Neurosensory Disorders

Which finding(s) in a client with a seizure disorder prescribed phenytoin most concerns the nurse? Select all that apply. 1. Red rash on the torso 2. Behavior changes 3. Client is breastfeeding 4. History of depression 5. Drowsiness

1, 2, 3, 4. Phenytoin is an anti-epileptic drug used to control seizures. A skin rash of any kind, fever, severe weakness, jaundice, or blood dyscrasias can indicate a severe reaction to phenytoin and should be reported to the healthcare provider immediately. Clients taking phenytoin are at increased risk of suicide; therefore, behavior changes and a history of depression would concern the nurse. Clients taking phenytoin should not breastfeed because it will pass into the milk and is not safe for infants. Side effects of phenytoin include drowsiness, confusion, and slurred speech.

The nurse is collecting data on a client with herniated nucleus pulposus (HNP) of L4-L5. Which finding(s) will the nurse anticipate? Select all that apply. 1. Urinary incontinence 2. Increased muscle weakness 3. Paresthesia 4. Constant low back pain 5. Pain radiating across the buttocks 6. Positive Kernig's sign

1, 2, 3. Progressive neurologic deficits at L4-L5 including worsening muscle weakness, paresthesia, and loss of bowel and bladder control are symptoms of spinal cord compression. The other symptoms usually occur in clients with HNL without spinal cord compression.

The nurse teaches a client with Parkinson's disease to avoid which food(s) while taking selegiline? Select all that apply. 1. Salami 2. Eggs 3. Aged cheese 4. Soy sauce 5. Milk 6. Sauerkraut

1, 2, 4, 6. Selegiline is a monoamine oxidase B (MAO-B) inhibitor used in clients with Parkinson's disease. The nurse should tell the client to avoid foods with high tyramine content while on this medication because it would cause hypertensive crisis. Salami, aged cheese, soy sauce, and sauerkraut are foods with high tyramine content and should be avoided. Milk and eggs can be safely given to the client while on selegiline.

A client is admitted with complications related to myasthenia gravis. Which medication(s) will the nurse question administering to this client? Select all that apply. 1. Lithium 2. Ciprofloxacin 3. Pyridostigmine 4. Propanolol 5. Ambernonium

1, 2, 4. The client with myasthenia gravis should avoid taking ciprofloxacin, propanolol, and lithium because these drugs will further cause muscle weakness. Pyridostigmine and ambernonium are anticholinesterase agents used in clients with myasthenia gravis.

A client with a history of seizures is receiving gabapentin. For which side effect(s) will the nurse monitor this client? Select all that apply. 1. Drowsiness 2. Transient dizziness 3. Increased salivation 4. Weight loss 5. Noticeable tremors

1, 2, 5. Gabapentin is a medication used for seizures and neuropathic pain. The nurse should monitor for the side effects of this drug, which include drowsiness, dizziness, and tremors. Gabapentin also causes weight gain and dry mouth.

The nurse is assessing a client with increased intraocular pressure (IOP). The nurse will expect which finding(s)? Select all that apply. 1. Severe eye pain 2. Halos around lights 3. Loss of central vision 4. Soft globe on palpation 5. Decreased accommodation

1, 2, 5. Glaucoma is largely asymptomatic. Symptoms can include: severe eye and head pain, loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, halos around lights, and occasional eye pain. Loss of central vision is seen in clients with macular degeneration.

A client is scheduled for magnetic resonance imaging (MRI) of the head. The nurse knows which assessment finding(s) is priority before the procedure? Select all that apply. 1. History of claustrophobia 2. Presence of metal fillings, prostheses, or pacemaker 3. Food or drink intake within the past 8 hours 4. Presence of carotid artery disease 5. Voiding before the procedure

1, 2. Strong magnetic waves may dislodge metal in the client's body, causing tissue injury. Although the client may be told to restrict food for 8 hours, particularly if contrast is used, metal is an absolute contraindication for this procedure. The client with history of claustrophobia should be evaluated because the client will be confined in a small, enclosed, tube-shaped machine during MRI. Voiding beforehand would make the client more comfortable and better able to remain still during the procedure, but it is not essential for the test. Having carotid artery disease is not a contraindication to having an MRI.

The nurse is assigned to care for a client with Parkinson's disease who practices orthodox Judaism. Which dietary instruction(s) will the nurse consider when developing the client's plan of care? Select all that apply. 1. Any combination of meat and milk is forbidden. 2. Strictly adhere to lacto-ovo-vegetarian diet. 3. Only fish that have scales and fins can be offered. 4. Meat products not ritually slaughtered are forbidden. 5. Fasting is observed during the month of Ramadan.

1, 3, 4. Jewish dietary kosher laws include eating only fish that have scales and fins, prohibiting eating meat products not ritually slaughtered, and avoiding eating meat with milk products. Seventh day Adventists and Buddhists may follow a lacto-ovo-vegetarian diet. Muslims may fast during the month of Ramadan.

A client is receiving levodopa-carbidopa. Which information will the nurse include while providing client teaching? Select all that apply. 1. Avoid sudden changes in positions. 2. Always take with grapefruit. 3. Avoid eating high-protein foods. 4. Encourage use of central nervous system depressants. 5. Avoid large doses of pyridoxine.

1, 3, 5. Levodopa-carbidopa is used to treat symptoms of Parkinson's disease. This client should avoid sudden changes in position because the medication will cause orthostatic hypotension. High-protein diet and large doses of pyridoxine (vitamin B₆) should be avoided, because they will reduce the effectiveness of the levodopa-carbidopa. Because the medication will cause drowsiness, central nervous system depressants should also be avoided. Grapefruit should be avoided because it will decrease the breakdown of the medication by the liver and cause increased drug level in the blood.

The nurse is caring for a client prescribed neostigmine. The nurse will be most concerned if which symptom(s) is noted? Select all that apply. 1. Dry mouth 2. Abdominal cramps 3. Increased sweating 4. Sudden tachycardia 5. Increased urination

1, 4. Neostigmine is an anticholinesterase drug used to improve muscle strength in clients with myasthenia gravis. It blocks the action of cholinesterase and increases the level of acetylcholine at the neuromuscular junction. This drug causes excessive salivation, not dry mouth. The client may also experience bradycardia, not tachycardia. Therefore, the nurse would be most concerned about any unexpected symptoms. Abdominal cramps, increased sweating, and increased urination are all side effects of neostigmine.

After cataract surgery, the nurse will provide which discharge education to the client? Select all that apply. 1. Avoid bending over at the waist. 2. Reduce sodium intake to reduce intraocular pressure. 3. If you notice flashing lights, sit and rest for 15 minutes. 4. Eye makeup can be applied beginning tomorrow. 5. Call your healthcare provider if you have vision loss. 6. When sleeping, lie on the unaffected side.

1, 5, 6. Bending over may increase intraocular pressure and strain the sutures. Vision loss or seeing flashing lights may signal complications, such as retinal detachment or increased intraocular pressure, and should be reported. Intraocular pressure is reduced when sleeping on the nonsurgical side. Reducing sodium intake does not decrease intraocular pressure. Applying eye makeup may introduce infection and cause irritation.

A client is admitted with amyotrophic lateral sclerosis (ASL) is prescribed riluzole. The nurse will immediately notify the healthcare provider if which finding(s) is noted? Select all that apply. 1. History of hepatitis B 2. Client stumbles while walking 3. History of constipation 4. Blood pressure 130/86 mm Hg 5. The client is 6 weeks pregnant

1, 5. Amyotrophic lateral sclerosis (ALS), or Lou Gehrig's disease, is a progressive motor neuron disease that causes muscle wasting or atrophy. Riluzole is prescribed to delay disease progression and prolong life expectancy. Riluzole should not be prescribed to a client with liver disease, such as hepatitis B, because it can worsen liver disease. It also should not be taken while pregnant unless the benefit exceeds the risk (category C). Stumbling and constipation are common early symptoms of ALS. A blood pressure within normal range is appropriate for receiving riluzole.

A client is admitted with Ménière's disease. Which condiment(s) will the nurse educate the client to avoid? Select all that apply. 1. Soy sauce 2. Pepper 3. Vinegar 4. Olive oil 5. Ketchup

1, 5. Ménière's disease is a disorder of the inner ear in which there is an excess production of endolymphatic fluid in the semicircular canals. The client's diet should be low in sodium. Both soy sauce and ketchup are high in sodium and should be avoided.

The nurse is preparing a client for a myelography. Which intervention will the nurse perform before the test? 1. Determine if the client is allergic to iodine. 2. Mark distal pulses on the foot in ink. 3. Check and document pain along the sciatic nerve. 4. Tell the client to cough or pant to clear the dye.

1. A radiopaque dye, commonly iodine-based, is instilled into the spinal canal to outline structures during myelography; therefore, asking about iodine allergy is needed. Pain may be expected along the sciatic nerve with herniated nucleus pulposus. During cardiac catheterization, a client coughs or pants to clear the dye; before cardiac catheterization or arteriogram, the nurse marks pedal pulses in ink.

A client has a phenytoin level of 32 mg/dL (127 µmol/L). For which symptoms will the nurse monitor the client, based on this level? 1. Ataxia and confusion 2. Hyponatremia and confusion 3. Tonic-clonic seizure and ataxia 4. Urinary incontinence and hematuria

1. A therapeutic phenytoin level is 10 to 20 mg/dL (39.7 to 79.4 µmol/L). A level of 32 mg/dL (127 µmol/L) indicates phenytoin toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin does not cause hyponatremia, hematuria seizure, or urinary incontinence. Incontinence may occur during or after a seizure.

When evaluating an arterial blood gas (ABG) from a client with a subdural hematoma, the nurse notes the client is in respiratory acidosis with hypoxia. Which nursing intervention is appropriate? 1. Increase the client's respiratory rate. 2. Give 100% oxygen via nasal cannula. 3. Administer a sedative to the client. 4. Lower the client's head of the bed.

1. ABGs in respiratory acidosis are pH less than 7.35 and a PaCO₂ of more than 45 mm Hg. Hypoxia is an indication of oxygen at the tissue level and is evaluated by SpO₂ readings. The goal is to get the client to blow off more carbon dioxide (CO₂) by increasing the respiratory rate. Decreasing the respiratory rate will increase the CO₂, and 100% oxygen is not given by nasal cannula.

A client is admitted with thrombotic cerebral vascular accident (CVA). The nurse understands which condition can be a contributing factor? 1. Atrial fibrillation (AF) 2. Premature ventricular contractions (PVC) 3. Deep vein thrombosis (DVT) 4. Myocardial infarction (MI)

1. CVA is associated with cardiac arrhythmias, usually atrial fibrillation. Atrial fibrillation occurs with the irregular and rapid discharge from multiple ectopic atrial foci that cause quivering of the atria without atrial systole. This asynchronous atrial contraction predisposes to mural thrombi, which may embolize, leading to a stroke. PVCs, past MI, or DVT do not lead to arterial embolization.

The nurse notes clear fluid draining from the nose of a client who sustained a severe head injury. The nurse notifies the healthcare provider about a suspicion of which condition? 1. Basilar skull fracture 2. Cerebral concussion 3. Cerebral palsy exacerbation 4. Acute sinus infection

1. Clear fluid draining from the ear or nose of a client may mean a cerebrospinal fluid leak, which is common in basilar skull fractures. Concussion is associated with a brief loss of consciousness; sinus infection is associated with facial pain and pressure with or without nasal drainage; and cerebral palsy is associated with nonprogressive paralysis present since birth.

A client is diagnosed with right subarachnoid hemorrhage. It is important for the nurse to place the client in which position following assessment? 1. Elevate the head of bed. 2. Turn the client onto the right side. 3. Put the client in modified Trendelenburg. 4. Place the client supine.

1. Elevating the head of the bed enhances cerebral venous return and thereby decreases intracranial pressure (ICP). The other positions would not decrease ICP.

A client admitted to the emergency department for head trauma following a skiing accident is diagnosed with an epidural hematoma. What is the priority nursing action? 1. Prepare the client for emergency surgery. 2. Monitor the client closely for 24 hours. 3. Apply direct pressure to the scalp. 4. Obtain vital signs every hour.

1. Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. This condition is emergent and requires immediate evacuation of the hematoma. Applying direct pressure to the scalp is an ineffective treatment because the artery that is ruptured is not a surface vessel. Vital signs will be obtained at least every 15 minutes prior to surgery.

Which nursing intervention is most appropriate to prevent foot drop and contractures in a client recovering from a subdural hematoma? 1. Wearing high-top sneakers 2. Starting low-dose heparin therapy 3. Referring the client to physical therapy 4. Applying sequential compression devices

1. High-top sneakers are used to prevent foot drop and contractures in neurologic clients. Low-dose heparin therapy and sequential compression boots will prevent deep vein thrombosis. A consultation with physical therapy is important to prevent foot drop and should be initiated by the nurse.

A client had a lumbar laminectomy. Which nursing action is best postoperatively? 1. Encourage the client to be out of bed the first postoperative day. 2. Ensure the client wears a supportive brace at all times. 3. Limit movement in bed and reposition only when necessary. 4. Place a soft microfoam mattress with extra support on the client's bed.

1. In most cases, clients should be out of bed the first postoperative day. Frequent repositioning, use of a chair-like brace for the lower back when out of bed, and a firm mattress will help minimize complications.

The nurse is assessing a client in the emergency department and notes: blood pressure, 82/40 mm Hg; pulse, 34 beats/minute; dry skin; and flaccid paralysis of the lower extremities. Which condition will the nurse suspect? 1. Neurogenic shock 2. Septic shock 3. Autonomic dysreflexia 4. Absolute hypervolemia

1. Loss of sympathetic control and unopposed vagal stimulation below the level of the injury typically causes hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Hypervolemia is indicated by a bounding and rapid pulse and edema. Autonomic dysreflexia occurs after neurogenic shock abates. Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate.

The nurse is administering mannitol to a client in the intensive care unit. Which finding indicates to the nurse the client is responding appropriately to the medication? 1. Urine output of 450 mL in 4 hours 2. Pupils are 8 mm and nonreactive 3. Systolic blood pressure of 150 mm Hg 4. Serum creatinine of 2.5 mg/dL (221 μmol/L)

1. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubules. The normal urine output is 30 to 50 mL/hour. A urine output of 450 mL in 4 hours indicates the client has an increase in urine output; therefore, is a sign of effectiveness of the medication. The normal serum creatinine is 0.6 to 1.2 mg/dL (53 to 106 μmol/L). Serum creatinine of 2.5 mg/dL (221 μmol/L) is not a sign of effectiveness of the medication because the result is elevated. The systolic blood pressure should go down because of diuresis. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage.

The nurse understands which client is most at risk for secondary Parkinson's disease caused by pharmacotherapy? 1. A 30-year-old client with schizophrenia taking chlorpromazine 2. A 50-year-old client taking nitroglycerin tablets for angina 3. A 60-year-old client taking prednisone for chronic obstructive pulmonary disease 4. A 75-year-old client using naproxen for rheumatoid arthritis

1. Phenothiazines, such as chlorpromazine, deplete dopamine, which may lead to tremor and rigidity (extrapyramidal effects). The other clients are not at a greater risk for developing Parkinson's disease caused by pharmacotherapy.

A client has a spinal cord transection at the level of the nipple line. The nurse will expect the client to have which symptoms? 1. Paraplegia 2. Quadriplegia 3. Autonomic dysreflexia 4. Hemiplegia

1. Spinal cord injuries at the T4 level affect all motor and sensory nerves below the level of injury and result in dysfunction of legs, bowel, and bladder. Paraplegic injuries involve the thoracic, lumbar, or sacral regions of the spinal cord. Quadriplegic injuries result from damage to the cervical region of the spine. Autonomic dysreflexia occurs because of a massive sympathetic discharge of stimuli from the autonomic nervous system.

After starting therapy with sucralfate, a client reports a dry mouth. Which nursing intervention is best to relieve the client's dry mouth? 1. Offer the client ice chips and frequent sips of water. 2. Withhold the drug and notify the healthcare provider. 3. Change the client's diet to clear liquid until symptoms subside. 4. Encourage the client to brush teeth after each meal.

1. Sucralfate is an anti-ulcer medication that may cause constipation, dry mouth, upset stomach, and nausea. Ice chips and frequent sips of water will help relieve the client's dry mouth. There is no need to withhold the drug unless these symptoms persist or worsen. A clear liquid diet does not provide adequate nutrition and will not provide relief from dry mouth. Frequent oral hygiene may be helpful, but would not provide as much relief as ice and water.

The nurse is educating the family of a client being discharged on tracheostomy suctioning. The nurse will include which information in the teaching? 1. Suction for no more than 20 seconds when withdrawing the catheter. 2. Regulate the suction machine to intermittently suction at 200 cm. 3. Apply suction to the catheter when inserting until meeting resistance. 4. Pass the suction catheter into the opening of the tracheostomy 1 to 1.5 in (2.5 to 3.75 cm).

1. Suction should be applied no more than 20 seconds at a time. When suctioning the trachea, the catheter is inserted 4 to 6 in (10 to 15 cm) or until resistance is felt. Suction should be applied only during withdrawal of the catheter. Suction is regulated to 80 to 120 cm.

A client with breast cancer reports back pain and difficulty in moving the legs. Which nursing intervention is most appropriate? 1. Notify the client's healthcare provider. 2. Prop the client on the side with a foam wedge. 3. Request a physical therapy consultation. 4. Administer 1,000 mg acetaminophen orally.

1. Symptoms of back pain and neurologic deficits may indicate metastasis; therefore, the healthcare provider should be notified. Repositioning the client, physical therapy, or acetaminophen may help the pain but may delay evaluation and treatment.

The nurse is caring for a client with C8 quadriplegia 8 hours after the injury. During assessment the nurses notes: blood pressure, 80/44 mm Hg; pulse, 48 beats/minute; and respiratory rate, 18 breaths/minute. The nurse suspects which condition? 1. Neurogenic shock 2. Autonomic dysreflexia 3. Hemorrhagic shock 4. Pulmonary embolism

1. Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this would not be suspected without an injury. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.

Which nursing intervention is priority for the client experiencing a tonic-clonic seizure? 1. Maintain a patent airway. 2. Time the duration of the seizure. 3. Note the origin of seizure activity. 4. Insert tongue bade inside the mouth.

1. The priority during and after seizure is to maintain a patent airway. Noting the origin of the seizure activity and the duration of the seizure are important, but they do not take priority over maintenance of a patent airway. Nothing should be placed in the client's mouth during a seizure because teeth may be dislodged or the tongue pushed back, further obstructing the airway.

A client with an open head trauma develops a urine output of 300 mL/hour, dry skin, and dry mucous membranes. Which nursing intervention is most appropriate? 1. Check urine specific gravity. 2. Anticipate treatment for renal failure. 3. Restrict sodium intake. 4. Increase IV fluid rate.

1. Urine output of 300 mL/hour may indicate diabetes insipidus, which is failure of the pituitary to produce antidiuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There is no evidence that the client is experiencing renal failure. Restricting sodium is not a priority. Increasing the IV rate may be done after the specific gravity has been evaluated.

A client is receiving dabigatran. Which medication instruction(s) will the nurse include during client teaching? Select all that apply. 1. Avoid eating green, leafy vegetables. 2. Do not chew, break, or open capsules. 3. Immediately report signs of bleeding. 4. Take medication with a full glass of water. 5. Monitor prothrombin time (PT) regularly.

2, 3, 4. Dabigatran is a direct thrombin inhibitor that reduces the risk of cerebrovascular accident, atrial fibrillation, deep vein thrombosis, and pulmonary embolism. Unlike warfarin, there is no need to avoid foods high in vitamin K and it is not necessary to monitor the PT/international normalized ratio (INR) while on this medication. Client should not chew, break, or open capsules while taking this drug. The medication should also be taken with a full glass of water. Signs of bleeding should be immediately reported because of its anticoagulant effect.

When assisting the client to eat during the rehabilitation phase of an ischemic stroke, the nurse will include which educational information during teaching? Select all that apply. 1. "Look up at the ceiling when you swallow." 2. "Tuck your chin in when you swallow." 3. "Turn your head to your weaker side when swallowing." 4. "After swallowing food, wait a few seconds then swallow again." 5. "Swallow softly between each bite of food."

2, 3, 4. Tucking the chin in reduces the size of the airway opening, which helps prevent aspiration, and a double swallow helps clear the pharynx between bites of food. Having the client turn the head toward toward the weaker side makes swallowing easier. Waiting a few seconds before swallowing again allows time for the esophagus to clear. Swallowing forcefully reduces the amount of residual food in the client's pharynx.

A client is receiving clopidogrel bisulfate. The nurse will closely monitor the client for which potential complication(s) while on this medication? Select all that apply. 1. Sepsis 2. Melena 3. Ecchymosis 4. Drowsiness 5. Hematuria 6. Petechiae

2, 3, 5, 6. Clopidogrel bisulfate is an antiplatelet agent. The client should be monitored for signs of bleeding like ecchymosis, melena, hematuria, and petechiae while on this medication. The other manifestations are not related to bleeding.

When preparing a client for an electroencephalogram (EEG), which nursing action(s) is appropriate? Select all that apply. 1. Determine if the client is allergic to iodine or shellfish. 2. Tell the client to shampoo hair before the procedure. 3. Tell the client to avoid caffeine 12 hours prior to the test. 4. Instruct the client not to eat or drink anything after midnight. 5. Inform the client that the procedure is painful.

2, 3. EEG is a test that measures the electrical activity of the brain. The nurse should advise the client to shampoo hair and avoid using hair products before the procedure because electrodes will be placed on the client's scalp. Caffeine should also be avoided 12 hours prior to the test. A dye or contrast medium is not injected during EEG; therefore, asking the client about allergy to iodine or shellfish is not necessary. The client should avoid fasting because hypoglycemia will alter the result of the test. EEG is a painless procedure.

The nurse is administering acyclovir to a client with encephalitis. Which laboratory test(s) will the nurse monitor while the client is taking acyclovir? Select all that apply. 1. Amylase 2. Creatinine 3. Lipase 4. Blood urea nitrogen (BUN) 5. Aspartate aminotransferase (AST) 6. Alanine aminotransferase (ALT)

2, 4, 5, 6. Acyclovir is an antiviral medication. The nurse should monitor the BUN and creatinine because this drug is nephrotoxic. AST and ALT should also be monitored because acyclovir is hepatotoxic. The other tests are not indicated.

During the assessment of a client with suspected meningitis, which nursing finding(s) indicates support of the diagnosis? Select all that apply. 1. Turner sign 2. Brudzinski sign 3. Murphy sign 4. Kernig sign 5. Cullen sign 6. Battle sign

2, 4. A client with meningitis will experience signs of meningeal irritation, which include nuchal rigidity (stiff neck), Brudzinski sign, and Kernig sign. Brudzinski sign is a flexion at the hip and knee in response to forward flexion of the neck. Kernig sign is severe stiffness and pain in the hamstring muscle when attempting to extend the leg when the hip is flexed. Turner sign and Cullen sign are both signs of retroperitoneal bleeding seen in clients with acute pancreatitis. Murphy sign is used to assess for gallbladder inflammation. Battle sign is the ecchymosis behind the ear, which is a sign of head injury.

A client is admitted with homonymous hemianopsia. Which intervention(s) will the nurse implement? Select all that apply. 1. Check gag reflex before allowing the client to eat. 2. Approach client each time on the unaffected side. 3. Allow enough time for the client to answer the questions. 4. Test bath water with the use of thermometer each time. 5. Gradually teach client to compensate by scanning.

2, 5. Homonymous hemianopsia is the loss of half of each visual field. This is usually seen in clients with cerebrovascular accident or stroke. The nurse should approach the client on the unaffected side and teach the client to compensate by scanning or turning the head to see things on the affected side. The other interventions are not related to homonymous hemianopsia.

When treating a client after a spinal cord injury for spastic leg syndrome, the nurse will prepare to administer which medication? 1. Hydralazine 2. Baclofen 3. Lidocaine 4. Methylprednisolone

2. Baclofen is a skeletal muscle relaxant used to decrease spasms. Methylprednisolone, an anti-inflammatory drug, is used to decrease spinal cord edema. Hydralazine is an antihypertensive and afterload-reducing agent. Lidocaine is an antiarrhythmic and a local anesthetic.

What will the nurse include in the plan of care when treating a client with Bell's palsy? 1. Protect the client's skin integrity. 2. Provide routine bilateral eye care. 3. Prevent complications of immobility. 4. Maintain normal bowel elimination.

2. Bell's palsy is the disorder of the cranial nerve VII (facial nerve) that causes weakness or paralysis of one side of the face. The client will also have difficulty closing the eye of the affected side. The nurse should provide eye care by using eye drops and an eye patch to prevent corneal dryness and to protect the eye from irritation. The other options are not appropriate.

A client is admitted with a brain tumor. Which vital signs will the nurse expect the client to exhibit? 1. Temperature, 98ºF (36.7ºC); pulse, 108; respirations, 14; blood pressure, 120/82 mm Hg 2. Temperature, 97ºF (36.1ºC); pulse, 60; respirations, 23; blood pressure, 158/94 mm Hg 3. Temperature, 99ºF (37.2ºC); pulse, 52; respirations, 23; blood pressure, 176/86 mm Hg 4. Temperature, 96ºF (35.6ºC); pulse, 82; respirations, 16; blood pressure 149/82 mm Hg

3. A client with brain tumor will experience an increase in intracranial pressure (ICP). One of the assessment findings in increased ICP is Cushing's triad, which includes hypertension, bradycardia, and widening pulse pressure.

The nurse notes clear fluid draining from the right ear and nose of a client after a blunt trauma to the head. Which nursing intervention is priority? 1. Position the client in the supine position. 2. Check the fluid for glucose with a dipstick. 3. Suction the nose to maintain airway patency. 4. Insert nasal and ear packing with sterile gauze.

2. Clear liquid from the nose (rhinorrhea) or ear (otorrhea) can be determined to be cerebral spinal fluid or mucus by the presence of glucose. Glucose would be present in cerebral spinal fluid. Placing the client in bed may increase intracranial pressure and promote pulmonary aspiration. Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection. The nose would not be suctioned because of the risk of suctioning brain tissue through the sinuses.

A healthcare provider instills a topical anesthetic in the affected eye of a client with severe eye pain. The client asks the nurse, "Will I get a prescription for those drops?" Which nursing response is most appropriate? 1. "Overuse of these drops can lead to an increased risk of eye infections." 2. "No; damage could occur to the cornea because of lack of sensation." 3. "These drops cannot be taken at home because they cause dependence and rebound pain." 4. "You will have to ask the healthcare provider if you will be given a prescription."

2. Corneal damage may occur with the prolonged use of topical anesthetics. Infections, dependence and rebound pain do not occur from topical anesthetics. Telling the client to ask the healthcare provider is not therapeutic and does not address the client's question.

A client is receiving dabigatran. Which information will the nurse include while providing client teaching? 1. Avoid people with upper respiratory infections. 2. Discontinue the medication before surgery. 3. Check daily for signs of calf pain or tenderness. 4. Take the medication with urokinase.

2. Dabigatran is an anticoagulant used to reduce the risk of having stroke, atrial fibrillation, and pulmonary embolism. It should be discontinued at least 48 hours prior to elective surgery or invasive procedures because it would cause bleeding. The client does not need to monitor daily for symptoms of deep vein thrombosis while taking anticoagulants. Giving dabigatran with antiplatelet agents, heparin, aspirin, NSAIDs, and fibrinolytic agents such as urokinase is not appropriate because this would cause further bleeding.

The nurse is educating a client with an acute head injury on famotidine capsules. Which statement made by the client indicates the education is understood? 1. "I will be sure to take this medication with food." 2. "I will take famotidine once every day." 3. "I can take famotidine even though I am allergic to ranitidine." 4. "It is okay to chew or crush this medication."

2. Famotidine is a histamine-2 (H2)-receptor antagonist, which decreases acid produced by the stomach. Famotidine can be taken with or without food once a day. Clients allergic to another H2-receptor antagonist should not take famotidine due to the high probability of hypersensitivity. Capsules should not be crushed or chewed. If the client cannot swallow the pill, a chewable tablet may be prescribed.

After receiving report, the nurse will see which client first? 1. A 17-year-old client 24 hours post-appendectomy. 2. A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome. 3. A 50-year-old client 3 days post-myocardial infarction (MI). 4. A 42-year-old client with diverticulitis exacerbation.

2. Guillain-Barré syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorders of airway, breathing, and then circulation. There is no information to suggest the post-MI client has an arrhythmia or other complications. There is no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.

During the assessment of an older adult client, the nurse notes the client has decreased hearing bilaterally. Which method will the nurse use first when communicating with this client? 1. Speak loudly when talking to the client. 2. Lower voice pitch while facing the client. 3. Ask the family to locate the hearing aids. 4. Write down all words spoken to the client.

2. Hearing loss in the older adult typically involves the upper ranges; lowering the pitch of the voice and facing the client is essential for the client to use other means of understanding, such as lip reading, mood, and so on. Shouting is typically in the upper ranges and could cause the client to become anxious. Alternate means of communication, such as writing, may be used if speaking in a lower range is not sufficient.

The nurse is caring for a client diagnosed with thrombotic right brain stroke with swelling of the left arm. The nurse will monitor the client's affected extremity for which complication? 1. Elbow contracture 2. Loss of muscle contraction 3. Deep vein thrombosis (DVT) 4. Hypoalbuminemia

2. In clients with hemiplegia or hemiparesis, loss of muscle contraction decreases venous return and may cause swelling of the affected extremity. Stroke is not linked to protein loss. DVT may develop in clients with a stroke but is more likely in the lower extremities. Contractures, or bony calcifications, may occur with stroke but do not appear with swelling.

Which early intervention describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? 1. Insert an indwelling urinary catheter. 2. Schedule intermittent catheterization every 2 to 4 hours. 3. Perform a straight catheterization every 8 hours while awake. 4. Perform Credé maneuver to the lower abdomen before the client voids.

2. Intermittent catheterization should begin every 2 to 4 hours early in treatment. When residual volume is less than 400 mL, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are removed as soon as possible. Credé maneuver is applied after voiding to enhance bladder emptying.

Which intervention will the nurse emphasize when providing education for a client with multiple sclerosis (MS) to avoid exacerbation of the disease? 1. Patch the affected eye. 2. Get adequate rest each night. 3. Take hot baths for relaxation. 4. Drink 2,000 mL of fluid daily.

2. MS is exacerbated by exposure to stress, fatigue, and heat. Clients should balance activity with rest. Patching the affected eye may result in improvement in vision and balance but will not prevent exacerbation of the disease. Adequate hydration will help prevent urinary tract infection secondary to neurogenic bladder.

A client diagnosed with a brain abscess is prescribed nafcillin. Which finding(s) noted in the client's history will cause the nurse to question this prescription? Select all that apply. 1. History of asthma 2. Allergy to penicillin 3. Blood urea nitrogen (BUN) 15 mg/dL (5.4 mmol/L) 4. Alanine aminotransferase (ALT) 30 u/L (0.5 µkat/L) 5. Urine output 865 mL over the past 24 hours

2. Nafcillin is a penicillin antibiotic given to treat bacterial infections. Clients with previous hypersensitivity reactions to penicillins or cephalosporins should not receive nefcillin due to the high risk of an anaphylactic reaction. Clients with a history of asthma should be monitored closely for a reaction, but can receive nafcillin. The BUN and ALT levels and urine output are all within normal range; therefore, the client can receive nafcillin. Clients with liver or renal impairment may not be candidates for nafcillin therapy.

A 17-year-old client is admitted after suffering blunt trauma to the head. When offered acetaminophen, the client asks for a stronger pain medication. Which response by the nurse is most appropriate? 1. "You have a mild concussion; acetaminophen is the best choice right now." 2. "Opioids are avoided after a head injury because they may hide a worsening condition." 3. "Aspirin is avoided because of the danger of Reye syndrome in children or young adults." 4. "Stronger medications may lead to vomiting, which increases intracranial pressure (ICP)."

2. Opioids may mask changes in the level of consciousness (LOC) that indicate increased ICP and should not be given. Saying acetaminophen is strong enough ignores the client's question and therefore is not appropriate. Aspirin is contraindicated in conditions that may cause bleeding, such as trauma, and for children or young adults with viral illnesses because of the danger of Reye syndrome. However, this response does not address the client's concern. Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in the LOC.

The nurse is caring for a client postoperatively following an intracapsular lens implant. Which finding will the nurse teach the client to report immediately to the healthcare provider? 1. Blurred vision 2. Eye pain 3. Yellow glare 4. Occasional itching

2. Pain should not be present after cataract surgery. Pain may be an indication of hyphema or clouding in the anterior chamber, and of infection. The client should be informed that blurred vision, a yellow glare, and intermittent itching may be present following the procedure.

A client admitted to the hospital with a subarachnoid hemorrhage (SAH) reports severe headache, nuchal rigidity, and projectile vomiting. The healthcare provider prescribes a lumbar puncture (LP). Which action will the nurse complete next? 1. Have the client sign the written consent. 2. Clarify the prescription with the healthcare provider. 3. Obtain the equipment needed to perform an LP. 4. Anticipate admission to the intensive care unit (ICU).

2. Severe headache, nuchal rigidity, and projectile vomiting are signs of ICP. Sudden removal of cerebrospinal fluid results in pressures in the lumbar area lower than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Clarifying the procedure is priority. Because it is undetermined if an LP is appropriate for this client, obtaining consent and equipment are not needed at this time. Admission to ICU may be required but is not a priority.

Which assessment finding indicates to the nurse spinal shock is resolving in a client with C7 quadriplegia? 1. No pain sensation in the chest 2. Noted reflexes 3. Spontaneous respirations 4. Urinary continence

2. Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. Slight muscle contraction at the bulbocavernosus reflex occurs but not enough for urinary continence. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above. The absence of pain sensation in the chest does not apply to spinal shock.

A client with a cervical spine injury is placed in a Minerva body vest. The client is uncomfortable and would like to try a different device. Which information will the nurse explain to the client? 1. The vest protects the neck against excessive motion. 2. The vest will provide significant immobilization, including lateral flexion. 3. The vest will provide for immobilization of the mid-cervical segments. 4. There are other soft-type collars that can be used.

2. The Minerva vest will provide significant immobilization, including lateral flexion. Most soft collars do not limit cervical motion but act as a reminder against excessive motion. More rigid devices such as the Philadelphia collar provide reasonable immobilization of the mid-cervical segments for flexion and extension but not for lateral flexion.

A client is diagnosed with a brain stem infarction. During assessment, the nurse will monitor the client for which conditions? 1. Aphasia and motor deficits 2. Bradypnea and change in pulse 3. Contralateral hemiplegia and tachycardia 4. Numbness of the face and arms

2. The brain stem contains the medulla and the vital cardiac, vasomotor, and respiratory centers. A brain stem infarction leads to vital sign changes such as bradypnea. Numbness, tingling in the face, contralateral hemiplegia, and aphasia may occur with a stroke.

The nurse is caring for a client who underwent a stapedectomy. The nurse knows which position will have the greatest benefit for this client? 1. Lying in the prone position 2. Lying on the unaffected side 3. Sitting semi- to high-Fowler's 4. Being in modified Trendelenburg

2. The client should be positioned on the unaffected side with the operative ear up. Semi- or high-Fowler's position does not facilitate drainage or hearing. Modified Trendelenburg is contraindicated as the client should not be flat with legs up.

The nurse recognizes which findings as an early sign of increased intracranial pressure (ICP)? 1. New onset bradycardia 2. Restlessness and confusion 3. Widened pulse pressure 4. Large amounts of very dilute urine

2. The earliest symptom of increased ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there is damage to the posterior pituitary.

The nurse is obtaining vital signs for a client with an unstable seizure disorder. Which method will the nurse use to obtain the most accurate measurement? 1. Assess for a pulse deficit. 2. Review for pulsus paradoxus. 3. Perform an axillary temperature. 4. Check the blood pressure for an auscultatory gap.

3. To reduce the risk of injury, the nurse should take an axillary temperature, or the nurse should use a metal thermometer when taking an oral temperature to prevent injury if a seizure occurs. An auscultatory gap occurs in hypertension. Pulse deficit occurs in an arrhythmia. Pulsus paradoxus may occur with cardiac tamponade.

When discharging a client with a halo vest from the hospital, which statement will the nurse provide to the client and family? 1. "You really need to be extra careful while you are driving a car." 2. "Keep the wrench that opens the vest attached to the client at all times." 3. "Clean the pin sites every other day especially when there is drainage." 4. "Perform range of motion (ROM) exercises to the neck and shoulders four times daily."

2. The wrench must be attached at all times to remove the vest in case the client needs cardiopulmonary resuscitation. The vest is designed to improve mobility; the client may use a wheelchair but cannot drive as movement is limited. The pins are cleaned daily. The purpose of the vest is to immobilize the neck; ROM exercises to the neck are prohibited but should be performed to other areas.

One hour after receiving pyridostigmine, a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the healthcare provider and prepares to administer which medication? 1. Pyridostigmine 2. Atropine 3. Edrophonium 4. Acyclovir

2. These symptoms suggest cholinergic crisis or excessive acetylcholinesterase medication, typically appearing 45 to 60 minutes after the last dose of acetylcholinesterase inhibitor. Atropine, an anticholinergic drug, is used to antagonize acetylcholinesterase inhibitors. The other drugs are acetylcholinesterase inhibitors. Edrophonium is used to diagnose myasthenia gravis, and pyridostigmine is used to treat the condition and would worsen the symptoms. Acyclovir is an antiviral and would not be used to treat the client's symptoms.

When administering cromolyn ophthalmic drops to an adult client, which nursing action is appropriate? 1. Place the client supine and hold the eye open. 2. Tilt the client's head back and pull the lower conjunctival sack down. 3. Place the tip of the dropper to the corner of the client's eye. 4. Have the client blink repeatedly immediately following administration.

2. To administer ophthalmic drops, the nurse should slightly tilt the client's head back and pull the lower conjunctival sack downward to create a small pocket. The nurse would then administer the prescribed number of drops into the pocket and have the client close the eyes for 2 to 3 minutes, without blinking or squinting. Touching the tip to the client's eye will contaminate the dropper and could lead to infection.

The nurse is caring for a client with Ménière's disease. Which symptom(s) will the nurse report to the healthcare provider? Select all that apply. 1. Dizziness 2. Vertigo 3. Epistaxis 4. Facial pain 5. Ptosis 6. Tinnitus

3, 4, 5. The nurse would report unexpected findings. Epistaxis, facial pain, and ptosis are not expected findings in clients with Ménière's disease. Facial pain may occur with trigeminal neuralgia. Ptosis occurs with a variety of conditions, including myasthenia gravis. Epistaxis may occur with a variety of blood dyscrasias or local lesions. Tinnitus, dizziness, and vertigo occur in Ménière's disease.

A client is admitted with a stiff neck, photophobia, fever, and malaise after a viral infection. The nurse will implement which precaution(s) when caring for this client? Select all that apply. 1. Wear gloves. 2. Wear a gown. 3. Wear a mask. 4. Wear goggles. 5. Wash hands.

3, 5. A client with meningitis is placed on airborne precautions. The nurse should wear a mask or respirator when taking care of this client. The nurse should always wash hands before and after client care. gloves and gown are both used for contact precaution. Goggles are used when there is any chance of splashing.

The family of a client diagnosed with hemorrhagic stroke asks the nurse, "What can cause this?" The nurse will include which risk factor(s) in the response? Select all that apply. 1. Coronary artery disease 2. Juvenile onset diabetes 3. Uncontrolled hypertension 4. Recent viral infection 5. Cerebral aneurysm

3, 5. Uncontrolled hypertension and cerebral aneurysm are major causes of hemorrhagic stroke. The other options are not directly linked to this condition.

The nurse is assigned to care for four clients. Which client with the nurse see first? 1. A client with meningitis experiencing nuchal rigidity 2. A client diagnosed with a cerebrovascular accident with hemianopsia 3. A client with myasthenia gravis reporting flu-like symptoms 4. A client with trigeminal neuralgia with stabbing pain on the face

3. A client with myasthenia gravis with flu-like symptoms should be checked first because infection may cause myasthenic crisis. The client may have an abrupt onset of extreme muscle weakness with inability to swallow, speak, and maintain respiration. Airway is the priority for this client. A client with meningitis is expected to have stiff neck or nuchal rigidity. Hemianopsia, or loss of half of visual field, is usually seen in clients with stroke. A client with trigeminal neuralgia will usually report stabbing pain on one side of the face during an acute episode.

A client is admitted to the progressive care unit with an acute injury to the cervical spine from a motorcycle collision. Which nursing action is priority? 1. Assessing for bladder distention 2. Monitoring neurologic deficit 3. Checking pulse oximetry readings 4. Referral for rehabilitation evaluation

3. After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation through pulse oximetry readings is necessary. Although the other options would be necessary at a later time, observation for respiratory failure is the priority.

A client is admitted to the emergency department following a head-on motor vehicle collision. Which nursing intervention will the registered nurse do first? 1. Perform full range of motion (ROM). 2. Call for an immediate chest x-ray. 3. Immobilize the client's head and neck. 4. Open airway using head tilt/chin lift maneuver.

3. All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. Performing ROM would be contraindicated at this time. There is no indication the client needs a chest x-ray. The airway does not need to be opened because the client appears alert and not in respiratory distress. In addition, the head tilt/chin lift maneuver would not be used until cervical spine injury is ruled out.

A client is admitted to the hospital with a diagnosis of transient ischemic attack (TIA) secondary to atrial fibrillation. Which medication will the nurse administer to prevent further neurologic deficit? 1. Digoxin 2. Diltiazem 3. Heparin 4. Quinidine gluconate

3. Atrial fibrillation may lead to the formation of mural thrombi, which may embolize to the brain. Heparin will prevent further clot formation and clot enlargement. The other drugs are used in the treatment and control of atrial fibrillation but will not affect clot formation.

The nurse will assess which client on the rehabilitation unit most closely for the development of autonomic dysreflexia. 1. A client with a traumatic brain injury 2. A client with a herniated nucleus pulposus 3. A client with a high cervical spine injury 4. A client with a frontal ischemic stroke

3. Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries above the level of T10. The other clients are not prone to dysreflexia.

A client is admitted with a burst fracture at the level of T12 and reports loss of movement of the lower extremities. Which medication will the nurse anticipate administering to this client? 1. Acetazolamide 2. Furosemide 3. Methylprednisolone 4. Sodium bicarbonate

3. High doses of methylprednisolone are used within 24 hours of spinal cord injury to reduce cord swelling and limit neurologic deficits. The other drugs are not indicated in this circumstance.

A client is admitted with new onset ptosis, progressive muscle weakness, and blurred vision. Which nursing intervention is priority? 1. Observe for bleeding. 2. Promote mobility. 3. Monitor breathing. 4. Prevent dehydration.

3. Myasthenia gravis is a neuromuscular disorder that causes extreme muscle weakness, ptosis (early onset), and blurred vision due to the deficiency of acetylcholine at the myoneural junction. The nurse should monitor the respiratory status frequently because the respiratory muscles may also be involved. Bleeding is not a common complication of myasthenia gravis. The nurse will need to determine the client's muscle involvement before determining if mobility is appropriate at this time. Dehydration is not an immediate complication. This may be a concern as muscle weakness progresses.

Which precaution will the nurse take when giving phenytoin to a client with a nasogastric (NG) tube for feeding? 1. Check the phenytoin level after giving the drug. 2. Place the client supine before administering phenytoin. 3. Give phenytoin 1 hour before or 2 hours after NG tube feedings. 4. Place the end of the tube in water to verify proper NG tube placement.

3. Nutritional supplements and milk interfere with the absorption of phenytoin, decreasing its effectiveness. The nurse verifies NG tube placement by checking for stomach contents before giving drugs and feedings. The head of the bed is elevated when giving all drugs or solutions. Phenytoin levels are checked before giving the drug, and the drug is withheld for elevated levels to avoid compounding toxicity.

Which nursing response is most appropriate for the client newly diagnosed with paraplegia who becomes verbally aggressive while transferring to a wheelchair? 1. "You know I want to help you; I have offered several times." 2. "I will pick these things up for you and come back later." 3. "You seem angry today. How do you feel about your transfer to rehab?" 4. "If you will cooperate, you will be able to get into the wheelchair."

3. The nurse should always focus on the feelings underlying a particular action. The nurse saying that he or she offered to help or telling the client to cooperate is confrontational. Offering to pick up the client's belongings does not deal with the situation and assumes the client cannot do it alone.

The nurse is performing a neurological assessment on the client's cranial nerves (CN). Which technique will the nurse use to assess the function of the facial nerve (CN VII)? 1. Have the client tightly clench their teeth. 2. Place a tongue applicator against the pharynx. 3. Ask the client to frown, smile, and raise the eyebrows. 4. Give the client a straw to suck on and swallow.

3. To check the motor function of CN VII, the nurse should ask the client to frown, smile, and raise the eyebrows. If these facial expressions are symmetrical, motor function is intact. Jaw clenching is a test for CN V function. Testing the gag reflex by placing an applicator against the pharynx, and checking swallowing ability, are ways to evaluate CN IX function. Testing the gag reflex also helps evaluate CN X function.

When discharging a client from the hospital after a cervical laminectomy, the nurse recognizes further education is necessary when the client makes which statement? 1. "I will sleep on a firm mattress using only one pillow." 2. "I will not drive for 2 to 4 weeks until I see the healthcare provider." 3. "When I pick things up, I will always bend my knees." 4. "I cannot wait to toss my granddaughter up in the air."

4. Lifting more than 10 lb (4.5 kg) for several weeks after surgery is contraindicated. The other responses are appropriate.

The nurse is caring for a client prescribed phenytoin 750 mg IV now followed by 100 mg PO three times per day. The client asks the nurse, "Why do I have to take some of the medication through an IV?" Which nursing response is appropriate? 1. "The IV dose is to ensure that the drug reaches the cerebrospinal fluid." 2. "Getting both IV and oral phenytoin will omit the need for surgery." 3. "The IV form will help to reduce secretions in case another seizure occurs." 4. "The stronger IV dose will help you reach a therapeutic level quickly."

4. A loading dose of phenytoin and other drugs is given to reach therapeutic levels more quickly; maintenance dosing follows. A loading dose of phenytoin can be oral or parenteral. Surgical excision of an epileptic focus is considered when seizures are not controlled with anticonvulsant therapy. Phenytoin does not reduce secretions.

When caring for a client with trigeminal neuralgia, the client tells the nurse, "I have severe stabbing pain on my affected side." Which action will the nurse perform first? 1. Ask the client to take slow deep breaths. 2. Medicate the client as prescribed. 3. Notify the healthcare provider. 4. Assess for pain using a numerical scale.

4. A pain assessment should be completed prior to medicating the client. The healthcare provider does not need to be notified as this is an expected finding. Diversion techniques are not priority at this time.

A client with a history of petite mal seizures reports a visual aura. Which nursing action is priority? 1. Ask the client the describe the aura in detail. 2. Place the client near the nurses' station. 3. Immediately notify the healthcare provider. 4. Pad side rails and lower the head of the bed.

4. A visual aura is a warning sign of an impending seizure. The nurse should immediately institute seizure precautions such as padding the side rails and lowering the bed. Completing a more detailed assessment is important as well as notifying the healthcare provider and placing the client near the nurses' station, but these are not priority over client safety.

The nurse is providing dietary instructions to a client with Parkinson's disease. Which findings are most important for the nurse to address? 1. Leaking of urine and dementia 2. Tremors and a distorted sense of smell 3. Confusion in the afternoon and drooling 4. Dysphagia and increased difficulty standing

4. All of the findings are expected with Parkinson's disease. However, the nurse would be most concerned with dysphagia due to the risk of choking and aspiration, and increased difficulty standing due to the risk for falling.

A client with quadriplegia is apprehensive and flushed, and has a blood pressure of 210/100 mm Hg and heart rate of 50 beats/minute. Which intervention will the nurse complete first? 1. Place the client in the supine position. 2. Check patency of the indwelling urinary catheter. 3. Give one sublingual nitroglycerin tablet. 4. Raise the head of the bed to 90 degrees.

4. Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli as a full bladder, fecal impaction, or pressure injury. The client is immediately placed in a sitting position to lower blood pressure. Placing the client flat will cause the blood pressure to increase. Nitroglycerin is given to relieve chest pain and reduce preload; it is not used for hypertension or dysreflexia. The indwelling urinary catheter should be checked immediately after the head of the bed is raised.

The nurse is caring for a client in the acute phase of an ischemic stroke. Which nursing intervention is priority? 1. Thicken all dietary liquids. 2. Recline the client to less than 30 degrees. 3. Place the client in the supine position. 4. Have tracheal suction available.

4. Because of a potential loss of gag reflex and potential altered level of consciousness, the client should be kept in Fowler's or a semi-prone position with tracheal suction available at all times. Unless heart failure is present, restricting fluids is not indicated. Thickening dietary liquids is not done until the gag reflex returns or the stroke has evolved and the deficit can be assessed.

The nurse is discharging a 25-year-old client diagnosed with myasthenia gravis. When providing education on cyclophosphamide, which statement will the nurse include in the teaching? 1. "You need to limit your daily fluid intake to 1 liter." 2. "You may notice wounds take longer to heal while on cyclophosphamide." 3. "This medication may affect your ability to have children in the future." 4. "If you develop a fever, notify the healthcare provider immediately."

4. Cyclophosphamide is given to client with myasthenia gravis, an autoimmune disorder, to decrease the immune system to limit autoantibody production. These autoantibodies cause the destruction of acetylcholine receptors, which leads to muscle weakness. Clients with a fever, or any signs of an illness, should notify their healthcare provider immediately. Their dosage may need to be adjusted or the medication may need to be held to allow healing. Clients taking cyclophosphamide should consume ample fluids daily to prevent renal complications such as hemorrhagic cystitis. Wound healing may be delayed due to immunosuppression. Cyclophosphamide may affect fertility in both men and women.

When reviewing the cerebrospinal fluid (CSF) laboratory results of a client diagnosed with multiple sclerosis (MS), what does the nurse expect to find? 1. Presence of blood in the CSF 2. Elevated white blood cell count 3. Increased glucose level 4. Increased protein levels

4. Elevated gamma globulin fraction in CSF without the presence of blood occurs in MS. Blood may be found with trauma or subarachnoid hemorrhage. Increased glucose concentration is a nonspecific finding indicating infection or subarachnoid hemorrhage. Elevated WBCs or pus indicate infection.

To evaluate the effectiveness of levodopa-carbidopa in a client with Parkinson's disease, the nurse will observe for which outcome? 1. Improved visual acuity 2. Increased dyskinesia 3. Reduced short-term memory 4. Lessened rigidity and tremor

4. Levodopa-carbidopa increases the amount of dopamine in the central nervous system, allowing for smooth, purposeful movements. The drug does not affect visual acuity and should improve dyskinesia and short-term memory.

The nurse notes lucid intervals in a client following a closed head injury. How will the nurse document this finding? 1. Experiences neurological aura intermittently 2. Speech is garbled, and unclear sounds are made 3. Awake, alert to person and time but cannot recall recent events 4. Oriented to person, place, and time but then becomes somnolent

4. Lucid interval is described as a brief period of unconsciousness at the time of the trauma followed by alertness; after several hours, the client deteriorates neurologically. Garbled speech is known as dysarthria. An interval in which the client is alert but cannot recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.

An adult client is admitted with myasthenia gravis. While reviewing the client's chart, the nurse noticed the medication administration record, noted below. Based on the findings, what will the nurse do next? Progress Notes Medications • Furosemide 20 mg PO bid • Neostigmine 15 mg PO every 4 hours • Potassium chloride 20 mEq PO once a day • Morphine sulfate 10 mg IM every 4 hours • Docusate sodium 100 mg PO once a day 1. Administer neostigmine and morphine together. 2. Administer the morphine sulfate and hold the neostigmine. 3. Check the platelet count before administering neostigmine. 4. Call the healthcare provider and question the morphine sulfate prescription.

4. Myasthenia gravis is a neuromuscular disease characterized by deficiency of acetylcholine at the myoneural junction, causing extreme voluntary muscle weakness. Clients with myasthenia gravis are usually given an anticholinesterase drug like neostigmine to improve muscle strength. Anticholinesterase drugs may potentiate the effect of morphine. The nurse should inform the healthcare provider and question the medication because narcotic analgesics such as morphine may cause respiratory depression.

The nurse is discharging a client with autonomic dysreflexia. The nurse teaches the client to carefully monitor for which potential complication? 1. Moderate tension headache 2. Low back strain when lifting 3. Decreased temperature sensation 4. Fecal impaction or distended bladder

4. Noxious stimuli, such as a full bladder, fecal impaction, or a pressure injury, may cause autonomic dysreflexia. Autonomic dysreflexia is most commonly seen with injuries at T10 or higher. A headache is a symptom, not a cause, of autonomic dysreflexia. The client will not be able to lift as the level of injury is at T10.

Which nursing intervention is priority when caring for a client with a foreign body protruding from the eye following head trauma? 1. Irrigating the eye with sterile saline 2. Assessing visual acuity with a Snellen chart 3. Removing the object with sterile forceps 4. Temporarily patching both eyes

4. One or both eyes may be patched to prevent pain with extraocular movement or accommodation. Assessment of visual acuity is not a priority, although it may be done after treatment. Chemicals or small foreign bodies may be irrigated. Protruding objects are not removed by the nurse because the vitreous body may rupture.

The nurse is caring for a client with an essential tremor and pending diagnosis of Parkinson's disease. For which complication will the nurse observe this client? 1. Bilateral exophthalmos 2. Diminished distal extremity sensation 3. Excessive involuntary movements 4. Bradykinesia and shuffling gate

4. Parkinson's disease is characterized by the slowing of voluntary muscle movement (bradykinesia), muscular rigidity, shuffling gate, and resting tremor. Dopamine is deficient in this disorder. Diminished distal extremity sensation does not occur in Parkinson's disease. Bulging eyeballs (exophthalmos) occurs in Graves' disease. Excessive involuntary movement is a sign of Huntington's disease.

A client with a driving injury is admitted to the emergency department. What assessment finding does the nurse expect? 1. Aphasia 2. Hemiparesis 3. Paraplegia 4. Quadriplegia

4. Quadriplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below. Hemiparesis describes weakness of one side of the body. Aphasia refers to difficulty expressing or understanding spoken words.

The nurse is providing education to a client taking phenytoin. The client asks, "Can I still drink beer with dinner?" What is the best response by the nurse? 1. "The research is not clear regarding alcohol with phenytoin, so ask your healthcare provider." 2. "It is very dangerous for you to drink alcohol, because it will raise your seizure threshold." 3. "You can drink alcohol, but you need to understand it will impair judgment and coordination." 4. "You should avoid alcohol because it will decrease the effectiveness of your phenytoin."

4. The greatest concern is that alcohol will lower phenytoin levels. Telling the client to ask another healthcare provider is not appropriate. Phenytoin will lower the client's seizure threshold. Alcohol should not be consumed due to it decreasing the drug's effectiveness.

The emergency room nurse is assigned a client who is suspected to have a brain injury after falling out of a tree. When the nurse enters the client's room, the nurse notes the client is lying rigidly on the stretcher, with the arms bent toward the chest, clenched fists, extension and internal rotation of the legs, and plantar flexion of the feet. The client does not respond to verbal stimuli. Which action will the nurse take? 1. Assess the client's vital signs. 2. Monitor the client's pupils. 3. Perform sternal rub. 4. Notify the healthcare provider.

4. The nurse would first notify the healthcare provider. The client is exhibiting signs of decorticate posturing, which is seen in clients with damage in the corticospinal tract. This is an emergency situation and generally requires intubation and admission to the intensive care unit. The nurse would assess the client's vital signs after notifying the healthcare provider as intubation is priority for this client. It is not appropriate to monitor the client's pupils or perform sternal rub at this time.

The nurse is caring for a client with a cerebral injury who is showing signs of receptive aphasia and unilateral deafness. Which part of the brain does the nurse suspect has been affected? 1. Frontal lobe 2. Parietal lobe 3. Occipital lobe 4. Temporal lobe

4. The portion of the cerebrum that controls speech and hearing is the temporal lobe. Injury to the frontal lobe causes personality changes, difficulty speaking, and disturbances in memory, reasoning, and concentration. Injury to the parietal lobe causes sensory alterations and problems with spatial relationships. Damage to the occipital lobe causes vision disturbances.

A client diagnosed with stroke involving Wernicke's area is being admitted to the unit. Which action by the nurse is most appropriate? 1. Listen and watch carefully while the client is speaking. 2. Allow enough time for the client to answer questions. 3. Check the client's gag reflex during admission. 4. Give the client simple and slow instructions.

4. Wernicke's area is located on the left side of the temporal region and is likely the cause of receptive aphasia. Receptive aphasia means that the client is having difficulty understanding spoken and written language. Giving simple and slow directions would help the client understand the message. Listening and watching carefully while the client is speaking, and giving enough time to answer questions, are appropriate nursing interventions for a client with expressive aphasia. Checking the gag reflex is necessary for a client with dysphagia or difficulty in swallowing.

The healthcare provider prescribed t-PA, a thrombolytic agent, at 0.9 mg/kg over 1 hour for a client weighing 125 lb (56.7 kg). How many milligrams will the nurse give in each dose? Record your answer using a whole number.

51. full dosage ordered ✕ weight = amount by dose 0.9 mg / kg ✕ 56.7 kg = 51.03 mg

The nurse is assisting a client during lumbar puncture. Which position will the nurse place the client in for this procedure?

During lumbar puncture, the client will be placed on a lateral (side-lying) position to widen the intervertebral spaces for easy insertion of the spinal needle.

The healthcare provider prescribed a nasogastric tube to be inserted on a client with dysphagia. Place the following nursing actions in chronological order of how the nurse will perform the procedure. Use each option once. 1. Instruct the client to hyperextend the head. 2. Advance tube 1 to 2 in (2.5 to 5 cm) with each swallow. 3. Instruct client to flex head forward. 4. Position client in high Fowler's. 5. Measure distance to insert tube. 6. Pass lubricated tube along floor of nasal passage.

Ordered Response: 4. Position client in high Fowler's. 5. Measure distance to insert tube. 1. Instruct client to hyperextend the head. 6. Pass lubricated tube along floor of nasal passage. 3. Instruct client to flex head forward. 2. Advance tube 1 to 2 in (2.5 to 5 cm) with each swallow.