Med-Surg III Ch.36-40
The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care? -"Hospice care uses a team approach and provides complete care." -"Clients and families are the focus of hospice care." -"The physician coordinates all the care delivered." -"All hospice clients die at home."
"Clients and families are the focus of hospice care."
The nurse is caring for a client with tetraplegia following a motor vehicle accident. A family member of the client states, "I know there is grief associated with the loss of independence, but how do I help my loved one to move past that?" The nurse is most helpful to say which of the following? -"There is nothing you can do. It must come from the client." -"Grief is a normal process. Let's discuss offering support throughout the process." -"Ask your loved one what you can do and decorate the room to elevate mood." -"Provide comfort foods, which expresses your love and support."
"Grief is a normal process. Let's discuss offering support throughout the process."
A client is prescribed sumatriptan (Imitrex) for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? -"I use this to prevent migraines." -"I take this when I get a headache." -"It constricts the blood vessels in my head." -"It alleviates my sensitivity to light and sound."
"I use this to prevent migraines."
A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? -Avoid heavy lifting. -Avoid fiber in the diet. -Take an antacid frequently. -Take an herbal form of feverfew.
-Avoid heavy lifting.
A client, who was adopted at birth, recently discovers that Huntington's disease is prevalent in the biological family history. How can the nurse best assist the client in dealing with personal fears? -Provide information of the progression of the disease. -Encourage client to verbalize fears. -Explain that inherited risk is 50%. D) -Offer genetic testing.
-Encourage client to verbalize fears.
A client presents to the emergency department status postseizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? -Lumbar puncture -Echoencephalography -Nerve conduction studies -EMG
-Lumbar puncture
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? -Insert an airway or bite block. -Manually restrain the extremities. -Turn client to side-lying position -Monitor vital signs.
-Turn client to side-lying position
A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam (Valium) 0.25 mg/kg. How many milligrams will be given to this client? _______________________________ mg
15mg
The nurse is caring for a client with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used? -A cervical collar -Bandages and tape -A firm mattress -Traction equipment
A cervical collar
A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, which deficits are anticipated? -A delayed reaction in identification of information due to slowed passages of information to brain -A delayed reaction in cognitive ability to understand the relayed information -A delayed reaction in processing the information transferred from the environment -A delayed reaction in response due to the interrupted impulses from the central nervous system
A delayed reaction in response due to the interrupted impulses from the central nervous system
The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action? -Assess client's reaction to new medication schedule. -Administer medications at exact intervals ordered. -Document medication given and dose. -Give client plenty of fluids with medications.
Administer medications at exact intervals ordered
A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy? -Encourage deep breathing and coughing. -Observe for facial swelling. -Anticipate need for endotracheal intubation. -Resume antilipemic drugs.
Anticipate need for endotracheal intubation.
The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered? Select all that apply. -Loop diuretics -Anticonvulsants -Corticosteroids -Analgesics -Antibiotics -Antidepressants
Anticonvulsants, Analgesics, Antibiotics
The nurse is assisting in the discharge process where a female, paralyzed client is returning home with her husband and two children. Which of the following prescription classifications, used prior to hospitalization, is most important to relate to the physician when discharging? -Birth control pills -A rescue inhaler -An analgesic -An antihistamine
Birth control pills
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? -Extreme thirst -Intake and output -Nutritional status -Body temperature
Body temperature
The nurse is caring for a client with a spinal cord injury leaving paralysis. When planning care related to the musculoskeletal system, which considerations are important? Select all that apply. -Bone demineralization -Contractures -Weight bearing -Spasticity -Limited range of motion
Bone demineralization, Contractures, Spasticity, Limited range of motion
A client is prescribed warfarin. Client teaching has included instructions to avoid a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to avoid? -Fish, meats, and vegetable oils -Citrus fruits -Milk and dairy products -Cereals, soybeans, and spinach
Cereals, soybeans, and spinach
Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. -Cloudy cerebral spinal fluid -Pain and stiffness of the extremities -Purpura of hands and feet -Low white blood cell (WBC) count -Low red blood cell (RBC) count -Low antidiuretic hormone (ADH) levels
Cloudy cerebral spinal fluid, Purpura of hands and feet
While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind his right eye, which is red and tearing. What type of headache would you suspect this client of having? -Migraine -Tension -Cluster -Sinus
Cluster
An emergency department nurse is admitting a client brought in by the paramedics after falling from a tree stand. The client has fractured vertebrae at T3 and T4. The nurse knows the client is in the acute phase of neurologic deficit. What should the nurse know about the medical management of this client? -Goal is to keep the client stable and prevent or treat complications, such as pneumonia, and further neurologic impairment. -Goal is to plan a rehabilitation program in several domains according to the client's abilities and limitations. -Goal is to admit the client to a hospital for treatment of complications. -Goal is to stabilize the client and prevent further neurologic damage.
Goal is to stabilize the client and prevent further neurologic damage
A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client? -Blood pressure 180/98 mm Hg -Alert and oriented times three -Grade V on the Hunt-Hess Scale -Complaint of severe splitting headache
Grade V on the Hunt-Hess Scale
The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/or leaking of cerebral spinal fluid? -Change in the level of consciousness (LOC) -Signs of increased intracranial pressure (IICP) -Halo sign -Swelling
Halo sign
The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved? -Additional inflammation occurs in the brain. -Blood vessels dilate circulating blood. -Herniation occurs through the foramen magnum. -Venous congestion occurs causing peripheral edema.
Herniation occurs through the foramen magnum
A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client? A) Impaired Home Maintenance B) Altered Nutrition C) Hopelessness D) Disturbed Sleep Pattern
Hopelessness
The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae with bone from which location? -Iliac crest -Floating rib -Femur -Mandible
Iliac crest
A video fluoroscopy has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client? -Risk for Fluid Volume Deficit -Risk for Aspiration -Impaired Swallowing -Altered Nutrition: Less Than Body Requirements
Impaired Swallowing
A client is brought to the emergency department (ED) by family members who tell the triage nurse that the client doesn't recognize them. The client is diagnosed with a neurologic deficit. What other conditions are considered neurologic deficits? Select all that apply. -Impaired speech -Abnormal bladder elimination -Muscle strength -Normal gait -Paralysis
Impaired speech, Abnormal bladder elimination, Paralysis
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? -Decreased pulse rate, respirations of 20 breaths/minute -Increased pulse rate, adventitious breath sounds -Increased pulse rate, respirations of 16 breaths/minute -Decreased pulse rate, abdominal breathing
Increased pulse rate, adventitious breath sounds
You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should you keep always ready at the bedside? -Nebulizer and thermometer -Intubation tray and suction apparatus -Blood pressure apparatus -Incentive spirometer
Intubation tray and suction apparatus
Which of the following assessment tools should the nurse use to perform a neurologic assessment? -Cutaneous triggering -Mini-Mental Status Examination -Credé's maneuver -Mechanical lift
Mini-Mental Status Examination
A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? -Complaint of headache off and on for past month -No bowel movement since yesterday -Nausea -Frequent voiding
Nausea
You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? -Radiography -Myelography -Neurologic examination -Computed tomography (CT) scan
Neurologic examination
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? -Cardiovascular system -Respiratory system -Endocrine system -Neurovascular system
Neurovascular system
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? -Sciatic nerve pain -Herniation -Paresthesia -Paralysis
Paresthesia
In which of the following disease processes is the nurse most likely to care for a client in the chronic phase of a neurologic disease? -Transient ischemic attack (TIA) -Malignant brain tumor -Parkinson's disease -Pneumonia
Parkinson's disease
The nurse is assessing a client's ability to detect sensation in the upper extremity. Which nursing actions would be appropriate? Select all that apply. -Place a warm cotton ball on the arm. -A light prick using a needle. -A gentle pinch using the fingers. -Drag the alcohol pad over the skin. -Touch the client with the pads of the finger.
Place a warm cotton ball on the arm, A gentle pinch using the fingers, Drag the alcohol pad over the skin, Touch the client with the pads of the finger
A client you are caring for experiences a seizure. What would be a priority nursing action? -Restrain the client during the seizure. -Insert a tongue blade between the teeth. -Protect the client from injury. -Suction the mouth during the convulsion.
Protect the client from injury.
The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord? -Coccyx -Second lumbar vertebrae -Eleventh thoracic vertebrae -Fifth lumbar vertebrae
Second lumbar vertebrae
The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline (Eldepryl) with carbidopa-levodopa (Sinemet) to the medication regime should result in which purpose? -Slows the progression of the disease -Replaces dopamine -Relieves symptoms of dyskinesia -Prevents side effects from Sinemet
Slows the progression of the disease
A home health nurse is assisting the wheelchair-dependent, post-cerebrovascular accident client in transition from the rehabilitative center to home. Which of the following concerns would the nurse address first when assessing the client's home? -Steps to the front door -Tub for bathing -Throw rugs in the kitchen -Untrained companion staying with client
Steps to the front door
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? -Epidural -Subdural -Intracerebral -Cerebral
Subdural
Which nursing assessment finding is most indicative of a hemorrhagic stroke? -Client history of atrial fibrillation -Sudden onset of breathing alterations -Symptoms evolving over 24 to 48 hours -Client history of hyperlipidemia
Sudden onset of breathing alterations
A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? -Loss of bowel and bladder control -Choreiform movements -Suicidal ideations -Emotional apathy
Suicidal ideations
The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms? -Autonomic nervous system -Central nervous system -Peripheral nervous system -Sympathetic nervous system
Sympathetic nervous system
A critical care nurse is documenting her assessment of a client she is caring for. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean? -The client has an abnormal posture response to stimuli. -The client is not responding to stimuli. -The client is hyperresponsive on the left. -The client is hyporesponsive on the left.
The client is not responding to stimuli.
The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care? -The client with history of seizures -The client who was in a bike accident last summer -The client who played soccer in college -The client whose father has Parkinson's disease
The client who played soccer in college
A client with increased intracranial pressure is receiving mannitol (Osmitrol) via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment? -Blood pressure is rising. -Level of consciousness is improving. -Urine output is increased. -Hyperpyrexia is resolving.
Urine output is increased.
A client presents to the walk-in clinic complaining of a migraine. The client is prescribed a neuronal stabilizer. What should the nurse suggest to the client? -Avoid crowds. -Take drugs only after meals at night. -Avoid caffeine and alcohol. -Use caution while driving or performing hazardous activities.
Use caution while driving or performing hazardous activities.
A nursing instructor is teaching the senior nursing class about clients with neurologic disorder. The instructor tells the students that these clients are at risk of disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. What nursing intervention helps prevent plantar flexion? -Use of parallel bars or a walker -Application of an abdominal binder -Use of a footboard -Use of a flotation mattress
Use of a footboard
The nurse is assisting a client, with a right-sided brain infarction, to transfer from the wheelchair to the bed. Which is the best placement of the wheelchair to facilitate this transfer? -Wheelchair placed so client leads with his left side -Wheelchair placed on the right side of the bed facing the foot -Wheelchair placed on the left side of the bed facing the head -Wheelchair placed on the right side of the bed facing the head
Wheelchair placed on the right side of the bed facing the foot
The nurse is instructing the client on how to perform Credé's maneuver. In which situation is this maneuver helpful? -When a client is experiencing a vagal response during a bowel movement -When a client is experiencing orthostatic hypotension upon arising -When a client is attempting to empty the bladder -When a client is experiencing numbness of the lower extremities
When a client is attempting to empty the bladder
A mother brings her 6-year-old to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be? -"A concussion is a blow to the head that bruises the brain." -"A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull." -"A concussion is a blow to the head that is minor and has no real consequences." -"A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."
"A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."
A client, with a recent closed head injury, began experiencing partial (focal) seizures and asks the nurse to explain why this is happening. Which is the best response from the nurse? "It is not uncommon for seizure activity to occur after head trauma." -"Only a portion of your brain has been irritated." -"Generalized seizures are much worse and involve the entire brain." -"Electrical impulses become confused and chaotic resulting in a seizure."
"It is not uncommon for seizure activity to occur after head trauma."
The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm? -"Don't worry. The aneurysm has probably been there since birth." -"The headache can be an indication that the aneurysm is growing." -"A headache means your aneurysm is leaking blood into the brain." -"Your physician wants to evaluate the location and condition of the aneurysm."
"Your physician wants to evaluate the location and condition of the aneurysm."
When using pharmacologic aids to assist with bowel training, which aid would the nurse anticipate to be used first? A mineral oil enema -A glycerin suppository -A bisacodyl suppository -Prune juice
A glycerin suppository
The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate to the nurse that the client is in a semicomatose state? -A score of 20 -A score of 15 -A score of 9 -A score of 4
A score of 9
The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious stating, "What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain." The nurse is most correct to turn the teaching to which surgical procedure? -A diskectomy -A laminectomy -A spinal fusion -Aggressive traction
A spinal fusion
A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes? -A unit of fresh frozen plasma is infusing. -Neurological checks are ordered every 2 hours. -Keppra is ordered for treatment of focal seizures. -Oropharyngeal suctioning as needed.
A unit of fresh frozen plasma is infusing.
A client is admitted for scheduled gamma-knife radiosurgery, in the treatment of a brain tumor. Which nursing measure is primary in the postsurgical care of this client? -Assessing skull dressing for excess drainage -Time, distance, and shielding against radiation -Assess neurological findings. -Maintain airway via artificial ventilation.
Assess neurological findings
You suspect that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? Select all that apply. -Bladder distention -Poikilothermia -Loss of hunger sensation -Circulatory failure -No perspiration below the level of the injury
Bladder distention, Poikilothermia, No perspiration below the level of the injury
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? -Epilepsy -Trigeminal neuralgia -Hypostatic pneumonia -Brain tumor
Brain tumor
A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of cell transplantation therapy. Which early outcome of treatment is anticipated? -Cell transplantation therapy produced a reduction in swelling and pain. -Cell transplantation therapy allowed organs to be brought from one person to another. -Cell transplantation therapy improves the growth of new neurologic connections. -Cell transplantation therapy allows the replacement of nerve cells that are damaged
Cell transplantation therapy allows the replacement of nerve cells that are damaged
The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? -Myelogram -Electroencephalogram -Echoencephalography -Cerebral angiography
Cerebral angiography
The nurse and physician are viewing a brain scan, which indicates bleeding at the point of impact to the skull and edema on the opposite side. The client is sleeping but can be aroused. The client has no memory of accident. The nurse provides all details to the next shift and is most accurate to report which type of injury? -Coup injury -Contusion -Head injury -Contrecoup injury
Contrecoup injury
A client with atrial fibrillation is placed on Coumadin to reduce the potential of developing a cerebrovascular accident (CVA). The international normalized ratio (INR) is 1.5. What does this finding indicate to the nurse? -Therapeutic range is achieved. -Coumadin will be increased. -Coumadin will be decreased. -INR is too high.
Coumadin will be increased.
The nurse is employed in a neurologist's office, performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve? -Cranial nerve II -Cranial nerve VI -Cranial nerve VIII -Cranial nerve XI
Cranial nerve VIII
The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? -Cranial nerve I -Cranial nerve V -Cranial nerve XI -Cranial nerve XII
Cranial nerve XII
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? -Elevate the head of the bed. -Complete a head-to-toe assessment. -Administer morning dose of anticonvulsant. -Administer Percocet as ordered
Elevate the head of the bed
Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply. -Stiff neck -Generalized pain -Glasgow Coma Scale of 15 -Elevated systolic blood pressure -Brisk pupil response -Wide pulse pressure
Elevated systolic blood pressure, Wide pulse pressure
The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? -Extradural hematoma -Epidural hematoma -Subdural hematoma -Intracranial hematoma
Epidural hematoma
A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? -Abnormal posture -Flaccidity -Weak muscular tone -Decorticate posturing
Flaccidity
A nurse is working in a neurologist's office. The physician orders a Romberg test. Which nursing action is correct? -Have the client touch his nose with one finger. -Have the client close his eyes and stand erect. -Have the client close his eyes and discriminate between dull and sharp. -Have the client close his eyes and jump on one foot
Have the client close his eyes and stand erect.
The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority? -Provide instruction on blood-thinning medication. -Praise client when using adaptive equipment. -Include client in planning of care and setting of goals. -Assess client for ability to ambulate independently.
Include client in planning of care and setting of goals.
A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility? -Provide a well-balanced diet. -Position the client. -Keep the client hydrated. -Help the client perform exercises.
Keep the client hydrated.
The client is switched to a different dose of carbidopa-levodopa (Sinemet). Which nursing assessment is primary during this time of medication change? -Observe for jaundice. -Assess for euphoria. -Monitor vital sign fluctuation. -Monitor for elevation of glucose levels.
Monitor vital sign fluctuation.
Which neurons transmit impulses from the CNS? -Sensory -Neurilemma -Dendrites -Motor
Motor
When a nurse is caring for a client diagnosed with neurologic deficit who has begun responding to those around him, what therapy should the nurse suggest to help strengthen muscles that are under voluntary control? -Occupational therapy -Range-of-motion (ROM) exercises -Recreational therapy -Physiotherapy
Occupational therapy
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken? -Perform a vision field assessment. -Reposition the tray and plate. -Assist the client with feeding. -Know this is a normal finding for CVA.
Perform a vision field assessment.
The nurse is providing care to a client with neurologic problems and notices that the client is experiencing a penile erection. Which nursing reaction is correct? -Excuse yourself and return later. -Inquire what the client is thinking about. -Ask the client if he would like a few minutes alone. -Perform duties professionally and explain that spontaneous erections are unpredictable.
Perform duties professionally and explain that spontaneous erections are unpredictable.
When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms? -Apply cool or warm cloth to head or eyes. -Eliminate use of bright lights when working. -Avoid certain foods. -Perform stretching exercises and frequent position change.
Perform stretching exercises and frequent position change
A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of TPA in a client with CVA requires which of the following? Select all that apply. -The symptoms are no longer evolving. -Presence of an ischemic stroke -Used concurrently with heparin therapy -Administer intramuscular for faster response. -Administer within 3 hours of onset of symptoms. -Administer for hemorrhagic strokes.
Presence of an ischemic stroke, Administer within 3 hours of onset of symptoms
The nurse caring for a client in the chronic phase of a neurologic deficit knows that nursing management focus on what? -Working with team members to plan a rehabilitation program -Retraining the client's bowel and bladder -Supporting the client during recovery -Preventing physical and psychological complications
Preventing physical and psychological complications
What phase of a neurologic deficit begins when the client's condition is stabilized? -Recovery -Chronic -Terminal -Acute
Recovery
A client with a neurologic deficit has been admitted to your unit. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Which of the following action should the nurse perform immediately? -Use the Glasgow Coma Scale. -Use the Mini-Mental Status Examination. -Report the change to the physician. -Monitor the blood pressure
Report the change to the physician
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? -Seizure began at 1300 hours. -The client cried out before the seizure began. -Seizure was 1 minute in duration including tonic-clonic activity. -Sleeping quietly after the seizure
Seizure was 1 minute in duration including tonic-clonic activity.
The nurse is caring for a stuporous client in the intensive care unit. Which assessment finding is documented to reflect an improvement in the client's level of consciousness? -Conscious -Somnolent -Stuporous -Semicomatose
Somnolent
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? -Take small meals of nutrient and calorie-dense food. -Increase the intake of calcium and proteins. -Include additional servings of fruits and raw vegetables. -Include fish, liver, and chicken in diet.
Take small meals of nutrient and calorie-dense food
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? -The client will take the seizure medication at the same time daily. -The client will remain free of injury if a seizure does occur. -The client will verbalize an understanding of feelings that preempt seizure activity. -The client will post emergency numbers on the refrigerator for ease of obtaining
The client will remain free of injury if a seizure does occur.
The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first? -The client with an open head injury -The client with a basilar fracture -The client with a concussion -The client with a coup injury
The client with a basilar fracture
A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse? -The client is a heart transplant recipient. -The client's medications include warfarin (Coumadin). -The client is HIV positive. -The client has a history of concussions from playing hockey.
The client's medications include warfarin (Coumadin)
The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm? -The interaction may cause the client to become violent. -The interaction may cause migraine in the client. -The stimulation can increase intracranial pressure (ICP) or trigger a seizure. -The client may become emotional and lose interest in the treatment.
The stimulation can increase intracranial pressure (ICP) or trigger a seizure.
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? -Cervical collar -Cast -Traction with weights and pulleys -Turning frame
Traction with weights and pulleys
The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client? -Change in level of consciousness -Vomiting -Vector bites -Seizures
Vector bites
The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer? -Headache and pain in the neck -Claustrophobia -Allergic reaction to the imaging material -Allergic reaction to radioactive rays
Allergic reaction to the imaging material
A female client undergoes a scheduled electroencephalogram (EEG). Which of the following postprocedure activities should the nurse carry out for the client? -Allow the client to rest and shampoo the client's hair. -Provide the client with adequate caffeine-rich drinks. -Measure the level of consciousness (LOC) of the client. -Measure the heart and the pulse rate.
Allow the client to rest and shampoo the client's hair
The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? -An absence seizure -A myoclonic seizure -A partial seizure -A tonic-clonic seizure
An absence seizure
Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field? -Provide a well-lit environment. -Announce yourself when approaching the client. -Ensure a clutter-free walkway. -Instruct on adaptive plates with rims
Ensure a clutter-free walkway.
You are caring for a client who has had intracranial surgery and is being discharged home. What instructions would you give the client besides instructions on the medication? -Understand that headaches are uncommon. -You can cover the incision with your hair. -You can expect swelling above the incision. -Expect sensory changes, such as hearing a clicking sound, around the bone flap.
Expect sensory changes, such as hearing a clicking sound, around the bone flap.
The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client? -Optimizing nutrition -Managing muscle weakness -Explaining hospice care and services -Offering family support group
Explaining hospice care and services
The nurse is caring for a client with paraplegia in the acute care setting. The client's last bowel movement was 4 days ago. Which nursing action is best to assist the client in accomplishing the goal of an enema? -Tape the client's buttocks together so to retain the enema. -Instill the enema slowly (1 to 2 oz at a time) followed by a waiting period. -Prop the client over a toilet to allow gravity to assist in the defecation process. -Insert the enema tubing high into the bowel to increase fecal mass elimination.
Instill the enema slowly (1 to 2 oz at a time) followed by a waiting period.
You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has? -Ischemic -Hemorrhagic -Right-sided -Left-sided
Ischemic
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? -Transient ischemic attack (TIA) -Left-sided cerebrovascular accident (CVA) -Right-sided cerebrovascular accident (CVA) -Completed Stroke
Left-sided cerebrovascular accident (CVA)
A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? -Symptoms will evolve over a period of 1 week. -Monitoring is needed as rapid neurologic deterioration may occur. -The crash cart with defibrillator is kept nearby. -Bleeding continues into the intracerebral area.
Monitoring is needed as rapid neurologic deterioration may occur
The family nurse practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? -Moving the head toward both sides -Lightly tapping the lower portion of the neck to detect sensation -Moving the head and chin toward the chest -Gently pressing the bones on the neck
Moving the head and chin toward the chest
The brain stem holds the medulla oblongata. What is the function of the medulla oblongata? -Transmits sensory impulses from the brain to the spinal cord -Controls striated muscle activity in blood vessel walls -Controls parasympathetic nerve impulses in the pons -Transmits motor impulses from the brain to the spinal cord
Transmits motor impulses from the brain to the spinal cord
The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. -Unequal pupils -Pupil reaction quick -Pinpoint pupils -Absence of pupillary response -Pupil reacts to light
Unequal pupils, Pinpoint pupils, Absence of pupillary response
A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA? -Unilateral ptosis -Respiratory distress -Severe headache -Nausea and vomiting
Unilateral ptosis
The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? -Physician maintains aseptic procedure. -Cerebrospinal fluid is cloudy in nature. -Client states a piercing feeling. -Client states a pressure relief in the head.
Cerebrospinal fluid is cloudy in nature.
Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of a muscular body area? -Computed tomography (CT) -Magnetic resonance imaging (MRI) -Positron emission tomography (PET) -Single-photon emission computed tomography (SPECT)
Computed tomography (CT)
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? -Damage to the nerves that facilitate vision and hearing -Damage to the vagal nerve -Damage to the olfactory nerve -Damage to the facial nerve
Damage to the nerves that facilitate vision and hearing
The nurse is caring for a post-lumbar puncture client experiencing an intense headache. The physician is notified and arriving to assess the client. If the physician chooses aggressive treatment, which nursing action is anticipated? -Hanging an intravenous solution -Drawing venous blood to perform a blood patch -Applying ice to the back of the neck -Offering caffeinated drinks
Drawing venous blood to perform a blood patch
An elderly client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client? -Becomes confused during the night -Drooling from side of mouth -Bruit heard over carotids -Irregular heart rhythm
Drooling from side of mouth
The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate? -Edema to the head and a blackened eye -Edema to the head with a large scalp laceration -Edema to the head with fixed pupils -Edema to the head with bruising of the mastoid process
Edema to the head with bruising of the mastoid process
What would the nurse do to best assist the client in increasing peristalsis and encouraging defecation after suffering from a neurologic deficit? -Help the client to the bathroom at a particular time each day. -Administer a low-volume enema each day at the same time. -Encourage liquids throughout the day. -Encourage a high-fiber diet.
Help the client to the bathroom at a particular time each day
A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture? -Administer antihistamines to the client. -Provide adequate caffeine-rich drinks to the client. -Assess the level of consciousness (LOC) and the pupil response of the client. -Position the client flat for at least 3 hours.
Position the client flat for at least 3 hours.
The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? -Numbness and tingling -Respiratory pattern -Pulse and blood pressure -Pain level
Pulse and blood pressure
The nurse is caring for a client with neurologic deficits who is interested in implementing a bowel training program. Which of the following does the nurse identify as the first step? -Obtaining a laxative -Eating a select diet -Recording bowel movements -Providing privacy
Recording bowel movements
You are caring for an 82-year-old client who needs bladder training. You know that bladder training is difficult for older adult clients with neurologic deficit because of what? -Urinary incontinence -Urinary retention -Decreased energy expenditure -Relaxation of the internal bladder sphincter
Relaxation of the internal bladder sphincter
A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? -Reduces hypotension -Increases appetite -Relaxes muscles -Relieves migraines
Relaxes muscles
The nurse is caring for a client following intracranial surgery. In the plan of care, the nurse states to remove antiembolism stockings. What would the nurse do to accurately complete this intervention? -Remove the antiembolism stockings nightly and reapply by 8 AM. -Place the antiembolism stockings on the lower extremities as tolerated. -Remove the antiembolism stockings briefly every 8 hours. -Apply the antiembolism stocking prior to ambulation daily.
Remove the antiembolism stockings briefly every 8 hours
Which nursing technique best allows the client with slight expressive aphasia to communicate his feelings about using adaptive equipment in public? -Use a communication board to express thoughts. -Enlist a close family member to interpret words. -Sit beside client and patiently assist in interpreting communication. -Allow the client time to process the words to express and return later for the conversation.
Sit beside client and patiently assist in interpreting communication.
The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence? -The client grasps the affected arm at the wrist and raises it. -The client arranges a community service to deliver meals. -The client ambulates with the assistance of one. -The client uses a mechanical lift to climb steps.
The client grasps the affected arm at the wrist and raises it
The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? -The client has cerebral spinal fluid (CSF) leaking from the ear. -The client has ecchymosis in the periorbital region. -The client has an elevated temperature. -The client has serous drainage from the nose.
The client has cerebral spinal fluid (CSF) leaking from the ear
The nurse is caring for clients on a neurologic floor. Which client goal is most appropriate for the acute phase of a neurologic injury? -The client will use the adaptive devices to assist with feeding. -The client's vital signs will stabilize returning to baseline. -The client's skin will remain clean, dry, and intact. -The client will return to optimal level of functioning.
The client's vital signs will stabilize returning to baseline
The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders? -The second cervical vertebrae -The first thoracic vertebrae -The seventh thoracic vertebrae -The first lumbar vertebrae
The first thoracic vertebrae
The home care nurse is evaluating a post-cerebrovascular accident (CVA) client 1 week after returning to the home from a rehabilitation setting. Which of the following statements, made by the client, most concerns the nurse? -"I am so happy to be home, but I am not able to go upstairs to my bedroom." -"I find it difficult to get up so I am remaining in bed until the home health aide comes." -"My spouse goes to work in the morning and leaves my lunch at my bed stand." -"A lot of family is coming to see me, which is nice but makes me very tired."
"My spouse goes to work in the morning and leaves my lunch at my bed stand."
The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? -Observing the reaction of pupils to light -Observing the client's response to painful stimulus -Using the Romberg test -Assessing the client's sensitivity to temperature, touch, and pain
Observing the client's response to painful stimulus
A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? -Frontal -Parietal -Temporal -Occipital
Occipital
Which of the following occupations are anticipated to improve the functioning of a client with a neurologic deficit? Select all that apply. -Occupational therapist -Speech therapist -Neurologist -Electrocardiography technician -Electroencephalogram technician -Physical therapist
Occupational therapist, Speech therapist, Neurologist, Physical therapist
The nurse is caring for a client newly diagnosed with multiple sclerosis. The client indicates that there is so much to understand at one time. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. Which nursing action is correct? -Tell the client not to worry about the fine details. -Tell the client that there is so much to learn; you can meet to discuss it again. -Tell the client that the covering is called myelin and that you can discuss at the next meeting. -Tell the client that the disease process requires more research.
Tell the client that the covering is called myelin and that you can discuss at the next meeting.
The critical care nurse is giving report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? -Comatose -Somnolence -Stupor -Normal
Comatose
The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful? -Adoption is an option to complete your family but not put your life in jeopardy. -Conception is not impaired; the birth process is determined with the physician. -Birth via surrogate is best because your baby can be implanted in another woman. -Sterilization is best; it would be difficult to care for a baby in your condition.
Conception is not impaired; the birth process is determined with the physician
A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? -"I sense that you are happy it was not a stroke." -"People who experience a TIA will develop a stroke." -"TIA symptoms are short lived and resolve within 24 hours." -"TIA is a warning sign. Let's talk about lowering your risks."
"TIA is a warning sign. Let's talk about lowering your risks."
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? -Dextrose 5% in water (D5W) -Half-normal saline (0.45% NSS) -One-third normal saline (0.33% NSS) -Mannitol (Osmitrol)
Mannitol (Osmitrol)
The nurse is talking with the mother of a client who is diagnosed with a traumatic brain injury. The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction, made by the nurse, is most correct? -"The client may be experiencing a change in affect due to the brain injury." -"The client has demonstrated this behavior before and is now anticipated." -"The client has underlying aggression problems, which manifest in behavior." -"All traumatic brain injury clients act in this similar way."
"The client may be experiencing a change in affect due to the brain injury."
The nurse is caring for a client with dysphagia. Which instruction to the family is most important? -Do not open/crush a medication in a capsule. -Stir thickening products in liquids and serve immediately. -Raise client to a semi-Fowler's position -Provide small bites at the client's pace.
Do not open/crush a medication in a capsule.
The nurse is caring for a 55-year-old client on a rehabilitated unit following a cerebrovascular accident (CVA). The nurse is instructing on range of motion exercises when the client begins to cry. The client states she has always taken care of the family and does not want to be a burden. Which nursing diagnosis would the nurse add to the plan of care? -Ineffective Coping related to refusing to acknowledge physical limitations -Deficient Diversional Activity related to the inability to participate in family activity -Impaired Home Maintenance related to inability to care for home setting -Ineffective Role Performance related to inability to function in family role
Ineffective Role Performance related to inability to function in family role
The nurse is instructing the paralyzed client on a method to stimulate the relaxation of the urinary sphincter aiding in urinary elimination. Which instruction would be correct? -Lightly massage or tap the skin above the pubic area -Press directly over the urinary bladder. -Bear down increasing abdominal pressure. -Pour water over the genitals
Lightly massage or tap the skin above the pubic area
Which of the following would the nurse include in the rationale for the nursing intervention to maintain body alignment? Select all that apply. -Maintaining body alignment prevents contractures -Maintaining body alignment promotes circulation -Maintaining body alignment assists in urinary elimination -Maintaining body alignment decreases pain -Maintaining body alignment decreases respiratory effort
Maintaining body alignment prevents contractures, Maintaining body alignment decreases pain
The nurse is working on a neurosurgical unit. Which of the following nursing interventions are included in the plan of care following spinal surgery? Select all that apply. -Monitor vital signs -Intake and output -Coughing and deep breathing -PEARLA -Neurovascular assessment of the lower extremity -Dressing assessment
Monitor vital signs, Intake and output, Coughing and deep breathing, Neurovascular assessment of the lower extremity, Dressing assessment
A 58-year-old client has scheduled a sick visit to the physician's office, stating symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and identified potential causes of the pain. Which area of the drawing would the nurse emphasize? -Spinal cord pathway -Nucleus pulposus -Bony vertebrae -Associated musculature
Nucleus pulposus
The nurse is caring for a client who was discovering unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? -Tylenol may be administered for aches. -Observe for any signs of behavioral changes. -A light meal may be eaten if desired. -Follow up with regular physician is encouraged.
Observe for any signs of behavioral changes.
Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident? -Prevention of joint contractures -Promoting ability to critically think -Creating a positive environment -Use of adaptive equipment
Prevention of joint contractures
The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, "What do you want?" Which level of conscious should the nurse document? -Conscious -Semicomatose -Somnolent -Stuporous
Somnolent
The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse is correct to instruct on the action of which system? -Musculoskeletal system -Sympathetic nervous system -Parasympathetic nervous system -Endocrine system
Sympathetic nervous system
The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? -The client has periorbital edema and ecchymosis. -The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. -The client's level of consciousness has improved. -The client prefers to rest in the semi-Fowler's position.
The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg
The nurse is talking with a newly paralyzed client and his wife. The wife is trying to raise the client's spirits and begins talking about the possibility of them having a baby. When the wife is alone, which instruction in essential? -Continue to talk about a baby as it seems to give him hope. -Do not overwhelm the client with such a big decision. -There is a reduced ability for your husband to be able to father children. -We will provide you and the client with a counselor so that you can explore all options.
There is a reduced ability for your husband to be able to father children
The client with Guillain-Barré syndrome is scheduled for plasmapheresis and is questioning how this process works. Which of the following statements by the nurse best describes plasmapheresis in the management of this syndrome? -"Antibodies that triggered the autoimmune response are removed from your blood." -"The blood removal allows for replacement of cleaner blood from a healthy person." -"Blood transfusions are the gold standard for the treatment of this syndrome." -"Plasma replacement dilutes the organisms that are causing the symptoms."
"Antibodies that triggered the autoimmune response are removed from your blood."
A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? -"I will have progressive muscle weakness." -"I will lose strength in my arms." -"My children are at greater risk to develop this disease." -"I need to remain active for as long as possible."
"My children are at greater risk to develop this disease."
A client is receiving baclofen (Lioresal) for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following? -Sleep pattern -Mood and affect -Appetite -Muscle spasms
Muscle spasms
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment to include which of the following? -Cholesterol-lowering drugs -Anticoagulant therapy -Monthly prothrombin levels -Carotid endarterectomy
Anticoagulant therapy
The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated? -Bronchodilator -Antihistamine -Cardiotonic -Antibiotic
Antihistamine
A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply. -Balloon angioplasty of the carotid artery followed by stent placement -Removal of the carotid artery -Percutaneous transluminal coronary artery angioplasty -Carotid endarterectomy
Balloon angioplasty of the carotid artery followed by stent placement, Carotid endarterectomy
Following the use of a thrombolytic agent in the management of cerebrovascular accident (CVA) client, which is the priority nursing assessment? -Pulse -Respirations -Airway -Blood pressure
Blood pressure
A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? -Prothrombin level -Chest x-ray -Brain CT scan or MRI -Lumbar puncture
Brain CT scan or MRI
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? -Shortness of breath -Sensitivity to bright light -Muscle spasms -Drooping eyelids
Drooping eyelids
A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client? -Identify and avoid factors that precipitate or intensify an attack. -Keep a record of activities following an attack. -When an attack occurs, stay in a brightly lit area. -Write down any adverse drug effects.
Identify and avoid factors that precipitate or intensify an attack.
You are caring for a client with an inoperable brain tumor. What is a major threat to this client? -Increased ICP -Decreased ICP -Hypervolemia -Hypovolemia
Increased ICP
A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. -Left-sided hemiplegia -Tendency to distractibility -Impairment of long-term memory -Hyperaware of deficits -Neglect of objects and people on the left side
Left-sided hemiplegia, Tendency to distractibility, Neglect of objects and people on the left side
Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? -Blood pressure 100/60 mm Hg -Lethargy -Nausea -Periorbital edema
Lethargy
Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease? -Involvement with diversion activities -Enhancement of the immune system -Establishing balanced nutrition -Maintaining a safe environment
Maintaining a safe environment
The nurse is caring for a client in the neurologic intensive care unit. The nurse is noting from the assessment findings that the client is lacking a connection because motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit? -Midbrain -Medulla oblongata -Pons -Subarachnoid space
Medulla oblongata
A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? -Cluster headaches can cause severe debilitating pain. -Migraines often coincide with menstrual cycle. -Tension headaches are easier to treat. -Headaches are the most common type of reported pain.
Migraines often coincide with menstrual cycle
The client is waiting in a triage area to learn the medical status of his family following a motor vehicle accident. The client is pacing, taking deep breaths, and wringing the hands. Considering the effects in the body systems, what effects does the nurse anticipate in the liver? -The liver will cease function and shunt blood to the heart and lungs. -The liver will convert glycogen to glucose for immediate use. -The liver will produce a toxic by product in relation to stress. -The liver will maintain a basal rate of functioning.
The liver will convert glycogen to glucose for immediate use.
The nurse is caring for a client in the emergency department with diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. For which action, made by the nurse aide, would the nurse provide further instruction? -The nurse aide used mild soapy water to clean the face. -The nurse aide moved the client's head to clean behind the ears. -The nurse aide cleaned the eye area from the inner to outer eye area. -The nurse aide cleaned the neck and upper chest area
The nurse aide moved the client's head to clean behind the ears
The nurse is working in an outpatient studies unit administering neurologic tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. The nurse is most correct to state which? -The paste is removed with acetone. -The paste is removed with a special soap. -The paste is removed with standard shampoo. -The paste is removed by flushing with warm water.
The paste is removed with standard shampoo.
Which of the following goals is the priority in the care planning of a client with cerebrovascular accident (CVA) who is being transferred to a rehabilitation unit? -To prevent contractures and joint deformities -To decrease risk for ineffective cerebral tissue perfusion -To develop appropriate coping mechanisms -To increase activity tolerance
To prevent contractures and joint deformities
The client with hemiplegia is at risk for impaired walking. Which nursing intervention would best assist this client in preventing complications associated with lower extremity impairment? -Occupational therapy daily -Use of walker for ambulation -Use of high-top tennis shoes throughout the day -Whirlpool tub baths and massage therapy
Use of high-top tennis shoes throughout the day
Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy? -Avoid stimuli that trigger pain. -Use ophthalmic lubricant and protect the eye. -Encourage semiannual dental exams. -Complete the course of antibiotics as prescribed.
Use ophthalmic lubricant and protect the eye.
When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data? -When, if any, was your last narcotic use? -Do you have any history of forgetfulness? -Have you been diagnosed with any mental health issues? -Have you experienced any unusual sensations?
When, if any, was your last narcotic use?
