Neuro notes
A nurse is reinforcing teaching with a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual course of MS. Which of the following responses should the nurse provide?
"Acute episodes are usually followed by remissions, which can last varying lengths of time."
A nurse is assisting with preparing a client for an electroencephalogram (EEG). When the client asks the nurse what this test does, which of the following responses should the nurse make?
"An EEG records the electrical activity of your brain cells."
A nurse is reinforcing teaching about auras with a client who has a new diagnosis of simple partial seizures. Which of the following statements by the client indicates an understanding of the teaching?
"An aura is a sensory warning that a seizure is imminent."
A nurse is collecting data from a client who has cataracts. Which of the following findings should the nurse expect?
B. Opacity visible behind the pupil
A nurse is collecting data from a client who has encephalitis due to West Nile virus. Which of the following findings should the nurse expect? (Select all that apply.) A. Unilateral weakness B. Stiff neck C. Photophobia D. Epigastric pain E. Lethargy
B. Stiff neck C. Photophobia E. Lethargy
A nurse is assisting with triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils?
Black tag
A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a positive Romberg test, indicating which of the following alterations?
Cerebellar dysfunction
A nurse is caring for a client who has Ménière's disease. The nurse should identify that Ménière's disease affects which structure of the ear?
Cochlea
A nurse in a rehabilitation center is collecting data from a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect?
Difficulty with speech
a poor prognostic sign and an indication of severely increased intracranial pressure.
Dilated pupils that are fixed or nonreactive to light
A nurse is caring for a client who had a cerebrovascular accident (CVA). The client appears alert and engaged during the visit but does not respond verbally to questions. The nurse should document this finding as which of the following alterations?
Expressive aphasia
A nurse is caring for a client who has a hearing impairment. Which of the following actions should the nurse take when communicating with the client?
Face the client when speaking
A nurse is collecting data from a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment?
Inability to locate eyeglasses
A nurse is reinforcing teaching with a client who is preoperative for cataract surgery. The nurse should include in the teaching that which of the following is an adverse effect of cataract surgery?
Intraocular hemorrhage
red tag
Life-threatening and requires immediate attention but can survive once stabilized
yellow tag
Major injury & should be given attention within 30 minutes to 2 hours.
green tag
Non-urgent 2 to 4 hours
black tag
Not seen don't have survival potential
A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside?
Oral-nasal suction equipment
A nurse is reinforcing discharge teaching with the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first if a seizure occurs?
Protect the client's head
A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following actions should the nurse take?
Redirect the client to a different activity with a small group of people
A nurse is reinforcing discharge teaching with a client who had a transient ischemic attack (TIA). Which of the following instructions should the nurse include?
Reduce dietary sodium
A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect?
Right-sided hemiplegia
A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. Which of the following items in the client's history is a contraindication to the procedure?
The client has a pacemaker.
A nurse is collecting data from a client who is recovering from a recent stroke. Which of the following data is the nurse's priority to collect?
The client's ability to clear oral secretions
A nurse is caring for a client who begins to have a generalized tonic-clonic seizure while lying in bed. Which of the following actions should the nurse take?
Turn the client onto the side
A nurse is collecting data from a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect?
Weakness of the lower extremities
visual receptive aphasia
difficulty understanding written words.
dysarthria
slurred speech
