neuro test

A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (SATA) . Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells

A, C, D ~ In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

Which of the following would be the most important when caring for a child during a seizure: A. intervene to halt the seizure. B. Restrain the child. C. protect the child from injury. D. place a solid object between the teeth.

C. Protect the child from injury.

cranial nerve 4

Trochlear (eye movement)

Which of the following would be appropriate when caring for an infant with myelomeningocele preoperatively?SATA a. inspection of the sac for leakage along with frequent dressing changes b. placing infant in prone position c. placing infant under radiant warmer

all of them

What is the priority prior to surgery for a infant with myelomeningocele?

infection control. Keep prone if possible, maintain feeding as tolerated, elevate bed, and cover sac with ns soaked gauze.

Cranial nerve 3

oculomotor helps eye movement

What does cranial nerve 1 do

olfactory...smell

What should you do to prevent a febrile temperature?

tylenole and ibprofin.

nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should plan to place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral 3.Flat, with head turned to the side 4.Head of bed elevated 30 to 45 degrees 5.Head of bed elevated with the neck extended

1, head midline 2. neck neutral 4. hob 30-45 degrees The client who is at risk for or who has increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

The client with a head injury is experiencing signs of increased intracranial pressure (ICP), and mannitol (Osmitrol) is prescribed. The nurse administering this medication expects which as an intended effects of this medication? Select all that apply. 1. Increased diuresis 2. Reduced intracranial pressure 3. Increased osmotic pressure of glomerular filtrate 4. Reduced tubular reabsorption of water and solutes 5. Reabsorption of sodium and water in the loop of Henle

1,2,3,4 Rationale: Mannitol is an osmotic diuretic that induces diuresis by raising the osmotic pressure of glomerular filtrate, there by inhibiting tubular reabsorption of water and solutes. It is used to reduce intracranial pressure in the client with head trauma. The incorrect option would cause fluid retention through reabsorption, thereby increasing the intracranial pressure.

The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. 1.Thicken liquids. 2.Assist the client with eating. 3.Assess for the presence of a swallow reflex. 4.Place the food on the affected side of the mouth .5.Provide ample time for the client to chew and swallow. .

1,2,3,5 Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. 1.Keep suction equipment at the bedside. 2.Elevate the head of the bed 30 degrees. 3.Keep the client lying in a supine position. 4.Keep the head and neck in good alignment. 5.Administer prescribed respiratory treatments as needed.

1,2,4,5 The nurse maintains a patent airway for the client with difficulty breathing by keeping the head and neck in good alignment and elevating the head of the bed 30 degrees unless contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The client should be kept in a side-lying position whenever possible to minimize the risk of aspiration.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1.Padding the side rails of the bed 2.Placing an airway at the bedside 3.Placing the bed in the high position 4.Putting a padded tongue blade at the head of the bed 5.Placing oxygen and suction equipment at the bedside 6.Flushing the intravenous catheter to ensure that the site is patent

1,2,5,6 Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

What are the S/S of bacterial meningitis in infants and young children 3 months to 2 years?

1. Absence of classic signs b. ill, with generalized symptoms c. Poor feeding d. Vomiting, irritability e. Bulging fontanels (an important sign) f. Seizures nuchal rigidity possible Abrupt fever

A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications? 1. Administer the eye drop first, followed by the eye ointment. 2. Administer the eye ointment first, followed by the eye drop. 3. Administer the eye drop, wait 15 minutes, and administer the eye ointment. 4. Administer the eye ointment, wait 15 minutes, and administer the eye drop.

1. Administer the eye drop first, followed by the eye ointment. Rationale: When an eye drop and an eye ointment are scheduled to be administered at the same time, the eye drop is administered first. The instillation of two medications is separated by 3 to 5 minutes.

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.

1. Avoid Bending 3.Take acetaminophen. 5.Eye shield at bedtime 6. Contact surgeon if decrease in visual acuity Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon, because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves? 1.Eye movements 2.Response to verbal stimuli 3.Affect, feelings, or emotions 4.Insight, judgment, and planning

1. Eye movements. Eye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.

The client arrives at the emergency department complaining of back spasms. The client states, "I have been taking 2 to 3 aspirin every 4 hours for the last week, and it hasn't helped my back." Since acetylsalicylic acid intoxication is suspected, the nurse should assess the client for which manifestation? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Photosensitivity

1. Tinnitus. Mild intoxication with acetylsalicylic acid is called salicylism and is experienced commonly when the daily dosage is higher than 4gm. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation may occur, because salicylate stimulates the respiratory center. Fever may result, because salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production.

A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action? 1. Irrigate the eyes with water. 2. Come to the emergency department. 3. Call the primary health care provider (PHCP). 4. Irrigate the eyes with diluted hydrogen peroxide.

1. Irrigate the eyes with water (or Normal saline) In this type of accident, the client is instructed to irrigate the eyes immediately with running water for at least 20 minutes, or until the emergency medical services personnel arrive. In the emergency department, the cleansing agent of choice is usually normal saline. Calling the PHCP and going to the emergency department delays necessary intervention. Hydrogen peroxide is never placed in the eyes.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. 1. Loosening restrictive clothing 2. Restraining the client's limbs 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward 5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

1. Loosening restrictive clothing. 3. Removing the pillow and raising padded side rails. 4. Positioning the client to the side, if possible, with the head flexed forward. Rationale: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on 1 side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client. Test-Taking Strategy: Focus on the subject, interventions during a seizure. Think about ethical and legal issues to eliminate option 5. Next, evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options except for restraining the limbs. Remember to avoid restraints

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1.Padding the side rails of the bed 2.Placing an airway at the bedside 3.Placing the bed in the high position 4.Putting a padded tongue blade at the head of the bed 5.Placing oxygen and suction equipment at the bedside 6.Flushing the intravenous catheter to ensure that the site is patent

1. Padding s/r 2. airway @ bedside 5. o2 & suction equipment @ bedside 6.Flush iv catheter Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1.Taking medications as scheduled 2.Eating large, well-balanced meals 3.Doing muscle-strengthening exercises 4.Doing all chores early in the day while less fatigued

1. Taking medications as scheduled. Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? 1. The intracranial pressure reading is normal. 2. The intracranial pressure reading is elevated. 3. The intracranial pressure reading is borderline. 4. An intracranial pressure reading of 8 mm Hg is low.

1. The intracranial pressure reading is normal. The normal intracranial pressure is 5 to 15 mm Hg. A pressure of 8 mm Hg is within normal range.

The nurse prepares a client for ear irrigation as prescribed by the health care provider. Which action should the nurse take when performing the procedure? 1. Warm the irrigating solution to 98.6°F (37.0°C) . 2. Position the client with the affected side up following the irrigation. 3. Direct a slow, steady stream of irrigation solution toward the eardrum. 4. Assist the client to turn his or her head so that the ear to be irrigated is facing upward.

1. Warm the irrigating solution to 98.6°F (37.0°C) Rationale: Before ear irrigation, the nurse should inspect the tympanic membrane to ensure that it is intact. The irrigating solution should be warmed to 98.6°F (37.0°C) because a solution temperature that is not close to the client's body temperature will cause ear injury, nausea, and vertigo. The affected side should be down following the irrigation to assist in drainage of the fluid. When irrigating, a direct and slow steady stream of irrigation solution is directed toward the wall of the canal, not toward the eardrum. The client is positioned sitting, facing forward with the head in a natural position; if the ear is faced upward, the nurse would not be able to visualize the canal.

The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. 1. Wash hands. 2. Put gloves on. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheekbone. 5. Instruct the client to squeeze the eyes shut after instilling the eye drop. 6. Instruct the client to tilt the head forward, open the eyes, and look down.

1. Wash hands. 2. Put gloves on. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheekbone. Rationale: To administer eye medications, the nurse should wash hands and put gloves on. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1.The client is aphasic. 2.The client has weakness on the right side of the body. 3.The client has complete bilateral paralysis of the arms and legs. 4.The client has weakness on the right side of the face and tongue. 5.The client has lost the ability to move the right arm but is able to walk independently. 6.The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

1. client aphasic 2.client has weakness on right side. 4. Client has weakness on right side face of tongue. Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees 4.Head turned to the side when flat in bed5.Neck and jaw flexed forward when opening the mouth

1. head midline. 2. Neck in Neutral position. 3. Head of bead 30-45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 3.Limiting bladder catheterization to once every 12 hours 4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the client has a bowel movement at least once a week

1. wrinkle-free linen 2.prevent unnecessary pressure of lower limbs 4. turn and reposition The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

Cranial Nerve 1=olfactory = smell Cranial nerve 2= optic =vision Cranial nerve 3=oculomotor=eye move Cranial nerve 4=trochlear= cranial nerve 5=trigeminal cranial nerve 6=abducens cranial nerve 7=facial cranial nerve 8=acoustic cranial nerve 9=glossopharyngeal cranial nerve 10=vagus cranial nerve 11=spinal accessory cranial nerve 12=hypoglossal

1=smell 2. vision 3. eye movevent 4. eye movement 5. touch forehead &cheek clench teeth 6.side vision 7. taste front 2/3 tongue and smile 8. hearing & equilibrium 9. speech back 1/3 of tongue 10. digestion(poop) slow heart rate 11. shoulder shrug 12. tongue movement

The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? 1.Extend the arms. 2.Extend the tongue. 3.Turn the head toward the nurse's arm. 4.Focus the eyes on the object held by the nurse.

2. Impairment of cranial nerve XII can occur with a stroke. To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse would assess the client's ability to extend the tongue. The maneuvers noted in the remaining options do not test the function of cranial nerve XII.

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? 1. "Alcohol is not contraindicated while taking this medication." 2. "Good oral hygiene is needed, including brushing and flossing." 3. "The medication dose may be self-adjusted, depending on side effects." 4. "The morning dose of the medication should be taken before a serum medication level is drawn."

2. "Good oral hygiene is needed, including brushing and flossing." Typical antiseizure medication instructions include taking the prescribed daily dosage to keep the blood level of the medication constant and having a sample drawn for serum medication level determination before taking the morning dose. The client is taught not to stop the medication abruptly to avoid alcohol, to check with a primary health care provider before taking over the counter medications, to avoid activities in which alertness and coordination are required until medication effects are known, to provide good oral hygiene, and to obtain regular dental care. The client also needs to wear a MedicAlert bracelet.

The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings? 1.Normal 2.Abnormal 3.Insignificant 4.Inconclusive

2. Abnormal In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? 1.Is disoriented to person, place, and time 2.Affect is flat, with periods of emotional lability 3.Cannot recall what was eaten for breakfast today 4.Demonstrates inability to add and subtract; does not know who is the president of the United States

2. Affect is flat, with periods of emotional lability. The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data? 1. Turn the flashlight on directly in front of the eye and watch for a response. 2. Ask the client to follow the flashlight through the six cardinal positions of gaze. 3.Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye. 4. Check pupil size, and then ask the client to alternate looking at the flashlight and the examiner's finger.

2. Ask the client to follow the flashlight through the six cardinal positions of gaze. Rationale:The nurse asks the client to follow the flashlight through the six cardinal positions of gaze to assess for eye movement related to cranial nerves III, IV, and VI. Options 1 and 3 relate to pupillary response to light. Also, shining the light directly into the client's eye without asking the client to focus on a distant object is not an appropriate technique. Option 4 assesses accommodation of the eye.

The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly? 1.Thalamus 2.Hypothalamus 3.Limbic 4.Reticular activating system

2. Hypothalamus. The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for sensory and motor information. The limbic system is responsible for emotions. The reticular activating system is responsible for the sleep-wake cycle.

The nurse is caring for the client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1.Sternal rub 2.Nail bed pressure 3.Pressure on the orbital rim 4.Squeezing of the sternocleidomastoid muscle

2. Nail bed pressure It tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? 1. Apply normal saline drops. 2. Note the time of day the test was done. 3. Contact the primary health care provider (PHCP). 4. Instruct the client to sleep with the head of the bed flat.

2. Note the time of day test was done. Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma. It is not necessary to contact the PHCP as an initial action. Flat positions may increase the pressure.

A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? 1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear

2. Tinnitus Tinnitus is the most common complaint of clients with ontological problems, especially problems involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. Other options are not specific to inner ear.

Which assessment finding should the nurse expect to note in the client hospitalized with a diagnosis of stroke who has difficulty chewing food?1.Dysfunction of vagus nerve (cranial nerve X) 2.Dysfunction of trigeminal nerve (cranial nerve V) 3.Dysfunction of hypoglossal nerve (cranial nerve XII) 4.Dysfunction of spinal accessory nerve (cranial nerve XI)

2. Trigeminal nerve The motor branch of cranial nerve V is responsible for the ability to chew food. The vagus nerve is active in parasympathetic functions of the autonomic nervous system. The hypoglossal nerve aids in swallowing. The spinal accessory nerve is responsible for shoulder movement, among other things.

The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position following the procedure?1.Prone in semi Fowler's position 2.Supine in semi Fowler's position 3.Prone with a small pillow under the abdomen 4.Lateral with the head slightly lower than the rest of the body

3, Prone w/ pillow under abd. After the procedure, the client assumes a flat position. If the client is able, a prone position with a pillow under the abdomen is the best position. This position helps reduce cerebrospinal fluid leakage and decreases the likelihood of post-lumbar puncture headache. The remaining options are incorrect.

A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? 1. "The medication will help dilate the eye to prevent pressure from occurring." 2. "The medication will relax the muscles of the eyes and prevent blurred vision." 3. "The medication causes the pupil to constrict and will lower the pressure in the eye." 4. "The medication will help block the responses that are sent to the muscles in the eye."

3. "The medication causes the pupil to constrict and will lower the pressure in the eye." Rationale: Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect.

A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint? 1. Doxycycline 2. Atropine sulfate 3. Acetylsalicylic acid 4. Diltiazem hydrochloride

3. Acetylsalicylic acid Rationale: Aspirin is contraindicated for GI bleeding and is potentially ototoxic. The client should be advised to notify the prescribing health care provider so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 2, and 4 do not have effects that are potentially associated with hearing difficulties.

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa, in which position? 1.15 degrees of Trendelenburg's 2.Side-lying with the head of the bed flat 3.With the head of the bed elevated at least 30 degrees 4.With the head of the bed elevated no more than 10 degrees

3. HoB elevated at least 30 degrees. Correct positioning of the client following cranial surgery is important to avoid increased intracranial pressure and to promote optimal cerebral tissue perfusion. The surgeon's prescription for positioning is always followed. The client with an incision in the anterior or middle fossa should be positioned with the head of bed (HOB) elevated at least 30 degrees. If the incision is in the posterior fossa or burr holes have been made, the client is positioned flat, or with the HOB elevated no more than 10 to 15 degrees. If a craniectomy (bone flap) is performed, the client should not be positioned to the operative side. Trendelenburg's position is contraindicated in the postoperative phase following cranial surgery.

Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication? 1. Assessing for edema 2. Monitoring temperature 3. Monitoring blood pressure 4. Assessing blood glucose level

3. Monitoring blood pressure Rationale: Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are side and adverse effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 2, and 4 are not specifically associated with this medication

The nurse is caring for a client following enucleation to treat an ocular tumor and notes the presence of bright red drainage on the dressing. Which action should the nurse take at this time? 1. Document the finding. 2. Continue to monitor the drainage. 3. Notify the primary health care provider (PHCP). 4. Mark the drainage on the dressing and monitor for any increase in bleeding.

3. Notify PHCP If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the PHCP, because this indicates hemorrhage. Options 1, 2, and 4 are inappropriate at this time.

The home health nurse visits a client who is taking phenytoin (Dilantin) for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching plan? 1. Pregnancy should be avoided while taking phenytoin. 2. The client may stop the medication if it is causing severe gastrointestinal effects. 3. There is the potential of decreased effectiveness of birth control pills while taking phenytoin. 4. There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together.

3. Potential of decreased effectiveness of birth control pills while taking phenytoin. Rationale: Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options 1, 2, and 4 are inappropriate instructions.

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1.Giving client full control over care decisions and restricting visitors 2.Providing positive feedback and encouraging active range of motion 3.Providing information, giving positive feedback, and encouraging relaxation 4.Providing intravenously administered sedatives, reducing distractions, and limiting visitors

3. Providing information, giving positive feedback, and encouraging relaxation The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication? 1. Sodium level, 140 mEq/L (140 mmol/L) 2. Uric acid level, 4.0 mg/dL (0.24 mmol/L) 3. White blood cell count, 3000 mm3 (3.0 × 109/L) 4. Blood urea nitrogen level, 10 mg/dL (3.6 mmol/L)

3. White blood cell count, 3000 mm3 (3.0 × 109/L) Carbamazepine, classified as an antiseizure medication, is used to treat nerve pain. Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances, including thrombophlebitis and dysrhythmias; and dermatological effects. The low white blood cell count reflects agranulocytosis. The laboratory values in 1,2,&4 are normal values.

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? 1.Head of bed flat, head and neck midline 2.Head of bed flat, head turned to the nonoperative side 3.Head of bed elevated 30 to 45 degrees, head and neck midline 4.Head of bed elevated 30 to 45 degrees, head turned to the operative side .

3. head of bed elevated 30-45 degrees head & neck midline. After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1.A negative Kernig's sign 2.Absence of nuchal rigidity 3.A positive Brudzinski's sign 4.A Glasgow Coma Scale score of 15

3. positive Brudzinski Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration? 1.Using adult diapers 2.Inserting a Foley catheter 3.Establishing a toileting schedule 4.Padding the bed with an absorbent cotton pad

3. tolieting schedule. A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. A Foley catheter should be used only when necessary because of the associated risk of infection. Use of diapers or pads is the least acceptable alternative because of the risk of skin breakdown.

A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment? 1.Taste 2.Smell 3.Vision 4.Hearing

3. vision The occipital lobe is responsible for reception of vision and contains visual association areas. This area of the brain helps the individual to visually recognize and understand the surroundings. The other senses listed are not a function of the occipital lobe.

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? 1. I can sit down to put on my pants and shoes. 2. I try to exercise every day and rest when i'm tired. 3. My son removed all loose rugs from my bedroom. 4. I don't need to use my walker to gt the bathroom.

4. "I don't need to use my walker to get to the bathroom." The client with Parkinson's disease would be instructed regarding safety measures in the home. The client needs to use a walker as support to get the bathroom because of bradykinesia. The client would sit down to put on pants and shoes to prevent falling. The client needs to exercise every day in the morning when energy levels are highest. The client needs to have all loose rugs in the home removed to prevent falling.

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem? 1. Total loss of vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision

4. A sense of a curtain falling across the field of vision. A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this problem. A retinal detachment is an ophthalmic emergency, and even more so if visual acuity is still normal.

A client with myasthenia gravis has become increasingly weaker. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? 1. No change in the condition 2. Complaints of muscle spasms 3. An improvement of the weakness 4. A temporary worsening of the condition

4. A temporary worsening of the condition An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis. Muscle spasms are not associated with this test.

The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote should the nurse prepare for administration if prescribed? 1. Pentostatin 2. Auranofin 3. Fludarabine 4. Acetylcysteine

4. Acetylcysteine The antidote for acetaminophen is acetylcysteine. The normal therapeutic serum level of acetaminophen is 10 to 20mcg/ml. A toxic level is higher than 50mcg/ml, and levels higher than 200mcg/ml. 4 hours after ingestion indicate that there is a risk for liver damage. Auranofin is a gold preparation that may be used to treat rheumatoid arthritis. Pentostatin and fludarabine are antineoplastic agents.

Which medication, if prescribed for the client with glaucoma, should the nurse question? 1. Betaxolol 2. Pilocarpine 3. Erythromycin 4. Atropine sulfate

4. Atropine sulfate Rationale: Options 1 and 2 are miotic agents used to treat glaucoma. Option 3 is an anti-infective medication used to treat bacterial conjunctivitis. Atropine sulfate is a mydriatic and cycloplegic (also anticholinergic) medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

4. Blurred vision A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1.Gets angry with family if they interrupt a task 2.Experiences bouts of depression and irritability 3.Has difficulty with using modified feeding utensils 4.Consistently uses adaptive equipment in dressing self

4. Consistently uses adaptive equipment in dressing self. Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve

4. Cranial nerve VII, facial nerve Rationale:An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1.Nebulizer and pulse oximeter 2.Blood pressure cuff and flashlight 3.Flashlight and incentive spirometer 4.Electrocardiographic monitoring electrodes and intubation tray.

4. Electrocardiographic monitoring electrodes and intubation tray. The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?1. Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning

4. Exhaling during repositioning. Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1.Fluid is clear and tests negative for glucose. 2.Fluid is grossly bloody in appearance and has a pH of 6. 3.Fluid clumps together on the dressing and has a pH of 7. 4.Fluid separates into concentric rings and tests positive for glucose.

4. Fluid separates into concentric rings and tests positive for glucose. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

When teaching a client with glaucoma about the effects of a miotic medication, the nurse should tell the client that the medication will produce which effect? 1. Reshape the lens to eliminate blurred vision 2. Dilate the pupil to reduce intraocular pressure3. Interrupt the drainage of aqueous humor from the eye 4. Lower intraocular pressure and improve blood flow to the retina

4. Lower intraocular pressure and improve blood flow to the retina Rationale: Miotics are used to lower the intraocular pressure, which then increases blood flow to the retina. This in turn decreases retinal damage and loss of vision. Miotics cause a contraction or constriction of the ciliary muscle and widen the trabecular meshwork. The other options are incorrect.

The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse should instruct the client to take which action? 1. Eat before instilling the drops. 2. Swallow several times after instilling the drops. 3. Blink vigorously to encourage tearing after instilling the drops. 4. Occlude the nasolacrimal duct with a finger after instilling the drops.

4. Occlude the nasolacrimal duct with a finger after instilling the drops. Rationale: Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication. Options 1, 2, and 3 will not prevent systemic absorption.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1.Meningitis or encephalitis during the last 5 years 2.Seizures or trauma to the brain within the last year 3.Back injury or trauma to the spinal cord during the last 2 years 4.Respiratory or gastrointestinal infection during the previous month

4. Respiratory or GI infection during the previous month. Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1."We need to discourage him from wearing eyeglasses." 2."We need to place objects in his impaired field of vision." 3."We need to approach him from the impaired field of vision." 4."We need to remind him to turn his head to scan the lost visual field."

4. We need to remind him to turn his head to scan the lost visual field. Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

The nurse should place the client in which position? 1.Prone 2.Supine 3.Semi Fowler's with the hip and the neck flexed 4.Head of the bed elevated 30 degrees with the head in midline position

4. hob 30 degrees and head midline. The health care provider's prescriptions are always followed with regard to positioning the client after stroke. Clients with hemorrhagic stroke usually have the head of the bed elevated to 30 degrees to reduce intracranial pressure that can occur from the hemorrhage. The head should be in a midline, neutral position to facilitate venous drainage from the brain. Extreme hip and neck flexion should be avoided to prevent an increase in intrathoracic pressure and to promote venous drainage from the brain. For clients with ischemic stroke, the head of the bed usually is kept flat to ensure adequate blood flow and thus oxygenation to the brain. Prone, supine, and hip and neck flexion are incorrect positions for clients with hemorrhagic stroke.

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? 1."I will wash my face with cotton pads." 2."I'll have to start chewing on my unaffected side." 3."I should rinse my mouth if toothbrushing is painful." 4."I'll try to eat my food either very warm or very cold."

4. i'll try to eat my food either very warm or very cold. Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If brushing the teeth triggers pain, an oral rinse after meals may be helpful instead.

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? 1.A pink-colored tympanic membrane 2.A pearly colored tympanic membrane 3.A transparent and clear tympanic membrane 4.A red, dull, thick, and immobile tympanic membrane

4.A red, dull, thick, and immobile tympanic membrane Otoscopic examination in a client with mastoiditis reveals red, dull, thick and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.

The nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? 1.5 mm Hg 2.8 mm Hg 3.14 mm Hg 4.22 mm Hg

4.Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion.

When a client is admitted to the hospital with Guillain-Barré syndrome (GBS), the most important assessment the nurse should make is for a. decreasing alertness. b. respiratory difficulty. c. seizure activity. d. urinary retention.

ANS: B. Resp. difficulty The two most dangerous features of GBS are respiratory muscle weakness and autonomic neuropathy involving both the sympathetic and the parasympathetic systems.

A nurse admits a 5-year-old child with bacterial meningitis to the pediatric intensive care unit. Which information obtained by the nurse during the intake history is most helpful for the nurse to document? A. Fell off swing hitting head 2 months ago B. History of recent sinus infection C. Mother with history of herpes simplex D. Sibling with upper respiratory infection

B ~ In a child this age, common causes of bacterial meningitis include septicemia, surgical procedures involving the CNS, penetrating wounds, otitis media, sinusitis, cellulitis of the scalp or face, dental cavities, pharyngitis, and orthopedic diseases. Blunt trauma from falling off a swing and a sibling with a URI are noncontributory. Herpes simplex is an important cause of neonatal viral meningitis.

A client with Meniere's disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo? A. Increase fluid intake to 3000 ml a day B. Avoid sudden head movements C. Lie still and watch the television D. Increase sodium in the diet

B. Avoid sudden head movements. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid sometimes are prescribed. Lying still and watching television will not control vertigo.

An infant had surgical correction of myelomeningocele and is 5 days postop. The nurse includes in the discharge plan for the parents to do: a. monitor the operative site for redness and leaking. b. breastfeed or feed the infant a commercial formula as tolerated. c. perform passive range of motion when appropriate d. place the newborn prone to sleep or side liying if permited by md pick up or hold the newborn as little as possible

B. BREASTFEAD AS TOLERATED.

The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test? A. Stand 4 feet away from the client to ensure that the client can hear at this distance. B. Whisper a statement and ask the client to repeat it. C. Whisper a statement with the examiners back facing the client. D. a statement while the client blocks both ears.

B. Whisper test. The examiner stands 1-2 feet away from the client and asks the client to block one external ear canal. The nurse whispers a statement and asks the client to repeat it. Each ear is tested separately.

What is the goal of therapeutic management for the child with CP? a. assisting with motor control of voluntary muscle b. maximizing the capabilities of the child c. delaying the development of sensory deprivation D. surgical correction for deformities

B. maximize capabilities

How should a child lay for a spinal tap (diagnostic for menigitis)

Bow back hand under head and knees (curve the back) which increases space between spinal vertebrae.

A child has been admitted with bacterial meningitis. Which action by the nurse takes priority? A. Administering broad-spectrum antibiotics B. Assessing and treating pain aggressively C. Facilitating blood cultures and lumbar puncture D. Maintaining a quiet, nonstimulating environment

C ~ All actions are appropriate for the child with acute bacterial meningitis. However, the priority is obtaining cultures so that appropriate therapy can be identified. After cultures are obtained, the nurse will administer broad-spectrum antibiotics until the culture and sensitivity results are known.

After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says, a. "I will take the topiramate (Topamax) as soon as any headaches start." b. "The sumatriptan (Imitrex) will help to increase the blood flow to my brain." c. "I will try to lie down someplace dark and quiet when the headaches begin." d. "A glass of wine might help me relax and prevent headaches from developing."

Correct Answer: C. lie someplace dark and quiet. Rationale: It is recommended that the patient with a migraine rest in a dark, quiet area. Topamax is used to prevent migraines and must be taken for several months to determine effectiveness. Blood flow to the brain is decreased by the triptan drugs. Alcohol may precipitate migraine headaches

Cranial nerve 7

Facial: smile and taste for front 2/3 of tongue.

What should you do if a child develops a purpuric or petechial rash?

The child must receive medical atteniton immediately. Monitor closely.