Neuro

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the client's first response to pain will be to:

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After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which of the following activities would be contraindicated? a) Lying in bed on the nonoperative side. b) Bending over the sink to wash the face. c) Walking down the hall unassisted. d) Performing isometric exercises.

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Define corumen

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Multiple Sclerosis

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The nurse should assess clients with chronic open-angle glaucoma (COAG) for: a) Eye pain. b) Colored light flashes. c) Excessive lacrimation. d) Decreasing peripheral vision.

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Which of the following statements indicates that the client has understood home care instructions following cataract surgery?

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define rhizotomy

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laminectomy

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A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?

15 The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of eye opening, best motor response, and best verbal response on a scale of 3 to 15. The client who scores the best on all three assessments scores 15 points

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: a) body temperature control. b) thinking and reasoning. c) balance and equilibrium. d) visual acuity.

body temperature control.

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:

demonstrate eyedrop instillation. Explanation: Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma

The primary nursing goal for a client with myasthenia gravis is to:

in myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure. Providing a safe environment is a secondary goal. Pain is not commonly associated with problem with myasthenia gravis

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

"The paralysis caused by this disease is temporary." The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the leg

Which of the following statements indicates the client understands the expected course of Ménière's disease? a) "Bilateral deafness is an inevitable outcome of the disease." b) "The disease process will gradually extend to the eyes." c) "Control of the episodes is usually possible, but a cure is not yet available." d) "Continued medication therapy will cure the disease."

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A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which of the following areas that is a potential pressure point when the client is in this position?

Ankles. Common pressure points in the side-lying position include the ears, shoulders, ribs, greater trochanter, medial and lateral condyles, and ankles. The sacrum, occiput, and heel are pressure points in the supine position.

After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which of the following activities would be contraindicated?

Bending over the sink to wash the face. Bending over the sink to wash the face is contraindicated after cataract surgery because it increases intraocular pressure. Walking, lying in bed on the nonoperative side, and performing isometric exercises are not contraindicated.

A client who has Ménière's disease is experiencing an acute attack of vertigo. Which of the following interventions should the nurse include in the plan of care? - Darken the room -A low-sodium diet -Pain medication for headaches. -Drink fluids

Darken the client's room and provide a quiet environment. During an acute attack of vertigo, it is best for the client to lie down in a darkened, quiet room and to avoid sudden position changes. A low-sodium diet may be helpful in decreasing the number of attacks, but it is not recommended during the attack. Headaches are not a component of the vertigo attack. Because vertigo is frequently accompanied by nausea and vomiting, the client will not want to eat or drink. Fluids are usually administered parenterally to maintain hydration and administer medications.

Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will: -speech -coordination -vision -cognition

Develop cognition. MS is a progressive, chronic neurologic disease characterized by patchy demyelination throughout the central nervous system. This interferes with the transmission of electrical impulses from one nerve cell to the next. MS affects speech, coordination, and vision, but not cognition. Care for the client with MS is directed toward maintaining joint mobility, preventing deformities, maintaining muscle strength, rehabilitation, preventing and treating depression, and providing client motivation

A client is receiving an I.V. infusion of mannitol (Osmitrol) 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 The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

The best method to remove cerumen from a client's ear involves:

Irrigating the ear gently. Irrigation is the first strategy to loosen cerumen. Successful removal of the cerumen involves gentle irrigation behind the impacted cerumen. The flow of the water must be behind the impaction to remove the cerumen from the canal. A cotton-tipped applicator or other device is not appropriate because it can cause damage to the eardrum. Use of aural suction or a cerumen curette is appropriate only if the impacted cerumen cannot be removed by irrigation.

The nurse has administered mannitol I.V. Which of the following is a priority assessment for the nurse to make after administering this drug? Monitor urine output.

Mannitol is an osmotic diuretic used in acute clinical situations. It increases osmotic pressure and draws fluid into the vascular space. Monitoring hourly urine output is a priority nursing assessment when administering mannitol. Electrolyte levels should also be monitored, most specifically sodium, chloride, and potassium. Calcium levels are not affected by mannitol. Bowel sounds and pupil reaction to light are not priority nursing assessments with mannitol.

A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the physician immediately? back pain footdrop pain in the lower back when the leg is lifted pain that radiates to the hip

New onset of footdrop Neurologic symptoms, such as footdrop, or bowel or bladder changes should be reported to the physician immediately. When musculoskeletal strain causes back pain, these symptoms may take 4 to 6 weeks to resolve. As an accompanying symptom of acute low back pain, the client may have a diffuse, aching sensation in the L4 to L5 area, pain in the lower back when the leg is lifted, or pain that radiates to the hip

A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests?

Physicians use EEG and neuroimaging studies to diagnose neurologic problems. Blood cultures can identify infection that can cause seizures. Electrocardiography, TEE, and troponin levels are cardiac-specific diagnostic tests. X-ray of the brain reveals skeletal condition. Bone marrow aspiration isn't indicated for seizure disorder. PT and INR reflect blood coagulation.

A client with a ruptured intervertebral disc at L4-5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. The nurse interprets this finding as indicating which of the following?

Postural deformity. Standing with a flattened spine slightly tilted forward and slightly flexed to the affected side indicates a postural deformity. Motor changes would include findings such as hypotonia or muscle weakness. Absent or diminished reflexes related to the level of herniation would indicate alteration in reflexes. Sensory changes would include findings such as paresthesia and numbness related to the specific tract of the herniation

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best 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. Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing. Standard precautions don't adequately protect staff and other clients from bacterial meningitis.

pallidotomy

The goal of a pallidotomy is to improve functional ability for the client with Parkinson's disease. This is a priority. The pallidotomy creates lesions in the globus pallidus to control extrapyramidal disorders that affect control of movement and gait. If functional ability is improved by the pallidotomy, the client may experience a secondary response of an improved emotional response, but this is not the primary goal of the surgical procedure. The procedure will not improve alertness or appetite

A nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:

a lower motor neuron lesion. Explanation: Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower motor neuron lesion at the myoneural junction. It isn't a genetic disorder. A combined upper and lower motor neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron.

A client who had open heart surgery is being transported to the intensive care unit (ICU) for postoperative recovery from anesthesia. The nurse in the ICU is assessing the client's level of consciousness. When asked, the client can give his name b`ut is not sure about where he is or the time of day. What should the nurse do?

a) Tell the client where he is and the time of day. b) Notify the surgeon. c) Encourage the client's wife to orient the client. d) Rub the client's sternum to arouse the client.

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: a) provide instructions on eye patching. b) assess the client's visual acuity. c) demonstrate eyedrop instillation. d) teach about intraocular lens cleaning.

c) CORRECT ANSWER demonstrate eyedrop instillation. Reason: Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma.

After an eye examination, a client is diagnosed with open-angle glaucoma. The physician orders pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by:

instilling one drop of pilocarpine 0.25% into both eyes four times daily. The abbreviation "gtt" stands for drop, "i" is the apothecary symbol for the number 1, "OU" signifies both eyes, and "q.i.d." means four times per day. Therefore, one drop of pilocarpine 0.25% should be instilled into both eyes four times daily

When communicating with a client who has aphasia, which of the following are helpful? Select all that apply. - Make use of gestures. - Speak with normal volume. - Encourage pointing to the needed object. - Present one thought at a time. - Don't write messages

• Make use of gestures. • Speak with normal volume. • Encourage pointing to the needed object. • Present one thought at a time. The goal of communicating with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating

Which of the following statements indicates the client has understood the instructions to follow at home after cataract surgery?

"I should not bend over to pick up objects from the floor." Explanation: When picking up objects from the floor, the client should be instructed to bend at the knees and keep the head up and back straight. The client may watch television and read in moderation. The eye shield is usually worn only at night. Lifting should be restricted for the first week to less than 15 pounds (6.8 kg).

A client is having a cataract removed and will use eyeglasses after the surgery. The nurse should develop a teaching plan that includes which of the following? Select all that apply. a) Stay out of the sun for 2 weeks. b) The changes will be immediate. c) Images will appear to be one-third larger. d) Look through the center of the glasses. e) Use handrails when climbing stairs.

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A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which of the following areas that is a potential pressure point when the client is in this position? a) Occiput. b) Ankles. c) Sacrum. d) Heel.

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A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which of the following responses by the nurse conveys the best understanding of the client's behavior? a) "Talking about the past is a form of denial. We have to help you focus on today." b) "Be patient. It takes time to adjust to such a massive loss." c) "Reviewing your losses is a way to help you work through your grief and loss." d) "It's a simple escape mechanism to go back and live again in happier times."

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Hemiplegia

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Ménière's disease

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The nurse is planning care for a client who has sustained a spinal cord injury. The nurse should assess the client for: a) Lost vibratory sense. b) Tingling in the fingers. c) Anesthesia below the level of the injury. d) Pain below the site of the injury.

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A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for ___ to ___ minutes. What is the primary purpose of this first-aid treatment?

15 to 20; To prevent vision loss Prolonged eye irrigation after a chemical burn is the most effective way to prevent formation of permanent scar tissue and thus help prevent vision loss. After a potentially serious eye injury, the victim should always seek medical care. Eye irrigation isn't considered a stopgap measure

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare to assist with ventilation. - Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.

When assessing the client with Parkinson's disease, the nurse should note which of the following?

A stiff, masklike facial expression. Explanation: Typical signs of Parkinson's disease include drooling; a low-pitched, monotonous voice; and a stiff, masklike facial expression. Dry mouth and aphasia are not associated with Parkinson's disease. An exaggerated sense of euphoria would not be typical; more likely, the client would exhibit depression, probably related to the progressive nature of the disease and the client's difficulties dealing with it.

Which of the following statements would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?

Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks

2. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: a. take a hot bath. b. rest in an air-conditioned room c. increase the dose of muscle relaxants. d. avoid naps during the day

Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

The nurse is administering propranolol (Inderal) to a client for control of migraine headaches. The client's pulse rate is 56 bpm. What should the nurse do next?

Assess blood pressure. One of the actions of propranolol (Inderal), a drug used in the treatment of migraine headaches, is to decrease the heart rate. The nurse should assess the client's blood pressure to evaluate overall circulatory response to the medication. Until the blood pressure value is assessed, there is no immediate need to contact the physician. The nurse should complete the blood pressure assessment before administering the drug. There is no immediate need to administer oxygen or contact a relative because a slowed pulse rate is an expected action of propranolol

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent?

Contractures. Explanation: Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications. Ascites, fluid volume overload, and dry mouth are not associated with multiple sclerosis

The nurse should assess clients with chronic open-angle glaucoma (COAG) for:

Decreasing peripheral vision. Explanation: Although COAG is usually asymptomatic in the early stages, peripheral vision gradually decreases as the disorder progresses. Eye pain is not a feature of COAG but is common in clients with angle-closure glaucoma. Excessive lacrimation is not a symptom of COAG; it may indicate a blocked tear duct. Flashes of light is a common symptom of retinal detachmen

The nurse is caring for an elderly client who has experienced a sensorineural hearing loss. The nurse anticipates that the client will exhibit which symptom?

Difficulty hearing high-pitched sounds. Explanation: The client with sensorineural hearing loss has difficulty hearing high-pitched sounds. Aging and ototoxicity are two causes of sensorineural hearing loss. The client's ability to speak is not affected. The client who cannot assign meaning to sound has central hearing loss. Vertigo is commonly an indication of an inner ear problem

The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order?

Ease the client to the floor. Maintain a patent airway. Obtain vital signs. Record the seizure activity observed. Explanation: To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded.

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an I.V. injection of a medication. What is the medication the nurse tells the client he'll receive during this test?

Edrophonium (Tensilon) The most useful and reliable diagnostic test for myasthenia gravis is the edrophonium (Tensilon) test. Within 30 to 60 seconds after injection of edrophonium, most clients with myasthenia gravis will demonstrate a marked improvement in muscle tone that lasts about 4 to 5 minutes. Cyclosporine, an immunosuppressant, is used to treat myasthenia gravis, not to diagnose it. Immunoglobulin G is used during acute relapses of the disorder. Azathioprine is an immunosuppressant that's sometimes used to control myasthenia gravis symptoms

he nurse has asked the patient care assistant (PCA) to ambulate a client with Parkinson's disease. The nurse observes the PCA pulling on the client's arms to get the client to walk forward. The nurse should:

Explain how to overcome a freezing gait by telling the client to march in place. Explanation: Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bedrest. A muscle relaxant is not indicated

A client has had a cerebrovascular accident (CVA) which has affected the left side of the client's brain. The nurse should assess the client for:

Expressive aphasia. Broca's area, which controls expressive speech, is located on the left side of the brain. Therefore, a client with a cerebrovascular accident in this area is likely to exhibit expressive or motor aphasia. Dyslexia, the inability of a person with normal vision to interpret written language, is thought to be due to a central nervous system defect in the ability to organize graphic symbols. Apraxia is the inability to perform purposeful movements in the absence or loss of motor power, sensation, or coordination. Agnosia is the loss of comprehension of auditory, visual, or other sensations despite an intact sensory sphere.

A short time after cataract surgery, the client has nausea. The nurse should first:

Medicate the client with an antiemetic, as ordered. A prescribed antiemetic should be administered as soon as the client reports feelings of nausea following a cataract extraction. Vomiting can increase intraocular pressure, which should be avoided after eye surgery because it can cause complications. Deep breathing is unlikely to relieve nausea. Postoperative nausea may be common; however, it doesn't necessarily pass quickly and can lead to vomiting. Telling the client to call only if vomiting occurs ignores the client's need for comfort and intervention to prevent complications.

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital Explanation: The occipital lobe is responsible for interpreting visual stimuli. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The temporal lobe controls hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain). The parietal lobe interprets and integrates sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture

The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. The nurse should:

Readminister the residual to the client and continue with the feeding. Gastric residuals are checked before administration of enteral feedings to determine whether gastric emptying is delayed. A residual of less than 50% of the previous feeding volume is usually considered acceptable. In this case, the amount is not excessive and the nurse should reinstill the aspirate through the tube and then administer the feeding. If the amount of gastric residual is excessive, the nurse should notify the physician and withhold the feeding. Disposing of the residual can cause electrolyte and fluid losses

Which of the following would not be appropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a ruptured disc?

Starting an I.V. line at keep-open rate. Explanation: An I.V. line is not required for an MRI. If a client has an I.V. line, it is usually converted to an intermittent infusion device, such as a saline lock, to avoid infiltration during transport of the client and completion of the procedure. When a contrast agent is used, the client is moved out of the cylinder, the contrast material is injected, and the client is moved back in. An MRI scan is painless. Typically the staff positions the client with pillows, blankets, earplugs, and music, to ensure client comfort, before the procedure is started. A history of past surgeries is important, especially if the surgery involved implantation of any metallic devices (e.g., implants, clips, pacemakers). Additionally, the nurse needs to assess for hearing aids, electronic devices, shrapnel, bra hooks, necklaces, jewelry, credit cards, zippers, or any type of metal that the magnet of the MRI unit would attract. Although open MRI units are now available, they are not in widespread use. Therefore, the nurse needs to determine whether the client is claustrophobic because the unit is a closed cylinder in which the client hears pops of noise. A number of clients develop claustrophobia that causes the procedure to be cancelled. If the client is claustrophobic, the procedure may need to be rescheduled after an open MRI unit is located or made available

Sodium polystyrene sulfonate (Kayexalate) is prescribed for a client following crush injury. The drug is effective if: - Weak, irregular pulse -Tall peaked T waves on ECG -The serum potassium is 4.0 meq/liter (4/0 mmol/l). - Muscle weakness is a sign

The serum potassium is 4.0 meq/liter (4/0 mmol/l). Following crush injury, serum potassium rises to high levels. Sodium polystyrene sulfonate (Kayexalate) is a potassium-binding resin. The resin combines with potassium in the colon and is then eliminated. Serum potassium levels should return to normal. Normal serum potassium values are between 3.5 and 5.2 meq/liter (3.5 to 5.2 mmol/l). Weak, irregular pulse and tall peaked T waves on ECG are signs of hyperkalemia, and muscle weakness is a sign of hypokalemia.

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report:

The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double vision is common in clients with cataracts

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?`

Trigeminal neuralgia Explanation: Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40. Bell's palsy is a disease of cranial nerve VII that produces unilateral or bilateral facial weakness or paralysis. Migraine headaches are throbbing vascular headaches that usually begin to occur in childhood or adolescence. Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Occasionally, jaw pain may indicate angina pectori

One day after cataract surgery the client is having discomfort from bright light. The nurse should advise the client to:

Use sunglasses that wrap around the side of the face when in bright light. Explanation: To prevent discomfort from bright light the client should wear sunglasses that cover the front and side of the face, thus minimizing light that comes into the eye from any direction. It is not necessary to remain in dim light or inside. Attaching sun shields or sunglasses to existing glasses will not cover the eye sufficiently and bright light will come in on the side of the face. It is not necessary to patch the affected eye

Multiple sclerosis symptoms

With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the I.V. line. Which nursing intervention protects the client without increasing the intracranial pressure (ICP)?

Wrap the hands in soft "mitten" restraints. Correct Explanation: It is best for the client to wear mitts, which help prevent the client from pulling on the I.V. without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the drawsheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP

A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:

electromyography (EMG). To help confirm ALS, the physician typically orders EMG, which detects abnormal electrical activity of the involved muscles. To help establish the diagnosis of ALS, EMG must show widespread anterior horn cell dysfunction with fibrillations, positive waves, fasciculations, and chronic changes in the potentials of neurogenic motor units in multiple nerve root distribution in at least three limbs and the paraspinal muscles. Normal sensory responses must accompany these findings. Doppler scanning, Doppler ultrasonography, and quantitative spectral phonoangiography are used to detect vascular disorders, not muscular or neuromuscular abnormalitie

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in an air-conditioned room.. Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.

A client with a ruptured intervertebral disc at L4-5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. The nurse interprets this finding as indicating which of the following? a) Postural deformity. b) Sensory changes. c) Alteration of reflexes. d) Motor changes.

standing with a flattened spine slightly titled forward and slightly flexed to the affected side indicates a postural deformity. Motor changes would include findings such as hypotonia or muscle weakness. Absent or diminished reflexes related to the level of herniation would indicate alteration in reflexes. Sensory changes would include findings such as paresthesia and numbness related to the specific tract of the herniation.

A history of which factors will complicate the recovery from a concussion? Select all that apply. -Asthma -Previous concussion - Migraines - Attention deficit/hyperactivity disorder (ADHD) -Depression -obesity

• Previous concussion • Migraines • Attention deficit/hyperactivity disorder (ADHD) • Depression Concussion recovery can be complicated by any previous brain injury, such as a previous concussion. Recovery can also be complicated by other neurologic problem, such as migraine, ADHD, and depression. Asthma and obesity have not been linked to concussion recovery.

A nursing student has been assigned care of a patient with the diagnosis of autonomic dysreflexia and is unfamiliar with this diagnosis. What would be appropriate actions by the nursing student? Select all that apply? -Search the Internet for evidence-based practice in a peer-reviewed journal. - Review the condition in a textbook and review the chart and nursing care plan. -Using a dictionary -consulting the physician -asking the family how they plan to care for the client

• Search the Internet for evidence-based practice in a peer-reviewed journal. • Review the condition in a textbook and review the chart and nursing care plan. Explanation: Nurses need to have the knowledge and to understand important considerations regarding assessment, setting of priorities, and important care measures before taking care of a patient with an unfamiliar diagnosis. Using a dictionary would only provide a diagnosis. Assessing the client's knowledge about the condition and consulting the physician or asking the family how they plan to care for the client are not appropriate ways to gain knowledge