Chapter 78 Neurological

The nurse is caring for a client with a diagnosis of multiple sclerosis who has been prescribed oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which question?

"Are you getting up at night to urinate?"

A client arrives at the clinic complaining of a severe headache. The client states "It's a 10/10 headache. I took 600 mg of ibuprofen over the past few hours, and it has not decreased the pain." The nurse suspects that the client is experiencing a migraine but wants to validate the suspicion by asking which questions associated with a migraine? Select all that apply.

"Can you describe the pain?" "What other symptoms are you experiencing?" "What did you experience right before the headache began?" "Do you or a family member have a history of severe headaches?"

A female client with myasthenia gravis comes to the primary health care provider's office for a scheduled office visit. The client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. Which is the appropriate nursing response?

"Have you thought about sharing your feelings with your husband?"

The nurse is caring for an older client with a diagnosis of myasthenia gravis and has reinforced self-care instructions. Which statement by the client indicates a need for further teaching?

"I can change the time of my medication on the mornings that I feel strong."

A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client makes which statement?

"I can resume a full activity level immediately."

The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement?

"I can't swallow very well today."

The nurse is reinforcing discharge instructions to a client who has undergone transsphenoidal surgery for a pituitary adenoma. Which statement by the client indicates understanding of the discharge instructions?

"I need to call the doctor if I develop frequent swallowing or postnasal drip."

The nurse has given medication instructions to the client receiving phenytoin. The nurse determines that the client understands the instructions if the client makes which comments? Select all that apply.

"I should not suddenly stop taking this medication." "Good oral hygiene is needed, including brushing and flossing."

A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching?

"I will bend at the waist, keeping the halo vest straight to pick up items."

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?

"I will drive only during the daytime."

The nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further teaching?

"I will not hear sounds clearly unless they are loud."

The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement?

"I will try to eat my food either very warm or very cold."

A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." An appropriate response by the nurse is which?

"I'm glad you told me that. Let's have a cup of coffee and you can tell me about your father."

The nurse is caring for a client with a diagnosis of multiple sclerosis (MS) who has been prescribed amantadine. The client asks the nurse why the amantadine has been prescribed. Which response would the nurse make?

"It is prescribed to relieve fatigue."

The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statement?

"Resting in a sauna will be a relaxing form of activity."

Family members of an elderly client ask the nurse if there is any test to determine if a person will eventually get Alzheimer's disease. Which appropriate response would the nurse make?

"There are no tests to determine if a person will get Alzheimer's disease, but research for new diagnostic tests will continue."

A postoperative client received a spinal anesthetic. The client has not experienced pain because the anesthetic has not yet worn off. The nurse would monitor the client closely for pain and provide the client with which instruction?

"You will need to let me know when you start to get feeling back in your legs."

A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which position will be used during the procedure?

A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which position will be used during the procedure?

The nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that which is an earlysign of rupture?

A decline in the level of consciousness

Which symptoms would validate the diagnosis of a cluster headache? Select all that apply.

A runny nose Burning sensation in the eye Tearing on the affected eye

A client with myasthenia gravis verbalizes complaints of feeling much weaker than normal. The primary health care provider plans to implement a diagnostic test to determine if the client is experiencing a myasthenic crisis and administers edrophonium. Which data would indicate that the client is experiencing a myasthenic crisis?

A temporary improvement in the condition

A client with myasthenia gravis becomes increasingly weaker. The primary health care provider injects a dose of edrophonium to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if the client is in cholinergic crisis?

A temporary worsening of the condition

A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse?

Acknowledge the client's anger and continue to encourage participation in care.

The nurse is caring for a client with the diagnosis of myasthenia gravis. Which primary health care provider's prescription would the nurse question?

Administer the prescribed anticholinesterase medication 30 minutes after meals.

The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which would the nurse check before the procedure?

Allergy to iodine or shellfish

The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems?

Allergy to pollen

The nurse is caring for a client who appears agitated. What first approach would the nurse take to assess this client for agitation?

Assess the client using the Richmond Agitation-Sedation Scale (RASS) tool.

The nurse is ambulating a client with a known seizure disorder. The client says, "I'm seeing those flashing lights again," then loses consciousness and develops a clonic-tonic seizure. Which would be the nurse's initial action?

Assist the client to the floor.

A client with Parkinson's disease is developing dementia. Which action would the nurse plan to assist the client in maintaining self-care abilities?

Break down activities into small steps.

The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? Select all that apply.

Bruising behind ears ("Battle's sign") Bruising around eyes ("raccoon eyes") Bloody or clear drainage from the auditory canal

The nurse reviews the primary health care provider's treatment plan for a client with Guillain-Barré syndrome. Which prescription noted in the client's record would the nurse question?

Clear liquid diet

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse would institute which interventions? Select all that apply.

Collect data to determine factors for fall risk. Instruct the client to ask for assistance when getting up to walk.

The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse would perform which essential action when caring for this client?

Comparing the amount of prescribed weights with the amount in use

The nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure (ICP). Which indicates an early sign of increased ICP?

Confusion

The nurse is collecting data on a client diagnosed with Parkinson's disease. Which finding indicates a serious complication of this disorder?

Congested cough and coarse rhonchi heard during auscultation

Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. The nurse monitors the client for effectiveness of this medication, knowing which is its primary action?

Decrease cerebrospinal fluid production

A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before that. The findings have been reported to the primary health care provider, and the nurse anticipates a prescription for which medication?

Desmopressin

A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity?

Doing active range of motion to finger joints

The nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. This conclusion is based on which findings? Select all that apply.

Drainage from ear Bruising around the eyes Pink-tinged drainage from the nose

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse would bring which items into the client's room?

Electrocardiographic monitoring electrodes and intubation tray

The nurse is caring for a client who sustained a spinal cord injury. While administering morning care, the client developed signs and symptoms of autonomic dysreflexia. Which is the initialnursing action?

Elevate the head of the bed.

A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse would plan which approach as therapeutic in assisting the client to cope with the disease?

Encourage and praise perseverance in exercising and performing activities of daily living.

A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that there is a need for further teaching if the nurse observes which action by the family?

Encouraging the client to stand unassisted on the leg

A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which observations? Select all that apply.

Excessive tearing Inability to furrow brow A lag in closing the bottom eyelid

The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity?

Exhaling during repositioning

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention would the nurse plan to incorporate into the care routine for the client?

Explaining equipment and procedures on an ongoing basis

The nurse is assisting in gathering data on cranial nerve XII of a client who sustained a brain attack (stroke). The nurse understands that the client would be asked to perform which action?

Extend the tongue.

The nurse determines that motor function of which cranial nerve is intact if the client can perform this action? Refer to figure.

Facial

A client has just undergone lumbar puncture (LP). The nurse assists the client into which optimal position?

Flat, turning from side to side as needed

The nurse is caring for a client with a spinal cord injury. High-top sneakers on the client's feet will prevent the occurrence of which?

Foot drop

The nurse is assisting in the care of a client receiving codeine sulfate for pain. The nurse would make note of which finding to detect an adverse effect of this medication?

Frequency of bowel movements

The client a nurse has been caring for has become increasingly agitated. The nurse knows that which finding(s) most likely would contribute to the client's possible agitation? Select all that apply.

Full bladder Postoperative pain Separation from family Uncomfortable position

The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse would plan to place the client in which position postoperatively?

Head of bed elevated 30 to 45 degrees, head and neck midline

A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which findings noted in the client history indicates that the client may be ineligible for this diagnostic procedure? Select all that apply.

Hip replacement Permanent pacemaker Prosthetic valve replacement

The nurse is collecting neurological data on a poststroke adult client. Which technique would the nurse perform to adequately check proprioception?

Hold the sides of the client's great toe, and while moving it, ask what position it is in.

The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom indicates this crisis is taking place?

Hypertension

The nurse suspects neurogenic shock in a client with complete transection of the spinal cord at the T3 (thoracic 3) level if which clinical symptoms are observed?

Hypotension and bradycardia

The nurse is assisting in the care of a client with Parkinson's disease who is receiving carbidopa/levodopa. The nurse plans to monitor the client for which adverse effect, which could appear with elevated serum levels of this medication?

Impaired voluntary movements

A client with Parkinson's disease is experiencing a Parkinsonian crisis. The nurse would immediately place the client where?

In a quiet, dim room with respiratory and cardiac support available

The nurse is caring for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, which action does the nurse plan?

Increase the client's awareness of the affected side.

The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How would the nurse interpret the client's situation?

It is possible the client can hear the family.

The nurse is assigned to care for a client with a diagnosis of hepatic encephalopathy. Which prescribed medication would the nurse most anticipate administering?

Lactulose syrup

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

Limiting bladder catheterization to once every 12 hours

The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which item would be included as part of the precautions?

Maintaining the head of the bed at 15 degrees

The nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which information?

Masklike facies is a component of Parkinson's disease.

The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom?

Minor headache

The nurse develops a plan of care for a client following a lumbar puncture. Which interventions would be included in the plan? Select all that apply.

Monitor the client's ability to void. Maintain the client in a flat position. Monitor the client's ability to move the extremities. Inspect the puncture site for swelling, redness, and drainage.

A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client?

Monitoring the respiratory rate

Which signs/symptoms are observed in the clonic phase of a seizure? Select all that apply.

Muscular relaxation Contortion of the face with eye rolling Extension spasms of the body

The nurse is monitoring a client for Biot's respirations. Which condition causes Biot's respirations?

Neurological disorders

A client is recovering at home after suffering a brain attack (stroke) 2 weeks ago. A home caregiver tells the home health nurse that the client has some difficulty swallowing food and fluids. Which nursing action would be appropriate?

Observe the client feeding himself or herself.

A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor?

Omitted doses of medication

A client with a seizure disorder is being admitted to the hospital. Which would the nurse plan to implement for this client? Select all that apply.

Pad the bed's side rails. Place an airway at the bedside. Place oxygen equipment at the bedside. Place suction equipment at the bedside.

The clinic nurse is reviewing the medical record of a client scheduled to be seen in the clinic. The nurse notes that the client is prescribed selegiline hydrochloride. The nurse understands that this medication is prescribed for which disorder?

Parkinson's disease

A client with a stroke (brain attack) is experiencing residual dysphagia. The nurse would remove which food item that arrived on the client's meal tray from the dietary department?

Peas

A client complains of pain in the lower back and pain and spasms in the hamstrings when the nurse attempts to extend the client's leg. How would the nurse record this finding on the client's medical record? Refer to figure.

Positive Kernig's sign

A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety?

Provide a clear path for ambulation without obstacles.

An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets which finding as abnormal if present?

Red blood cells

The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which assessment will provide the nurse with the best information about recovery from the spinal shock?

Reflexes

The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which?

Remind the client to turn the head to scan the lost visual field.

The nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse reviews the client's plan of care, expecting to note that the client would be maintained in which position?

Semi-Fowler's position

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply.

Semi-Fowler's position With the foot of the bed flat

The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria?

Separates into concentric rings and tests positive for glucose

The nurse is reviewing a client's chart who is experiencing symptoms of restless legs syndrome. Which laboratory test would aid in the diagnosis of secondary restless legs syndrome?

Serum ferritin

The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted?

Severe, throbbing headache

The nurse has applied a hypothermia blanket to a client with a fever. The nurse would inspect the skin frequently to detect which complications of hypothermia blanket use? Select all that apply.

Skin breakdown Diminished peripheral perfusion

Which data collection finding supports the possible diagnosis of Bell's palsy?

Speech or chewing difficulties accompanied by facial droop

The nurse is suctioning an unconscious client who has a tracheostomy. The nurse would avoid which action during this procedure?

Suctioning for longer than 30 seconds

The nurse is told in a report that a client has a positive Chvostek's sign. Which other data would the nurse expect to find on data collection? Select all that apply.

Tetany Diarrhea Possible seizure activity Positive Trousseau's sign

The nurse caring for a client notes that the client has become disoriented and is displaying some inappropriate behavior. The nurse is concerned about this new finding because of the sudden onset. The nurse recognizes that which manifestation is most likely occurring?

The client is experiencing delirium.

The nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure (ICP). Which sign, if noted in the client, would the nurse report immediately?

The client vomits.

The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time?

The primary health care provider (PHCP) reviews the x-ray results.

The nurse caring for a comatose client with encephalitis is creating a care plan. Which interventions would be appropriate to include in the care of this client? Select all that apply.

Turn the client every 2 hours Maintain the bed in the lowest position Conduct a neurological assessment at least every 2 hours

A client with new onset migraine headaches is being seen in the clinic. The client has a history of hypotension and diabetes mellitus. The nurse understands the client is at risk for cardiac side effects if the primary health care provider prescribes which medications? Select all that apply.

Verapamil Propranolol Sumatriptan

A client is suspected of having a diagnosis of Guillain-Barré syndrome (GBS). Which findings would support a diagnosis of Guillain-Barré syndrome? Select all that apply.

Visual and hearing disturbances Ascending symmetrical muscle weakness

A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item?

Walker

A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will do which?

Wear the patch continuously, alternating eyes each day.

The nurse is reading the laboratory results for a client being treated with carbamazepine for prophylaxis of complex-partial seizures. The nurse interprets that which value is consistent with an adverse effect to this medication?

White blood cell count 3200 mm3

The nurse is planning care for a client with hemiparesis of the right arm and leg. Where would the nurse plan to place objects needed by the client?

Within the client's reach, on the left side