Neuro-sensory Disorders
a nurse is working on a surgical floor. the nurse must logroll a client following which procedure?
laminectomy
The nurse is to check a client's gag reflex. The most effective technique to achieve this is to
Touch the back of the client's throat with a tongue blade
Which is an initial sign of Parkinson's?
Tremor
When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse suspect the injury has occurred?
C5
For a neurologically injured client, the nurse should assess motor strength by
Comparing equality of hand grasps
when developing a long term plan for the client with MS, the nurse should instruct the client to prevent
contractures
a client with Guillain-Barre syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. when the client asks the nurse about the paralysis, how should she respond?
the paralysis caused by this disease is temporary
which statement indicates that a client understands the nurse's teaching about PHENYTOIN for the diagnosis of seizures?
this medication will not cure my disease
a client is scheduled for a prostatectomy, and the anesthetist plans to use a spinal block during surgery. in the OR, the nurse positions the client according to instruction. why is the special positioning necessary for this type of anesthesia?
to prevent CSF leakage
what emergency procedures would the nurse anticipate being implemented during a crisis of myasthenia gravis?
tracheotomy with mechanical ventilation
for the client who is experiencing expressive aphasia, which nursing intervention should be used to promote communication?
using a "picture board" for the client to point to pictures
the client with a cataract tells the nurse about being afraid of being awake during surgery. which response by the nurse would be most appropriate?
what is it that disturbs you about the idea of being awake?
an elderly client had a thrombotic CVA and now has flaccid paresis on the right side. when planning care, the nurse understands that rehab starts
when the client is admitted to the hopsital
the nurse is assessing a client recovering from a hemorrhagic CVA that occurred 7 days ago. which finding should be reported to the HCP?
worsening headache
the nurse has asked the UAP to ambulate the client with Parkinson's. the nurse observes the UAP pulling on the client's arms to get the client to move forward. the nurse should
explain how to overcome a freezing gait by telling the client to march in place.
the nurse is teaching the family of a client with dysphagia about decreasing the risk for aspiration while eating. what should the nurse include
-maintaining upright position -keeping distractions to a minimum -introducing foods on the unaffected side of mouth
a client has had a CVA which has affected the left side of the brain. the nurse should assess for
expressive aphasia
Which measure would be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery?
Apply ice compresses
To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid
Coughing
A client undergoes cerebral angiography for evaluation after a cat scan revealed a subarachnoid hemorrhage. afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. which findings indicate the occlusion of a cerebral vessel by a clot?
Hemiplagia, seizures, and decreased LOC
a 7 year old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. the child weighs 22 kg and currently has an IV of D5 NA and 20 meq KCL/L running. he has a temp of 100.4, HR 120, R 28 and o2 92%. using SBAR, what should the nurse recommend to the physician?
IV lorazepam
a nurse is assessing a client with meningitis. the nurse places the client in a supine position and flexes the clients leg at the hip and knee. the nurse notes resistance and the client reports pain. the nurse should document this as a positive
Kernig's sign
a nurse is assisting during a lumbar puncture. how should the nurse position the client during the procedure?
Lateral recumbent, with chin resting on flexed knees.
a client with hydrocephalus reports having a bad headache in the morning on arising the past 3 days, but it disappears later in the day. the nurse should
notify the HCP
a nurse is preforming a neuro assessment on a client. the nurse observes the tongue for symmetry, tremors, and strength, and assess the client's speech. which intracranial nerves is the nurse assessing?
XII
A client with a head injury regains consciousness after several days. When the patient wakes up, what should the nurse say?
You are in the hospital. You were in an accident and unconscious.
which of the following clients requires increased sensory stimulation to prevent sensory deprivation?
a 65-year old client who has employment-induced presbycusis and advanced glaucoma
a client has just undergone a lumbar puncture. which finding should the nurse report to the HCP?
a moderate amount of serous fluid was noted on the lumbar dressing
the client with glaucoma is schedule for a hip replacement. which prescription requires clarification before the nurse carries it out
administer atropine sulfate
a home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. the nurse notes that the client's solution is cloudy. what should the nurse do?
advise the client to discard the drug because it may have undergone chemical changes or become contaminated
a client is admitted with bacterial meningitis. which hospital room is the best?
an isolation room three doors from the nurse's station
a nurse has received a shift report on four clients. which client should she assess first?
an older adult returning to the unit after having a carotid endarterectomy
a client receiving continuous mandatory ventilation begins to experience cluster breathing after a recent intracranial occipital bleeding. what should the nurse do
notify the HCP of the client's breathing pattern
when the nurse talks with a client with MS who has slurred speech. which intervention is contraindicated?
asking the client to speak louder when tired
when planning care for a client with myasthenia gravis, the nurse understands the client is at highest risk for
aspiration
a client undergoes intense rehab after a CVA and is discharged with residual hemiparesis. what is the most important responsibility of the case manager?
assess capabilities, demonstrate the use of assisstive devices, and assess how the client will manage at home
a client is admitted to the hospital after sustaining a closed head injury in a skiing accident. the physician ordered a neuro assessment q2h they have been unchanged since admission. the client complains of a headache. which intervention by the nurse is appropriate?
assess the client's neuro status for subtle changes, administer acetaminophen and reassess client in 30 min
assessment of a client taking a NSAID for pain should include specific questions regarding which body system
gastrointestinal
the client with a lumbar laminectomy asks to be turned onto the side. the nurse should
get another nurse to help logroll the client into position
a client with glaucoma is to receive 3 gtt of acetazolamide in the left eye. what should you do?
have the client look up while the nurse administers the eyedrops.
which of the following statements by a client receiving carbamazepine would require further instruction
if i have a seizure, i should take two pills immediately
the nurse is teaching a client with MS about prevention of UTI and renal calculi. which nutrition recommendations are most likely to reduce the risk of these conditions?
increase fluids (2500 ml/day) and maintain urine acidity by drinking cranberry juice
in a client with ALS and respiratory distress, which is the earliest sign of reduced oxygenation
increased restlesness
a client is receiving an IV infusion of mannitol after undergoing intracranial surgery to remove a brain tumor. to determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant
increased urine output
after an eye examination, a client is diagnosed with open-angle glaucoma. the physician orders pilocarpine opthalmic solution, 0.25% i, OU q.i.d. based on this, the nurse should instruct the client to administer the drug by
instilling one drop into both eyes four times daily
a physician order diazepam, 10 mg IV for a client experiencing status epilepticus. what statement about IV diazepam is true?
it should be administered no faster than 5 mg/minute in an adult
when obtaining the health history from a client with retinal detachment, a nurse should expect the client to report
light flashes and floaters in front of the eye
a client with weakness and tingling in both legs is admitted to the med-surg unit with a tentative dx of guillain-barre. on admission, which assessment is priority for this client?
lung auscultation and measurement of vital capacity and tidal volume
A short time after cataract surgery, the client has nausea. the nurse should first
medicate the client with an antiemetic, as prescribed
which of the following nursing intervention can prevent a client from experiencing autonomic dysreflelxia
monitoring the patency of an indwelling urinary catheter
the nurse is caring for a client with an injury to the thalamus. the nurse should anticipate
monitoring the temperature of the bathwater
a client comes to the ED complaining of headache, malaise, and stiff neck. vital sign assessment reveals a fever, increased HR and respirations, and normal BP. on physical exam, nurse notes rash, nuchal rigidity, and positive Brudzinski's and Kernig's signs. what do these manifestations mean/.
possible meningeal irritation
a client admitted with bacterial meningitis must be transported to the radiology department to repeat a CT scan of the head. his LOC is decreased and he requires nasopharyngeal suctioning before transport. which infection control protocol should be used when caring for this client?
put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport
the unconscious client is to receive 200 ml of tube feeding q4h. the nurse checks the gastric residual before administration and gets 40mg. she should
readminister the residual to the client and continue with the feed
a nurse is teaching a client with MS. when teaching the client how to avoid fatigue, the nurse should tell the client to
rest in an air-conditioned room
a nurse caring for a client who has left homonymous hemianopsia following a CVA. which nursing diagnosis should take the highest priority?
risk for injury
The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?
semi fowlers
after the client returns from surgery for a deviated nasal septum, the nurse puts the client in what position?
semi-fowlers
an older adult has vertigo accompanied with tinnitus as the result of meniere's disease. what should you instruct the client to restrict in a dietary element?
sodium
after cataract removal surgery, the nurse teaches the client about activities that are safe to do at home. which would be contraindicated?
bending over the sink to wash the face
a client experienced a stroke that damaged the hypothalamus. the nurse should anticipate that the client will have problems with
body temperature control
the nurse knows that dexamethasone exerts its therapeutic effect by
decreasing leukocyte infiltration at the site of ocular inflammation
when a client is recovering as expected from spinal anesthesia, the nurse should expect to check
degree of response to pinpricks in legs and toes
a client has just been diagnosed with early glaucoma. during a teaching session, the nurse should
demonstrate eyedrop instillation
an elderly client has suffered a CVA. the right side of their face has visible ptosis. the nurse would want to be alert to which of the following?
dysphagia
the nurse is caring for a client with a subdural hematoma. which of the following is the priority outcome
ensure airway patency and optimal oxygen levels and prevent from injury
which action would not be appropriate to include when preparing a client for MRI to evaluate a ruptured disc
starting an IV line at keep-open rate
when reviewing the results of a client's lumbar puncture, a nurse notes a glucose level of 32 mg/dl. what does this result suggest?
the client may have bacterial meningitis
the client with spinal cord compression due to a tumor is questioning the treatment to be given. which is an accurate statement by the nurse
the client will receive radiation therapy to shrink the tumor and relieve the pressure on nerves and spine
a nurse is discharging a client after successful same-day cataract surgery. which activities by the client would indicate understanding of postoperative instructions
cooking a meal on the stove
a client who has meniere's disease is experiencing an acute attack of vertigo. what should you do
darken the client's room and provide a quiet enviornment
a nurse is assessing an elderly client with senile dementia. which NT is most likely to contribute to this client's cognitive changes?
decreased acetylcholine level
A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer?
ask the nursing assistant to finish providing care and the LPN to administer the remaining medications so the RN can accept the new admit
