HESI: MedSurg Neurologic and Sensory
Closed Head Injury Individuals with serious head injuries are not treated immediately during mass casualty events because the need in those situations is to treat the largest number of people who have the least severe injuries and make the best use of limited resources. People with fractures or survivable radiation or chemical exposures or those requiring uncomplicated abdominal surgeries are treated during mass casualty events.
The nurse on a community terrorism response team is reviewing triage protocols. Which type of injury would be deferred for later treatment during a mass casualty event? 1 Multiple fractures 2 Closed head injury 3 Internal abdominal trauma 4 Radiation/chemical exposure
Do not blow your nose. Avoid bending from the waist. The client needs to avoid activities that cause a sudden rise in intraocular pressure, such as bending from the waist, blowing the nose, sneezing, and coughing. It is not necessary to remain flat in bed for 3 hours after surgery, and the diet is not restricted.
Which information would the nurse include in postoperative teaching for a client who had cataract 11 surgery? Select all that apply. One, some, or all responses may be correct. . 1 Do not blow your nose. 2 Remain flat for 3 hours. 3 Eat a soft diet for 2 days. 4 Breathe and cough deeply. 5 Avoid bending from the waist.
The main characteristic of dry age-related macular degeneration is loss of central vision, which is gradual. Primary angle-closure glaucoma causes pain. Blurred vision may be caused by a refractive error. Loss of peripheral vision does not occur with macular degeneration; peripheral vision loss can occur with glaucoma.
Which ocular symptom would the nurse expect a client with a diagnosis of dry age-related macular degeneration to report? Loss of central vision Attacks of acute pain Constant blurred vision Decreased peripheral vision
Immediate corrective therapy based on current assessments must be implemented. After an infratentorial craniotomy the client is positioned flat on one side with the head on a small, firm pillow unless otherwise instructed by the health care provider. Administering medication or adjusting an IV rate is a dependent function of the nurse, and the prescription must be followed exactly. Changes to prescriptions may be received when the health care provider is notified. STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience
A client who had an infratentorial craniotomy is admitted to the intensive care unit after discharge from the postanesthesia care unit. Frequent assessments reveal that the client's intracranial pressure is increasing. Which action would the nurse take? 1 Notify the health care provider. 2 Elevate the head of the bed. 3 Reduce the prescribed flow rate of intravenous (IV) fluid. 4 Administer the next scheduled dose of osmotic diuretic early.
A migraine is a clinical syndrome characterized by recurrent episodic attacks of head pain. The first phase of a migraine headache is called the prodromal phase. In the prodromal phase, a variety of neurological changes are seen. These include drowsiness, acute confusion, vertigo, numbness and tingling of lips or tongue, aphasia, and unilateral weakness. Severe pain over the ear is pain in the templar region and is the second phase of a migraine headache. Throbbing pain in the head occurs in the third phase of a migraine
After interacting with a client, the nurse thinks the client is in the prodromal phase of a migraine. Which statements made by the client led the nurse to reach this conclusion? Select all that apply 1 "I feel drowsy all the time." 2 "I feel severe pain over my ear." 3 "I feel a throbbing pain in my head." 4 "I feel confused at this point in time." 5 "I feel weakness in the left side of my body."
Cholesterol deposition in the peripheral cornea The condition inferred in the image is arcus senilis, which is characterized by a milky, white-gray ring encircling the periphery of the cornea. This occurs due to cholesterol deposits in the peripheral cornea. Increased rigidity of the iris may result in decreased pupil size. Lipid deposition in the sclera may result in a yellowish discoloration of the sclera. A prolapse of fat into the eyelid tissue may result in blepharochalasis manifested as excessive upper lid skin.
Which rationale is related to the condition inferred in the image? 1 Increased rigidity of the iris 2 Lipid deposition in the sclera 3 Prolapse of fat into the eyelid tissue 4 Cholesterol deposition in the peripheral cornea
The client's eye problems are a conversion reaction. Avoiding discussion of the physical problems prevents the client from using this topic to avoid an exploration of feelings. Focusing on the safe topic of activities may eventually progress to a discussion of emotion-laden topics such as feelings. Encouraging involvement with group activities is too soon; the client is too introspective to become involved with group activities at this time. Focusing on the physical problem allows the client to avoid feelings. The data did not indicate the client had an organic problem and was going blind. STUDY TIP: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts.
An ophthalmologist, neurologist, and internist were not able to identify an organic cause for a client's reports of stabbing eye pain, blurring vision, and gradual loss of vision. Which intervention would the nurse implement after admitting the client to the mental health unit because of increased eye complaints? 1 Encourage the client to become involved in the group activities 2 Assess the client's eye discomfort every 2 hours and PRN 3 Explore the client's feelings about the possibility of impending blindness 4 Focus the client on daily activities, while avoiding discussion of the eye complaints
Passive range-of-motion exercises at least every 8 hours maintain the range of joint movement with a minimum of energy expenditure by the client. Ambulation may fatigue the client and does not provide sufficient movement of the upper extremities. Isometric exercises do not provide the joint movement necessary to prevent contractures. Active range-of-motion exercises at least every 4 hours increase the client's metabolic rate and need for oxygen; the client's ability to meet increased oxygen demand is decreased in the presence of pneumonia.
Which action would be included in the plan of care for a client with a history of parkinsonism who has recently developed rigidity, tremors, and signs of pneumonia? 1 Gait training in the physical therapy department daily 2 Isometric exercises every 2 hours while awake 3 Active range-of-motion exercises at least every 4 hours 4 Passive range-of-motion exercises at least every 8 hours
1 3 5 6 Increased intracranial pressure from bleeding into and swelling of tissues within the cranium results in a slowing of the heart rate, an increased pulse pressure (due to increasing systolic blood pressure with a sustained diastolic blood pressure), and an altered level of consciousness. Bleeding from the oral cavity can occur in this situation and should be assessed for the presence of cerebrospinal fluid (CSF). Carotid circulation is not altered. Spinal reflexes generally remain intact.
Which assessments would the nurse include in a focused assessment for a client who has sustained a head injury? Select all that apply. One, some, or all responses may be correct. 1 Heart rate 2 Carotid pulse strength 3 Inspection of the oral cavity 4 Deep tendon reflexes 5 Pulse pressure 6 Level of consciousness
Frequent voiding Suprapubic distention With retention, the total amount of urine produced is unaffected. Atony permits the bladder to fill without being able to empty. As pressure builds within the bladder, the urge to void occurs, and the client eliminated just enough urine to relieve the pressure and the urge to void. The cycle repeats as pressure again builds. Thus small amounts are voided without emptying the bladder. As the client retains urine and the bladder enlarges, suprapubic distention occurs. Edema is a sign of fluid volume excess, not urinary retention. Oliguria (urinary output less than 400 mL/day) is a sign of acute kidney injury. Continual incontinence does not occur with urinary retention
Which clinical manifestations would the nurse identify as indicators suggesting a client has urinary retention and overflow after sustaining a cerebrovascular accident (CVA, also known as a "brain attack")? Select all that apply. One, some, or all responses may be correct
3 Normal biceps reflexes in the arms The client will have normal biceps reflexes with a T1 injury. The nerves for arm innervation are at C4, which is above the injury level of T1. Diaphragm innervation is not affected by this injury; the diaphragm is innervated above C4. Innervation of muscles used to move the lower arms is not affected by this injury; these muscles are innervated above C7. Innervation for pain sensation of the hands is not affected by this injury; these nerves are innervated above C7.
Which finding would the nurse expect when assessing a client who has a vertebral fracture at the T1 level? 1 Difficulty breathing 2 Inability to move the lower arms 3 Normal biceps reflexes in the arms 4 Loss of pain sensation in the hands
1, 5 The Credé maneuver is the use of manual pressure over the suprapubic area to compress the bladder and promote emptying. Urinary retention is a risk factor for urinary tract infection. Physical stressors, such as infections, can trigger exacerbations in clients with MS. Early recognition and treatment of infection are important to decrease the risk of exacerbation in the client with MS. Use of an indwelling urinary catheter puts the client at risk for urinary tract infection. Some clients with urinary retention are taught intermittent self-catheterization. Risk of urinary tract infection is lower with intermittent catheterization than with the use of an indwelling urinary catheter. Acetylcholine is the primary neurotransmitter of the parasympathetic nervous system. Stimulation of the parasympathetic nervous system causes the detrusor muscle to contract, which promotes bladder emptying. Anticholinergic medications inhibit the cholinergic response and lead to urinary retention. Oral fluids should be encouraged in the client with voiding difficulties, as concentrated urine increases the risk of urinary tract infection
Which instructions would the nurse include when teaching a client with multiple sclerosis (MS) about managing urinary retention? Select all that apply. One, some, or all responses may be correct 1 Using the Credé maneuver 2 Using an indwelling catheter 3 Using anticholinergic medications 4 Monitoring and restricting fluid intake to 800 mL daily 5 Monitoring for and reporting signs of urinary tract infection
