Med Surg Final Neruo

A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)

Slower processing time Change in sleep patterns

A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)

Sodium level Clotting factors

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the clients coping strategies? (Select all that apply.)

Spiritual beliefs Family support Level of independence Previous coping strategies

. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The clients spouse is very frustrated, stating that the clients personality has changed and the situation is intolerable. What action by the nurse is best?

Explain that personality changes are common following brain injuries.

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this clients discharge teaching?

. Avoid crowds and people with colds.

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

. Check and document oxygen saturation every 1 to 2 hours Position the client supine with the head in a neutral midline position

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the clients neurologic examination is normal. About what drug should the nurse plan to teach the client?

. Clopidogrel (Plavix)

A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include?

. Discharging the client on a statin medication Providing and charting stroke education Preventing venous thromboembolism

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.)

A 26-year-old woman with a left temporal brain tumor A 38-year-old male client in an alcohol withdrawal program A 42-year-old football player with a traumatic brain injury

A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain?

A 45-year-old male with osteoarthritis

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.)

A client with a moderate trauma may need hospitalization A client with a Glasgow Coma Scale score of 3 has severe TBI. The terms mild TBI and concussion have similar meanings.

An older adult client is hospitalized with Guillain-Barr syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.)

Advising the client to have help getting up Consulting the provider about the drug Placing the client on safety precautions

A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider?

Auscultated stridor

A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?

Avoid large crowds and people who are ill

A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.)

Admission can overwhelm the coping mechanisms for older clients. These clients are more susceptible to systemic and wound infections. Other medical conditions can complicate treatment for these clients

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.)

Alcohol intake High-fat diet Obesity Smoking

After a stroke, a client has ataxia. What intervention is most appropriate to include on the clients plan of care?

Ambulate only with a gait belt

A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this clients plan of care?

Apply a heating pad for 20 minutes at least four times daily

A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Applying a cool washcloth to the head Assisting the client to a position of comfort Keeping voices soft and soothing Maintaining low lighting in the room

The nurse caring for a client with Guillain-Barr syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.)

Ask occupational therapy to help the client with activities of daily living. Consult with the provider about a physical therapy consult. Work with speech therapy to design a high-protein diet

A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the clients record. What action by the nurse is best?

Ask the client how long ago the clip was placed.

A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best?

Ask the client to explain his feelings related to this disorder

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best?

Assess the clients sodium level.

A client with a stroke has damage to Brocas area. What intervention to promote communication is best for this client?

Assess whether or not the client can write

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The clients mental status is deteriorating. What action by the nurse is most appropriate?

Attempt to find the family to sign a consent.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?

Bradycardia

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority?

Call the provider or Rapid Response Team

A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.)

Clear Increased protein level Normal glucose level

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?

Client in a coma for 2 weeks from a motor vehicle crash

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?

Client who has a temperature of 102 F (38.9 C)

A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)?

Cutting foods up into small bites Thickening liquids prior to drinking

After teaching a client with a spinal cord tumor, the nurse assesses the clients understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.)

Even though turning hurts, I will remind you to turn me every 2 hours. Radiation therapy can shrink the tumor but also can cause more problems. My family is moving my bedroom downstairs for when I am discharged home.

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?

Even when my seizures stop, I will continue to take this drug

A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer?

Dexmedetomidine (Precedex)

A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.)

Dilated pupils Widened pulse pressure Bradycardia

A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.)

Do not eat a full meal for 45 minutes after taking the drug. Seek immediate care if you develop trouble swallowing The dose may change frequently depending on symptoms

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask?

Do you live in a crowded residence?

A nurse cares for a client with advanced Alzheimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond?

Engage the client in scheduled activities throughout the day

A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)

Ensure that an informed consent is present. Ask the client about any allergies. Evaluate the clients renal function.

A nurse assesses a client with Alzheimers disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete?

Evaluate the clients reaction to a change of environment.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met?

Has clear lung sounds on auscultation

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

Have suction equipment at the bedside Keep bed rails up at all times Ensure that the client has IV access.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wifes understanding. Which statement by the clients wife indicates she correctly understands changes associated with this disease?

He may have trouble chewing, so I will offer bite-sized portions

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.)

Heart rate of 34 beats/min Urine output less than 30 mL/hr Decreased level of consciousness

A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.)

Hoarseness Dysphagia

A nurse witnesses a client with late-stage Alzheimers disease eat breakfast. Afterward the client states, I am hungry and want breakfast. How should the nurse respond?

I see you are still hungry. I will get you some toast.

After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?

If I am nauseated, I will not take my epilepsy medication.

A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)

Impairment of respiratory muscles

. A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)

Incisional bulging Clear drainage on the dressing Sudden and severe headache

A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this clients plan of care? (Select all that apply.)

Incorporate physical exercise into your daily routine Participate in a smoking cessation program. Increase your intake of fruits and vegetables

After administering a medication that stimulates the sympathetic division of the autonomic nervous system, the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply.)

Increased heart rate Increased force of contraction

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?

Increased pressure from the abscess can cause seizures.

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best?

Inform the student that the docusate should be given. (to help decrease ICP)

A nurse prepares to discharge a client with Alzheimers disease. Which statement should the nurse include in the discharge teaching for this clients caregiver?

Install deadbolt locks on all outside doors

A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, Will the medication my mother is taking improve her dementia? How should the nurse respond?

It will not improve her dementia but can help control emotional responses

A nurse assesses a client with Huntington disease. Which motor changes should the nurse monitor for in this client?

Jerky hand movements

A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this clients plan of care?

Keep the head of the bed at 30 degrees or greater

A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication?

Kidney function tests

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.)

Lip smacking Picking at clothing Patting of the hand on the leg

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer?

Lorazepam (Ativan)

A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best?

MG is an autoimmune problem in which nerves do not cause muscles to contract.

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer?

Methylprednisolone (Medrol)

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered a test on my heart, how should the nurse respond?

Most of these types of blood clots come from the heart.

The nurse assesses a clients Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client?

Needs frequent re-orientation

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority?

Notify the Rapid Response Team.

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find?

Nystagmus (Rapid, rhythmic, repetitious, and involuntary eye movements)

The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?

Obtaining atropine sulfate

A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living?

Occupational therapist

A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?

Palpate the bladder for distention.

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education?

Participate in an exercise program to strengthen muscles

A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client?

Poor prognosis and cognitive function

A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider?

Prinzmetals angina

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this clients constipation? (Select all that apply.)

Provide a diet high in fluids and fiber Implement a consistent daily time for elimination Perform manual disimpaction

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum. Which actions should the nurse take? (Select all that apply.)

Re-position the client off of the reddened areas Obtain a low-air-loss mattress to minimize pressure

A nurse delegates care for a client with early-stage Alzheimers disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care?

Reorient the client to the day, time, and environment with each contact

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?

Risk for acquiring an infection

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client?

Rotate the clients meal tray when the client stops eating

The nurse learns that the pathophysiology of Guillain-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what?

Slowed nerve impulse transmission

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment should the nurse wear? (Select all that apply.)

Surgical mask Gloves

A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this clients teaching?

Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches

. A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

Tape a halo wrench to the clients vest. Assess the pin sites for signs of infection Assess the chest and back for skin breakdown.

A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the clients score to be 36. How should the nurse plan care for this client?

The client will need near-total care.

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this clients teaching?

Tighten your abdominal muscles to stimulate urine flow.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain?

Time of symptom onset

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity?

Tonic-clonic seizure

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take?

Turn the clients head to the side

A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura?

Visual disturbances

A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this clients postoperative instructions?

Wear your brace whenever you are out of bed

A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met?

Weight gain of 3 pounds in 1 month

A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, I do not want to be placed on a mechanical ventilator. How should the nurse respond?

What would you like to be done if you begin to have difficulty breathing?

A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority?

informed consent is on the chart.