting data from a client following a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? A. Widened pulse pressure B. Tachycardia C. Periorbital edema D. Decrease in urine output

A. Widened pulse pressure Rationale: A widening of the 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. Tachycardia can be a manifestation of hypovolemia; however, bradycardia is a manifestation of increased intracranial pressure. Periorbital edema can occur following eye trauma or a craniotomy; however, it is not a manifestation of increased intracranial pressure. A decrease in urine output can be a manifestation of hypovolemia; however, it is not a manifestation of increased intracranial pressure.

A nurse is collecting data from a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid 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 Rationale: 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. Paradoxical respirations, or a flail chest, is a pattern of breathing in which the chest wall contracts during inspiration and expands during expiration. This can occur in a client who has sustained rib fractures. Kussmaul respirations is a deep, rapid respiratory pattern of hyperventilation that can occur in a client who has diabetic ketoacidosis. A client who has orthopnea experiences shortness of breath when in a supine position and is able to breathe easily when sitting upright.

A nurse is reinforcing teaching with the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings 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 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. ALS does not affect the sensory nervous system. It is a progressive neurodegenerative disease that affects the motor nerve cells in the brain and the spinal cord. ALS does not cause visual changes. It is a progressive neurodegenerative disease that affects the motor nerve cells in the brain and the spinal cord. ALS does not affect the autonomic nervous system or temperature regulation. It is a progressive neurodegenerative disease that affects the motor nerve cells in the brain and the spinal cord.

A nurse is reinforcing teaching with a client who has a new diagnosis of Meineres 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: Ménière's disease is a disorder of the inner ear affecting balance and hearing, characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations. The nurse should instruct the client to reduce sodium intake and drink an evenly distributed amount of fluids throughout the day to stabilize fluid levels in the body. The nurse should instruct the client to avoid caffeine and drink an evenly distributed amount of fluids throughout the day to stabilize fluid levels in the body. Bearing down, or using the Valsalva maneuver, does not increase the manifestations of Ménière's disease.

A nurse is reinforcing teaching with 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 solution into the ear after swimming D. Irrigate the ear with cool tap water to clean

C. Instill a diluted solution into the ear after swimming Rationale: 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. The client can gently irrigate the ear with warm tap water to remove cerumen after the inflammation is gone. The client should not use cool water to irrigate the ear because it can cause nausea or dizziness. The client should apply a warm, moist towel or a heating pad set at the lowest setting to the ear to reduce pain. The client should not insert any object smaller than a finger into the ear because it can injure the delicate tissue of the external ear canal, push cerumen further back against the tympanic membrane, or puncture the eardrum.

A nurse is caring for a client who has a closed head injury. 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: To prevent an increase in intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30º. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure. Sims' is a side-lying position with flexion of the client's hip and knee. Flexing the client's hip or neck can cause an increase in intracranial pressure; therefore, the Sims' position is contraindicated following a craniotomy. Prone refers to the client lying flat on his abdomen. This position can cause an increase in intracranial pressure; therefore, the prone position is contraindicated following a craniotomy. Trendelenburg is a position in which the entire bed is tilted with the head of the bed down. This position can cause an increase in intracranial pressure; therefore, the Trendelenburg position is contraindicated following a craniotomy.

A nurse is collecting data from 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 Rationale: Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headache, brow pain, and nausea and vomiting. Double vision can be a manifestation of multiple sclerosis. This is not a manifestation of acute angle-closure glaucoma. Flashes of light in front of the affected eye is a manifestation of a detached retina. This is not a manifestation of acute angle-closure glaucoma. Multiple floaters, or floating dark spots, seen in the affected eye are manifestations of a detached retina. This is not a manifestation of acute angle-closure glaucoma.

A nurse is collecting data from 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-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. Guillain-Barré syndrome is an inflammatory disorder of the peripheral nerves. Decreased level of consciousness is not a manifestation of Guillain-Barré syndrome. Guillain-Barré syndrome is an inflammatory disorder of the peripheral nerves. Severe headaches are not a manifestation of Guillain-Barré syndrome. Guillain-Barré syndrome is an inflammatory disorder of the peripheral nerves. Tonic-clonic seizures are not a manifestation of Guillain-Barré syndrome.

A nurse is reinforcing teaching with a group of client's about transient ischemic attacks (TIAs). Which of the following 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. Rationale: TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include loss of vision in one eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness. TIAs do not produce edema of the cerebrum. Cerebral edema can be the result of a stroke. A hemorrhagic stroke can be the result of cerebral bleeding. TIAs are caused by a temporary reduction of oxygen supply to the brain, such as from a thromboembolism or cerebral vasospasm. TIAs are brief episodes of a neurologic deficit that last less than 24 hr after onset without any permanent disabilities.

A nurse is reinforcing teaching with a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following information should the nurse include in the teaching? SOA 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: Lost vision can improve with eye drops is incorrect. Eye drops will not improve vision; however, they can reduce intraocular pressure and prevent further vision loss. Administer eye drops as needed for vision loss is incorrect. The client should administer eye drops on a regular schedule to reduce intraocular pressure. Glasses will be necessary to correct the accompanying presbyopia is incorrect. Presbyopia, which is a decrease in near vision that occurs after 40 years of age, is not related to POAG. Vision loss that occurs with POAG will not improve with glasses. Driving can be dangerous due to the loss of peripheral vision is correct. Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can cause complete vision loss if not treated. Laser surgery can help reestablish the flow of aqueous humor is correct. Laser surgery can reopen the trabecular meshwork and widen the Canal of Schlemm.

A nurse is reinforcing teaching with the family of a client who has stage II Alzheimer's disease (AD). Which of the following 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: Choices should be limited for the client who has stage II AD to reduce confusion and frustration. A client who has stage II AD can become agitated from reality orientation. Validation therapy can show acceptance of the client's feelings. Noises can increase anxiety in a client who has stage II AD. The client's environment should be quiet to reduce stress and promote rest. A client who has stage II AD can become fearful of pictures of people or objects. The client's room should not have pictures on the wall that might confuse or scare the client.

A nurse is collecting data from 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 a headache

D. Report of a headache Rationale: Autonomic dysreflexia is a neurologic 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. Autonomic dysreflexia is a neurologic emergency that occurs in clients who have a cervical or thoracic spinal cord injury above the level of T6. Manifestations include bradycardia but not tachycardia. Autonomic dysreflexia is a neurologic emergency that occurs in clients who have a cervical or thoracic spinal cord injury above the level of T6. Manifestations include hypertension but not hypotension. Autonomic dysreflexia is a neurologic emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Manifestations include flushing above the level of injury and pallor below the level of injury.

A nurse is collecting data from a client who has a recent head trauma and a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to monitor for DI? A. Blood urea nitrogen (BUN) B. Blood glucose C. Urine ketones D. Specific gravity

D. Specific gravity Rationale: Diabetes insipidus is caused by damage to the hypothalamus, or the pituitary gland, as a result of cranial surgery, infection, or a tumor. It is a condition in which an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus. Urine ketones are used to measure diabetic ketoacidosis and are not used to monitor DI. Blood glucose is used to monitor a client who has diabetes mellitus and is not used to monitor DI. BUN measures the ability of a client's kidney to excrete urea nitrogen and is not used to monitor DI.

A nurse is reinforcing with the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is the priority? A. Dysphagia B. Emotional liability C. Impaired speech D. Self-care dependency

A. Dysphagia Rationale: The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning, which is having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and should be the nurse's priority concern. When applying the ABC priority-setting framework, the airway is the priority because it must be clear and open for oxygen exchange to occur. Breathing is the second priority in the ABC priority-setting framework because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Dysphagia is the priority manifestation for this client because it can lead to aspiration. The nurse should teach the partner of the client about emotional lability and depression associated with Parkinson's disease; however, another manifestation is the priority. The nurse should teach the partner of the client about the development of impaired speech associated with Parkinson's disease; however, another manifestation is the priority. The nurse should teach the partner of the client about the occurrence of self-care dependency associated with Parkinson's disease; however, another manifestation is the priority.

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 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: A client who exhibits a decerebrate posture rigidly extends and pronates his four extremities and externally rotates his wrists. Decerebrate posturing indicates severe brain stem injury and late neurologic decline. A client who exhibits decorticate posturing internally flexes his wrists and arms and extends and plantar flexes his legs. A fetal position is not a manifestation of a decerebrate posture. A client who exhibits decorticate posturing flexes his arms with internal rotation of the forearms and extends and plantar flexes his legs.

A nurse is reinforcing discharge teaching with 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 expect to see flashing lights in front of the affected eye after the procedure." C. "You can remove eye shields when you're sleeping." D. "You should not lift objects that weigh more than 25 pounds."

B. "You should expect to see flashing lights in front of the affected eye after the procedure." Rationale: The client should expect to see flashing lights in front of the affected eye for several weeks following the procedure. The client's vision will not be restored immediately after the procedure because of swelling of the eye and the dilating effects of eye drops. The client's vision should return gradually over several weeks. The client should wear eye shields for 2 to 6 weeks after surgery when sleeping to protect the eye from injury. The client should not lift objects that weigh more than 20 pounds to prevent an increase in intraocular pressure.

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

B. 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 client who is recovering from a right-hemisphere stroke can be impulsive. Clients who are recovering from a left-hemisphere stroke are cautious. A client who is recovering from a right-hemisphere stroke can neglect the left side of his body. The client can inadvertently injure his arm or leg since he cannot feel or see anything on the left side of the body. A client who is recovering from a left-hemisphere stroke will demonstrate hemiplegia of the right side of the body because the pyramidal pathway crosses over at the base of the brain.

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

B. Elevated protein Rationale: An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include an increase in protein in the cerebrospinal fluid. Manifestations of bacterial meningitis include a decrease in glucose in the cerebrospinal fluid. RBCs present in the cerebrospinal fluid can be an indication of bleeding; however, WBCs in the cerebrospinal fluid is a manifestation of bacterial meningitis. D-dimer measures coagulation activity and is used to evaluate blood clotting. The presence of D-dimer in the cerebrospinal fluid is not a manifestation of bacterial meningitis.

A nurse is reinforcing discharge teaching with 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 during the event of a seizure? A. Reorient the client. B. Protect the client's head. C. Loosen constrictive clothing. D. Turn the client on his side.

B. Protect the client's head Rationale: The nurse should apply the safety and risk reduction priority-setting framework. This framework 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 posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The client is at greatest risk for injury from hitting his head; therefore, the first action the nurse should take is to protect the client's head from injury. The family should reorient the client as he regains consciousness following a seizure; however, another action is the priority. The family should loosen constrictive clothing to protect the client from injury during a seizure; however, another action is the priority. The family should turn the client on his side to protect the client from injury during a seizure; however, another action is the priority.

A nurse is reinforcing teaching with a client who is preoperative for cataract surgery. The nurse should include in the teaching that which of the following is an adverse effect of cataract surgery? A. Eyelid twitching B. Photosensitivity C. Intraocular hemorrhage D. Dry eyes

C. Intraocular hemorrhage Rationale: Intraocular hemorrhage is an adverse effect of cataract surgery. The client should immediately report manifestations of intraocular hemorrhage, such as eye pain, brow pain, and decreased vision, to the provider. Dry eyes can be an adverse effect of laser-assisted in situ keratomileusis (LASIK) surgery; however, this is not an adverse effect of cataract surgery. Photosensitivity, sensitivity of the skin to light, is not an adverse effect of cataract surgery. There is no surgical manipulation of the nerves of the face or eyelid; therefore, tics or twitching of the eyelid are not associated with cataract surgery.

A nurse is collecting data from a client who is admitted to the facility for observation following a closed head injury. Which of the following data is the priority for the nurse to collect to detect a change in the client's neurological status? A. Vital signs B. Body posture C. Level of consciousness D. Examination of pupils

C. Level of consciousness Rationale: The nurse should apply the urgent vs. nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs the priority because they pose more of a risk to the client. The nurse might also use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify the most urgent finding. Therefore, the priority data collection is level of consciousness. A change in the client's level of consciousness can be the first indication of a change in neurologic status. A change in the client's pupils is a later finding that can indicate a change in neurologic status; therefore, there is another data collection that is the priority. A change in pupils, such as dilated or fixed pupils, can indicate increasing intracranial pressure or discrete areas of brain ischemia. Abnormal posturing, such as decerebrate or decorticate posturing, are later findings that indicate a change in the client's neurologic status; therefore; there is another data collection that is the priority. Posturing is seen when cortical control over motor function is lost. Changes in the client's vital signs, such as bradycardia and a widening pulse pressure, are later findings that indicate a change in neurologic status; therefore, there is another data collection that is the priority. Vital sign changes can indicate increasing intracranial pressure and pressure on the hypothalamus.

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

D. Feeling of fullness in the ear Rationale: A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations can include ear pain, a cracking sound when yawning or swallowing, and mild dizziness. A client who has external otitis can develop itching on the ear canal. A client who has an inner ear disorder can develop nystagmus or rapid eye movement. A client who has otitis media can develop a low-pitched sound in the affected ear.

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

D. Oral-nasal suction equipment Rationale: The client who has myasthenia gravis is at risk for aspiration because of progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune 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. External defibrillator pads are used for a client who has a cardiac dysrhythmia; however, they are not indicated for a client who has myasthenia gravis. A continuous passive motion machine is used to provide continuous motion of a joint for a client who is postoperative following joint surgery; however, it is not indicated for a client who has myasthenia gravis. A metered-dose inhaler is used to administer medications for a client who has asthma; however, it is not indicated for a client who has myasthenia gravis.

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history is a contraindication to the 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: An MRI uses strong magnets and radio waves that are evaluated using computer technology to view three-dimensional images of the body. Since an MRI is magnetically generated, it is not indicated for use in the presence of certain medical implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures. An MRI uses strong magnets and radio waves that are evaluated using computer technology to view three-dimensional images of the body. Peripheral vascular disease is not a contraindication for an MRI. The client who is unable to sit upright is able to obtain an MRI because the client does not need to be in an upright position during the MRI. An MRI uses magnetic fields to view three-dimensional images of the body. An old tattoo can contain lead and be a contraindication to an MRI; however, a new tattoo is not a contraindication to an MRI.

A nurse is reinforcing teaching about auras with a client who has a new diagnosis of simple partial seizures. Which of the following statements by the client indicates and 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." Rationale: An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or smelling an odor. A continuous seizure state is a medical emergency called status epilepticus and requires immediate medical support. A period of sleepiness, or lethargy, following a seizure is referred to as the postictal state. A brief loss of consciousness accompanied by staring is a manifestation of an absence, or petit mal, seizure. These seizures occur primarily in children.

A nurse is collecting data from a client who has a brain tumor. Which of the following indicates cranial nerve involvement? A. Dysphagia B. Positive Babinski sign C. Decreased deep-tendon reflexes D. Ataxia

A. Dysphagia Rationale: Dysphagia, or difficulty swallowing, can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus). A positive Babinski sign, or the turning up of the toes upon plantar stimulation, is associated with an upper motor neuron lesion. The cranial nerves primarily innervate the face, neck, and a few organs. Decreased deep-tendon reflexes indicate impairment in the electrical conduction of spinal nerves that interfere with reflex arcs. The cranial nerves primarily innervate the face, neck, and a few organs. Ataxia, or uncoordinated movements of the extremities, can indicate damage to the cerebellum or motor pathways. The cranial nerves primarily innervate the face, neck, and a few organs.

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

A. Swelling behind the affected ear Rationale: Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include swelling and pain behind the ear. Facial drooping can be a manifestation of a tympanoplasty, but it is not a manifestation of mastoiditis. Bilateral nystagmus can be a manifestation of labyrinthitis, but it is not a manifestation of mastoiditis. A pearly gray eardrum is an expected finding of a healthy eardrum. A red, thick eardrum is a manifestation of mastoiditis.

A nurse is collecting data from a client who has a closed head injury and is receiving mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates to the nurse that the medication is having a therapeutic effect? A. The client's urine output is 250 mL/hr. B. The client's pupils are dilated. C. The client's heart rate is 56/min. D. The client is restless.

A. The client's urine output is 250 mL/hr. Rationale: Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. An increase in urine output is desired. A decrease in cerebral edema should result in a decrease in ICP. Dilated pupils, pinpoint pupils, and asymmetrical pupils are manifestations of increased ICP. Mannitol is an osmotic diuretic used to decrease cerebral edema and reduce ICP. Bradycardia is a manifestation of increased ICP. Mannitol is an osmotic diuretic used to decrease cerebral edema and reduce ICP. Restlessness and behavior changes are manifestations of increased ICP. Mannitol is an osmotic diuretic used to decrease cerebral edema and reduce ICP.

A nurse is reinforcing teaching with 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: The nurse should instruct the client to lie down in a dark room to reduce migraine pain. The nurse should instruct the client to avoid scents that can increase the severity of a migraine. The nurse should instruct the client to avoid foods that can trigger migraines, such as caffeinated beverages. The nurse should instruct the client to place a cool cloth on the forehead to reduce migraine pain.

A nurse is reinforcing teaching with a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements made by the client indicates and understanding of the teaching? 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." Rationale: 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 result in intraocular hemorrhage. There are no specific diet modifications for a client who has an intraocular lens implant for cataract correction. The nurse should instruct the client to avoid aspirin, which can increase the risk for bleeding. The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as placing his head in a dependent position and sleeping on the affected side.