neuro class q's

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first? 1.Evaluate the client's neurological status. 2.Perform a complete blood count. 3.Check the client's temperature. 4.Administer an oral analgesic.

1. Evaluate the client's neurological status. Manifestations of a headache and stiff neck (nuchal rigidity) are indications that the client might have meningitis. The greatest risk to the client is injury from increased intracranial pressure, which can lead to brain herniation and death. Therefore, the nurse should complete a neurological assessment as a baseline. If the client does have meningitis, neurological checks should be completed every 2 to 4 hr.

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.) 1.Hypotension 2.Polyuria 3.Hypoglycemia 4.Absence of bowel sounds 5. Weakened gag reflex

1. Hypotension 4. Absence of bowel sounds 5. Weakened gag reflex Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal cord. Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client to develop a paralytic ileus. Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? 1.A change in the Glasgow Coma Scale score from 13 to 11 2.Diplopia 3.A drop in heart rate from 76 to 70/min 4.Ataxia

1.A change in the Glasgow Coma Scale score from 13 to 11 In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider.

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? (Select all that apply.) 1.Assess legs for redness. 2.Apply elastic compression stockings. 3.Perform passive range of motion exercises. 4.Place pillows under the client's knees when in bed. Massage the calves every shift.

1.Assess legs for redness. 2.Apply elastic compression stockings. 3.Perform passive range of motion exercises. Assess legs for redness is correct. The nurse should assess the client's legs for redness, which would be an indication of thrombophlebitis formation, which can lead to a PE without appropriate treatment. Apply elastic compression stockings is correct. The nurse should apply elastic compression stockings to prevent thrombophlebitis formation and possible PE and improve blood return to the heart. Perform passive range of motion exercises is correct. The nurse should perform passive range of motion exercises to improve blood return to the heart and prevent thrombophlebitis formation and possible PE.

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care? 1.Obtain IV access. 2.Keep the lights on when the client is sleeping. 3.Place the client's bed in the high position. 4.Keep a padded tongue blade available at the client's bedside.

1.Obtain IV access. The nurse should obtain IV access as a precaution so the client can receive IV medications in the event of a seizure.

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? 1.Reduce edema of the brain. 2.Provide fluid hydration. 3.Lower blood pressure. 4.Expand extracellular fluid volume.

1.Reduce edema of the brain. An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream.

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? 1.Severe headache 2.Bradycardia 3.Blurred vision 4.Oriented to person, place, and year

1.Severe headache The nurse should expect a client who has meningitis to manifest a severe headache due to meningeal inflammation.

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? 1.Administer a nitrate antihypertensive. 2.Assess the client for bladder distention. 3.Place the client in a high-Fowler's position. 4.Obtain the client's heart rate.

3.Place the client in a high-Fowler's position. The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse's initial action should be to place the client in a high-Fowler's position to assist in providing immediate reduction in blood pressure and intracranial pressure.

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? 1.Perform passive range of motion on each extremity. 2.Monitor the client's electrolyte levels. 3.Suction saliva from the client's mouth. 4.Record the client's intake and output.

3.Suction saliva from the client's mouth. The unconscious client is unable to independently maintain a clear airway and is at risk for ineffective airway clearance. According to the safety and risk reduction priority setting framework, maintaining the client's airway, breathing, and circulation is the highest priority.

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan? 1.Apply restraints. 2.Administer opioids. 3. Darken the room. 4. Reduce stimuli.

4. Reduce stimuli. The nurse should reduce stimuli by decreasing the number of visitors, speaking calmly, and creating a quiet environment.

A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority? 1.Intracranial pressure 2. Serum electrolytes 3.Temperature 4.Respiratory status

4.Respiratory status When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respirations, noting the rate and pattern, and evaluating arterial blood gases. Following intracranial surgery, even slight hypoxia can worsen cerebral ischemia.

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? 1.Tachycardia 2.Amnesia 3.Hypotension 4.Restlessness

4.Restlessness Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern (early indicator)

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache? 1. Administer pain medication. 2.Darken the client's room and close the door. 3.Increase fluid intake. 4.Elevate the head of the bed to 30º.

Increase fluid intake The client who has had a lumbar puncture is at risk for continued leaking of CSF from the puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is helpful in quickly replacing the cerebrospinal fluid that was removed during the procedure and increasing fluids will facilitate resolution of the headache. The client should also be instructed to remain in a prone position for 6 hours to prevent leaking of CSF fluid.

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? 1. Test the drainage for glucose. 2.Suction the nostril. 3.Notify the physician. 4.Ask the client to blow his nose.

Test the drainage for glucose This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF, which will test positive for glucose.

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? 1.The client states having a severe headache. 2.The client's bladder becomes distended. 3.The client's blood pressure becomes elevated. 4.The client states having nasal congestion.

The client's bladder becomes distended. Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face. The other choices are manifestations of autonomic dysreflexia

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? 1.Turn the client's head to the side. 2.Check the client's motor strength. 3.Loosen the clothing around the client's waist. 4.Document the time the seizure began.

Turn the client's head to the side. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration.

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? 1.The client can follow simple motor commands. 2.The client is unable to make vocal sound. 3.The client is unconscious. 4.The client opens his eyes when spoken to.

4.The client opens his eyes when spoken to. A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? 1."Turn the screws on the device once each day." 2."The purpose of this device is to immobilize the cervical spine." 3. "Apply talcum powder under the vest to limit friction." 4."The purpose of this device is to allow for neck movement during the healing process."

2."The purpose of this device is to immobilize the cervical spine." A client who has an injury to the cervical spine can have a halo fixation device to provide immobilization of the head and neck for a period of 8 to 12 weeks.

A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take? 1.Obtain a culture of the specimen using sterile swabs. 2.Allow the drainage to drip onto a sterile gauze pad. 3.Suction the nose gently with a bulb syringe. 4.Suction the nose gently with a bulb syringe.

2.Allow the drainage to drip onto a sterile gauze pad. The nurse should allow the drainage to drip onto a sterile gauze pad in order to assess for the presence of cerebrospinal fluid. This intervention allows for the collection of data without increasing the risk for further injury.

A nurse is caring for an unconscious client who has a loss of the corneal reflex. Which of the following actions should the nurse take? 1.Keep the room darkened. 2.Apply lubricating eye drops. 3.Alternate warm saline compresses to the eyes. 4.Clean the eyes with a mild soap.

2.Apply lubricating eye drops. The nurse should apply lubricating drops to the eyes of a client who has a loss of corneal reflexes to prevent a corneal abrasion, due to the client's inability to blink.