Neuro

A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" What is the nurse's best response? "Tell me about your fears regarding pain." "Analgesics will be prescribed to control the pain." "Pain is not a characteristic symptom of this condition." "Let's make a list of the things you need to ask your primary healthcare provider."

"Pain is not a characteristic symptom of this condition" The response "Pain is not a characteristic symptom of this condition" is a truthful answer that provides hope for the client. The response "Tell me about your fears regarding pain" avoids the client's question and can increase anxiety. Analgesics commonly are not prescribed unless pain results from some other condition. The response "Let's make a list of the things you need to ask your primary healthcare provider" avoids the client's question; the nurse should respond directly.

Immediately after cataract surgery a client reports feeling nauseated. What should the nurse do? -Provide some dry crackers to eat -Administer the prescribed antiemetic -Explain that this is expected after surgery -Encourage deep breathing until the nausea subsides

An antiemetic will prevent vomiting; and vomiting increases intraocular pressure and should be avoided. Aggressive intervention is required rather than dry crackers. Explaining that this is expected after surgery is incorrect. Deep breathing will not minimize nausea; aggressive intervention is required to prevent vomiting.

Battle sign

Battle sign represents ecchymosis around the mastoid process from head trauma that has caused a temporal bone fracture. The sign can suggest a posterior fossa basilar skull fracture that might not show on an x-ray until two to three days after the injury. To prevent further tearing of the meninges, the client is told not to blow the nose, cough vigorously, or strain.

The nurse is reviewing the cerebrospinal fluid (CSF) laboratory findings of four neurologically compromised clients. Which client does the nurse suspect to have had a previous meningeal hemorrhage?

Brown CSF The brown color of the CSF indicates the client has had a meningeal hemorrhage. A yellow color of the CSF is due to the hemolysis of the red blood cells (RBC) that leads to increased production of bilirubin. An unclear or hazy appearance of the CSF indicates an elevated white blood cell count. A pink-red to orange color indicates the presence of RBCs.

A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client? Maintain balance to improve stability Relieve pressure on weight-bearing joints Prevent further injury to weakened muscles Aid in controlling involuntary muscle movements

Correct1: Maintain balance to improve stability Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability. Hemiparesis affects muscle strength on one side of the body; the joints are not directly affected. Activity should strengthen, not injure, weakened muscles. The use of a cane will not prevent involuntary movements if they are present.

The nurse is conducting a neurologic assessment on a client brought to the emergency room after a motor vehicle accident. While assessing the client's response to pain, the client pulls his arms upward and inward. The nurse recognizes that this response represents an injury to what part of the brain? Frontal lobe Midbrain Pons Brainstem

Decorticate posturing is a sign of significant deterioration in a client's neurologic status and is manifested by rigid flexing of elbows and wrists. This can represent an injury to the midbrain. Damage to the frontal lobe would affect motor function, problem solving, spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior. The pons (which is part of the brainstem) and brainstem help control breathing and heart rate, vision, hearing, sweating, blood pressure, digestion, alertness, sleep, and sense of balance. Damage to this area would manifest itself as abnormal responses in the above listed areas.

Which clinical indicators does the nurse expect to identify when assessing a client with tic douloureux? Select all that apply. Multiple petechiae Excruciating facial pain Twitching of the mouth Unilateral muscle weakness

Fine-motor tremors of the eyelid Tic douloureux, also referred to as trigeminal neuralgia is an inflammation of the fifth cranial (trigeminal) nerve that innervates the midline of the face and head, which includes the mouth. Petechiae are minute subcutaneous hemorrhages; they are not present in this disorder. Pain, not weakness, occurs in this disease. Impairment of facial muscles occurs with Bell palsy. The third (oculomotor), not fifth, cranial nerve innervates the eyelid.

Inappropriate secretion of antidiuretic hormone (ADH).

Increased weight Decreased serum sodium Decreased level of consciousness As fluid is retained, the body weight will increase. One liter of fluid weighs 2.2 pounds (1 kilogram). Excess ADH causes water retention, which leads to dilutional hyponatremia. Dilution of blood and hyponatremia cause a decreased level of consciousness. Water retention and decreased urinary output occur because of ADH excess. Urine output decreases to less than 20 mL/hour. This client will be lethargic, confused, or comatose, depending on the degree of hyponatremia. Tachycardia occurs in response to fluid volume excess associated with increased ADH.

The caretaker of a client who sustained a head injury reports to the nurse that the client always says that food tastes unappealingly bland even though the food is good. Which area of the brain may the nurse suspect to be affected in the client? Frontal lobe Parietal lobe Occipital lobe Temporal lobe

Parietal lobe Functions of the parietal lobe of brain include interpretation of taste impulses and spatial perception and understanding of sensory inputs. Any injury to the parietal lobe causes absence of taste perception. Functions of the frontal lobe are voluntary eye movement, access to current sensory data, affective response to a situation, ability to develop long term goals, and ability to reason and concentrate. Any injury to the frontal lobe may cause an inability to perform these tasks. Injury to the occipital lobe may be associated with compromised vision. Injury to the temporal lobe may be associated with hearing impairments.

A client reports severe right-sided headache with runny nose, droopy eyelids, and tearing of the eye on the right side. Which drugs are specific to treat this headache? Select all that apply. Lithium Acetaminophen Naproxen Ibuprofen Oral glucosamine

Severe unilateral headache with runny nose, drooping eyelids, ipsilateral tearing of the eye, and facial sweating are indicative of cluster headache. Oral glucosamine and lithium are specifically prescribed to treat cluster headache. Naproxen, ibuprofen, and acetaminophen are indicated for relieving mild migraines.

Guillain-Barré syndrome

The classic feature of Guillain-Barré syndrome is ascending weakness, beginning in the lower extremities and progressing to the trunk, upper extremities, and face; more frequent assessment, especially of respiratory status, is needed. Deep tendon reflexes are absent with Guillain-Barré syndrome. "Raise the barre".