Neurological (45, 66, 67)

A mother arrives at an ED with her 5-year old and states that the child fell off a bunk bed. A head injury is suspected, and the nurse checks the child's airway status and assess the child for early and late signs of ICP. Which is the late sign of increased ICP?

Bradycardia

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions?

Good oral hygiene is needed, including brushing and flossing

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?

I don't need to use my walker to get to the bathroom

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions?

I will drive only during the daytime

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 make which statement;

I'll try to eat my food either very warm or very cold.

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.

Acetylcysteine (Mucomyst)

A client has a neurological deficit involving the limbic system On assessment, which finding is specific to this type of deficit?

Affect is flat, with periods of emotional lability

The parent of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition?

A chronic disability characterized by impaired muscle movement and posture

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?

A positive Brudzinski's sign

A client with myasthenia gravis has become increasingly weaker. The HCP prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis). An injection of edrophonium is administered. What finding would indicate that the client is having a cholinergic crisis?

A temporary worsening of the condition

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and CSF is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?

Cloudy CSF, elevated protein, and decreased glucose levels

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?

Consistently uses adaptive equipment in dressing self.

A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?

Direct bilirubin level of 2 mg/dl

The nurse is admitting a client with Guillain-Barre 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 to the client's room?

Electrocardiographic monitoring electrodes and intubation tray

A client is recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in ICPif the nurse observes the client doing which activity?

Exhaling during repositioning

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists

Flaccid paralysis

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that CSF is present?

Fluid separates into concentric rings and tests positive for glucose

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect?

Impaired voluntary movements

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of occurrence?

Limiting bladder catheterization to once every 12 hours

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care?

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

The nurse is caring for a client with severe back pain. Codeine sulfate has been prescribed for the client. Specific to this medication, which intervention should the nurse include in the plan of care while the client is taking this medication?

Monitor bowel activity

The nurse us assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client's peripheral response to pain?

Nail bed pressure

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 the apply.

Padding the side rails of the bed, placing an airway at the bedside, placing oxygen and suction equipment at the bedside, having intravenous equipment ready for insertion of an IV catheter

A child is diagnosed with Reye's syndrome. The nurse develops a nursing care plan for the child and should include which intervention in the plan?

Providing a quiet atmosphere with dimmed lighting

The client with Guillain-Barre 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?

Providing information, giving positive feedback, and encouraging relaxation

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Reposition the infant frequently

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?

Respiratory or gastrointestinal infection during the previous month

The nurse is caring for a client who begins to experience seizure activity while in bed. What action by the nurse is contraindicated?

Restraining the clients limb

The nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristics of this type of posturing?

Rigid extension and pronation of the arms and legs

A client is taking the prescribed dose of phenytoin (Dilantin) to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of this lab result?

Slurred speech

The nurse is assigned to care for an 8-year old child with a diagnosis of a basilar skull fracture. The nurse reviews the HCPs prescription and show contact the HCP to question which prescription?

Suction as needed

The nurse develops a plan of care for a child ay risk for tonic-clonic seizures. In the plan of care. the nurse identifies seizure precautions and documents that which items need to be placed at the child's bedside?

Suctioning equipment and oxygen

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. Which client activity suggest that teaching is most effective?

Taking medications as sheduled

The nurse notes documentation that a child with meningitis is exhibiting a positive Kernig's sign. Which observation is characteristic of this sign?

The child is not able to extend the leg when the thigh is flexed anteriorly at the hip

The nurse is assigned to care for a client with complete right-sided hemiparesis. Which characteristics are associated with this condition? Select all that apply.

The client is aphasic, the client has weakness in the face and tongue, the client has weakness on the right side of the body

The home health nurse visits a client who is taking phenytoin 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?

There is the potential of decreased effectiveness of birth control pills while taking phenytoin

The nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

Time the seizure, stay with the child, move furniture away from the child.

The client arrives at the ED complaining of back spasms. The client states, "I have been taking 2-3 aspirins every 4 hours for the last week, and it hasn't helped my back." Since aspirin intoxication is suspected, the nurse should assess the client for which manifestation?

Tinnitus

Meperidine hydrochloride (Demerol) has been prescribed for a client to treat pain. What are side/adverse effects of this medication? Select all that apply.

Tremors, drowsiness, hypotension

A client with trigeminal neuralgia is being treated with carbamazepine (Tegretol), 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication?

WBC count, 3000 cells/mm

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?

We need to remind him to turn his head to scan the lost visual field.