Neurological System

A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? "Get medication to bring down your sodium levels." "Have your heart checked." "Stop smoking." "Eat a nutritious diet."

"Stop smoking."

A client with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? Positive Babinski reflex along with spastic extremities Absence of reflexes along with flaccid extremities Hyperreflexia along with spastic extremities Spasticity of all four extremities

Absence of reflexes along with flaccid extremities

A critically ill client shows signs and symptoms of altered level of consciousness (LOC), hypertension, fever, and difficulty in breathing. Identify the phase of neurologic deficit in which the client is. Irreversible Recovery Acute Chronic

Acute

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What dysrhythmia does this client most likely have? Atrial fibrillation Bundle branch block Ventricular tachycardia Supraventricular tachycardia

Atrial fibrillation

A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes Flexor spasm, clonus, and negative Babinski reflex Blurred vision, intention tremor, and urinary hesitancy Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

Blurred vision, intention tremor, and urinary hesitancy

A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state? Urinary incontinence Body rigidity Epileptic cry Confusion

Confusion

Which is a sympathetic effect of the nervous system? Dilated pupils Increased peristalsis Decreased blood pressure Decreased respiratory rate

Dilated pupils

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? Magnetic resonance imaging (MRI) Electromyography (EMG) Electroencephalography (EEG) Computed tomography (CT)

Electroencephalography (EEG)

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? Comprehend spoken words Form words that are understandable or comprehend spoken words Form words that are understandable Speak at all

Form words that are understandable or comprehend spoken words

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? Parietal Frontal Temporal Occipital

Frontal

Which cerebral lobes is the largest and controls abstract thought? Frontal Parietal Temporal Occipital

Frontal

A patient with a brain tumor is complaining of headaches that are worse in the morning. What does the nurse know could be the reason for the morning headaches? Migraines Increased intracranial pressure Dehydration The tumor is shrinking.

Increased intracranial pressure

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? Administers an oral analgesic for pain Administers acetaminophen (Tylenol) for headache Irrigates the wound to remove debris Shaves the hair around the wound

Irrigates the wound to remove debris

A nurse is caring for a patient diagnosed with a haemorrhagic stroke. What goal is a priority for this patient? Relieve anxiety. Relieve sensory deprivation. Maintain and improve cerebral tissue perfusion. Maintain adequate urine output.

Maintain and improve cerebral tissue perfusion.

Which cranial nerve is responsible for muscles that move the eye and lids? Oculomotor Facial Vestibulocochlear Trigeminal

Oculomotor

What phase of a neurologic deficit begins when the client's condition is stabilized? Chronic Recovery Acute Terminal

Recovery

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? Disturbed sensory perception (visual) Risk for injury Dressing or grooming self-care deficit Impaired verbal communication

Risk for injury

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? Drowsiness is normal for the first week after discharge. Mild, intermittent seizures can be expected. Take ibuprofen for complaints of a serious headache. Take antihypertensive medication as prescribed.

Take antihypertensive medication as prescribed.

Which cerebral lobe contains the auditory receptive areas? Temporal Parietal Occipital Frontal

Temporal

A nurse is collaborating with the interdisciplinary team to help manage a client's recurrent headaches. What aspect of the client's health history should the nurse identify as a potential contributor to the client's headaches? The client takes vasodilators for the treatment of angina. The client leads a sedentary lifestyle. The client takes vitamin D and calcium supplements. The client has a pattern of weight loss followed by weight gain.

The client takes vasodilators for the treatment of angina.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? After the nurse has received the discharge orders The day the patient has the stroke After the patient has passed the acute phase of the stroke The day before the patient is discharged

The day the patient has the stroke

Which of the following is a sign of increasing ICP? Decreasing systolic blood pressure Bradypnea Widening pulse pressure Tachycardia

Widening pulse pressure

Clients who have suffered neurologic deficits from various causes, including cerebrovascular accident, closed head injury, etc., have all experienced which phase of neurologic deficit? chronic acute recovery management

acute

A typical spinal cord functions as a "highway" for sensory and descending motor neurons, providing conduction of impulses to and from the brain. The spinal cord is surrounded and protected by bony vertebrae, and ends between the: first and second lumbar vertebrae. fourth and fifth thoracic vertebrae. first and second cervical vertebrae. first and second thoracic vertebrae.

first and second lumbar vertebrae.

A nurse is noting from a client's neurologic assessment findings that the client's motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit? midbrain subarachnoid space pons medulla oblongata

medulla oblongata

A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke? severe exploding headache difficulty finding appropriate words slurred speech left-sided weakness

severe exploding headache

The nurse is assessing the client's pupils following a sports injury. Which assessment findings indicate a neurologic concern? Select all that apply. absence of pupillary response unequal pupils quick pupil reaction pinpoint pupils pupil reacts to light

unequal pupils pinpoint pupils absence of pupillary response

A client with neurologic disorder is at risk for disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. Which nursing intervention facilitates the functional use of the limbs? Keep extremities at neutral position. Remove and reapply elastic stockings. Use a flotation mattress. Change client's position.

Keep extremities at neutral position.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? Right-sided cerebrovascular accident (CVA) Left-sided cerebrovascular accident (CVA) Completed Stroke Transient ischemic attack (TIA)

Left-sided cerebrovascular accident (CVA)

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern? Pulse oximetry decrease from 99% to 97% room air Urinary output increase from 40 to 55 mL/hr Temperature increase from 98.0°F to 99.6°F Heart rate decrease from 100 to 90 bpm

Temperature increase from 98.0°F to 99.6°F

A nurse is assisting a client with a neurologic deficit to use a flotation mattress. What is the primary purpose of this device in the client's care? To help ensure the safe transfer of the client To keep bedding and linens dry and protect the client's skin integrity To position the lower limbs in a way that prevents plantar flexion To relieve pressure for the client when he or she is lying and sitting

To relieve pressure for the client when he or she is lying and sitting

A client with a neurologic deficit is at risk for urinary retention because her sensation of the urge to void is compromised. The nurse is aware that the client will optimally need to void when her bladder contains how much fluid? 150 to 300 mL 300 to 450 mL 450 to 600 mL 600 to 750 mL

150 to 300 mL

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? 2:00 p.m. 3:00 p.m. 4:00 p.m. 7:00 p.m.

4:00 p.m.

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache? Perform the Heimlich maneuver. Use pressure-relieving pads or a similar type of mattress. Apply warm or cool cloths to the forehead or back of the neck. Maintain hydration by drinking eight glasses of fluid a day.

Apply warm or cool cloths to the forehead or back of the neck.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? So that the patient will not have a respiratory arrest Because hypoxemia can create or worsen a neurologic deficit of the spinal cord To increase cerebral perfusion pressure To prevent secondary brain injury

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? Cerebral aneurysm Cardiogenic emboli Small artery thrombosis Large artery thrombosis

Cerebral aneurysm

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? Drainage of cerebrospinal fluid from the ears Drainage of cerebrospinal fluid from the nose Bruising under the eyes Ecchymosis over the mastoid

Ecchymosis over the mastoid

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? Unclassified seizure Absence seizure Generalized seizure Focal seizure

Generalized seizure

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? Bradycardia A bounding pulse Lethargy and stupor Hypertension

Lethargy and stupor

An older adult patient has been brought to the emergency department (ED) after being found unconscious by a neighbor. What action should be the ED nurse's highest priority in the care of this patient? Maintain the patency of the patient's airway. Establish IV access. Assess the patient's level of consciousness (LOC). Obtain a full set of vital signs.

Maintain the patency of the patient's airway.

A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? Migraines often coincide with menstrual cycle. Tension headaches are easier to treat. Headaches are the most common type of reported pain. Cluster headaches can cause severe debilitating pain.

Migraines often coincide with menstrual cycle.

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? Sciatic nerve pain Herniation Paresthesia Paralysis

Paresthesia

The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client? Cafergot Prednisone Phenytoin Dexamethasone

Phenytoin

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? Pain level Pulse and blood pressure Respiratory pattern Numbness and tingling

Pulse and blood pressure

The spouse of a client with a neurologic deficit reports fatigue and exhaustion from constant care. Which of the following strategies would the nurse be most likely to recommend to the spouse? Hospice services Institutionalization of the client Temporary move of the client to a relative's home Respite care

Respite care

A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? Pureed food with water Thin liquids only Solid food with thin liquids Semisolid food with thick liquids

Semisolid food with thick liquids

After a seizure, the nurse should place the patient in which of the following positions to prevent complications? Semi-Fowler's, to promote breathing Side-lying, to facilitate drainage of oral secretions High Fowler's, to prevent aspiration Supine, to rest the muscles of the extremities

Side-lying, to facilitate drainage of oral secretions

A patient is admitted to the Neuro ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What does the nurse suspect? Hypoactivity in reflexes. Spinal shock. Hypovolaemia. Hypertension.

Spinal shock

The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? The client has serous drainage from the nose. The client has ecchymosis in the periorbital region. The client has an elevated temperature. The client has cerebral spinal fluid (CSF) leaking from the ear.

The client has cerebral spinal fluid (CSF) leaking from the ear.

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The brain stem consists of the midbrain, pons, and medulla oblongata. Which part of the brain contains regulatory centers for heartbeat, vasomotor activity, and breathing? medulla oblongata cerebral cortex pons midbrain

medulla oblongata

A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from occurring? Placing the patient on a fluid restriction Assisting the patient with passive range of motion exercises Applying thigh-high elastic stockings Administering an antifibrinolytic agent

Applying thigh-high elastic stockings

Which of the following types of skull fractures may be evident by Battle's sign? Comminuted Basilar Simple Depressed

Basilar

A client with a spinal cord injury has full head and neck control when the injury is at which level? C1 C2 to C3 C4 C5

C5

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? The type of anticonvulsant prescribed to manage the epileptic condition Recent stress level Recent weight gain and loss Compliance with the prescribed medication regimen

Compliance with the prescribed medication regimen

A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? Hyperthermia Disturbed sensory perception Adult failure to thrive Post-trauma syndrome

Disturbed sensory perception

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? Administer Percocet as ordered. Administer morning dose of anticonvulsant. Elevate the head of the bed. Complete a head-to-toe assessment.

Elevate the head of the bed.

Splints have been prescribed for a client who is at risk of developing foot drop following a spinal cord injury. The nurse should remove and reapply the splints when? Every 2 hours At the client's request Each morning and evening One hour prior to mobility exercises

Every 2 hours

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? Evidence of hemorrhagic stroke Previous thrombolytic therapy within the past 12 months Evidence of stroke evolution Blood pressure of ≥ 180/110 mm Hg

Evidence of hemorrhagic stroke

The nurse is caring for a client who has had intracranial surgery and is being discharged home. What instructions would the nurse give the client besides instructions on the medication? You can cover the incision with your hair. You can expect swelling above the incision. Expect sensory changes, such as hearing a clicking sound, around the bone flap. Understand that headaches are uncommon.

Expect sensory changes, such as hearing a clicking sound, around the bone flap.

A patient is scheduled for a myelogram. The nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse knows that the preparation is similar to which of the following neurological tests? Cerebral angiography. Magnetic resonance imaging (MRI). Electroencephalography (EEG). Lumbar puncture.

Lumbar puncture.

A 37-year-old man is brought to the clinic by his wife because he is experiencing loss of motor function and sensation. The health care provider suspects the client has a spinal cord tumor and hospitalizes him for diagnostic testing. In light of the need to rule out spinal cord compression from a tumor, the nurse will most likely prepare the client for what test? Lumbar puncture Anterior-posterior x-ray MRI Ultrasound

MRI

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury? Administer opioids PRN as prescribed. Pad the side rails of the client's bed. Restrain the client as ordered. Arrange for friends and family members to sit with the client.

Pad the side rails of the client's bed.

A client, diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in health status would the nurse attribute to the client's metastatic brain disease? Chronic pain Fixed pupils Respiratory distress Personality changes

Personality changes

A client has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? Place the client in the prone position for 30 minutes/day. Assist the client in acutely flexing the thigh to promote movement. Place the client's hand in pronation. Place a pillow in the axilla when there is limited external rotation.

Place a pillow in the axilla when there is limited external rotation.

A client with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action? Helping the client perform deep breathing and coughing exercises Positioning the client with the head of the bed elevated 45 degrees Administering IV morphine sulfate to prevent headache Limiting fluids for the next 12 hours

Positioning the client with the head of the bed elevated 45 degrees

Stephen Oswald, a 68-year-old retired salesman, was brought by squad into the acute care facility where you practice nursing. His wife accompanies him and relates how Stephen reported a severe headache and then was unable to talk or move his right arm and leg. His wife indicates Mr. Oswald has hypertension. What should be your focus of management during this phase? Preventing further neurologic damage Reporting to the physician Assessing Mr. Oswald's vital signs Destabilizing Mr. Oswald

Preventing further neurologic damage

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware? Hypersensitivity to painful stimuli Reduction in cerebral blood flow Increased cerebral metabolism Hyperactive deep tendon reflexes

Reduction in cerebral blood flow

A nurse in the ICU is providing care for a client who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the client is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? Report this to the health care provider as a possible sign of clinical deterioration. Provide more stimulation to the client and monitor the client closely. Report this finding to the health care provider as an indication of decreased metabolism. Recognize this as the expected clinical course of a hemorrhagic stroke.

Report this to the health care provider as a possible sign of clinical deterioration.

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? IV VI V III

V

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? Therapy is not necessary prophylactically and should only be used if the person develops symptoms. Within 72 hours after exposure Within 24 hours after exposure Within 48 hours after exposure

Within 24 hours after exposure

A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? Flaccidity Decorticate posturing Weak muscular tone Abnormal posture

flaccidity

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: nuchal rigidity and Kernig's sign. motor loss in the legs that exceeds that in the arms. raccoon's eyes and Battle sign. pupillary changes.

raccoon's eyes and Battle sign.

A physician has ordered home health and physical therapy for an older adult who will be discharged home following an acute stroke. The nurse's discharge teaching should include instructions about: the daily exercise routine for the physical therapist to follow. calling the home health nurse with any questions instead of bothering the physician and therapist. avoiding any social activity until the effects of the stroke have reversed. reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns.

reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns.

The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care? "The physician coordinates all the care delivered." "All hospice clients die at home." "Hospice care uses a team approach and provides complete care." "Clients and families are the focus of hospice care."

"Clients and families are the focus of hospice care."

A client has been exhibiting neurological symptoms for several weeks and the neurologist is admitting the client to the hospital for extensive testing. Since diagnostics have not yet revealed the cause of the symptoms, which client statement would indicate the need for further client education? "It's good to know the continual tingling in my fingers and toes is not connected with my nervous system!" "I need to be careful with my allergy to seafood!" "There are several types of tests to see what's causing the tingling in my fingers and toes." All of the comments indicate need for further client education.

"It's good to know the continual tingling in my fingers and toes is not connected with my nervous system!"

A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test? "You need to fast for 8 hours prior to the test." "You will need to lie still throughout the procedure." "There will be a lot of noise during the test." "No metal objects can enter the procedure room."

"You will need to lie still throughout the procedure."

A client has a total score of 60 on the Modified Barthel Index. The nurse knows to help coordinate care involving what maximum number of hours per week for help for the client?

20

A client fell at home and sustained a head injury. The client exhibits signs and symptoms of head trauma with indications of increased ICP. What is the normal ventricular ICP? 16 to 20 mm Hg 31 to 40 mm Hg 5 to 15 mm Hg 21 to 30 mm Hg

5-15 mm Hg

The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate that the client is in comatose state? D+ 17 or lower 7 D

7

A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? Generalized seizure Focal seizure Unclassified seizure Absence seizure

Absence seizure

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? Supine positioning Passive range-of-motion exercises to prevent contractures Absolute bed rest in a quiet, nonstimulating environment Early initiation of physical therapy

Absolute bed rest in a quiet, nonstimulating environment

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? Autonomic dysreflexia Orthostatic hypotension Thrombophlebitis Spinal shock

Autonomic dysreflexia

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? Brain CT scan or MRI Chest x-ray Prothrombin level Lumbar puncture

Brain CT scan or MRI

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful? Conception is not impaired; the birth process is determined with the physician. Adoption is an option to complete your family but not put your life in jeopardy. Birth via surrogate is best because your baby can be implanted in another woman. Sterilization is best; it would be difficult to care for a baby in your condition.

Conception is not impaired; the birth process is determined with the physician.

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply. Visual disturbances Epistaxis (nosebleed) Confusion Sudden ear pain Sudden numbness

Confusion Sudden numbness Visual disturbances

A middle-aged woman has sought care from her primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? Difficulty in coordination Cognitive declines Personality changes Contractures

Difficulty in coordination

A patient is exhibiting bradykinesia, rigidity, and tremors related to Parkinson's disease. The nurse understands that these symptoms are directly related to what decreased neurotransmitter level? Phenylalanine Serotonin Dopamine Acetylcholine

Dopamine

A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has? Dysfunction of the spinal accessory nerve Dysfunction of the facial nerve Dysfunction of the vagus nerve Dysfunction of the acoustic nerve

Dysfunction of the vagus nerve

Which term refers to a method of recording, in graphic form, the electrical activity of a muscle? Electromyography Electrocardiography Electrogastrography Electroencephalography

Electromyography

A client with MS has been admitted to the hospital following an acute exacerbation. When planning the client's care, the nurse addresses the need to enhance the client's bladder control. What aspect of nursing care is most likely to meet this goal? Administer anticholinergic drugs as prescribed. Perform intermittent catheterization q6h. Avoid foods that change the pH of urine. Establish a timed voiding schedule.

Establish a timed voiding schedule.

Which is a nonmodifiable risk factor for ischemic stroke? Smoking Gender Hyperlipidemia Atrial fibrillation

Gender

healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Heparin sodium Methyldopa Dexamethasone Phenytoin

Heparin sodium

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? High in protein and low in carbohydrate At least 50% carbohydrate Restricts protein to 10% of daily caloric intake Low in fat

High in protein and low in carbohydrate

While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the clients' cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action? Page the health care provider and report this sign of infection. Inform the surgeon of the possibility of a dural leak. Reposition the client to prevent further hemorrhage. Reinforce the dressing and reassess in 1 to 2 hours.

Inform the surgeon of the possibility of a dural leak.

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? It is the only device that can be applied for stabilization of a spinal fracture. It is less bulky and traumatizing for the patient to use. The patient can remove it as needed. It allows for stabilization of the cervical spine along with early ambulation.

It allows for stabilization of the cervical spine along with early ambulation.

During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? It indicates an injury at the midbrain level. It indicates paralysis on the right side of the body. It indicates paralysis of cranial nerve X (CN X). It suggests onset of metabolic problems.

It indicates an injury at the midbrain level.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? Positioning the client to prevent airway obstruction Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess Keeping the client in one position to decrease bleeding Maintaining the client in a quiet environment

Keeping the client in one position to decrease bleeding

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? Pregabalin (Lyrica) Heparin Lioresal (Baclofen) Diphenhydramine (Benadryl)

Lioresal (Baclofen)

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? Open the client's jaws to insert an oral airway. Restrain the client to prevent injury. Loosen the client's restrictive clothing. Place client in high Fowler position.

Loosen the client's restrictive clothing.

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? 50 to 100 mL/h More than 200 mL/h 100 to 150 mL/h 150 to 200 mL/h

More than 200 mL/h

An emergency department nurse has just received a call from the Ambulance Service that they are transporting a 17-year-old male who has just sustained a spinal cord injury. The nurse recognises that the most common cause of this type of injury is what? Injuries due to a fall. Sports-related injuries. Acts of violence. Motor vehicle accidents.

Motor vehicle accidents

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord? Multiple sclerosis Creutzfeldt-Jakob disease Parkinson disease Huntington disease

Multiple sclerosis

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? Pain upon ankle dorsiflexion of the foot Neck flexion produces flexion of knees and hips Inability to stand with eyes closed and arms extended without swaying Numbness and tingling in the lower extremities

Neck flexion produces flexion of knees and hips

Following a spinal cord injury a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? Stabilize the head in a lateral position. Reattach the pin to prevent further head trauma. Notify the neurosurgeon of the occurrence. Complete the pin site care to decrease risk of infection.

Notify the neurosurgeon of the occurrence.

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage her potential sensory and perceptional difficulties? Keep the lighting in the client's room low. Place the client's extremities where she can see them. Approach the client on the side where vision is impaired. Place the client's clock on the affected side.

Place the client's extremities where she can see them.

A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? Arrange for the client to receive a low residue diet. Suction the client following each meal. Withhold liquids until the client has finished eating. Position the client upright during feeding.

Position the client upright during feeding.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? Seizure was 1 minute in duration including tonic-clonic activity. Seizure began at 1300 hours. Sleeping quietly after the seizure The client cried out before the seizure began.

Seizure was 1 minute in duration including tonic-clonic activity.

A client with Parkinson disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method? Total parenteral nutrition (TPN) Minced foods and a fluid restriction Semisolid food with thick liquids Provision of a low-residue diet

Semisolid food with thick liquids

Which condition occurs when blood collects between the dura mater and arachnoid membrane? Epidural hematoma Subdural hematoma Intracerebral hemorrhage Extradural hematoma

Subdural hematoma

Which condition occurs when blood collects between the dura mater and arachnoid membrane? Subdural hematoma Epidural hematoma Extradural hematoma Intracerebral hemorrhage

Subdural hematoma

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? The client received a blood transfusion. The client's analgesia regimen was recently changed. The client's urinary catheter became occluded. The client was not repositioned during the night shift.

The client's urinary catheter became occluded.

A client diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the client's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable? The specific hormones secreted by the tumor The client's pre-existing health status Whether the tumor utilizes aerobic or anaerobic respiration Whether the tumor is primary or the result of metastasis

The specific hormones secreted by the tumor

In your assessment of a 39-year-old victim of a motor-vehicle collision, he directly and accurately answers your questions. Beginning at his head, you note a contusion to his forehead; the client reports a headache. As you assess his pupils, what reaction would confirm your suspicion of increasing intracranial pressure? Equal response Rapid response Sluggish response Unequal response

Unequal response

A nursing instructor is teaching the senior nursing class about clients with neurologic disorder. The instructor tells the students that these clients are at risk of disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. What nursing intervention helps prevent plantar flexion? Use of parallel bars or a walker Application of an abdominal binder Use of a flotation mattress Use of a footboard

Use of a footboard

A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? Administration of inotropic drugs Preparation for emergency craniotomy Fluid resuscitation Watchful waiting and close monitoring

Watchful waiting and close monitoring

The nurse is performing stroke risk screenings at a hospital open house. Identification of high-risk individuals is the goal of the screenings. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at highest risk for a stroke? White woman, age 60 with history of excessive alcohol intake Black man, age 50 with history of smoking White man, age 60 with history of uncontrolled hypertension Black man, age 60, with history of diabetes

White man, age 60 with history of uncontrolled hypertension

A neurologic deficit is best defined as a deficit of the: central nervous system with absent functioning. peripheral nervous system with decreased or impaired functioning. central nervous system that affects one body system. central and peripheral nervous systems with decreased, impaired, or absent functioning.

central and peripheral nervous systems with decreased, impaired, or absent functioning.

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? smelling chewing tasting swallowing

chewing

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: diminished responsiveness. pupillary changes. decreasing blood pressure. elevated temperature.

diminished responsiveness.

Cerebrospinal fluid (CSF) is manufactured in the ventricles and constantly circulates around the brain and spinal cord. The CSF functions as a cushion to protect structures and maintain relatively consistent intracranial pressure. Where does CSF circulate? arachnoid space subdural space subpial space subarachnoid space

subarachnoid space

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the: parasympathetic nervous system. endocrine system. sympathetic nervous system. musculoskeletal system.

sympathetic nervous system.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in motor ability. thought content. emotional status. intellectual function.

thought content

A public health nurse offers public education in high school classes on personal responsibility in preventing head injuries as a way of life. While avoiding alcohol and drugs not only complies with existing law for minors, it also is an available intervention to prevent head injuries. What other measures are available to prevent head injuries? None of the options is correct. holding infants tightly while riding in an automobile lowering neck restraints on seatbacks using seatbelts

using seatbelts

A 78-year-old resident of a long-term care facility has left the majority of his supper tray untouched, and the nurse has asked him about the reason for this. The resident states, "For a long time now, food just doesn't taste as well as it used to." The nurse should be aware that the etiology of this problem is most likely to involve: Cranial nerve dysfunction An upper motor neuron lesion Age-related changes to the neurological system The development of a posterior spinal nerve lesion

Age-related changes to the neurological system

A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken together with warfarin will produce which type of interaction? May increase cerebral blood flow, causing migraine headaches No drug to drug interactions, may be taken together Can cause platelet aggregation, increasing the risk of blood clotting Can greatly increase the international normalization ratio (INR), increasing the risk of bleeding

Can greatly increase the international normalization ratio (INR), increasing the risk of bleeding

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? Myelogram Electroencephalogram Echoencephalography Cerebral angiography

Cerebral angiography

A neurological nurse is conducting a focused neurological assessment of a patient who has just been admitted to the rehabilitative facility. During this assessment, the nurse has asked the patient to swallow and has tested the patient's gag reflex with a tongue depressor. These assessments test the function of which of the patient's cranial nerves? I (olfactory) and III (oculomotor) VI (abducens) and VII (facial) IX (glossopharyngeal) and X (vagus) IV (trochlear) and V (trigeminal)

IX (glossopharyngeal) and X (vagus)

The nurse in an extended care facility is planning the daily activities of a client with post-polio syndrome. The nurse recognizes the client will best benefit from physical therapy when it is scheduled at what time? In the early evening Immediately after meals Before bedtime In the morning

In the morning

In the aggressive treatment for increased ICP, IV therapy can be an instrumental tool in decreasing increased ICP. What type of IV solution would you expect a physician to order to maintain cerebral tissue perfusion? Choose all correct options. Normal saline Hypotonic saline Lactated Ringer's DW

Normal saline Lactated Ringer's

An elderly client is being discharged home. The client lives alone and has atrophy of his olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home? A smoke detector Baseboard heaters Nonslip mats Grab bars

A smoke detector

The nurse is caring for a client who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve? Trigeminal Trochlear Hypoglossal Acoustic

Acoustic

A client with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process? Cyclosporine Ampicillin Acyclovir Cyclobenzaprine

Acyclovir

The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? Audio hallucinations Respiratory depression Labile BP Falls

Falls

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? Ischemic Hemorrhagic Right-sided Left-sided

Ischemic

Which of the following would the nurse recognize as being the least likely reason for the procedure shown in the accompanying image? To evacuate a hematoma To aspirate a brain abscess To confirm a skull fracture To make a bone flap in the skull

To confirm a skull fracture

A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI? "My legs go numb sometimes when I sit too long." "I am trying to quit smoking and have a patch on." "I have been trying to get an appointment for so long." "I have not had anything to eat or drink since 3 hours ago

"I am trying to quit smoking and have a patch on."

The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following? "It is a test for balance." "It is a test for motor ability." "It is a test for muscle strength." "It is a test for coordination."

"It is a test for balance."

The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding? 3+ 0 2+ 1+

1+

A 65-year-old client was hit in the head with a ball and knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified? Subacute Acute Intracerebral Chronic

Acute

Paramedics have brought an intubated patient to the emergency department following a head injury due to acceleration-deceleration motor vehicle accident. Increased intracranial pressure (ICP) is suspected. An appropriate nursing intervention would include what? Perform endotracheal suctioning every hour Teach the patient to perform the Valsalva maneuver Keep the head of bed (HOB) flat at all times Administer antipyretics on a p.r.n. basis

Administer antipyretics on a p.r.n. basis

A client is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate? Implement distraction techniques. Apply a hot pack to the client's scalp. Administer morphine sulfate as prescribed. Reposition the client in a prone position.

Administer morphine sulfate as prescribed.

Which medication classification is used preoperatively to decrease the risk of postoperative seizures? Anticonvulsants Corticosteroids Diuretics Antianxiety

Anticonvulsants

The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication? Impaired skin integrity Autonomic dysfunction Cognitive deficits Hemorrhage

Autonomic dysfunction

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? Extreme thirst Intake and output Nutritional status Body temperature

Body temperature

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? Brain tumor Hypostatic pneumonia Trigeminal neuralgia Epilepsy

Brain tumor

The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? Epistaxis Unilateral facial numbness Periorbital edema Bruising over the mastoid

Bruising over the mastoid

A patient exhibiting an uncoordinated gait has presented at the clinic. The nurse knows that what brain structure has the function of balance and coordination? Pons Cerebellum Midbrain Medulla

Cerebellum

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? Disassociation Depression Confusion Uncertainty

Depression

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for? Diarrhea Dyskinesia Lactose intolerance Pruritus

Dyskinesia

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate? Edema to the head with bruising of the mastoid process Edema to the head with fixed pupils Edema to the head with a large scalp laceration Edema to the head and a blackened eye

Edema to the head with bruising of the mastoid process

A client, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? Emotional and personality changes Risk for stroke Metastasis Pathologic bone fractures

Emotional and personality changes

An emergency department (ED) nurse has administered an ordered bolus of tissue plasminogen activator (tPA) to a male patient who was diagnosed with stroke. During the administration of tPA, the nurse should prioritize assessments related to what problem? Fluid overload Peripheral edema Acute pain Hemorrhage

Hemorrhage

A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client? Impaired Home Maintenance Disturbed Sleep Pattern Hopelessness Altered Nutrition

Hopelessness

A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? Loss of hearing, tinnitus, and vertigo Loss of hearing, increased sodium retention, and hypertension Loss of vision, headache, and tachycardia Loss of vision, change in mental status, and hyperthermia

Loss of hearing, tinnitus, and vertigo

A patient is admitted to the Neuro ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure? PET scan Ultrasound MRI X-ray

MRI

The most important nursing priority of treatment for a patient with an altered LOC is to: Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. Position the patient to prevent injury and ensure dignity. Prevent dehydration and renal failure by inserting an IV line for fluids and medications. Maintain a clear airway to ensure adequate ventilation.

Maintain a clear airway to ensure adequate ventilation.

A Community Health Nurse is giving an educational presentation at the local senior citizens club. The nurse is speaking about stroke. What non-modifiable risk factors for stroke should the nurse list? Male gender Over age 50 Smoking Race

Male gender

Which of the following assessment tools should the nurse use to perform a neurologic assessment? Cutaneous triggering Mini-Mental Status Examination Mechanical lift Credé's maneuver

Mini-Mental Status Examination

To meet the sensory needs of a client with viral meningitis, which of the following should the nurse do? Choose the correct option. Minimize exposure to bright lights and noise Avoid physical contact with family members Promote an active range of motion Increase environmental stimuli

Minimize exposure to bright lights and noise

A client is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the client's LOC is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding? Understand that the surgery may have been unsuccessful. Recognize the need to refer the client to the palliative care team. Recognize that this may represent the peak of postsurgical cerebral edema. Alert the surgeon to the possibility of an intracranial hemorrhage.

Recognize that this may represent the peak of postsurgical cerebral edema.

The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? Avoiding naps during the day Taking a hot bath at least once daily Increasing the dose of muscle relaxants Resting in an air-conditioned room whenever possible

Resting in an air-conditioned room whenever possible

The nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge? The patient should prioritize energy conservation and remain on bed rest if possible. The patient should perform frequent physical activity but avoid becoming fatigued. The patient should attempt to maintain prediagnosis levels of activity and mobility. The patient should perform exercises that are brief but high-intensity.

The patient should perform frequent physical activity but avoid becoming fatigued.

A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of: Tremors and muscle rigidity Visual disturbances and muscle weakness Increasing forgetfulness and confusion Fatigue and respiratory difficulties

Tremors and muscle rigidity

A client has been having cluster headaches intermittently over the last year. In an effort to determine the trigger for the cluster headaches, the client has maintained a journal of all oral consumption. What on the list would the nurse suspect could be triggering headaches? alcoholic beverages commercially-prepared food spicy foods dairy products

alcoholic beverages

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, the nurse anticipates that the liver will: convert glycogen to glucose for immediate use. cease function and shunt blood to the heart and lungs. produce a toxic byproduct in relation to stress. maintain a basal rate of functioning.

convert glycogen to glucose for immediate use.

A client has been in a coma since being in a motor vehicle accident. Emergency surgery relieved intracranial pressure but, to date, the client has not regained consciousness. Which motor response is indicative of the most serious condition? decorticate decerebrate flaccidity comatose

flaccidity

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following? "The blood will replace the cerebral spinal fluid that has leaked out." "The blood provides moisture at the site, which encourages healing." "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." "The blood can repair damage to the spinal cord that occurred with the procedure."

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." "The sudden, severe headache increases muscle tone and can cause further nerve damage." "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state."

"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? Position the client with the head turned toward the side of the brain tumor. Provide sensory stimulation. Administer stool softeners. Encourage coughing and deep breathing.

Administer stool softeners.

A client with a metastatic brain tumor of the frontal lobe experiences a generalized seizure for the first time. The nurse should prepare for what action? A STAT MRI STAT computed tomography (CT) health care provider Intubation Administration of anticonvulsans

Administration of anticonvulsants

Which nursing intervention is the priority for a client in myasthenic crisis? Assessing respiratory effort Ensuring adequate nutritional support Administering intravenous immunoglobin (IVIG) per orders Preparing for plasmapheresis

Assessing respiratory effort

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? Check the equipment. Continue the assessment because no actions are indicated at this time. Contact the physician to review the care plan. Document the reading because it reflects that the treatment has been effective.

Check the equipment.

A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? 12-lead electrocardiogram Carotid ultrasound study Noncontrast computed tomogram Transcranial Doppler flow study

Noncontrast computed tomogram

A patient who suffered an ischemic stroke now has disturbed sensory perception. What should the nurse caring for this patient be aware of? The patient should be approached on the opposite side of where the visual perception is intact in order to increase perception and vision. Attention to the affected side should be minimised. The patient should avoid repetitious turning of his head in the direction of the defective visual field in order to minimise shoulder subluxation. The patient should be approached on the side where visual perception is intact.

The patient should be approached on the side where visual perception is intact.

A client who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? Urinary catheters should not remain in place for more than 7 days. Urinary catheters often lead to urinary tract infections. Urinary function is permanently lost following an SCI. Overuse of urinary catheters can exacerbate nerve damage.

Urinary catheters often lead to urinary tract infections.

The nurse caring for an 80-year-old client knows that the client has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation? Damage to cranial nerve VIII Adverse medication effects An undiagnosed cerebrovascular disease in early adulthood Age-related neurologic changes

Age-related neurologic changes

A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache? As soon as the client senses the onset of symptoms Twenty to 30 minutes after the onset of symptoms As soon as the client's pain becomes unbearable When the client senses his or her symptoms peaking

As soon as the client senses the onset of symptoms

The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? Calcium carbonate 1,000 mg PO b.i.d. Naproxen 250 PO b.i.d. Aspirin 81 mg PO o.d. Lorazepam 1 mg SL b.i.d. PRN

Aspirin 81 mg PO o.d.

A 73-year-old client is visiting the neurologist. The client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in her left carotid artery. What is the term for the auscultated discovery? TIA Atherosclerotic plaque Bruit Diplopia

Bruit

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? Application of Halo traction Burr holes Hypophysectomy Insertion of Crutchfield tongs

Burr holes

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve? CN III CN IV CN II CN I

CN I

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? Inform the nurse-manager. Call the physician immediately. Sit with the patient for a few minutes. Administer an analgesic.

Call the physician immediately

The nurse responds to the call light of a client who has had a cervical discectomy earlier in the day. The client states that she is having severe pain that had a sudden onset. What is the nurse's most appropriate action? Administer a dose of an NSAID. Remove the dressing to assess the surgical site. Call the surgeon to report the client's pain. Palpate the surgical site.

Call the surgeon to report the client's pain.

A client exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this client's health problem? Dysfunction of the medulla A lesion in the pons A hemorrhage in the midbrain Cerebellar dysfunction

Cerebellar dysfunction

A client with a brain tumor is experiencing changes in cognition that require the nurse to reorient the client frequently. When performing this task, which devices would be appropriate for the nurse to use? Select all that apply. Calendar Common words Client's clothing Picture of the client's family Clock

Client's clothing Picture of the client's family Clock Calendar

A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test? Orange juice Coffee Eggs Toast

Coffee

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client? Altered Nutrition: Less Than Body Requirements Risk for Electrolyte Imbalance Impaired Swallowing Risk for Fluid Volume Deficit

Impaired Swallowing

A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA? Nausea and vomiting Respiratory distress Impaired muscle coordination Severe headache

Impaired muscle coordination

A client has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The client has just exhibited seizure activity for the first time. What is the nurse's priority response to this event? Teach the client's family about the relationship between brain tumors and seizure activity. Ensure that the client is housed in a private room. Identify the triggers that precipitated the seizure. Implement precautions to ensure the client's safety.

Implement precautions to ensure the client's safety.

A client has just returned to the unit from the PACU after surgery for a tumor within the spine. The client complains of pain. When positioning the client for comfort and to reduce injury to the surgical site, the nurse will position to client in what position? In a flat side-lying position In the reverse Trendelenburg position In the high Fowler position In the Trendelenburg position

In a flat side-lying position

The nurse is caring for a 55-year-old client on a rehabilitated unit following a cerebrovascular accident (CVA). The nurse is instructing on range of motion exercises when the client begins to cry. The client states she has always taken care of the family and does not want to be a burden. Which nursing diagnosis would the nurse add to the plan of care? Ineffective Coping related to refusing to acknowledge physical limitations Ineffective Role Performance related to inability to function in family role Deficient Diversional Activity related to the inability to participate in family activity Impaired Home Maintenance related to inability to care for home setting

Ineffective Role Performance related to inability to function in family role

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client? Urinary retention related to inability to void spontaneously Impaired physical mobility related to loss of motor function Ineffective breathing patterns related to weakness of the intercostal muscles Risk for impaired skin integrity related to immobility and sensory loss

Ineffective breathing patterns related to weakness of the intercostal muscles

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? Monitoring is needed as rapid neurologic deterioration may occur. Symptoms will evolve over a period of 1 week. Bleeding continues into the intracerebral area. The crash cart with defibrillator is kept nearby.

Monitoring is needed as rapid neurologic deterioration may occur.

Which of the following occupations are anticipated to improve the functioning of a client with a neurologic deficit? Select all that apply. Speech therapist Occupational therapist Neurologist Physical therapist Electrocardiography technician Electroencephalogram technician

Occupational therapist Speech therapist Neurologist Physical therapist

A patient with a newly diagnosed seizure disorder is to be discharged home in the morning. You are preparing patient/family teaching and know that a priority to teach the family is what? Place the patient in a side-lying position. Withhold medication after a seizure. Keep a bite block nearby at all times. Pad the bed rails.

Place the patient in a side-lying position.

A male client presents to the clinic reporting a headache. The nurse notes that the client is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? Sluggish pupil reaction Negative Brudzinski sign Hyperpatellar reflex Positive Kernig sign

Positive Kernig sign

Your patient is scheduled for intracranial surgery in the morning. You know that it is important that the patient has adequate preparation for surgery to reduce what? Length of time under anesthesia. Establishing expectations that are too high. Length of time in the hospital. Postoperative complications.

Postoperative complications.

A patient diagnosed with Transient Ischaemic attack (TIA) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done to what? Prevent a stroke by removing atherosclerotic plaques blocking cerebral flow. Decrease cerebral oedema. Determine the cause of the TIA. Prevent seizure activity that is common following a TIA.

Prevent a stroke by removing atherosclerotic plaques blocking cerebral flow.

A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? Lorazepam (Ativan) Phenobarbital Propofol (Diprivan) Midazolam (Versed)

Propofol (Diprivan)

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits? Slow, shuffling gait Dementia Rapid, jerky, involuntary movements Dysphagia and dysphonia

Rapid, jerky, involuntary movements

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see: Left visual field deficit. Spatial-perceptual deficits. Impulsive behavior. Right-sided paralysis.

Right-sided paralysis

A client with a neurologic deficit is being discharged from the hospital to home. Which of the following strategies would the nurse be most likely to teach the client? Spend time only with one or two people so you are not overwhelmed. Use a cough suppressant regularly to prevent irritation to your throat. Perform deep breathing exercises every 4 hours while awake. Take as many rest periods as you need.

Take as many rest periods as you need.

A 17-year-old client reports frequent headaches and is seeing the physician to determine their cause. In your client education, which type of headache do you indicate is most common? Secondary Migraine Cluster Tension

Tension

A patient with Huntington's disease is prescribed medication to reduce the chorea. What medication will the nurse administer that is the only drug approved for the treatment of this symptom? Diazepam (Valium) Tetrabenazine (Xenazine) Carbamazepine (Tegretol) phenobarbital

Tetrabenazine (Xenazine)

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 9 3 12 6

3

A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? A 60-year-old African-American man A 28-year-old pregnant African-American woman A 40-year-old Caucasian woman A 62-year-old Caucasian woman

A 60-year-old African-American man

Which of the following is one of the earliest signs of increased ICP? Headache Decreased level of consciousness (LOC) Coma Lethargy

Decreased level of consciousness (LOC)

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? Projectile vomiting Decreased pulse and respirations Disorientation and restlessness Loss of corneal reflex

Disorientation and restlessness

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? Position changes every 15 minutes while awake Elevation of the head of the bed Head turned slightly to the right side Extension of the neck

Elevation of the head of the bed

A client adopted at birth recently discovers that Huntington's disease is prevalent in the biological family history. How can the nurse best assist the client in dealing with personal fears? Encourage client to verbalize fears. Offer genetic testing. Provide information of the progression of the disease. Explain that inherited risk is 50%.

Encourage client to verbalize fears.

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort? Encourage the client to drink liberal amounts of fluids Administer antihistamines according to the physician's prescription Keep the room brightly lit and play soothing music in the background Help the client take a brisk walk around the testing area

Encourage the client to drink liberal amounts of fluids

The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client? Optimizing nutrition Managing muscle weakness Offering family support groups Explaining hospice care and services

Explaining hospice care and services

The neurologic nurse is testing the function of a client's cerebellum and basal ganglia. What action will most accurately test these structures? Elicit the client's response to a hypothetical problem. Have the client identify the location of a cotton swab on his or her skin with the eyes closed. Ask the client to close his or her eyes and discern between hot and cold stimuli. Guide the client through the performance of rapid, alternating movements.

Guide the client through the performance of rapid, alternating movements.

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? Anti-inflammatory medications Analgesics Hot or cold packs Whirlpool baths

Hot or cold pakcs

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? Lumbar puncture Computed tomography (CT) scan Venous Doppler studies Magnetic resonance imaging (MRI)

Lumbar puncture

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? Change the client's position as indicated. Monitor arterial blood gas (ABG) values. Monitor serum electrolytes. Maintain NPO status.

Monitor serum electrolytes.

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? Administering prescribed antipyretics Hyperoxygenation before and after tracheal suctioning Maintaining adequate hydration Restricting fluid intake and hydration

Restricting fluid intake and hydration