neuro

A 21 year old female client takes clonazepam (Klonopin). What should the nurse ask this client about ?

1. Seizure activity 2. Pregnancy status 3. Alcohol use

A client with MS lives with her daughter and 3 year old granddaughter. The daughter asks the nurse what she can do at home to help her mother.

Regular exercise

A client is receiving vent-assisted mode ventilation begins to experience cluster breathing after recent Intracranial Occipital bleeding. which action would be most appropriate?

Notify the physician

Which of the following should the nurse include in the teaching plan for a client with seizure who is going home with gabapentin ?

Notify the physician If vision changes occur

Which statement by the client with a seizure disorder taking topiramate (Topamax) indicates that the client understood the nurse's instruction ?

"I will drink 6-8 glasses of water per day" **toxic effect includes nephrolithiasis

the nurse is monitoring a client with ICP. what indicators are the most critical for the nurse to monitor ?

1. Sytolic blood pressure 2.Cerebral perfusion pressure

The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin) Which statement indicates that the client understands how to take the drug?

1.Maximum dosage is not achieved until 3-4 days after starting the medication 2. Effects of the drugs continue 4-5 days after discontinuing the medication 3. I should have my blood levels tested periodically **peak action of 9hours **Vitamin K is the antedote

Which food-related behaviors are expected in a client who has had a stroke that has left him with homonymous hemianopia? 1. Increased preference for foods high in salt. 2. Eating food on only half of the plate. 3. Forgetting the names of foods. 4. Inability to swallow liquids.

2. Eating food on only half of the plate **homonymous hemianopia

For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following should the nurse do?

2. Remove the coffee *caffeine is avoided due to brain stimulation

A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? 1. The client exhibits intolerance to many drugs. 2. The client experiences spontaneous remissions from time to time. 3. The client requires multiple drugs simultaneously. 4. The client endures long periods of exacerbation before the illness responds to a particular drug.

2. The client experiences spontaneous remissions from time to time.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1. Speaking loudly. 2. Using a picture board. 3. Writing directions so client can read them. 4. Speaking in short sentences.

2. Using a picture board.

which of the following is NOT a typical clinical manifestation of multiple sclerosis? 1. Double vision 2.Sudden burst of energy 3.Weaness is the extremities 4.Muscle tremors

2.Sudden burst of energy

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Temperature.

3. Blood pressure

A client states that she is afraid she will not be able to drive again because of her seizures. which response by the nurse would be best?

A person with evidenced that the seizure are under medical control can drive

A client who had serious head injury with ICP is to be discharged to a rehabilitation facility. Which of the following outcomes would be appropriate?

Actively participate in the rehab process as appropriate

which intervention is the most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures?

Administer carbamazepine (tegetrol)

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a.dysphasia. b.confusion. c.visual deficits. d.poor judgment.

c.visual deficits.

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order for collaborative intervention should the nurse implement first? a.Administer ceftizoxime (Cefizox) 1 g IV. b.Give acetaminophen (Tylenol) 650 mg PO. c.Use a cooling blanket to lower temperature. d.Swab the nasopharyngeal mucosa for cultures.

d.Swab the nasopharyngeal mucosa for cultures. Rationale: Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider? a.Complaint of severe headache b.Large contusion behind left ear c.Bilateral periorbital ecchymosis d.Temperature of 101.4° F (38.6° C)

d.Temperature of 101.4° F (38.6° C) RATIONALE: Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture

which clinical manifestation does the nurse assess as a typical reaction to long term dilantin therapy?

excessive growth of the gums **provide good oral hygiene

Which os the following is an initial sign of Parkinson's disease?

first -Tremors **second-rigidity **third- bradykinesia

which activity should the nurse encourage the client to avoid when there is risk for increased ICP?

Coughing

The nurse is preparing a client with multiple sclerosis for discharge from the hospital to home. which of the following instruction is appropriate ?

"Keep active, use stress reduction strategies, and avoid fatigue"

A male client with a head injury regains consciousness after several days, which of the following nursing statements is the most appropriate as the clients awaken?

"You are in the hospital. You were in an accident and unconscious"

It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client?

"You will need to hold your head very still during the examination."

A healthcare provider has ordered sine met four times per day for a client with Parkinson's disease. The client states that he wants "to end it all now that the Parkinson's disease has progressed" What should the nurse do ?

1. Contact the HCP before administering Sinemet 2.Determine is the client is on antidepressants or monoamine oxidase (MOA) inhibitors 3. Determine if the client is at risk for suicide

A client who is unconscious from on overdose of an unknown drug is having generalized tonic clonic seizures. Which of the following should the nurse expect to administer ?

1. Dextrose 50% IV bolus 2.Thiamine 100mg IV 3.Nalaxone 0.45mg IV

The nurse is teaching a client with bladder dysfunction from multiple sclerosis about bladder training at home. which instructions should the nurse include in the teaching plan?

1. Drink 400-500ml with each meal 2.Drink fluids midmorning, midafternoon, and late afternoon 3. Attempt to void at least every 2 hours 4. Use intermittent catheterization as needed

following a craniotomy, a client has been admitted to the neurological ICU. The nurse has established a goal to maintain intracranial pressure within the normal range. what should the nurse do?

1. Elevate the head of bed 15 to 30 degrees 2. Contact the HCP if ICP is greater than 20 mm Hg 3.monitor numerological status using the Glasgow coma scale **coughing and ROM exercise increases ICP and should be AVOIDED

Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.

1. Placing the client on the back with a small pillow under the head. **A helpless client should be position on the side

The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which of the following topics that the nurse plans to discuss is the most important? 1. Maintaining a balanced nutritional diet. 2. Enhancing the immune system. 3. Maintaining a safe environment. 4. Engaging in diversional activity.

3. Maintaining a safe environment

Which information about a 72-year-old patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? a.Patient has generalized tonic-clonic seizures. b.Patient experiences an aura before seizures. c.Patient's most recent blood pressure is 156/92 mm Hg. d.Patient has minor elevations in the liver function tests

d.Patient has minor elevations in the liver function tests

The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses' notes of the chart for this client assessment? 1. "Has an intention tremor of the right hand." 2. "Right-hand tremor worsens with purposeful acts." 3. "Needs assistance with dressing and eating due to severe trembling and clumsiness." 4. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."

4. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."

Which of the following is contraindicated for a client with seizure precaution ?

Assessing oral temperature with a glass thermometer

Which of the following is an inappropriate outcome to establish with a client who has multiple sclerosis? The client will:

Develop cognition

which clinical manifestation does the nurse expect in the client in the postictal phase of generalized Tonic clonic seizure?

Drowsiness

In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when position the client?

Elevating the head of bed 30 degrees

which of the following nursing intervention is appropriate for a client with ICP of 20mm Hg?

Encourage the client to hyperventilate *normal ICP is less than 15 mm Hg

The client who has had a stroke with residual physical handicaps becomes discouraged by his physical appearance. What attitude is best for the nurse to display to help the client overcome his negative self-concept ?

Encouragement and Patience

A client with Parkinson disease asks the nurse to explain to his nephew "what the doctor said that the pallidotomy would do." The nurse best response includes stating that the main goal for the client after pallidotomy is improved :

Functional ability

Which nursing intervention has been found to be most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis ?

Have the client wear ankle-high tennis shoes at intervals throughout the day

What is priority nursing intervention when suctioning an unconscious client to maintain cerebral perfusion ?

Hyper-oxygenate before and after suctioning

The nurse administers mannitol to the client with ICP. which parameters requires close monitoring?

Intake and output *mannitol can cause hypokalemia

A client asks the nurse how phenytoin sodium (Dilantin) will help. Based on knowledge of the drugs action, What is the nurse's best response ?

It reduces the responsiveness of neurons in the brain to abnormal impulses

Which of the following will the nurse observe in the client I the ictal phase of general tonic-clonic seizure?

Loss of consciousness, body stiffening, and violet muscle contractions

Which of the following is most effective in assessing the client suspected of developing Diabetes Insipidus ?

Measuring urine output hourly

What nursing assessments should be documented at the beginning of the ictal phase of a seizure?

Movement of the head and eyes and muscle rigidity.

A client with Parkinson's disease is prescribed levodopa therapy. Improvement in which of the following indicates effective therapy ?

Muscle rigidity

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm. What position would be INAPPROPRIATE ?

Positioning the hands in a slightly pronated position

After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first? a.Patient who has not had a bowel movement for 5 days b.patient who has a stage II pressure ulcer on the coccyx c.Patient who is refusing to take the prescribed medications d.Patient who developed a new cough after eating breakfast

d.Patient who developed a new cough after eating breakfast

. A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? a.The patient has a chronic dry cough. b.The patient has four loose stools in a day. c.The patient develops a deep vein thrombosis. d.The patient's blood pressure is 92/52 mm Hg.

d.The patient's blood pressure is 92/52 mm Hg.

the client has a sustained ICP of 20mm Hg. which position would be most appropriate ?

The head of bed elevated 30-45 degrees

A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? a.Side-rail pads b.Tongue blade c.Oxygen mask d.Suction tubing e.Urinary catheter f.Nasogastric tube

a.Side-rail pads c.Oxygen mask d.Suction tubing

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a.Use an elevated toilet seat. b.Cut patient's food into small pieces. c.Provide high-protein foods at each meal. d.Place an armchair at the patient's bedside. e.Observe for sudden exacerbation of symptoms

a.Use an elevated toilet seat b.Cut patient's food into small pieces d.Place an armchair at the patient's bedside Rationale:Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.

The nurse advises a patient with myasthenia gravis (MG) to a.perform physically demanding activities early in the day. b.anticipate the need for weekly plasmapheresis treatments. c.do frequent weight-bearing exercise to prevent muscle atrophy. d.protect the extremities from injury due to poor sensory perception.

a.perform physically demanding activities early in the day.

Which nursing actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) who is part of the team caring for a patient with Alzheimer's disease (select all that apply)? a.Develop a plan to minimize difficult behavior. b.Administer the prescribed memantine (Namenda). c.Remove potential safety hazards from the patient's environment. d.Refer the patient and caregivers to appropriate community resources. e.Help the patient and caregivers choose memory enhancement methods. f.Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.

b.Administer the prescribed memantine (Namenda). c.Remove potential safety hazards from the patient's environment.

Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a.Auscultate the patient's bowel sounds. b.Notify the patient's health care provider. c.Administer the prescribed PRN antiemetic drug. d.Give the scheduled dose of prednisone (Deltasone).

b.Notify the patient's health care provider Rationale: The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

The spouse of a 67-year-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take next (select all that apply)? a.Suggest that a long-term care facility be considered. b.Offer ideas for ways to distract or redirect the patient. c.Teach the spouse about adult day care as a possible respite. d.Suggest that the spouse consult with the physician for antianxiety drugs. e.Ask the spouse what she knows and has considered about dementia care options.

b.Offer ideas for ways to distract or redirect the patient. c.Teach the spouse about adult day care as a possible respite e.Ask the spouse what she knows and has considered about dementia care options.

When administering the Mini-Cog exam to a patient with possible Alzheimer's disease, which action will the nurse take? a.Check the patient's orientation to time and date. b.Obtain a list of the patient's prescribed medications. c.Ask the person to use a clock drawing to indicate a specific time. d.Determine the patient's ability to recognize a common object such as a pen.

c.Ask the person to use a clock drawing to indicate a specific time.

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? a.Give phenytoin (Dilantin) 100 mg IV. b.Monitor level of consciousness (LOC). c.Obtain computed tomography (CT) scan. d.Administer lorazepam (Ativan) 4 mg IV.

d.Administer lorazepam (Ativan) 4 mg IV.

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a.Shuffling gait b.Tremor at rest c.Cogwheel rigidity of limbs d.Uncontrolled head movement

d.Uncontrolled head movement Rationale: Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a.The bedrails at the head and foot of the bed are both elevated. b.The patient receives a regular diet from the dietary department. c.The lights in the patient's room are turned off and the blinds are shut. d.Unlicensed assistive personnel enter the patient's room without a mask

d.Unlicensed assistive personnel enter the patient's room without a mask RATIONALE:Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

Aura

symptoms that occur just before the seizure

which of the following respiratory pattern indicates increasing ICP in the brain stem ?

1. slow, irregular respiration

Four days after surgery for internal fixation of C3 to C4 fracture, nurse is moving the client from the bed to the wheelchair. The nurse is checking for the correct features for this client. Which of the following is the correct features?

1.Back and head that are high 2.Seat that is lower than normal

When preparing to teach a client about dilantin therapy, the nurse should urge the client not to stop the drug suddenly because:

Status epileptics may develop

The nurse will assess a 67-year-old patient who is experiencing a cluster headache for a.nuchal rigidity. b.unilateral ptosis. c.projectile vomiting. d.throbbing, bilateral facial pain.

b.unilateral ptosis.

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a.The staff nurse assesses neurologic status every hour. b.The staff nurse elevates the head of the bed to 30 degrees. c.The staff nurse suctions the patient routinely every 2 hours. d.The staff nurse administers an analgesic before turning the patient.

c.The staff nurse suctions the patient routinely every 2 hours. Rationale: Suctioning increases intracranial pressure, and should only be done when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a.flexion withdrawal. b.localization of pain. c.decorticate posturing. d.decerebrate posturing.

c.decorticate posturing.

Which information about a 60-year-old patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a.The patient has relapsing-remitting MS. b.The patient walks a mile a day for exercise. c.The patient complains of pain with neck flexion. d.The patient has an increased serum creatinine level.

d.The patient has an increased serum creatinine level. Rationale:Dalfampridine should not be given to patients with impaired renal function

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a.The patient exhibits nuchal rigidity. b.The patient has a positive Kernig's sign. c.The patient's temperature is 101° F (38.3° C). d.The patient's blood pressure is 88/42 mm Hg

d.The patient's blood pressure is 88/42 mm Hg RATIONALE: Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

. After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a.cluster nursing activities to allow longer rest periods. b.turn and reposition the patient side to side every 2 hours. c.position the bed flat and log roll to reposition the patient. d.perform range-of-motion (ROM) exercises every 4 hours.

d.perform range-of-motion (ROM) exercises every 4 hours.

A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his wife to the hospital to deliver their child. The next morning, instead of asking about his wife and baby, he asked to see the football game on television thats he thinks is starting in 5 minutes. He is agitated that the nurse will not turn on the tv. What should the nurse do next ?

1. determine if the client's pupil are equal and react to light 2. Ask the client if he has a headache **confusion, agitation, and restlessness are subtle clinical manifestations of ICP

A client is being admitted with a spinal cord transection at C7. Which of the following assessment takes priority upon he clients arrival ?

1.Blood pressure 2.Temperature 3.Respiration **assess for spinal shock

When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? 1. Encouraging the client to speak slowly. 2. Encouraging the client to speak distinctly. 3. Asking the client to repeat indistinguishable words. 4. Asking the client to speak louder when tired.

4. Asking the client to speak louder when tired.

A new medication is ordered for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken?

At the time scheduled

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct the family members to try when the client experiences a crying episode ?

Attempt to divert the client's attention

which of the following is inappropriate for the nurse to include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation ?

Avoid kitchen activities because of the risk of injury

which of the following describes decerebrate posturing?

Back arched, rigid extension of all four extremities

A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? A) Stay out of direct sunlight. B) Restrict intake of high protein foods. C) Schedule extra rest periods. D) Go to the emergency room immediately.

C) Schedule extra rest periods.

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a.Document the increase in intracranial pressure. b.Ensure that the patient's neck is in neutral position. c.Notify the health care provider about the change in pressure. d.Increase the rate of the prescribed propofol (Diprivan) infusion.

b.Ensure that the patient's neck is in neutral position.

The nurse is assessing a client for movement after halo traction placement for C8 fracture. The nurse should document which of the following ?

C8- The clients hand grasp strength is equal *C4, C5- the client's shoulder shrug against downward pressure *C5, C6- The clients and pulls up from a resting position *C7- the clients arm straighten out from a flexed position against resistance

What is the priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

Pupil size and pupillary response **indicates cranial nerve changes

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is inappropriate ?

Restricting the diet to liquids until swallowing improves **Liquids should be thickened

Which of the following techniques does the nurse avoid when changing a client's position If the client has hemiparalysis ?

Sliding the client when moving the client up in bed **Sliding causes friction

The nursing assessment of a client's functional status before and after a stroke is essential, Why is it so important?

The rehabilitation plan will be guided by it

The nurse observes that a client's upper arm tremors disappear as he unbuttons his shirt. Which statement best guides the nurses analysis of this observation about the clients tremors?

The tremors sometimes disappear with purposeful and voluntary movements

At what time should the nurse encourage a client with Parkinsons disease to schedule the most demanding physical activities to minimize the effect of hypokinesia ?

To coincide with the peak action of drug therapy

What is the primary goal collaboratively established by the client with Parkinson disease, nurse and physical therapist?

To maintain joint flexibility

Which goal is the most realistic and appropriate for a client with Parkinson's disease?

To maintain optimal body function

A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. which does the nurse identify as the primary safety precaution to use?

Turn the head side to side when walking

A client is being switched from levodopa to carbidopa-levodopa (sinemet). The nurse should monitor for which of the following possible complication during medication changes and dosage adjustment?

Vital sign fluctuation

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her I.V. lines. which nursing intervention protects the client without increasing her ICP?

Wrap her hands in soft "mitten" restraints

A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a."MS symptoms may be worse after the pregnancy." b."Women with MS frequently have premature labor." c."MS is associated with an increased risk for congenital defects." d."Symptoms of MS are likely to become worse during pregnancy."

a."MS symptoms may be worse after the pregnancy."

A 68-year-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a.Check oxygen saturation. b.Assess pupil reaction to light. c.Verify Glasgow Coma Scale (GCS) score. d.Palpate the head for hematoma or bony irregularities.

a.Check oxygen saturation.

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a.Encourage family members to remain at the bedside. b.Apply soft restraints to protect the patient from injury. c.Keep the room well-lighted to improve patient orientation. d.Minimize contact with the patient to decrease sensory input.

a.Encourage family members to remain at the bedside.

A patient reports feeling numbness and tingling of the left arm before experiencing a tonic-clonic seizure. The nurse determines that this history is consistent with what type of seizure? a.Focal b.Atonic c.Absence d.Myoclonic

a.Focal

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a.Short-term memory b.Muscle coordination c.Glasgow Coma Scale d.Pupil reaction to light

a.Short-term memory

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a.risk for injury related to denial of deficits and impulsiveness. b.impaired physical mobility related to right-sided hemiplegia. c.impaired verbal communication related to speech-language deficits. d.ineffective coping related to depression and distress about disability

a.risk for injury related to denial of deficits and impulsiveness

Which statement by a 40-year-old patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a."I will return if I feel dizzy or nauseated." b."I am going to drive home and go to bed." c."I do not even remember being in an accident." d."I can take acetaminophen (Tylenol) for my headache."

b."I am going to drive home and go to bed."

Which finding for a patient who has a head injury should the nurse report immediately to the health care provider? a.Intracranial pressure is 16 mm Hg when patient is turned. b.Pale yellow urine output is 1200 mL over the last 2 hours. c.LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg. d.Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours.

b.Pale yellow urine output is 1200 mL over the last 2 hours. Rationale: The high urine output indicates that diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a.Administer IV furosemide (Lasix). b.Prepare the patient for craniotomy. c.Initiate high-dose barbiturate therapy. d.Type and crossmatch for blood transfusion.

b.Prepare the patient for craniotomy.

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a.Coordinate the transfer of the patient to the operating room. b.Provide discharge instructions about monitoring neurologic status. c.Transport the patient to radiology for magnetic resonance imaging (MRI). d.Arrange to admit the patient to the neurologic unit for 24 hours of observation.

b.Provide discharge instructions about monitoring neurologic status.

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a.Document the BP and ICP in the patient's record. b.Report the BP and ICP to the health care provider. c.Elevate the head of the patient's bed to 60 degrees. d.Continue to monitor the patient's vital signs and ICP.

b.Report the BP and ICP to the health care provider.

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a.Elevate the head of the bed 20 degrees. b.Restrict oral fluids to 1000 mL daily. c.Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d.Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

b.Restrict oral fluids to 1000 mL daily. Rationale: The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis.

Which action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder? a.Decrease the patient's evening fluid intake. b.Teach the patient how to use the Credé method. c.Suggest the use of adult incontinence briefs for nighttime only. d.Assist the patient to the commode every 2 hours during the day

b.Teach the patient how to use the Credé method

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? a.Pulse 102 beats/min b.Temperature 101.6° F c.Intracranial pressure 15 mm Hg d.Mean arterial pressure 90 mm Hg

b.Temperature 101.6° F RATIONALE:Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.

When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should a.assess for the presence of chest pain. b.inquire about urinary tract problems. c.inspect the skin for rashes or discoloration. d.ask the patient about any increase in libido.

b.inquire about urinary tract problems.

A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? a.Document intracranial pressure every hour. b.Turn and reposition the patient every 2 hours. c.Check capillary blood glucose level every 6 hours. d.Monitor cerebrospinal fluid color and volume hourly.

c.Check capillary blood glucose level every 6 hours.

A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a.Recommendation to drink at least 4 L of fluid daily b.Need to avoid driving or operating heavy machinery c.How to draw up and administer injections of the medication d.Use of contraceptive methods other than oral contraceptives

c.How to draw up and administer injections of the medication

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? a.Encourage adolescents and young adults to avoid crowds in the winter. b.Vaccinate 11- and 12-year-old children against Haemophilus influenzae. c.Immunize adolescents and college freshman against Neisseria meningitides. d.Emphasize the importance of hand washing to prevent the spread of infection

c.Immunize adolescents and college freshman against Neisseria meningitides.

Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a.Intracranial pressure of 15 mm Hg b.Cerebrospinal fluid (CSF) drainage of 25 mL/hour c.Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d.Cardiac monitor shows sinus tachycardia at 128 beats/minute

c.Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg Rationale: The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2