Management Q2: Neurologic Problems

The nurse on the neurological acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? Select all that Apply. 1. When did you first experience the headache symptoms? 2. Who is the Mayor of Cleveland? 3. What is your health care provider's name? 4. What year and month is this? 5. What is your parent's address? 6. What is the name of this health care facility?

1, 3, 4, 6

After the nurse receives the change of shift report at 0700, which client must the nurse assess first? A. A 23 year old client with a migraine headache who reports severe nausea associated with retching B. A 45 year old client who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching. C. A 59 year old client with parkinson disease who will need a swallowing assessment before breakfast. D. A 63 year old client with MS who has a oral temperature of 101.8 and flank pain.

D. UTIs are frequent in client's with MS because of the effect of the disease on bladder function.

An LPN, under the RN's supervision, is assigned to provide nursing care for a client with GBS. What observation should the LPN be instructed to report immediately? A. Reports of numbness and tingling B. Facial weakness and difficulty speaking C. Rapid heart rate of 102 D. Shallow respirations and decreased breath sounds.

4. Clients with GBS are at risk for respiratory failure.

A 23 year old client with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to assign to an LPN whom the nurse is supervising? Select all that apply. 1. Observing and documenting the onset and duration of any seizure activity. 2. Administering phenytoin 200mg PO three times a day. 3. Teaching the client about the need for frequent tooth brushing and flossing. 4. Developing a discharge plan that includes referral to the epilepsy foundation. 5. Assessing for adverse effects caused by new antiseizure medications 6. Turning the client to his or her side to avoid aspiration.

1, 2, 6

The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? Select all that Apply. 1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin and nifedipine should be avoided 3. Abortive therapy is aimed at eliminating the pain during the aura 4. A potential side effect of medications is rebound headache 5. Complementary therapies such as biofeedback and relaxation may be helpful 6. Estrogen therapy should be continued as prescribed by the client's HCP.

1, 2, 3, 4, 5 Estrogen supplements may actually trigger headaches

Which actions should the nurse delegate to an experienced UAP when caring for a client with a thrombotic stroke who has residual left sided weakness? Select all that apply. 1. Assisting the client to reposition every 2 hours. 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active ROM exercises 4. Assessing the extremities for redness and edema 5. Setting up meal trays and assisting with feeding 6. Using a lift to assist the client up to a bed side chair.

1, 2, 3, 5, 6

The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void? Select All that Apply. 1. Stroking the client's inner thigh. 2. Pulling on the client's pubic hair. 3. Initiating intermittent straight catheterization 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle 6. Reminding the client to void in a urinal every hour while awake.

1, 2, 4, 5

A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN? Select All that apply. 1. Checking the client's skin for pressure from the device. 2. Assessing the client's neurologic status for changes 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 5. Developing the nursing plan of care for the client 6. Administering oral medications as ordered.

1, 3, 4, 6

All of the following nursing care activities are included in the plan for a 78 year old man with parkinson disease who has been referred to the home health agency. Which activities will the nurse delegate to the UAP? Select all that apply 1. Checking for orthostatic changes in pulse and blood pressure 2. Assessing for improvement in tremor after levodopa is given 3. Reminding the client to allow adequate time for meals. 4. Monitoring for signs of toxic reactions to anti-parkinson medications 5. Assisting the client with prescribed strengthening exercises. 6. Adapting the client's preferred activities to his level of function.

1, 3, 5 Can remind teaching that is already done by RN. Will be instructed to report BP and HR monitoring to RN

A client who had a stroke needs to be fed. What instruction should the nurse give to the UAP who will feed the client? A. Position the client sitting up in bed before he or she is fed. B. Check the client's gag and swallowing reflexes C. Feed the client quickly because there are three more client's to feed D. Suction the client's secretions between bites of food.

A.

A client with MS tells the UAP after PT that she is too tired to take a bath. What is the priority nursing concern at this time? A. Fatigue B. Inability to perform ADLs C. Decreased mobility D. Muscular weakness

A.

The nurse is preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching? A. I will avoid exercise because the pain gets worse. B. I will use heat or ice to help control the pain C. I will not wear high heeled shoes at home or work D. I will purchase a firm mattress to replace my old one.

A.

The nurse is providing care for a client with newly dx with early Alzheimer disease. On assessment which finding would the nurse expect to discover? A. Short term memory impairment B. Rapid modd swings C .Physical aggressiveness D. Increased confusion at night.

A.

Which nursing action will be implemented first if a client has a generalized tonic-clonic seizure? A. Turn the client to one side B. Give lorazepam 2mg IV C. Administer O2 via nonrebreather mask D. Assess the client's LOC

A.

The nurse is in charge of developing a standard plan of care for an Alzheimer disease care facility and is responsible for assigning and supervising resident care given by LPNs and delegating and supervising care given by UAP. Which activity is best to assign to the LPN team leaders? A. Checking for improvement in resident memory after medication therapy is initiated. B. Using the Mini-Mental State Examination to assess residents every 6 months C. Assisting residents in using the toilet every 2 hours to decrease the risk for urinary incontinence. D. Developing individualized activity care plans after consulting with residents and family.

A. Can check therapeutic affects and adverse affects of medications.

The nurse is mentoring a student nurse in the ICU while caring for a client with meningococcal meningitis. Which action by the student requires that the nurse intervene most rapidly? A. Entering the room without putting on a protective mask and gown. B. Instructing the family that visits are restricted to 10 minutes. C. Giving the client a warm blanket when he says he feels cold. D. Checking the client's pupil response to light every 30 minutes

A. Meningococcal infections are spread through contact and respiratory secretions.

What is the priority nursing concern for a client experiencing a migraine headache? A. Pain B. Anxiety C. Hopelessness D. Risk for brain injury

A. Pain

The RN is supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene? A. Instructing the client to sit up straight and the client responds with a puzzled expression. B. Moving the client's food tray to the right side of the over bed table. C. Assisting the client with passive ROM exercises D. Combing the hair on the left side of the client's head when the client always combs his hair on the right side.

A. They often manifest neglect syndrome. They lean to the left, and when asked to sit up straight, they thing they are sitting up straight.

The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4mg IV push every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns the nurse the most? A. The client no longer recognizes family members B. The blood glucose level is 234 C. The client reports a continuing headache D. The daily weight has increased 2.2lbs

A. indicates a new neurological deficit and indicates a possible increased ICP

The critical care nurse is assessing a client whose baseline GCS score is 3. What is the nurse's best interpretation of this finding? A. The client's condition is improving B. The client's condition is deteriorating C. The client will need intubation and mechanical ventilation D. The client's medication regime will need adjustments.

B.

A 70 year old client with alcoholism who has become lethargic, confused, and incontinent during the last week is admitted to the ED. His wife tells the nurse that he fell down the stairs about a month ago but that "he didn't have a scratch afterward." Which collaborative interventions will the nurse implement first? A. Place the client on the hospital alcohol withdrawal protocol B. Transport the client to the radiology department for a CT scan C. Make a referral to the social services department D. Give the client phenytoin 100mgPO

B.

A client who has Alzheimer disease is hospitalized with new onset angina. Her spouse tells the nurse that he does not sleep well because he needs to be sure the client does not wander during the nurse. He insists on checking each of the medications the nurse gives the client to be sure they are "the same pulls she takes at home." Based on this information, which nursing problem is most appropriate for this client? A. Acute client confusion B. Care provider role stress C. Increased Risk for falls D. Noncompliance with therapeutic plans

B.

The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6 orally. Which prescribed intervention should be implemented first? A. Administer codeine 15mg orally for the client's headache. B. Infuse ceftriaxone 2000mg IV to treat the infection. C. Give acetaminophen 650mg orally to reduce the fever D. Give furosemide 40mg IV to decrease intracranial pressure.

B.

The nurse is floated from the ED to the neurologic flood. Which action should the nurse delegate to the UAP when providing nursing care for a client with a spinal cord injury? A. Assessing the clients respiratory status every 4 hours. B. Checking and recording the client's vital signs every 4 hours. C. Monitoring the client's nutritional status, including calorie counts D. Instructing the client how to turn, cough, and breathe deeply every 2 hours.

B.

The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN? A. Completing the admission assessment B. Setting up oxygen and suction equipment C. Placing a padded tongue blade at the bedside D. Padding the side rails before the client arrives

B.

Which client should the charge nurse assign to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? A. A 34 year old client with newly diagnosed MS B. A 68 year old client with chronic ALS C. A 56 year old client with GBS in respiratory distress D. A 25 year old client admitted with a C4 level spinal cord injury.

B.

A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of greatest concern? A. The gums appear enlarged and inflamed B. The WBC count is 2300. C. The client sometimes forgets to take the phenytoin until the afternoon. D. The client wants to renew her driver's license in the next month.

B. Leukopenia is a serious adverse side effect of phenytoin therapy.

Which client should the charge nurse assign to a new graduate RN who is orienting to the neurologic unit? A. A 28 year old newly admitted client with a spinal cord injury B. A 67 year old client who had a stroke 3 days ago and has left sided weakness. C. An 85 year old client with dementia who is to be transferred to long term care today D. A 54 year old client with Parkinson disease who needs assistance with bathing.

B. Stable patients, not a patient that the UAP can help.

For which client with severe migraine headaches would the nurse question an order for sumatriptan? A. A 58 year old client with gastrointestinal reflux disease B. A 48 year old client with HTN C. A 65 year old client with mild emphysema D. A 72 year old client with hyperthyroidism.

B. Sumatriptan is a triptan preparation developed to treat migraine headaches. Most are contraindicated in clients with acute or suspected heart disease.

The RN notes that a client with MG has an elevated temperature 102.2, and increased HR at 120, and a rise in BP 158/94 and is incontinent of urine and stool. What is the nurse's best action at this time? A. Administer an acetaminophen suppository. B. Notify the HCP immediately C. Recheck VS in 1 hour. D. Reschedule the client's PT

B. Symptoms of Myasthenic crisis- which often follows an infection.

A client with a spinal cord injury reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased BP (168/94) and decreased HR (48), diaphoresis, and flushing of the face and neck. What action should the nurse take first? A. Administer the ordered acetaminophen. B. Check the foley tubing for kinks or obstruction C. Adjust the temperature in the client's room. D. Notify the health care provider about the change in status.

B. The client's symptoms are reflective of autonomic dysreflexia- most often caused by distended bladder or constipation.

A client with GBS is to undergo plasmapheresis to remove circulating antibodies thought to be responsible for the disease. Which client care action should the nurse delegate to the experienced UAP? A. Observe the access site for ecchymosis or bleeding. B. Instruct the client that there will be three or four treatments C. Weight the client before and after the procedure D. Assess the access site for bruit and thrill every 2-4 hours.

C.

After a client has a seizure, which actin can the nurse delegate to the UAP? A. Documenting the seizure B. Performing neurologic checks C. Checking the client's vital signs D. Restraining the client for protection

C.

The nurse is preparing a nursing care plan for a client with a SCI for whom problems of decreased mobility and inability to perform ADLs have been identified. The client tells the nurse, "I don't know why we are doing this. My life is over." Based on this statement, which additional nursing concern takes priority. A. Risk for injury B. Decreased Nutrition C. Difficulty coping D. Impairment of body image.

C.

The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response? A. Your wife was not admitted within the time frame that alteplase is usually given B. This drug is used primarily for client's who experience an acute heart attack C. Alteplase dissolves clots and may cause more bleeding into your wife's brain D. Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase.

C.

The nurse is assessing a client with a neurologic health problem and discovers a change in the LOC from alert to lethargic. What is the nurse's best action? A. Perform a complete neurologic assessment B. Assess the cranial nerve functions C. Contact the Rapid Response Team D. Reassess the client in 30 minutes

C. Contact the rapid response team

Which client in the neurologic ICU should the charge nurse assign to an RN who has been floated from the medical unit? A. A 26 year old client with a basilar skull fracture who has clear drainage coming out of the nose. B. A 42 year old client admitted several hours ago with a headache and a dx of a ruptured berry aneurysm C. A 46 year old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due. D. A 65 year old client with a astrocytoma who has just returned to the unit after undergoing craniotomy.

C. Of these clients, the bacterial meningitis with a abx due is the most stable client.

A client with Parkinson disease has a problem with decreased mobility r/t neuromuscular impairment. The nurse observes the UAP performing all of these actions. For which action must the nurse intervene? A. Helping the client ambulate to the bathroom and back to bed. B. Reminding the client not to look at his feet when he is walking C. Performing the client's complete bathing and oral care. D. Setting up the client's tray and encouraging the client to feed himself.

C. Should help, but the goal is the keep the client as independent as possible.

A client with a spinal cord injury at C3 to C4 is being cared for by the nurse in the ED. What is priority nursing assessment? A. Determine the level at which the client has intact sensation B. Assess the level at which the client has retained mobility C. Check BP and pulse for signs of spinal shock D. Monitor respiratory effort and O2 saturation level.

D. Always assess airway, especially with a high spinal cord injury.

A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene? A. You should avoid consumption of all forms of alcohol B. Wear your medical alert bracelet at all times. C. Protect your loved one's airway during a seizure D. It's okay to take over the counter medications.

D. Always consult your HCP and any OTC medications