Neuro

The spouse of a client with an intracranial hemorrhage asks the nurse, "Why aren't they administering an anticoagulant?" How should the nurse respond? 1."It is contraindicated because bleeding will increase." 2."If necessary it will be started to enhance circulation." 3."If necessary it will be stated to prevent pulmonary thrombosis." 4."It is inadvisable because it masks the effects of the hemorrhage."

1."It is contraindicated because bleeding will increase."

Which alternative therapy may be beneficial for the nurse to discuss with a client who has terminal bone cancer? 1.Biofeedback 2.Radiotherapy 3.Bariatric therapy 4.Radioactive implants

1.Biofeedback

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply. 1.Vomiting 2.Anorexia 3.Irritability 4.Hypotension 5.Decreased level of consciousness

1.Vomiting 2.Anorexia 3.Irritability 5.Decreased level of consciousness

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurological examination. What should the nurse document in the client's medical record? 1."Has intact plantar reflexes." 2."Exhibits a positive Babinski sign." 3."Demonstrates normal sensory function." 4."Able to perform active range of motion."

2."Exhibits a positive Babinski sign."

A client taking levodopa (L-dopa) is taught about the signs of levodopa toxicity. The nurse instructs the client to contact the primary health care provider if the client develops: 1.Nausea 2.Dizziness 3.Twitching 4.Constipation

3.Twitching

A client's tibia is fractured in a motor vehicle accident, and a cast is applied. The nurse should assess for which manifestation indicating damage to major blood vessels caused by the fractured tibia? 1.Increased blood pressure 2.Prolonged edema in the thigh 3.Increased skin temperature of the foot 4.Prolonged reperfusion of the toes after blanching

4.Prolonged reperfusion of the toes after blanching

After three months of rehabilitation after a craniotomy, a client continues to have motor speech difficulties. To promote the client's use of speech the nurse should: 1.Support the client's efforts to communicate 2.Correct verbal mistakes immediately 3.Use simple words with short sentences 4.Explain why the client is having difficulty speaking

1.Support the client's efforts to communicate

A client has a diagnosis of trigeminal neuralgia. When assessing the client's trigeminal nerve function, the nurse should evaluate: 1.Corneal sensation 2.Facial expressions 3.Ocular muscle movement 4.Shrugging of the shoulders

1.Corneal sensation

The nurse understands that the primary reason that clients are fitted soon after an amputation of a limb usually is related to: 1.Improving the client's physical abilities 2.Helping the client look "normal" again 3.Helping with the client's acceptance 4.Communicating to the client that health care team members are trying to help

1.Improving the client's physical abilities

The nurse considers that sensory restriction in a client who is blind can: 1.Increase the use of daydreaming and fantasy 2.Heighten the client's ability to make decisions 3.Decrease the client's restlessness and lethargy 4.Lead to the use of permanent neurotic behaviors

1.Increase the use of daydreaming and fantasy

A nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reports back pain and an inability to move the legs. Which action should the nurse take first? 1.Leave the individual lying on the back with instructions not to move, and leave to seek additional help. 2.Roll the individual onto the abdomen, place a pad under the head, and cover with any material available. 3.Gently raise the individual to a sitting position to determine whether the pain either diminishes or increases in intensity. 4.Gently lift the individual onto a flat piece of lumber and, using any available transportation, rush to the closest medical institution

1.Leave the individual lying on the back with instructions not to move, and leave to seek additional help.

The nurse teaches a client who developed degenerative joint disease of the vertebral column positioning techniques, including turning from back to side, keeping the spine straight. The nurse explains that the least effort will be exerted if the client crosses the arm over the chest and: 1.Uses the overbed table to pull the upper body up to assist with turning 2.Bends the top knee to the side to which the client is turning 3.Crosses the ankles while turning and keeps both legs straight 4.Flexes the bottom knee to the side the client wishes to turn

2.Bends the top knee to the side to which the client is turning

A client is taking phenytoin (Dilantin) to treat clonic-tonic seizures. The client's phenytoin level is 16 mg/L. Which action should the nurse take? 1.Hold the medication and notify the health care provider. 2.Administer the next dose of the medication as prescribed. 3.Hold the next dose and then resume administration as prescribed. 4.Call the health care provider to obtain a prescription with an increased dose

2.Administer the next dose of the medication as prescribed.

A client with rheumatoid arthritis asks the nurse why it is necessary to inject hydrocortisone into the knee joint. What reason should the nurse include in a response to this question? 1.Lubricate the joint 2.Reduce inflammation 3.Provide physiotherapy 4.Prevent ankylosis of the joint

2.Reduce inflammation

A client arrives at the nursing unit with neurological deficits after a motor vehicle accident. Using the Glasgow Coma Scale, the nurse assesses what client responses? (Select all that apply.) 1.Pupil response to light 2.Verbal response to speech 3.Eye opening in response to speech 4.Deep tendon reflexes in response to percussion 5.Motor activity in response to a verbal command

2.Verbal response to speech 3.Eye opening in response to speech 5.Motor activity in response to a verbal command

A client with a seizure disorder is receiving phenytoin (Dilantin) and phenobarbital (Barbital). What client statement indicates that the instructions regarding the medications are understood? 1."I will not have any seizures with these medications." 2."These medicines must be continued to prevent falls and injury." 3."Stopping the drugs can cause continuous seizures and I may die." 4."By my staying on the medicines I will prevent postseizure confusion."

3."Stopping the drugs can cause continuous seizures and I may die."

During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states that it is important to: 1.Plan activities for later in the day 2.Eat meals in a semi-recumbent position 3.Avoid people with respiratory infections 4.Take muscle relaxants when under stress

3.Avoid people with respiratory infections

A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse explains that the chief aim of treatment is to: 1.Rest the eye 2.Dilate the pupil 3.Control the intraocular pressure 4.Prevent secondary infections

3.Control the intraocular pressure

A nurse is caring for two clients. One has Parkinson disease and the other has myasthenia gravis. For what common complication associated with both disorders, should the nurse assess these clients? 1.Cogwheel gait 2.Impaired cognition 3.Difficulty swallowing 4.Non-intention tremors

3.Difficulty swallowing

A client who is to have a total hip arthroplasty with an uncemented prosthesis asks, "When will I be able to get up and walk?" On what information should the nurse base an answer? 1.Full weight-bearing is permitted after two weeks. 2.Partial weight-bearing begins the day after surgery. 3.Full weight-bearing may begin the day after surgery. 4.Partial weight-bearing progresses to full weight-bearing after two weeks

3.Full weight-bearing may begin the day after surgery.

A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate? 1.Behind the client 2.In front of the client 3.On the client's left side 4.On the client's right side

3.On the client's left side

A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having an untoward reaction to the contrast medium? 1.Pelvic warmth 2.Feeling flushed 3.Shortness of breath 4.Salty taste in the mouth

3.Shortness of breath

A client with cancer is scheduled for a bone scan to determine the presence of metastasis. The nurse evaluates that the teaching before the scheduled bone scan is effective when the client states: 1."X-rays will be taken to identify where I may have lost calcium from my bones." 2."Portions of my bone marrow will be removed and examined for cell composition." 3."A radioactive chemical will be injected into my vein that will destroy cancer cells present in my bones." 4."A substance of low radioactivity will be injected into my vein and my body inspected by an instrument to detect where it is deposited."

4."A substance of low radioactivity will be injected into my vein and my body inspected by an instrument to detect where it is deposited."

Which statement by a female client with a non-weight-bearing long leg cast indicates the need for the nurse to reinforce discharge teaching? 1."The cast can be wrapped in plastic when I take a shower." 2."I called my office to let them know I will be back at work next week." 3."The physical therapist is going to teach me how to walk with crutches." 4."I am going to give myself a pedicure with red nail polish when I get home."

4."I am going to give myself a pedicure with red nail polish when I get home."

A client falls from a two-story building and is taken to the hospital unconscious. Which finding identified during the initial nursing assessment should be of most concern? 1.Glasgow Coma Scale (GCS) score of 15 2.Depressed fontanel 3.Elevated temperature 4.Bleeding from the ears

4.Bleeding from the ears

When providing discharge teaching to a client who had a total hip replacement, the nurse should instruct the client to avoid: 1.Climbing stairs 2.Stretching exercises 3.Sitting in a low chair 4.Lying prone for more than 15 minutes

3.Sitting in a low chair

A client with a fractured head of the right femur and osteoporosis is placed in Buck's extension before surgical repair. What should the nurse do when caring for this client until surgery is performed? 1.Remove the weights from the traction every two hours to promote comfort. 2.Turn the client from side to side every two hours to prevent pressure on the coccyx. 3.Raise the knee gatch on the bed every two hours to limit the shearing force of traction. 4.Assess the circulation of the affected leg every two hours to ensure adequate tissue perfusion

4.Assess the circulation of the affected leg every two hours to ensure adequate tissue perfusion

A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. The nurse instructs them to: 1.Speak louder than usual during visits while looking directly at the client 2.Tell the client to use the correct words when speaking 3.Give positive reinforcement for correct communication 4.Encourage the client to speak while being patient with each attempt

4.Encourage the client to speak while being patient with each attempt

When assisting a client who had a total hip replacement onto the bedpan on the first postoperative day, the nurse should instruct the client to: 1.Turn toward the operative side 2.Flex both knees while slowly lifting the pelvis 3.Extend both legs and pull on the trapeze to lift the pelvis 4.Flex the unaffected knee and pull on the trapeze to raise the pelvis

4.Flex the unaffected knee and pull on the trapeze to raise the pelvis

A client who has intermittently been having painful, swollen knee and wrist joints during the past three months is diagnosed with rheumatoid arthritis. What type of diet should the nurse expect the health care provider to prescribe? 1.Salt-free, low-fiber diet 2.High-calorie, low-cholesterol diet 3.High protein diet with minimal calcium 4.Regular diet with vitamins and minerals

4.Regular diet with vitamins and minerals