Concepts II - Intracranial Regulation

a nurse is teaching a client who has a prescription for baclofen. Which of the following instructions should the nurse include? 1 - Avoid driving until the drug's effects are evident. 2 - Stop taking the drug immediately if headache occurs. 3 - Take the drug as needed for spasticity. 4 - Take the drug with antacids to reduce gastric effects.

1 - Avoid driving until the drug's effects are evident. Rational 1 - Baclofen, a centrally-acting muscle relaxant, causes CNS depression. Clients taking the drug should avoid alcohol and other CNS depressants, and should not drive a vehicle until they know how the drug will affect them. 2 - Abrupt withdrawal of baclofen, a centrally-acting muscle relaxant, can cause seizures, fever, and hypotension. A better alternative is to treat the headache, which can have many other causes, and see if it resolves as drug therapy with baclofen continues. 3 - Clients typically take baclofen, a centrally-acting muscle relaxant, daily at regular doses. Clients should start with a low dose and titrate up as tolerated. 4 - Clients may take baclofen, a centrally-acting muscle relaxant, with food to help prevent nausea. They should take antacids 1 hr before or 2 hr after other drugs, including baclofen.

A nurse is teaching a client who has a new prescription for valproic acid to treat a seizure disorder. The nurse should instruct the client to monitor for which of the following adverse effects (Select all that apply) 1 - Hirsutism 2 - Drowsiness 3 - Headache 4 - Ataxia 5 -Rash

2 - Drowsiness 3 - Headache 5 -Rash Rational 1 - Hirsutism is incorrect. Valproic acid is more likely to cause hair loss rather than hirsutism, or excessive hair growth. 2 - Drowsiness is correct. Clients taking valproic acid should report CNS depressant effects, such as sedation or drowsiness, because these adverse effects can indicate the need for a reduction in dose. 3 - Headache is correct. Valproic acid can cause headache, along with other CNS adverse effects, such as sleep disturbances. 4 - Ataxia is incorrect. Ataxia is an adverse effect of phenytoin and carbamazepine, which are drugs used to treat seizure disorders. 5 - Rash is correct. Skin rash is an adverse effect of valproic acid and other antiepileptic drugs.

aA nurse is providing teaching for a client who has a new prescription for valproic acid to treat a seizure disorder. The nurse should instruct the client to monitor which of the following adverse effects? 1 - Hirsutism 2 - Depression 3 - Jaundice 4 - Gum irritation

3 - Jaundice Rational 1 - Valproic acid is unlikely to cause hirsutism, or excessive hair growth, but it can cause transient hair loss. 2 - Valproic acid is unlikely to cause depression, but it can cause aggression. 3 - Valproic acid can cause hepatic toxicity, characterized by jaundice, abdominal pain, and nausea. Clients taking the drug should report these manifestations, and the nurse should monitor liver function studies prior to treatment and periodically during therapy. 4 - Valproic acid is unlikely to cause gum irritation. Phenytoin can cause gingival hyperplasia.

a nurse is teaching a client who received a prescription for interferon beta-1a for the treatment of multiple sclerosis. Which of the following information should the nurse include? 1 - "Have kidney function tests done every month for a year." 2 - "Take an extra dose if muscle aches occur." 3 - "Store the drug at room temperature after mixing it." 4 - "Administer the drug in your thigh or upper arm."

4 - "Administer the drug in your thigh or upper arm." Rational 1 - Liver function tests should be performed before initiating treatment, and then at 1-month, 3-month, and 6-month intervals. 2 - Flu-like manifestations, such as muscle aches, sweating, weakness, and chills, can occur while taking interferon drugs. The nurse should instruct the client to take the drug exactly as prescribed and to take acetaminophen if fever and muscle aches occur. 3 - Interferon beta-1a should be stored in the refrigerator after reconstitution, not at room temperature. 4 - Interferon beta-1a is administered via the subcutaneous route. Therefore, the nurse should instruct the client how to perform subcutaneous injections for self-administration.

A nurse is reviewing treatment options with the parent of a child who has worsening seizures. Which of the following treatments options should the nurse include in the discussion? Select all A - Vagal nerve stimulator B - Additional antiepileptic medications C - Corpus callosotomy D - Focal resection E - Radiation therapy

A - Vagal nerve stimulator B - Additional antiepileptic medications C - Corpus callosotomy D - Focal resection Rational E - Radiation therapy is used in cancer treatment and is not indicated for the management or treatment of seizures.

A nurse is caring for a client following a lumbar puncture. Which of the following actions should the nurse take? select all A - ​Provide oral fluids ​B - Monitor for nausea ​C - Maintain fetal position ​D - Check level of consciousness ​E - Check sensation in the toes

A - ​Provide oral fluids ​B - Monitor for nausea ​D - Check level of consciousness ​E - Check sensation in the toes Rational A - ​Provide oral fluids is correct. The nurse should encourage fluid intake to replace fluid loss during the procedure. B - Monitor for nausea is correct. The nurse should monitor nausea as a possible manifestation of increased intracranial pressure. Additional findings to report include headache or drainage or redness at the puncture site. C - Maintain fetal position is incorrect. Following a lumbar puncture (LP), the nurse should keep the client flat and still for 4 to 8 hr to decrease leakage of cerebral spinal fluid from the LP site. The fetal position is used during the LP procedure to open the spaces in the vertebrae. D - Check level of consciousness is correct. The nurse should monitor for a change in the client's level of consciousness as a possible manifestation of increased intracranial pressure. The nurse should also monitor for photophobia. E - Check sensation in the toes is correct. A lumbar puncture could cause injury to the spinal cord; therefore, the nurse should monitor the client's neurological status in both lower extremities

A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? select all A- Encourage fluid intake. B - Monitor the puncture site for hematoma. C - Insert a urinary catheter. D- Elevate the client's head of bed. E - Apply a cervical collar to the client.

A- Encourage fluid intake. B - Monitor the puncture site for hematoma. Rational A - Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to replace the cerebrospinal fluid that was removed during the procedure and reduce the risk for a headache. B - Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a hematoma at the insertion site because this can indicate bleeding. C - Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion. D - Elevate the client's head of bed is incorrect. The client should remain flat in bed for 1 hr or more to reduce the risk for a headache. E - Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for this client

A nurse is contributing to the plan of care for a client who has bacterial meningitis. Which of the following interventions should the nurse include? Select all A - Monitor for hypertension B - Provide an emesis basin at the bedside C - Administer antipyretic medication D - Perform a skin assessment E - Keep the head of the bed flat

B - Provide an emesis basin at the bedside C - Administer antipyretic medication D - Perform a skin assessment Rational A - The nurse should plan to monitor for hypertension when a client has meningitis. E - The nurse should elevate the head of the client's bed 30° to promote venous drainage from the head and prevent increased ICP

a nurse is caring for a client who is receiving methohexital sodium. The nurse should monitor the client for which of the following adverse effects? A - Cardiac excitability B - Respiratory depression C - Hyperthermia D - Hypertension

B - Respiratory depression Rational A - Methohexital, a short-acting barbiturate, can cause cardiovascular depression. It is essential to have resuscitation equipment available whenever clients receive the drug. B - Methohexital, a short-acting barbiturate, causes respiratory depression. Mechanical ventilation and continuous monitoring are essential for clients receiving the drug. C- Methohexital, a short-acting barbiturate, is more likely to cause hypothermia than hyperthermia. D - Methohexital, a short-acting barbiturate, poses a significant risk for hypotension, not hypertension.

A nurse is caring for an adolescent who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the adolescent's parents is the priority for the nurse to address? A - "He only sleeps about 5 hours each night." B - "He takes his medication between meals with water." C- "He seems to be getting a lot more bumps and bruises lately." D - "He has not been eating as much lately."

C- "He seems to be getting a lot more bumps and bruises lately." Rational A - Decreased sleep patterns are nonurgent because they can be an expected finding for an adolescent client. Although the nurse should inform the client of the increased health risks associated with sleep deprivation, there is another statement that is the priority for the nurse to address. B - Taking the medication between meals is a nonurgent need because it does not affect the function of the medication. Although the nurse should instruct the client to take carbamazepine with food to prevent gastrointestinal distress, there is another statement that is the priority for the nurse to address. C - When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is increased bruising. Although adolescent clients have increased rates of intentional and unintentional injury, carbamazepine can cause bone marrow suppression. The nurse should collect further data to determine whether the client could have thrombocytopenia and intervene to prevent bleeding. D - Poor eating is a nonurgent need because anorexia is a common adverse effect of carbamazepine. Although the nurse should collect further data to determine whether the adolescent has an eating disorder; there is another statement that is the priority for the nurse to address.

A nurse is reviewing the medical record of a client who reprots urinary incontinence and asks about a prescription for oxybutynin. Which of the following conditions is a contraindication for taking oxybutynin. A - Peptic ulcer B - Peripheral edema C - Multiple sclerosis D - Angle-closure glaucoma

D - Angle-closure glaucoma Rational A - GI obstruction, non peptic ulcer disease, is a contraindication for taking oxybutynin B - Urinary retention, not peripheral edema, is a contraindication for taking oxybutynin. C - Myasthenia gravis, not multiple sclerosis, requires caution when taking oxybutynin D - Oxybutynin is an anticholinergic and can increase intraocular pressure. Glaucoma is a contraindication for taking oxybutynin.

a nurse is teaching a client who has a new diagnosis of Parkinson's disease about how levodopa/carbidopa can help control symptoms. The nurse should identify that the drug has which of the following pharmacologic effects? A - Increases available acetylcholine in the brain B - Inhibits norepinephrine metabolism in the brain C - Inhibits serotonin metabolism in the brain ​D - Increases available dopamine in the brain

​D - Increases available dopamine in the brain Rational A - Anticholinergics treat Parkinson's disease by decreasing available acetylcholine in the extrapyramidal system of the brain B -Levodopa/carbidopa relieves tremors associated with Parkinson's disease by converting to dopamine in the brain and serving as a neurotransmitter. Altered levels of cerebral norepinephrine can correlate with depression. C - Levodopa/carbidopa relieves tremors associated with Parkinson's disease by converting to dopamine in the brain and serving as a neurotransmitter. Altered levels of cerebral serotonin can correlate with depression. D - Levodopa/carbidopa, a dopaminergic agent, can increase dopamine in the extrapyramidal center of the brain, reducing involuntary motion, or tremors, associated with Parkinson's disease.

A nurse is teaching a client who is taking levodopa/carbidopa to treat Parkinson's disease. Which of the following nursing interventions should the nurse include? 1 - Change position slowly to prevent orthostatic hypotension. 2 - Eat a high-protein snack to increase absorption. 3- Take the drug at bedtime to avoid daytime drowsiness. 4-Expect eye twitching to develop with long-term therapy.

1 - Change position slowly to prevent orthostatic hypotension Rational 1 - Levodopa/carbidopa can cause orthostatic hypotension. 2 - High-protein foods can reduce the effectiveness of levodopa/carbidopa. Gastric irritation can be alleviated by eating shortly after taking the drug, but protein intake should be divided amongst all meals to avoid consuming foods high in protein at the same time the drug is taken. 3 - Clients typically take levodopa/carbidopa in divided doses during the day. 4 - Muscle twitching can indicate drug toxicity. This is an adverse effect clients should report.

A nurse is teaching a client who has a prescription for modafinil to treat narcolepsy. Which of the following instructions should the nurse include? 1 - Take the drug in the morning. 2 - Take the drug 30 min before bedtime. 3 - Anticipate daytime drowsiness. 4 - Expect urinary frequency.

1 - Take the drug in the morning. Rational 1 - Modafinil is a nonamphetamine stimulant. Taking it in the morning helps improve wakefulness for clients who have narcolepsy. Clients taking the drug for shift-work sleepiness should take it 1 hr before work. 2 - Modafinil is a nonamphetamine stimulant. Evening dosage can cause insomnia. Zolpidem is a drug clients should take just before bedtime to improve sleep and to prevent daytime drowsiness. 3 - Modafinil is a nonamphetamine stimulant that promotes wakefulness. It is unlikely to cause daytime drowsiness. Eszopiclone is a drug that can cause daytime drowsiness. 4 - Modafinil is a nonamphetamine stimulant. It is unlikely to cause urinary frequency, but it can cause diarrhea.

a nurse is reviewing the medical record of a client who has a newly diagnosed seizure disorder and a new prescription for valproic acid and phenytoin. The nurse should include that which of the following can occur as a result of an interaction between these drugs? 1 - Hyperammonemia 2 - Phenytoin toxicity 3 - Hypertension 4 -Peptic ulcer disease

2 - Phenytoin toxicity Rational 1 - Hyperammonemia is unlikely to result from a drug interaction between valproic acid and phenytoin. Taking valproic acid with topiramate, however, can increase the risk of excess ammonia in the blood. 2 - Valproic acid can cause an increase in phenytoin blood levels, resulting in phenytoin toxicity. The nurse should monitor serum phenytoin levels and notify the provider if levels begin to exceed the therapeutic range. 3 - Hypertension is unlikely to result from a drug interaction between valproic acid and phenytoin. Phenytoin does have CNS depressive effects and can cause hypotension, especially when administered via IV. 4 - Peptic ulcer disease is unlikely to result from a drug interaction between valproic acid and phenytoin. Taking cimetidine with phenytoin, however, can increase phenytoin levels.

A nurse is teaching a client who has Alzheimer's disease and their caregiver about memantine. Which of the following instructions should the nurse include? 1 - Increase fluid intake to improve renal excretion. 2 - Report memory loss or confusion. 3 - Watch for signs of liver impairment, such as jaundice and abdominal pain. 4 - Avoid taking over-the-counter antacids.

4 - Avoid taking over-the-counter antacids Rational A - It is not necessary to increase fluids. Memantine is essentially unchanged when it is excreted in the urine. Therefore, it is not necessary to increase fluids because fluid intake does not affect this process. B - Clients who have Alzheimer's disease already have and will continue to have memory loss and confusion. The drug can help slow the progressive decline, but will not eliminate the disease's manifestations. C - Memantine should not result in liver impairment, although it should be used cautiously with clients who have severe liver impairment. D - Antacids that contain sodium bicarbonate increase urine alkalinity and can decrease drug excretion, ultimately leading to toxicity.

a nurse is caring for a client who is taking interferon beta-1b. The nurse should identify that which of the following finding indicated a potential serious adverse effect of this drug? 1 - Tinnitus 2 - Twitching eyelids 3 - Blue-green skin discoloration 4 - Fatigue

4 - Fatigue Rational A - Tinnitus is not a typical adverse effect of interferon beta-1b. However, tinnitus is common with aspirin therapy. B - Eyelid and muscle twitching can be a sign of toxicity caused by some anticonvulsants. It is not a typical adverse effect of interferon beta-1b. C - Interferon beta-1b does not cause skin, sclerae, or urine to turn a blue-green color. This is an adverse effect of amphetamine/dextroamphetamine sulfate. D - The nurse should identify that potential serious adverse effects of interferon beta-1b include unexplained bruising, bleeding, and fatigue. Clients should report these adverse effects to their provider immediately because they can indicate bone marrow suppression and decreased platelet count.

A nurse is reviewing the plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? Select all A - "I think I might be pregnant." B - "I take warfarin." C - "I take antihypertensive medication." D- "I am allergic to shrimp." E - "I ate a light breakfast this morning."

A - "I think I might be pregnant." B - "I take warfarin." D- "I am allergic to shrimp." E - "I ate a light breakfast this morning." Rational C - There is no contraindication related to contrast dye for a client who is taking antihypertensive medication.

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? Select all A - "It is given to reduce swelling of the brain." B - "You will need to monitor for low blood sugar." C - "You may notice weight gain." D - "Tumor growth will be delayed." E - "It can cause you to retain fluids."

A - "It is given to reduce swelling of the brain." C - "You may notice weight gain." E - "It can cause you to retain fluids." Rational B - The client can experience hyperglycemia as an adverse effect of dexamethasone D - Dexamethasone does not affect tumor growth. It is given to prevent cerebral edema.

A nurse is reinforcing teaching with the parent of a child who is to have an electroencephalogram (EEG). Which of the following responses should the nurse include? A - "Offer decaffeinated beverages the morning of the procedure." B - "Do not wash your child's hair the night before the procedure." C - "Withhold all foods the morning of the procedure." D - "Promote extra hours of sleep the night before the procedure."

A - "Offer decaffeinated beverages the morning of the procedure." Rational A - Caffeine can alter the results of an EEG and should be avoided prior to the test. However, the child should maintain an adequate food and fluid intake prior to the EEG to prevent hypoglycemia during the procedure B - The child's hair should be wasted to remove oils that permit adherence of the EEG electrodes C - Foods are not withheld prior to an EEG. Fasting can cause hypoglycemia during the procedure D - Children are often required to be sleep deprived the night prior to the procedure.

A nurse is teaching a client about interferon beta-1a. Which of the following instructions should the nurse give to help the client avoid the adverse effects of this drug? A - "Premedicate with acetaminophen." B - "Take the drug with food." C - "Increase your fluid intake." D - "Take the drug in the morning."

A - "Premedicate with acetaminophen." Rational A - Interferon beta drugs can cause fever, chills, headaches, and muscle aches. Acetaminophen can help minimize these symptoms. B - The routes of administration of interferon beta drugs are parenteral (IM and subcutaneous). C - Increasing fluid intake will not help relieve the adverse effects of interferon beta drugs. D - Evening administration of interferon beta drugs ensures that flu-like adverse effects, such as muscle aches, stiffness, and malaise, will occur while the client is sleeping.

An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility? A - A reddened area over the sacrum B - Stiffness in the lower extremities C - Difficulty moving the upper extremities D - Difficulty hearing some types of sounds

A - A reddened area over the sacrum Rational A - A reddened area over a bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage. B - Depending on the location and extent of the stroke, varying degrees of leg stiffness are expected findings. C -Depending on the location and extent of the stroke, varying degrees of mobility impairment are expected findings. D - Presbycusis, or age-related sensorineural hearing loss, is typical among older adults and is not a complication of immobility.

A nurse is teaching a client who has a prescription for carbamazepine. Which of the following instructions should the nurse include to help the client avoid adverse effects of this drug? A - Begin taking the drug at a low dosage. B - Discontinue the drug immediately if diarrhea occurs. C - Have serum glucose levels checked regularly. D - Take the drug on an empty stomach.

A - Begin taking the drug at a low dosage. Rational A - Visual disturbances, vertigo, and ataxia can result from taking carbamazepine, a drug that treats seizure disorders. Dosages should be low to minimize or prevent these adverse effects. B - As with any drug that controls seizures, stopping it abruptly can make seizure activity return and possibly even trigger status epilepticus. Carbamazepine can cause diarrhea. If diarrhea does develop, a better alternative is to treat the diarrhea and see if it resolves as drug therapy with carbamazepine continues. C - Carbamazepine is not likely to alter glucose levels. It can, however, alter liver function. D - Taking carbamazepine with meals can help prevent GI upset and can enhance absorption.

A nurse is teaching a client who is about to begin sumatriptan therapy to treat migraine headaches. The nurse should instruct the client to monitor for which of the following adverse effects? A - Chest pain B - Polyuria C - Joint pain D - Insomnia

A - Chest pain Rational A - Sumatriptan, a serotonin agonist, can cause coronary vasospasm and chest pain. Clients should report any pressure, pain, or tightness in the jaw, chest, or back. Sumatriptan is not an appropriate choice for clients who have a history of coronary artery disease. B - Sumatriptan, a serotonin agonist, is unlikely to cause polyuria. Lithium carbonate can cause polyuria. C - Sumatriptan, a serotonin agonist, is more likely to cause muscle pain than joint pain. D - Sumatriptan, a serotonin agonist, is unlikely to cause insomnia. It can cause drowsiness and sedation.

A nurse is collecting data from a client who has increased intracranial pressure (ICP). Which of the following findings should the nurse expect? Select all A - Disoriented to time and place B - Restlessness and irritability C - Unequal pupils D - ICP 15 mm Hg E - Headache.

A - Disoriented to time and place B - Restlessness and irritability C - Unequal pupils E - Headache. Rational D - An ICP of 15 mm Hg is within the expected reference range

A nurse is reinforcing teaching with a group of parents about the risk factors for seizures. Which of the following factors should the nurse include? Select all A - Febrile episodes B - Hypoglycemia C - Sodium imbalances D - Low serum lead levels E - Presence of diphtheria

A - Febrile episodes B - Hypoglycemia C - Sodium imbalances Rational D - High serum lead levels are a risk factor for seizure activity E - Diphtheria is a respiratory illness causing difficulty breathing and is not a risk factor for seizures.

A nurse is reinforcing teaching with a client who has early Parkinson's disease and a new prescription for pramipexole. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? A - Hallucinations B - Increased salivation C - Diarrhea D - Discoloration of urine

A - Hallucinations Rational A - Pramipexole can cause hallucination within 9 months of the initial ose and might require discontinuation B - Increased salivation is an adverse effect of cholinesterase inhibitors. Dry mouth is an adverse effect of pramipexole. C - Constipation is an adverse effect of pramipexole D - Discoloration of urine is an adverse effect of COMT inhibitors and not an adverse effect of pramipexole

A nurse in the postanesthesia recovery unit is assisting with the care of a client who received a nondepolarizing neuromuscular blocking agent and has muscle weakness. The nurse should anticipate a prescription for which of the following medications? A - Neostigmine B - Naloxone C - Dantrolene D - Vecuronium

A - Neostigmine Rational A- Neostigmine is a cholinesterase inhibitor that reverse the effects of nondepolarizing neuromuscular blockers. B - Naloxone reverse the effects of opioids C - Dantrolene acts on skeletal muscle to reduce metabolic activity and treat malignant hyperthermia D - Vecuronium is an intermediate-acting nondepolarizing neuromuscular blocker.

A nurse is contributing to the plan care of a client who has dysphagia and a new dietary prescription. Which of the following interventions should the nurse include in the plan? select all A - Have suction equipment available for use B - Feed the client thickened liquids C - Place food on the unaffected side of the client's mouth D - Assign an assistive personnel to feed the client slowly E - Instruct the client to swallow with her neck flexed.

A - Have suction equipment available for use B - Feed the client thickened liquids C - Place food on the unaffected side of the client's mouth E - Instruct the client to swallow with her neck flexed. Rational D - Due to the risk of aspiration, assistive personnel should not be assigned to feed the client because the client's swallowing ability should be checked, and suctioning can be needed if choking occurs.

A nurse is contributing to the plan of care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following interventions should the nurse recommend? Select all A - Implement seizure precautions B - Perform neurological checks four times a day C - Administer morphine for the report of neck and generalized pain D - Turn off room lights and television E - Monitor for impaired extraocular movements F - Encourage the client to cough frequently

A - Implement seizure precautions D - Turn off room lights and television E - Monitor for impaired extraocular movements Rational B - The nurse should perform neurological checks more frequently due to client's risk for increased ICP C - The nurse should avoid administering opioids to a client who is at risk for increased ICP. Opioids can mask changes in the client's level of consciousness. F - The nurse should instruct the client to avoid coughing because this action can cause increased ICP

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following findings should the nurse expect? Select all A - Impulse control difficulty B - Left hemiplegia C - Loss of depth perception D - Aphasia E - Lack of situational awareness

A - Impulse control difficulty B - Left hemiplegia C - Loss of depth perception D - Aphasia E - Lack of situational awareness Rational D - A client who has experienced right-hemispheric stroke can demonstrate a lack of awareness of surroundings.

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? Select all A - Loosen restrictive clothing. B - Place a tongue depressor in the child's mouth. C- Clear the area of hard objects. D - Place the child in prone position. E - Restrain the child.

A - Loosen restrictive clothing. C- Clear the area of hard objects. Rational A-Loosen restrictive clothing is correct. Restrictive clothing can cause injury to the client during a seizure. It should be loosened. B - Place a tongue depressor in the child's mouth is incorrect. Placing something in the child's mouth can cause injury. C - Clear the area of hard objects is correct. Hard objects can cause injury to the child during a seizure and should be removed. D - Place the child in prone position is incorrect. The nurse should move the child into a side-lying position to prevent aspiration of secretions or vomit. E - Restrain the child is incorrect. Restraining the child can cause injury.

A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? Select all A - Loss of consciousness B - Appearance of daydreaming C - Dropping held objects D - Falling to the floor E - Having a piercing cry

A - Loss of consciousness B - Appearance of daydreaming C - Dropping held objects Rational D - It is rare for a child who has absence seizures to fall to the floor. However, this is a common manifestation of a tonic-clonic seizure E - A piercing cry is a manifestation of an atonic-akinetic seizure.

A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? A - Maintain the child in a side-lying position B - Check to see if the child bit his tongue C - Reorient the child to the environment D - Document the time and characteristics of the child's seizures

A - Maintain the child in a side-lying position Rational A- The greatest risk to this client is aspiration from vomiting. Therefore the priority intervention the nurse should take is to place the child in a side-lying position to maintain a patient airway and prevent aspiration of secretions. B - The nurse should check to see if child has bitten his tongue to provide appropriate treatment and make appropriate dietary modification. However, another intervention is the priority. C - The nurse should reorient the child to the environment following a generalized seizure because confusion is expected during the postseizure period. However, another intervention is the priority. D - The nurse should document the time and characteristic of the child's seizure in the child's medical record. However, another intervention is the priority.

A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take? A - Maintain the patency of the client's airway B - Identify the poison the client ingested. C - Measure the client's blood pressure. D - Position the client on her side.

A - Maintain the patency of the client's airway Rational A - The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to check the patency of the client's airway. Poisoning or its treatment often causes vomiting, which can obstruct the airway and lead to asphyxiation. During seizures, assuring patency of the airway is also a priority. B- The nurse should try to determine what the client ingested to help initiate the specific treatment protocol form the poison control center; however, another action is the priority. C - The nurse should measure the client's vital signs to monitor her status; however, another action is the priority. D - The nurse should position the client on her side to prevent aspiration of vomitus; however, another action is the priority.

A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following findings indicates viral meningitis? Select all A - Negative Gram stain B - Blood glucose level within the expected reference range C - Cloud cerebrospinal fluid D - Decreased WBC count E - Protein level within the expected reference range

A - Negative Gram stain B - Blood glucose level within the expected reference range E - Protein level within the expected reference range Rational C - The nurse should expect the cerebrospinal fluid to be clear for a client who has viral meningitis D - The nurse should expect a slightly elevated WBC count for a client who has viral meningitis.

A nurse is collecting data from an adult client who has meningococcal meningitis. Which of the following findings should the nurse expect? A - Petechial rash on the chest and extremities B - Tachycardia C - Negative Kernig's sign D - Mild headache

A - Petechial rash on the chest and extremities Rational A- The nurse should expect to find a petechial rash over the chest and extremities of the client who has meningococcal meningitis. B - The nurse should expect to find bradycardia in the client who has meningococcal meningitis due to increased intracranial pressure. C - The nurse should expect the client who meningococcal meningitis to have a positive Kernig's sign due to meningeal irritation. D - The nurse should expect the client who has meningococcal meningitis to exhibit a severe and persistent headache that is generally made worse by moving the client's head and neck.

A nurse is assisting with the care of a client who has malignant hyperthermia. Which of the following actions should the nurse expect to be part of the client's plan of care? Select all A - Place a cooling blanket on the client B - Administer oxygen at 50% C - Infusecold 0.9% sodium chloride D - Prepare for endotracheal intubation E - Monitor core body temperature

A - Place a cooling blanket on the client C - Infusecold 0.9% sodium chloride D - Prepare for endotracheal intubation E - Monitor core body temperature Rational A- The nurse should expect to place a cooling blanket on the client and apply ice packs to the client's axilla and groin B - The nurse should administer oxygen at 100% to help ensure optimal oxygen saturations. C - The nurse should assist with monitoring the infusion of cold IV fluids to help decrease the client's body temperature D - If initial stabilization is unsuccessful, client who intubation to correct acid-base imbalances E - The nurse should monitor core body temperature to help prevent hypothermia and determine progress of treatment measures.

A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take? A - Place the client in a darkened room. B - Encourage self-care. C - Administer a cleansing enema. D - Administer an anticoagulant.

A - Place the client in a darkened room. Rational A - The nurse should place the client in a private, quiet, darkened room as part of the aneurysm precautions in order to prevent an increase in intracranial pressure. B - The nurse should not encourage the client to perform self-care, because this activity may elevate the client's blood pressure and increase intracranial pressure. C - The nurse should not administer a cleansing enema, because straining or discomfort may elevate the client's blood pressure and increase intracranial pressure. D - The nurse should not administer anticoagulants, which may cause a cerebral bleed from the aneurysm.

A nurse is checking for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take? Select all A - Place the client in supine position B - Flex client's hip and knee C - Place hands behind the client's neck D - Bend client's head toward chest E - Straighten the client's flexed leg at the knee

A - Place the client in supine position C - Place hands behind the client's neck D - Bend client's head toward chest Rational B - The nurse should flexx the client's hip and knee when checking for Kernig's sign E - The nurse should straighten the client's flexed leg at the knee when checking for Kernig's sign

A nurse is assisting with the care of a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions should the nurse take? A - Place the client on NPO status B - Prepare the client for a liver biopsy C - Position the client dorsal recumbent D - Put the client in a protective environment

A - Place the client on NPO status Rational A - To prevent aspiration, the nurse should place the client on NPO status due to the decreased level of consciousness. B - The nurse should expect a client who has Reye syndrome to require a liver biopsy C - The nurse should position the client without a pillow and slightly elevate the head of the bed to prevent increased intracranial pressure D - Clients who are immunocompromised require a protective environment. The nurse should place a client who has suspected meningitis on respiratory isolation for at least 24 hr after the initiation of antibiotic therapy.

A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan? Select all A - Provide a suction setup at the bedside. B - Elevate the side rails when in bed. C - Place a bite stick at the bedside. D - Keep an oxygen setup at the bedside. E - Furnish restraints at the bedside.

A - Provide a suction setup at the bedside. B - Elevate the side rails when in bed. D - Keep an oxygen setup at the bedside. Rational A - Provide a suction setup at the bedside is correct. The nurse should provide a suction setup at the bedside to provide oral suctioning following the seizure to prevent aspiration. B - Elevate the side rails when in bed. The nurse should elevate the rails of the bed to prevent a fall in the event the client has a seizure. Additional measures may be taken such as padding the side rails to prevent injury from hitting the side rails during seizure activity. C - Place a bite stick at the bedside is incorrect. The nurse should recognize that attempting to insert anything into the mouth of a client who is having a seizure can result in injury to the client or the nurse. D - Keep an oxygen setup at the bedside is correct. The nurse should keep an oxygen setup at the bedside to administer oxygen during any seizure activity if this can be done safely. The nurse should recognize that, during tonic seizure activity, respirations cease and the client becomes cyanotic. E - Furnish restraints at the bedside is incorrect. The nurse should recognize that the client who is experiencing seizure activity should not be restrained, as this can lead to injury to the client, such as fractures.

A nurse is contributing to the plan of care for a client who has global aphasia (both receptive and expressive) Which of the following interventions should the nurse include in the client's plan? Select all A - Speak to the client at a slower rate B - Assist the client to use flashcards with pictures C - Speak to the client in a loud voice D - Compete sentences that the client cannot finish E - Give instructions one step at a time

A - Speak to the client at a slower rate B - Assist the client to use flashcards with pictures E - Give instructions one step at a time Rational C - For the client who has aphasia, speaking in a load voice in unnecessary and can be interpreted as patronizing. D - The nurse should allow the client adequate time to finish sentence and not complete the sentence for him.

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect? A - The client requires total nursing care. B- The client is alert and oriented. C- The client is in a deep coma. D - The client has a stable neurological status.

A - The client requires total nursing care. Rational A - The nurse should expect that a client who has a Glasgow Coma score of 8 is in a coma and requires total nursing care. B - The nurse should not expect a client who has a Glasgow Coma score of 8 to be alert and oriented. The client will be in a coma. C - The nurse should expect a client who is completely unresponsive and in a deep coma to have a Glasgow Coma score of 3. D - The nurse should not expect a client who has a Glasgow Coma score of 8 to be stable neurologically. The client is in a coma.

A nurse is caring for a client who has been taking amphetamine/dextroamphetamine sulfate for the treatment of AHDH for 2 weeks. The nurse should report which of the following findings to the provider? A - Weight loss of 2.3 kg (5 lb) B - BP 110/70 mm Hg C - Apical pulse 80/min D - Respiratory rate 16/min

A - Weight loss of 2.3 kg (5 lb) Rational A -Amphetamine/dextroamphetamine sulfate can cause a decreased appetite and weight loss. The nurse should instruct the client to weigh themself twice weekly and report unintended weight loss. B - This blood pressure is within the expected reference range and does not warrant reporting to the provider. The nurse should report hypertension or hypotension as adverse effects of the drug. C - This apical pulse is within the expected reference range and does not warrant reporting to the provider. The nurse should report tachycardia, or an elevated heart rate. D - This respiratory rate is within the expected reference range and does not warrant reporting to the provider. The nurse should monitor the client's respiratory rate periodically during therapy and report any abnormalities.

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? A - ​Administer antibiotics when available. ​B - Reduce environmental stimuli. ​C - Document intake and output. ​D - Maintain seizure precautions.

A - ​Administer antibiotics when available. Rational A - The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS. Antibiotic therapy has a marked effect on the course and prognosis of the illness. B - Reducing environmental stimuli is an appropriate action, but it is not the priority. C - Documenting intake and output is an appropriate action, but it is not the priority. D - Maintaining seizure precautions is an appropriate action, but it is not the priority.

A nurse is reviewing a new prescription for oxcarbazepine with a female client who has partial seizures. Which of the following instructions should the nurse include? Select all A -"Use caution if the doctor prescribe a diuretic medication." B - "Consider using another form of birth control if you are taking oral contraceptives." C - "Chew gum to increase saliva production." D - "Avoid driving until you see how the medication affects you." E - "Notify the doctor if you develop a skin rash

A -"Use caution if the doctor prescribe a diuretic medication." B - "Consider using another form of birth control if you are taking oral contraceptives." D - "Avoid driving until you see how the medication affects you." E - "Notify the doctor if you develop a skin rash Rational A- Taking diuretic medication when taking oxcarbazepine requires caution because of the high risk for hyponatremia B - Clients taking oxcarbazepine should use an alternate form of contraception because oxcarbazepine decrease oral contraceptive levels. C - Oxcarbazepine dose not cause dry mouth. Pregabalin is an example of an antiepileptic medication that causes dry mouth D - The client should avoid driving if CNS effects of dizziness, drowsiness, and double vision develop. E - The client should notify the provider if a skin rash occurs because life-threatening skin disorders can develop

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority? A- Place a pillow under the child's head. B - Move the child into a side-lying position. C- Remove the child's eyeglasses. D - Time the seizure.

B - Move the child into a side-lying position. Rational A - Placing a pillow under the child's head reduces the risk of head trauma; however, another action is the nurse's priority. B - Placing the child in a side-lying position prevents aspiration of vomitus; therefore, this action is the nurse's priority. C - Removing the child's eyeglasses reduces the risk of facial injury; however, another action is the nurse's priority. D - Timing the seizure allows for comparison with other seizures and assists with determining medication effectiveness; however, another action is the nurse's priority.

A nurse is reinforcing teaching with a client who has a new prescription for baclofen to treat muscle spasms. Which of the following statements indicates that the client understands the instructions? Select all A - "I will stop taking this medication right away if I develop dizziness." B - "I know the doctor will gradually increase my dose of this medication for a while." C - "I should eat more fiber to prevent constipation from this medication." D - "I shouldn't drink alcohol while I'm taking this medication." E - "I should take this medication on an empty stomach each morning."

B - "I know the doctor will gradually increase my dose of this medication for a while." C - "I should eat more fiber to prevent constipation from this medication." D - "I shouldn't drink alcohol while I'm taking this medication." Rational A- Abrupt cessation of baclofen therapy can result in withdrawal, with a number of adverse effects (Visual hallucinations, seizures) B - The provider prescuries a low dose initially, and then increases it gradually to prevent CNS depression C- The client should increase fluids and fiber to reduce the risk of constipation D - The intake of alcohol and other CNS depressants can exacerbate the CNS depressant effects of baclofen. Therefore, the client should avoid CNS depressants while taking baclofen. E - The client should take baclofen with meals to reduce gastric upset.

A nurse is reinforcing teaching with a client who is scheduled for a cerebral computed tomography (CT) scan with contrast. Which of the following statements by the clients indicates understanding of the teaching? A - "I should not have caffeine 48 hrs before the procedure" B - "I will have my kidney function checked before the test." C - "I should tape my wedding band to place before the procedure." D - "I will have my brain activity monitored during the test."

B - "I will have my kidney function checked before the test." Rational A - The nurse should recognize that a client should withhold stimulates, such as caffeine 24 - 48 prior ti electromyography. The client should be NPO 3-4 hrs prior to a CT scan C - The nurse should remind the client to remove jewelry and all forms of metal prior to the procedure to promote accurate results D - The nurse should recognize that a client will undergo monitoring of brain activity during electroencephalography

A nurse is reinforcing teaching with a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A - "Do not wash your hair the morning of the procedure." B - "Try to stay awake most of the night prior to the procedure." C - "The procedure will take approximately 15 minutes." D - "You will need to lie flat for 4 hours after the procedure."

B - "Try to stay awake most of the night prior to the procedure." Rational A - A nurse should instruct the client to wash her hair on the morning of the procedure to remove oils, gels, and sprays, which can affect the EEF readings. C - The nurse should inform the client that the procedure will take approximately 45 min to 2 hr D - The nurse should include that the clients can resume normal activity immediately following the procedure.

A nurse is planning care for several clients and is considering the client's risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke? A - A client who has uncontrolled hypertension B - A client who has chronic atrial fibrillation C - A client who has thrombocytopenia D - A client who has an arteriovenous malformation

B - A client who has chronic atrial fibrillation Rational A- Uncontrolled hypertension places a client at risk for hemorrhage stroke. B - Chronic atrial fibrillation places a client at risk for embolic stroke because a small thrombus might dislodge and migrate to the brain. C - Thrombocytopenia places a client at risk for bleeding-induced stroke. D - An arteriovenous malformation places a client at risk for hemorrhagic stroke.

A nurse is collecting data from an older adult client who has a hip fracture and is in Buck's traction. The nurse notes the client has a sudden decrease in level of consciousness, dyspnea, and crackles to the lungs upon auscultation. Which of the following actions should the nurse take? A - Prepare the client for a fasciotomy. B - Apply high-flow oxygen. C - Anticipate a prescription for antibiotics. D - Remove the traction weights.

B - Apply high-flow oxygen. Rational A - The client is experiencing symptoms indicating the development of a fat embolism. A fasciotomy is a surgical procedure used to treat compartment syndrome in which a linear incision is made in the fascia to release pressure and relieve compression of the blood vessels and nerves. It is not used to treat a client who has a fat embolism. B - A change in level of consciousness and crackles in the lungs are symptoms of a fat embolism. Other symptoms include tachypnea, tachycardia, fever, and petechiae over the trunk. The nurse should elevate the head of the bed, apply high flow oxygen, and notify the provider. C - The client is experiencing symptoms indicating the development of a fat embolism, which is a medical emergency. Initial treatment would not include the administration of antibiotics. D - The client is experiencing symptoms indicating the development of a fat embolism, which is a medical emergency. The nurse should elevate the head of the bed, apply high-flow oxygen, and notify the provider.

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? Select all A - Use the Glasgow Coma Scale to evaluate the client B - Assist the client to a supine position C - Administer an opioid medication D - Encourage the client to increase fluid intake E - Remove the bandage on the client's puncture site.

B - Assist the client to a supine position C - Administer an opioid medication D - Encourage the client to increase fluid intake Rational A - The GCS is used to assess a client's level of consciousness and is not necessary following a lumbar puncture E - Leaking CSF can cause a headache following lumbar puncture. THe client can require a patch to seal the puncture site if the headache doesn't resolve.

A nurse is collecting data from a school-age child who is undergoing a neurological assessment following a head injury. The nurse should document fross incoordination when walking as which of the following findings? A - Tremors B - Ataxia C - Dystonia D - Rigidity

B - Ataxia Rational A - The client will demonstrate tremors when he shows constant small involuntary movements, such as hand tremors. B - The client will demonstrate ataxia when he shows gross incoordination movements, which might get worse when he closes his eyes. C - The client will demonstrate dystonia when he shows slow, twisting movements of his limbs and trunk. D - The client will demonstrate rigidity when he is unable to flex or extend a joint.

A nurse is collecting data from an 8 month old infant who has increased intracranial pressure (ICP). Which of the following manifestations should the nurse expect? A - Insomnia B - Bulging fontanel C - Low-pitched cry D - Positive Babinski reflex

B - Bulging fontanel Rational A- An infant who has ICP will be lethargic and drowsy. B - A bulging fontanel is a clinical finding associated with ICP. Other clinical manifestations include separated sutures, disturbed scalp veins, poor feeding, and the setting sun sign. C - An infant who has ICP will have a high-pitched cry. D - An infant who is younger than 1 year of age should have a positive Babinski reflex; therefore, the presence of this reflex does not indicate ICP.

A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take? A - Insert a padded tongue blade into the client's mouth. B - Place a pillow under the client's head. C - Gently restrain the client's extremities. D - Keep the client in a supine position.

B - Place a pillow under the client's head. Rational A - The nurse should avoid placing anything in the client's mouth during a seizure due to the risk for injury and airway occlusion. B - The nurse should place a pillow or any soft padding under the client's head to protect the client from injury during the seizure. C - The nurse should avoid restraining the client's extremities during a seizure due to the risk for injury. D - The nurse should turn the client on his side or turn the head to the side to prevent aspiration of secretions.

A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? A - Observing for facial asymmetry B - Checking pupillary responses to light C - Eliciting the gag reflex D - Testing visual acuity

B - Checking pupillary responses to light Rational A- Cranial nerve VII, the facial nerve, is a motor nerve that controls facial symmetry. B - Cranial nerve III, the oculomotor nerve, is responsible for pupillary responses to light. Indications that intracranial pressure is increasing include lethargy, decreasing consciousness, tachypnea, hypertension, bradycardia, bounding pulse, and changes in the pupils, such as a sluggish response to light and dilation of one or both pupils. C - Cranial nerves IX and X, the glossopharyngeal and vagus nerves, are nerves that control the gag reflex. D - Cranial nerve II, the optic nerve, is responsible for visual acuity.

A nurse is caring for a client who has a new prescription for pramipexole to treat Parkinson's disease. The nurse should recognize that which of the following lab tests requires monitoring? A - C-reactive protein B - Creatinine clearance C - Thyroid function D - CBC

B - Creatinine clearance Rational A - Pramipexole, a direct-acting dopamine receptor agonist, is unlikely to alter C-reactive protein. Pravastatin is a drug that alters C-reactive protein in a beneficial way by helping to lower the risk of heart disease. B - Pramipexole, a direct-acting dopamine receptor agonist, should be used with caution for clients who have renal disease. Therefore, the nurse should monitor the client's renal function. C - Pramipexole, a direct-acting dopamine receptor agonist, is unlikely to alter thyroid function. Amiodarone is a drug that can alter thyroid function. D - Pramipexole, a direct-acting dopamine receptor agonist, is unlikely to alter CBCs. Interferon beta-1b, an immunomodulator, can cause myelosuppression and warrants monitoring of CBCs periodically.

A nurse is caring for a client who is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse take to decrease the potential for raising the client's ICP Select all A - Suction the client frequently B - Decreased the noise level in the client's room C - Elevate the client's head on two pillows D - Administer a stool softener E - Keep the client well hydrated

B - Decreased the noise level in the client's room D - Administer a stool softener Rational A - The nurse should limit suctioning to only when necessary because it can increase ICP B - Decreasing the noise level and resticint the number of people in the client's room can help prevent increased in ICP C - The nurse should avoid hyperflexion of the client's neck with pillows because it can increase ICP. The nurse should elevate the head of the bed to at least 30° and maintain the leint's head in an upright neutral position. D - The nurse should administer a stool softener to decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increase ICP E - The nurse should avoid overhydration because it can increase ICP. The nurse should monitor fluid and electrolyte levels closely for the client who has increased ICP

A nurse is using the Glasgow Coma Scale (GCS) to check a clients for changes in the level of consciousness. The client opens his eyes when spoken to , Speaks incoherently, amd moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A - E2 + V3 + M5 = 10 B - E3 + V4 + M4 = 11 C - E4 + V5 + M6 = 15 D - E2 + V2 + M4 = 8

B - E3 + V4 + M4 = 11

A nurse is contributing to the plan of care for a client who has increased intracranial pressure following a closed-head injury. Which of the following interventions should the nurse recommend? A - Have the client perform huff coughing hourly. B - Elevate the head of the bed. C - Place pillows under the client's knees. D - Encourage liberal fluid intake

B - Elevate the head of the bed. Rational A - ​The nurse should have the client limit activities that could increase intracranial pressure, such as coughing, blowing the nose, or straining to have a bowel movement. B - ​The nurse should position the client in a neutral position with the head of the bed elevated to promote venous drainage from the brain and minimize pressure within the central nervous system. C - The nurse should avoid flexion of the client's neck and hips because these positions could potentially increase intracranial pressure. D - The nurse should limit 24-hr fluid intake to reduce cerebral edema.

A nurse is preparing to administer a medication to a client who has absence seizures. The nurse should anticipate administering which of the following medications? Select all A - Phenytoin B - Ethosuximide C - Gabapentin D - Carbamazepine E - Valproic acid F - Lamotrigine

B - Ethosuximide E - Valproic acid F - Lamotrigine Rational A- Phenytoin treats partial seizure and tonic-clonic seizures and has no therapeutic effect on absence seizures. C - Gabapentin treats partial seizures and has no therapeutic effect on absence seizures D - Carbamazepine treats partial seizures and tonic-clonic seizures and has no therapeutic effect on absence seizures.

A nurse is collecting data from a client who reports severe headache and a stiff neck. Data collection reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A - Administer antibiotics B - Implement droplet precautions C - Obtain an IV access D - Decrease bright lights

B - Implement droplet precautions Rational A - The nurse should administer antibiotics to stop the microorganism from multiplying, but this is not the priority action B - The client is exhibiting manifestations of possible meningitis. When using the urgent vs non urgent approach to care, the nurse determines the priority action is to initiate droplet precautions to prevent spread of the disease to others C - The nurse should initiate IV access access to allow IV medication and fluid administration, but this is not the priority action. D - The should decrease bright lights because photophobia is a manifestation of meningitis, but this is not the priority action.

A nurse is caring for a client who has a new prescription for dantrolene to treat skeletal muscle spasms. The nurse should identify that which of the following laboratory tests requires monitoring? A - Serum potassium B - Liver function C - Serum sodium D - Thyroid function

B - Liver function Rational A - Dantrolene, a direct-acting muscle antispasmodic, is unlikely to alter serum potassium levels. Hydrochlorothiazide is a drug that can alter potassium levels. B - Liver toxicity is a serious adverse effect of dantrolene. The nurse should monitor the client's liver function prior to treatment and at regular intervals and advise the client to report jaundice or abdominal pain. C - Dantrolene, a direct-acting muscle antispasmodic, is unlikely to alter serum sodium level. Hydrochlorothiazide is a drug that can alter sodium levels. D - Dantrolene, a direct-acting muscle antispasmodic, is unlikely to alter thyroid function. Interferon alfa preparations are drugs than can alter thyroid function.

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following interventions should the nurse implement? A - Instruct the client to scan to the right to see objects on the right side of her body B - Place the bedside table on the right side of the bed C - Orient the client to the food on her plate using the clock method D - Place the wheelchair on the client's left side.

B - Place the bedside table on the right side of the bed Rational A - A client who has left homonymous hemianopsia has lost the left visual field of both eyes. The nurse should instruct the client to turn his head to the left to visualize the entire field of vision. B - The client is unable to visualize the left midline of her body. Placing the bedside table on the right side of the client's bed will permit visualization of items on the table C - Using the clock method of food placement is ineffective because the client can only see half of the pate D - THe nurse should place the wheelchair to the clients right or unaffected side.

A nurse is assisting with the development of an in-service about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children. Select all A - Inactivated polio vaccine (IPV) B - Pneumococcal conjugate vaccine (PCV) C - Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) D - Haemophilus influenzae type B (Hib) vaccine E - Trivalent inactivated influenza vaccine (TIV)

B - Pneumococcal conjugate vaccine (PCV) D - Haemophilus influenzae type B (Hib) vaccine Rational A - IPV does not decrease the incidence of bacterial meningitis C - The DTaP vaccine does not decrease the incidence of bacterial meningitis E - TIV does not decrease the incidence of bacterial meningitis.

A nurse is preparing to administer sumatriptan to a client for the first time. The nurse should instruct the client that sumatriptan is indicated for which of the following conditions A - Tonic-clonic seizures B - Presence of a migraine headache C - Exacerbation of multiple sclerosis D - Alzheimer's disease

B - Presence of a migraine headache Rational A - Fosphenytoin is administered to treat tonic-clonic seizures. B - Sumatriptan is used in the treatment of migraine headaches. C - Interferon beta-1a is administered for the treatment of multiple sclerosis. D - Memantine is used to treat Alzheimer's disease.

A nurse is caring for client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse? A - "It can spread to breast and kidneys." B - "IT can develop in your gastrointestinal tract." C - "It is limited to brain tissue." D - "It probably started in another area of your body and spread to your brain."

C - "It is limited to brain tissue." Rational A - Metastases of a benign brain tumor do not occur B - Metastases of a benign brain tumor do not occur C - Benign brain tumors develop from the meninges or cranial nerves and do not metastasize D - Benign brain tumors develop from the meninges or cranial nerves and are not secondary to other types of tumors.

A nurse is caring for an older adult client who has dysphagia and left-side weakness following a stoke. Which of the following actions should the nurse take? A - Instruct the client to tilt her head back when she swallows. B - Place food on the left side of the client's mouth. C - Add thickener to fluids. D - Serve food at room temperature.

C - Add thickener to fluids. Rational A - The nurse should instruct the client to tilt her head forward when she swallows to facilitate swallowing and prevent aspiration. B - The nurse should place food on the unaffected side of the client's mouth to facilitate swallowing and prevent aspiration. C - The nurse should thicken fluids to make them easier to swallow and prevent aspiration. D - The nurse should serve food cold or warm to facilitate swallowing and prevent aspiration.

A nurse is collecting data from a client who has meningitis. When passively flexing the client's neck, the nurse notes an involuntary flexion of both legs. Which of the following conditions is the client displaying? A - Kernig's sign B - Nuchal rigidity C - Brudzinski's sign D - Bradykinesia

C - Brudzinski's sign Rational A - ​The client who displays the Kernig's sign is unable to extend the leg completely when the thigh is flexed on the abdomen. B - The client who displays nuchal rigidity has a stiff, painful neck when the head is flexed. C- The client is manifesting a positive Brudzinski's sign. This is manifested by the hips and knees flexing when neck is flexed, which is a common sign of meningitis. D - The client who displays bradykinesia has slow or no movement of extremities, which is a manifestation of Parkinson's disease.

a nurse is preparing to administer memantine to a client who has Alzheimer's disease. Which of the following findings in the clients medical history indicated a need to withhold the drug and notify the provider? A - Pancreatic cancer B - Hypotension C - Cirrhosis D - Osteoporosis

C - Cirrhosis Rational A - A past diagnosis of pancreatic cancer does not affect the administration of memantine. Memantine should be used cautiously in clients who have severe renal impairment. B - Memantine can cause hypertension. Therefore, it is not contraindicated for a client who has hypotension. C - Memantine should be used cautiously in clients who have severe hepatic impairment. The nurse should contact the provider about the client's history of cirrhosis to see if laboratory testing is required before starting the drug or if the dosage needs to be adjusted. D - Osteoporosis has no effect on the administration of memantine. Taking drugs that alter the pH of the urinary tract can be a cause for cautious administration.

A nurse is assisting with the care of a client who received a dose of succinylcholine prior to endoscopy. During the procedure, the client suddenly develops rigidity, and his body temperature begins to rise. THe nurse should anticipate a prescription for which of the following medications? A - Neostigmine B - Naloxone C - Dantrolene D - Vecuronium

C - Dantrolene Rational A -Neostigmine is the reversal agent for pancuronium, a nondepolarizing neuromuscular blockers. It can delay inactivation of succinylcholine, prolonging the client's recovery from the complication B - Naloxone reverses the effects of opioids. It does not treat malignant hyperthermia C - Muscle rigidity an a sudden rise in temperature are manifestations of malignant hyperthermia. Dantrolene acts on skeletal muscles to reduce metabolic activity and treat malignant hyperthermia. D - Vecuronium is an intermediate-acting nondepolarizing neuromuscular blocker. It is not useful for treating malignant hyperthermia.

a nurse is caring for a client who has a prescription for dantrolene to treat skeletal muscle spasms. The nurse should instruct the client to report which of the following adverse effects? A - Slow heart rate B - Cough C - Diarrhea D - Hearing loss

C - Diarrhea Rational A -Dantrolene is more likely to cause tachycardia than bradycardia. B- Dantrolene is unlikely to cause a cough, but it can cause difficulty swallowing. C - Prolonged diarrhea can cause dehydration and other serious effects. Diarrhea, nausea, and vomiting are adverse effects of dantrolene. The client should report these effects so the nurse can monitor fluid balance and intervene accordingly. D - Dantrolene can cause blurred vision, but it is unlikely to cause hearing loss.

A nurse is assisting with the plan of care for a client who has cerebral aneurysm. The nurse should plan to monitor the client for which of the following early indications of increased intracranial pressure? A - Projectile vomiting ​B - Decorticate posturing C - Disorientation to time and place D - Widening pulse pressure and bradycardia

C - Disorientation to time and place Rational A - Projectile vomiting is a late sign of increased intracranial pressure. B - Decorticate posturing is a late sign of increased intracranial pressure. C - Disorientation to time and place is an early indication of increased intracranial pressure. This finding occurs due to reduced oxygen and glucose in the brain. D - Widening pulse pressure and bradycardia are late signs of increased intracranial pressure.

A nurse is collecting data for a client who has a prescription for bethanechol to treat urinary retention. Which of the following findings is a manifestation of muscarinic stimulation? A - Dry mouth B - Hypertension C - Excessive perspiration D - Fecal impaction

C - Excessive perspiration Rational A- increased salivation is a manifestation of muscarinic stimulation B - Hypotension is a manifestation of muscarinic stimulation C - Bethanechol is a muscarinic agonist. Muscarinic stimulation can increase sweating. D- Diarrhea is an adverse effect of bethanechol

A nurse is collecting data on a client who has experienced a left-hemispheric stroke. Which of the following manifestations should the nurse expect? A - Impulse control difficulty B - Poor judgement C - Frustrated about deficits D - Loss of depth perception

C - Frustrated about deficits Rational A - A client who has experienced a right-hemispheric stroke can experience difficulty with impulse control B - A client who has experience a right-hemispheric stroke can experience poor judgment C - A client who experienced a left-hemispheric stroke can demonstrate depression and frustration regarding physical limitations due to the stroke D - A client who experienced a right-hemispheric stroke can experience a loss of depth perception

A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care? A - Restrain the client as soon as seizure activity begins. B - Keep the lights on when the client is sleeping. C - Keep the client's bed in the lowest position. D - Have a padded tongue depressor available at the bedside.

C - Keep the client's bed in the lowest position. Rational A - Restraining the client can increase the risk for aspiration and for musculoskeletal injury. B - An important part of seizure precautions and management is to allow the client to rest. Light can interfere with the client's ability to rest and sleep. C - Keeping the client's bed in the lowest position is an important way to protect the client from injuries due to falling out of bed. Keeping a mattress on the floor can also help with this. D - Nurses should not use padded tongue depressors at all, as forcing a tongue blade into the client's mouth can chip teeth and put the client at risk for aspirating tooth fragments. It can also block the airway.

A nurse is administering fentanyl to a client to reduce pain. Which of the following drugs should the nurse have available to reserve the effects of fentanyl? A - Neostigmine B - Succinylcholine C - Naloxone D - Dantrolene

C - Naloxone Rational A- Neostigmine, a cholinesterase inhibitor, reverses the effects of pancuronium, a nondepolarizing neuromuscular blocking agent. B - Succinylcholine is a depolarizing neuromuscular blocking agent that will cause increased muscle relaxation. C - Naloxone is an opioid antagonist that reverses the effects of opioids. Fentanyl, an opioid agonist, can cause severe respiratory depression. The nurse should also have resuscitation equipment available when administering fentanyl to a client. D - Dantrolene is a skeletal muscle relaxant that treats malignant hyperthermia and spasticity.

A nurse is caring for a patient who is taking donepezil to treat Alzheimer's disease. For which of the following adverse effects should the nurse monitor? A - Confusion B - Dry mouth C - Nausea D - Double vision

C - Nausea Rational A - Donepezil, a cholinesterase inhibitor, can improve memory and reduce confusion. B - Muscarinic antagonists, not donepezil, can cause dry mouth. C - The most common adverse effects of donepezil, a cholinesterase inhibitor, are nausea, vomiting, and diarrhea. Taking donepezil with food can help minimize adverse effects. D - Donepezil, a cholinesterase inhibitor, is more likely to cause blurred vision than double vision.

A nurse is assisting with the care for a client following surgical evacuation of a subdural hematoma. Which of the following data is the priority to monitor? A - Glasgow Coma Scale B - Cranial nerve function C - Oxygen saturation D - Pupillary responses

C - Oxygen saturation Rational A - The Glasgow Coma Scale is important to detect a decline in neurological function. However, the nurse should identify other data as the priority B - Monitoring cranial nerve function is important to detect a decline in neurological function. However, the nurse should identify other data as the priority. C - When using the airway, breathing, and circulation approach to client care, the priority data to monitor is oxygen saturation. Brain tissue can only survive for 3 min before permanent damage occurs. D - Monitoring pupillary response is important to detect a decline in neurological function. However, the nurse should identify other data as the priority.

A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take? A - Ask another nurse to assist with holding the toddler in a prone position. B - Restrain the toddler for 1 hr after the procedure. C - Place the toddler in a side-lying, knee-chest position. D - Swaddle the toddler in a warm blanket.

C - Place the toddler in a side-lying, knee-chest position. Rational A - One nurse should be able to maintain the toddler in a side-lying position during the procedure B - There is no need to restrain the toddler for 1 hr following the procedure. C - A lumbar puncture is a procedure in which a small amount of the fluid that surrounds the brain and spinal cord called the cerebrospinal fluid is removed and examined. The nurse should position the toddler on his side in a fetal position with his knees curled to his abdomen and his chin tucked to his chest. D - Swaddling the toddler in a warm blanket would cover the lumbar area where the provider is going to be performing the procedure.

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe? A - Extension of the extremities B - Pronation of the hands C - Plantar flexion of the legs D - External rotation of the lower extremities

C - Plantar flexion of the leg Rational A - Extension of the extremities is an indicator of decerebrate rather than decorticate posturing. B - Pronation of the hands is an indicator of decerebrate rather than decorticate posturing. C - Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tracts. D - Internal rather than external rotation of the lower extremities is an indicator of decorticate posturing.

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record. A - Aura phase B - Presence of automatisms C - Postictal phase D - Presence of absence seizures

C - Postictal phase Rational A- The nurse should use the term "aura" to describe manifestations the client experienced prior to a seizure. B - The nurse should use the term "automatisms" to describe repetitive, non-purposeful actions a client might exhibit as part of a complex, partial seizure. C - The postictal phase is the recovery period following a tonic-clonic seizure. The client might be confused or agitated after a seizure and might sleep for several hours. D - The nurse should use the term "absence seizure" to describe a brief loss of consciousness experienced by a client accompanied by staring.

A nurse is reviewing the medical history of a school-age client who possibly has Reye syndrome. The nurse should identify which of the following findings as a risk factor for Reye syndrome? A - Recent history of infectious cystitis caused by candida B - Recent history of bacterial otitis media C - Recent episode of varicella D - Recent episode of Haemophilus influenzae meningitis.

C - Recent episode of varicella Rational A- Candida is a fungal infection and is therefore not a risk factor for Reye syndrome B - A bacterial infection is not a risk factor for Reye syndrome C - Varicella is a viral illness, which is a risk factor for developing Reye syndrome. Reye syndrome typically follows a viral illness, such as influenza, gastroenteritis, or varicella. D - Haemophilus influenzae is a bacteria and is therefore not a risk factor of Reye syndrome.

A health department nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A - The vaccine reduces the risk of respiratory infection B - Administer this vaccine in a series of four doses C - Recommend this vaccine for adolescents before starting college. D - The vaccine series begins at 2 months of age

C - Recommend this vaccine for adolescents before starting college. Rational A - the pneumococcal vaccine reduces the risk of respiratory infection. However, it also reduces the risk of CNS infection B - The HIB vaccine is administered to infant in the series of four doses D - The HIB vaccine series begins for infants at 2 months of age

A nurse on a medical surgical unit is checking the bowel sounds of a client who has epilepsy. The client begins to experience a tonic-clonic seizure. Identify the sequence of steps the nurse should follow. A - Check the clients for injuries B - Reorient and reassure the client C - Remain with the client and call for help D - Place the client in the lateral position

C - Remain with the client and call for help D - Place the client in the lateral position A - Check the clients for injuries B - Reorient and reassure the client Rational The nurse should first remain with the client and call for help. When a client experiences a seizure, remaining with the client is essential because it protects the client from injury. Calling for help will initiate additional team members to assist and is essential for client safety. The next step the nurse should take is to position the client safely in the lateral or side-lying position. Turning the client to the side is essential to allow secretions to drain from the mouth and to prevent aspiration or choking. The next step the nurse should take is to check the client from head to toe for injuries once the seizure is over. The next step the nurse should take is to reorient and reassure the client once they are awake and oriented. Some clients may be confused. As the client is regaining consciousness, the nurse should reorient the client, explain what happened, and provide reassurance to minimize anxiety. Client safety is the priority when caring for a client during a seizure episode.

A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? A - Provide a non skid mat to reduce plate movement B - Encourage the client to use her right hand-when feeding herself C - Remind that the client look for food on the left side of the tray D - Encourage the use of wide drip utensils

C - Remind that the client look for food on the left side of the tray Rational A - The nurse's action of providing a nonskid mat to reduce plate movement is appropriate. However, it does not resolve the problem of homonymous hemianopsia B - The nurse's action of encouraging the client to use her right hand when feeding herself is appropriate. However, it does not resolve the problem of homonymous hemianopsia. C -The nurse's action of reminding the client to look for food on the left side of the tray will train the client to scan the tray by moving her head and eyes. This action will help to resolve the problem of homonymous hemianopsia. D - The nurse's action of encouraging the use of the wide grip utensils is appropriate. However, it does not resolve the problem of homonymous hemianopsia.

A nurse is caring for a client who has a new prescription for amphetamine sulfate. The nurse should monitor the client for which of the following adverse effects? A - Hypotension B - Tinnitus C - Tachycardia D - Bronchospasm

C - Tachycardia Rational A - Amphetamine sulfate is an amphetamine stimulant. It is more likely to cause hypertension rather than hypotension. B - Amphetamine sulfate is an amphetamine stimulant. It is unlikely to cause tinnitus, but it can cause irritability and insomnia. C - Amphetamine sulfate is an amphetamine stimulant. It can cause tachycardia and dysrhythmias. The client should notify the nurse if they develop palpitations or chest pain. D - Amphetamine sulfate is an amphetamine stimulant. It is unlikely to cause bronchospasm, but it can cause diarrhea and nausea. Taking the drug with food can help reduce these effects.

A nurse is reinforcing teaching with a client who has a new prescription for levodopa/carbidopa for Parkinson's' disease. Which of the following instructions should the nurse include? A - Increase intake of protein-rich foods. B - Expect muscle twitching to occur C - Take this medication with food D - Anticipate relife of manifestations if 24 hr

C - Take this medication with food Rational A- The client should avoid protein-rich foods, which can result in decreased therapeutic effects of levodopa B - The client should monitor and report muscle twitching, which can indicate toxicity C - The cleint whoudl take thi smedication with doods to reduce GI effects D - The client would anticipate rellief of manifestations to take several weeks to months.

A nurse is caring for a client who has increased intracranial pressure. Which of the nursing interventions should the nurse take? A - Instruct the client to perform controlled coughing and deep breathing. B - Provide a brightly lit environment. C -Elevate the head of the bed 30°. D - Encourage a minimum intake of 2,000 mL/day of clear fluids.

C -Elevate the head of the bed 30°. Rational A - The nurse should instruct the client to avoid coughing, which increases intracranial pressure. B - The nurse should provide the client with a non stimulating environment to limit the risk of seizure activity. C - The nurse should elevate the head of the bed 15° to 30° to reduce intracranial pressure. D - The nurse should place the client on a fluid restriction to avoid increasing intracranial pressure.

A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first? A - Apply oxygen by nasal cannula. B- Administer an anticonvulsant medication. C- Turn the client to a lateral position. D - Check the client's oxygen saturation.

C- Turn the client to a lateral position. Rational A - The nurse should apply oxygen by nasal cannula or mask to treat hypoxia; however, the nurse should take another action first. B - The nurse should administer an anticonvulsant medication to prevent further seizure activity; however, the nurse should take another action first. C - The greatest risk to this client is injury from aspiration; therefore, the first action the nurse should take is to turn the client to a lateral position, which helps prevent the tongue from obstructing the airway and allows drainage of secretions. D - The nurse should check the client's oxygen saturation to monitor the client's respiratory status; however, the nurse should take another action first.

A nurse caring for a client who is recovering from a stroke. The client states "I feel like less of a man. My wife says she is thankful I am alive but I'm sure this is not how she expected us to spend our retirement years." Which of the following is an appropriate response? A - "I agree with your wife, and you should be thankful you are alive." B - "After an experience like this, everyone has feelings like these." C - "Are you worried that your wife might leave you?" D - "In what way to you feel like you are less of a man?"

D - "In what way to you feel like you are less of a man?" Rational A- This response is a barrier to communication. The nurse is telling the client how to feel, which is non-therapeutic. B - This response is a barrier to communication. It minimizes the client's feelings, which non-therapeutic. C - This response is a barrier to communication. It is prying and can make the client become defensive, which is non-therapeutic. D - The nurse should use the therapeutic technique of restating or rephrasing to encourage the client to state his concerns in greater detail.

a nurse is teaching the family of a client who has a new diagnosis of Alzheimer's disease about donepezil. Which of the following information should the nurse include? A - Monitor for constipation. B - The dosage will be increased weekly to provide optimum therapeutic effect. C - Administering the drug first thing in the morning promotes effectiveness. D - Avoid the use of NSAIDs for pain.

D - Avoid the use of NSAIDs for pain. Rational A - Donepezil can cause diarrhea, not constipation. The family should also monitor for and report nausea, anorexia, and vomiting. B- Donepezil dosages are only increased after 1 to 3 months of taking the initial dose to minimize adverse effects. C- Donepezil should be taken immediately before going to bed because it causes drowsiness and dizziness. D - Combining NSAIDs with donepezil can cause gastrointestinal bleeding. Therefore, the nurse should instruct the client's family to avoid the use of NSAIDs.

A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to check for this manifestation? A - Stroke the lateral aspect of the sole of the foot B - Ask the client to blink his eyes C - Observe for facial drooping D - Have the client stand erect with eyes closed

D - Have the client stand erect with eyes closed Rational A - A Babinski sign is elicited by stroking the lateral aspect of the sole of the foot B - Asking the client to blink his eyes assesses cranial nerve function and is not part of the Romberg test C - Observe for facial drooping assesses cranial nerve function and is not part of the Romberg test D - A positive Romberg sign is indicated when a client loses his balance while attempting to stand erect with his eyes closed.

A nurse is collecting data from a 4-month-old infant who has meningitis. Which of the following findings should the nurse expect? A - Depressed anterior fontanel B - Constipation C - Presence of the rooting reflex D - High pitched cry

D - High pitched cry Rational A- The nurse should expect a 4-month-old infant who has meningitis to have a bulging anterior fontanel B - vomiting is an expected finding of meningitis C - The rooting reflex is expected in infants until the age of 3 to 4 months, an can remain until the age of 12 months D - A high-pitch cry is a finding associated with meningitis between age 3 months to 2 years.

A nurse is assisting with cares for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? A - Polyuria B - Battle's sign C - Nuchal rigidity D - Lethargy

D - Lethargy Rational A - Polyuria is a manifestation of diabetes insipidus. B - Battle sign, or bruising behind the ear, is a manifestation of a skull fracture. C - Nuchal rigidity, or neck stiffness, is a manifestation of meningitis or bleeding into the subarachnoid space. D - An early manifestation of increased intracranial pressure is lethargy. The nurse should monitor and report any changes in the client's level of consciousness, such as restlessness or disorientation, because these are early manifestations of increased intracranial pressure.

An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. While performing a neurological examination, which of following findings is the earliest indicator of the client's cerebral status. A - Pupil response B - Deep tendon reflexes C -Muscle strength D - Level of consciousness

D - Level of consciousness Rational A- The nurse should include pupil response as part of a neurological examination; however, it is not the earliest indicator of cerebral status. B - The nurse should include deep tendon reflexes as part of a neurological examination; however, it is not the earliest indicator of cerebral status. C- The nurse should include muscle strength as part of a neurological examination; however, it is not the earliest indicator of cerebral status. D - The first action the nurse should take using the nursing process is to collect data about the client's level of consciousness, as this finding is the earliest indicator of the client's cerebral status.

a nurse is caring for a client who has been taking selegiline to treat Parkinson's disease. The provider is considering the use of analgesics for the client but should be aware that a drug interaction between selegiline and meperidine can result in which of the following? A - Frequent urination B - Jaundice C - Cellulitis D - Muscle rigidity

D - Muscle rigidity Rational A - A drug interaction between selegiline and meperidine is unlikely to result in frequent urination, which can indicate a urinary tract infection and glucose intolerance. B - A drug interaction between selegiline and meperidine is unlikely to result in jaundice. Liver toxicity is a serious adverse effect of dantrolene and many anticonvulsants, such as valproic acid. C - A drug interaction between selegiline and meperidine is unlikely to result in oral ulcers. Skin inflammation is a serious adverse effect of some anticonvulsants, such as phenytoin. D - A drug interaction between selegiline and opioids, especially meperidine, can result in rigidity, stupor, agitation, hypertension, and fever.

A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action. A - ​Apply restraints. ​B- Administer opioids. C -Blacken the room. ​D - Reduce stimuli.

​D - Reduce stimuli. Rational A - The nurse should avoid applying restrains which may increase the client's intracranial pressure. B - The nurse should avoid administering opioids, which may suppress respiratory rate, constrict pupil reaction, and alter appropriate responsiveness. C - The nurse should reduce the lighting in the client's room, not blacken the room, to decrease stimuli that may increase the client's intracranial pressure. D - The nurse should reduce stimuli by decreasing the number of visitors, remaining calm, and creating a quiet environment.