Neurosensory Disorders
The nurse is reinforcing education to a parent of a child with cerebral palsy. Which statement indicates that the education has been successful?
"My child will need continual therapy to maintain functioning."
After a stroke, a 75-year-old client is admitted to a health care facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which action is a priority for this client?
Elevating the head of the bed to 30 degrees
A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate?
Meningeal irritation
The nurse is caring for a child with a seizure disorder. Which nursing intervention would be included to support the goal of avoiding injury, respiratory distress, or aspiration during a seizure?
Place a hand under the child's head for support.
A client with Alzheimer's diseases is admitted for hip surgery after falling and fracturing the right hip. The spouse tells the nurse of feeling guilty for letting the accident happen and reports not sleeping well because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse?
Risk or caregiver role strain related to increased client care needs.
A 58-year-old client complaining of difficulty driving at night states that the "lights bother my eyes." The client wears corrective glasses. The nurse would expect the physician to have the client increase his or her intake of which vitamin because the client is experiencing a deficiency in this vitamin?
Vitamin A
A nurse instills atropine drops in both eyes of a client undergoing an ophthalmic examination. Which instruction should the nurse reinforce after administering the medication?
Wear dark glasses in bright light because the pupils are dilated.
Which nursing data should be given the highest PRIORITY for a child with clinical findings related to tubercular meningitis?
signs of increased intracranial pressure (ICP)
A nurse is educating the parents of a 1-year-old infant with otitis media. Which statement regarding predisposing factors for otitis media would be most accurate for the nurse to make?
"Eustachian tubes are short, wide, and straight and lie in a horizontal plane."
A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction?
"I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens."
A client with a mild concussion reports a headache. When offered acetaminophen, the client asks for a stronger pain medication, which response by the nurse is appropriate?
"Opioids are avoided after a head injury because they may hide a worsening condition."
A client with a mild concussion reports a headache. When offered acetaminophen, the client asks for a stronger pain medication. Which response by the nurse is appropriate?
"Opioids are avoided after a head injury because they may hide a worsening condition."
The nurse is caring for a client who had a cerebrovascular accident (CVA) and needs to be fed. What instruction would the RN give the unlicensed assistive personnel (UAP), who will fee the client?
"Position the client in a sitting position before feeding."
The nurse is caring for a client who had a cerebrovascular accident (CVA) and needs to be fed. What instruction would the RN give the unlicensed assistive personnel (UAP), who will feed the client?
"Position the client in a sitting position before feeding."
Identifying factors that trigger seizure activity could lead to which alteration in the child's environment or activities of daily living?
Avoid striped wallpaper and ceiling fans.
A nurse is caring for a client who has a history of epilepsy. After the client experiences a generalized tonic-clonic seizure, what is the priority nursing action?
Check the client's vital signs and remove restrictive clothing.
A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then he became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headaches and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse would expect to observe which sign first?
Declining level of consciousness
The nurse is collecting data on a geriatric client with senile dementia. When reviewing this client's file, which neurotransmitter condition is the nurse likely to find in the client's history as a contributory factor to his or her cognitive changes?
Decreased acetylcholine level
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway, attends to the client's immediate needs, and then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, the examination must be brief but will include which nursing intervention?
Evaluation of the corneal reflex response
A client is admitted with Meniere disease. Which instruction should the nurse reinforce in client teaching?
Get up slowly, turning the entire body.
A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings should the nurse notify the physician of because they indicate spasm or occlusion of a cerebral vessel by a clot?
Hemiplegia, seizures, and decreased level of consciousness (LOC)
The physician prescribes diazepam, 10 mg I.V., for a client experiencing status epilepticus. Which action would the nurse follow when administering I.V. diazepam?
It should be administered no faster than 5mg/minute in an adult.
A client is admitted with myasthenia gravis. Which nursing intervention should be priority?
Monitor respiratory status.
A nurse is caring for a client with a closed head injury. What is the appropriate action by the nurse?
Notify the health care provider of a blood pressure change from 147/72 mm Hg to 176/70 mm Hg.
A client with a history of seizures suddenly says to the nurse, "I see bright lights and zigzag lines." Which action should the nurse take first?
Pad side rails and lower the height of the bed.
A child has just returned to the pediatric unit following ventriculoperitoneal shunt placement for hydrocephalus. Which intervention would the nurse perform first?
Place the child on the side opposite the shunt.
A client is admitted to the emergency department with a suspected overdose of an unknown drug. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation.
Which method should the nurse use to properly instill eardrops in an adult client with otitis externa?
Pull the pinna up and back.
A nurse is preparing a client with suspected herniated nucleus pulposus (HNP) for myelography. Which nursing intervention should the nurse perform before the test?
Question the client about allergy to iodine.
A home health nurse is visiting a client with Alzheimer's disease who lives with two adult children. The nurse notes bruising on the client's upper arms. The client is more withdrawn than normal and is unable to communicate effectively because of the disease. What is the priority action by the nurse?
Report suspicion of elder abuse to the local agency on aging.
Which nursing diagnosis takes highest priority for a client admitted for evaluation for Meniere disease?
Risk for injury related to vertigo
Which early intervention describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?
Schedule intermittent catheterization every 2 to 4 hours.
When assisting with the education of the family of a client with C4 quadriplegia on how to perform tracheostomy suctioning, which instruction should the nurse be sure to include?
Suction for 10 to 15 seconds at a time.
A client who is paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?
The client uses a mirror to inspect skin
A client with quadriplegia is in spinal shock. Which finding should the nurse anticipate?
absence of reflexes along with flaccid extremities
The nurse observes clear fluid draining from the nose of a client who had a head trauma 3 hours ago. Which condition does the nurse suspect from this observation?
basilar skull fracture
A client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from the ears and nose. Which nursing intervention is appropriate?
checking the fluid for glucose with a dipstick
The nurse is reinforcing education for the family of a child with seizures. When should the nurse inform them to call emergency medical services in the event of a seizure?
continuous vomiting for 30 minutes after the seizure
A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when
documenting medications after administration.
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
electromyography (EMG).
The nurse is making assignments for the day. Which of the following tasks can be safely assigned to unlicensed assistive personnel (UAP)?
measuring the intake of a client with multiple sclerosis
A client with a T1 spinal cord injury arrives at the emergency department with a blood pressure of 82/40 mm Hg, pulse rate of 34 beats/minute, dry skin, and flaccid paralysis of the lower extremities. Which condition would most likely be suspected?
neurogenic shock
In caring for a child immediately after a head injury, the nurse notes a blood pressure of 110/60, a heart rate of 78 beats/minute, dilated and nonreactive pupils, minimal response to pain, and slow response to name. Which symptom would cause the nurse the most concern?
nonreactive pupils
A nurse gathers data from a client with suspected bacterial meningitis. Which documented finding of meningeal irritation suggests this diagnosis? Select all that apply.
nuchal rigidity positive Brudzinski's sign positive Kernig's sign photophobia
The nurse is working with the client who is experiencing right-sided weakness secondary to a thrombotic stroke. Where is the best area to place personal hygiene items?
on the overbed table on the left side
A client at the eye clinic is newly diagnosed with glaucoma. What should the nurse inform the client might occur if administration of the medication is not closely adhered to?
permanent vision loss
Which nursing data should be given the highest priority for a child with clinical findings related to tubercular meningitis?
signs of increased intracranial pressure (ICP)
A client is admitted with Meniere disease. Which condiment should the nurse tell the client to avoid? Select all that apply.
soy sauce ketchup
A nurse working on a surgical floor observes an unlicensed assistive personnel (UAP) completing assigned tasks. Which situation requires the nurse to intervene?
turning a client who is 24 hours post-op laminectomy
The nurse is reinforcing education to a client taking phenytoin for the treatment of seizures. The client asks, "Can I still have my beer every day"? What is the BEST response by the nurse?
"Alcohol decreases the effectiveness of phenytoin."
The nurse is reinforcing teaching about aspirin therapy with a client diagnosed with transient ischemic attacks (TIA). Which statement made by the client indicates understanding?
"Aspirin will help prevent me from having a stroke."
A client is scheduled for an electroencephalogram (EEG) after having a seizure for the first time. Which instruction does the nurse provide to the client as preparation for this test?
"Avoid stimulants and alcohol for 24 to 48 hours before the test."
A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?
"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
The nurse is reinforcing education for a client after cataract surgery. Which statement indicates that a client needs additional education?
"I can't wait to pick up my granddaughter."
A client is receiving phenytoin. Which response by a client best indicates an understanding of the adverse effects of the medication?
"I need to see the dentist every 6 months."
An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes and then take him to the emergency department of a nearby health care facility. He receives emergency care for corneal injury. The physician prescribes dexamethasone, two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate, 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. The nursing instructor asks the nursing student how will the dexamethasone work. How will the nursing student respond?
"It works by decreasing leukocyte infiltration at the site of ocular inflammation."
The parent of a child with a history of closed-head injury asks the nurse why the child would begin having seizures without warning. Which response by the nurse is the MOST accurate?
"It's not unusual to develop seizures after a head injury because of brain trauma."
A nurse is reinforcing education for the parents of a child who has been diagnosed with spina bifida. Which statement by the parents would indicate an understanding of spina bifida?
"Its presence indicates that many areas of the central nervous system (CNS) may not develop or function adequately."
A nurse is caring for a child with spina bifida. The child's mother asks the nurse what she did to cause the birth defect. Which statement would be the nurse's BEST response?
"The cause is unknown, and there are many environmental factors that may contribute to it."
A client is receiving pilocarpine eye drops. Which statement made by the client shows correct understanding of the medication?
"The medication will help decrease pressure in my eyes."
A client who sustained a closed head injury in a motor vehicle accident is diagnosed as brain dead by a neurosurgeon. The physician has scheduled a meeting with the client's family about discontinuing life support. Before the meeting, a family member asks the nurse her opinion about life support. Which response by the nurse is appropriate?
"What has the physician explained about the client's prognosis?"
A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse if he'll ever be able to walk again. Which response by the nurse is appropriate?
"What has your physician told you about your ability to walk again?"
A nurse has a client with multiple sclerosis who, after attending a meeting with the Multiple Sclerosis Society, states complementary therapies would work better. What is the BEST response by the nurse?
"You have a right to search out options and make decisions to help manage your symptoms. Share with me what you've learned."
A client injures his or her spinal cord in a diving accident. Which cerebral vertebral level would the nurse associates the injury site if the client is unable to breathe spontaneously?
C4
A client is scheduled for electroencephalogram (EEG). Which nursing action should be included in preparing the client before the procedure? select all that apply.
1. advise client to shampoo hair before the procedure. 2. tell client to avoid caffeine 8 to 12 hours prior to the test.
A client who's receiving phenytoin to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?
10 to 20 mcg/ml
The physician orders measurement of the serum acetaminophen level of a client admitted with a suspected overdose of this drug. To ensure an accurate result, the nurse should wait how long after acetaminophen ingestion before drawing the blood sample?
4 hours
The nurse is preparing to administer carbamazepine oral suspension, 150 mg by mouth. The pharmacy has dispensed carbamazepine suspension 100 mg/5 mL. How many milliliters of carbamazepine should the nurse administer to the client? Record your answer using one decimal place.
7.5
Which client on the rehabilitation unit is most likely to develop autonomic dysreflexia?
A client with a high cervical spine injjury
The nurse educator is preparing a lecture on dementia. The educator will include that which is the most common cause of dementia in an elderly client?
Alzheimer's disease
What should the nurse do when administering pilocarpine?
Apply pressure on the inner canthus to prevent systemic absorption.
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?
Attaching braces or splints to each foot and leg
Identifying factors that trigger seizure activity could lead to which alteration in the child's environment or activities of daily living?
Avoid striped wallpaper and ceiling fans
A client experienced a stroke that damaged the hypothalamus and was admitted to an acute unit. Which body function would the nurse anticipate that the client has problems with and assess as needed?
Body temperature control
The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first?
Call the physician immediately
The nurse is scheduled to administer an otic medication. Which action should the nurse perform first?
Check and verify the proper client's name.
A nurse is caring for a client who has a history of epilepsy. After the client experiences a generalized tonic-clonic seizure, what is the PRIORITY nursing action?
Check the client's vital signs and remove restrictive clothing
a nurse is caring for a client who has a history of epilepsy. After the client experiences a generalized tonic-clonic seizure, what is the PRIORITY nursing action?
Check the client's vital signs and remove restrictive clothing.
The neurologic unit has identified a 30% occurrence of pressure ulcers in clients admitted with the diagnosis of stroke. Which of the following actions should be included in the unit's performance improvement plan?
Creating spreadsheet on which nursing staff should document repositioning of clients admitted with a stroke.
The nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?
Elevate the head of the bed to 30 degrees
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?
Elevated 30 degrees
The nurse is caring for a client with a subdural hematoma. Which is the PRIORITY outcome?
Ensure airway patency and optimal oxygen levels and protect from injury.
A client who sustained a closed head injury in a skating accident pulls out his feeding tube, I.V. catheter, and indwelling urinary catheter. To ensure this client's safety, a physician prescribes restraints. Which action should a nurse take when using restraints?
Fasten the restraint to the bed frame using a quick-release knot
A client with cerebrovascular accident (CVA) is admitted with receptive aphasia. Which action by the nurse is appropriate?
Give the client simple and slow instructions.
When contributing to the development of an education session on glaucoma for the community, which statement would the nurse emphasize?
Glaucoma can be painless with loss of peripheral vision.
A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?
Helicopod
A client with meningitis is being prepared for a lumbar puncture. In which position should the nurse place the client for this procedure?
Laterally, with knees drawn up to the abdomen and chin touching the chest
The nurse is reinforcing education for a client and family about macular degeneration. Which photo would be utilized to best illustrate what these clients typically see?
Macular degeneration is a medical condition that typically affects the eyesight of older adults. The central vision is most affected in clients, thus revealing a blurred or distorted image in the middle of the visual field. Peripheral vision is usually maintained. The visual field is neither totally blurred nor completely clear.
A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take?
Make arrangements for the client to receive information about advance directives.
A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough violently. What should the nurse do?
Make sure a tonsil suction device is readily available when providing mouth care.
A client was admitted with an injury to the occipital lobe. Which nursing action should the nurse perform?
Monitor client for visual disturbances.
A client who experienced a severe stroke develops a fever and a cough that produces thick, yellow sputum. A nurse observes sediment in the client's urine in the indwelling urinary catheter tubing. Based on these findings, which action should the nurse take?
Notify a physician of the findings.
A nurse is caring for a client with a closed head injury. What is the appropriate action by the nurse?
Notify the health care provider of a blood pressure change from 147/74 mm Hg to 176/70 mm Hg.
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
Notify the physician.
The nurse is observing pupillary responses from a client. Which method should the nurse use to evaluate pupil accommodation?
Observe for pupil constriction and convergence while focusing on an object coming toward the client.
What is the nurse's most important intervention for a client having a tonic-clonic seizure?
Protect the client from further injury
A home health nurse is visiting a client with Alzheimer's disease who lives with two adult children. The nurse notes bruising on the client's upper arms. The client is more withdrawn than normal and is unable to communicate effectively because of the disease. What is the PRIORITY action by the nurse?
Report suspicion of elder abuse to the local agency on aging.
A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. Which nursing diagnosis takes highest priority in this client's plan of care?
Risk for injury
Which nursing diagnosis takes HIGHEST priority for a client admitted for evaluation for Meniere's disease?
Risk for injury related to vertigo.
A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse reviews the client's chart and prepares to administer which neuromuscular blocking agent?
Succinylcholine
A client accidently splashes chemicals into his eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment?
To prevent vision loss
A nurse is assisting with the development of a teaching plan for a client who will undergo a stapedectomy for the treatment of otosclerosis. Which instruction should the plan include?
Vertigo and dizziness are common after surgery.
A client is admitted to the facility for investigation of balance and coordination problems, including possible Meniere disease. When reviewing this client's chart, the nurse expects to find which signs and symptoms?
Vertigo, tinnitus, and hearing loss
A client is admitted because of an episode of acute angle closure glaucoma. Which medication should the nurse expect to administer?
acetazolamide
The nurse is discussing the purpose of an electroencephalogram with the family of a client who has massive cerebral hemorrhage and loss of consciousness. Which response by the nurse would be the most accurate in describing what the test measures?
activity o f the brain.
The nurse is discussing the purpose of an electroencephalogram with the family of a client who has massive cerebral hemorrhage and loss of consciousness. Which response by the nurse would be the most accurate in describing what the test measures?
activity of the brain
Which hormone deficiency should the nurse suspect as the underlying cause of diabetes insipidus in a postoperative craniotomy client?
antidiuretic hormone (ADH)
A nurse performs a neurologic data collection on a client reporting headaches and dizziness. Which data collection technique helps determine the motor function of cranial nerve VII?
asking the client to frown, smile, raise the eyebrows.
A client recovering from a spinal cord injury has a great deal of spasticity. What medication administered by the nurse may be used to control spasticity?
baclofen
The nurse is caring for a child with meningitis receiving IV fluids. What condition should the nurse monitor for closely?
cerebral edema
The nurse is reinforcing education for the family of a child with seizures. When should the nurse inform them to call emergency medical services in the event of a seizure?
continuous vomiting for 30 minutes after the seizure.
A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:
demonstrate eyedrop instillation
The nurse is preparing a client for magnetic resonance imaging (MRI). What does the nurse recognize as conditions that would exclude the client from MRI?
having a cardiac pacemaker/defibrillator
A client continues to improve after a left hemisphere cerebrovascular accident (CVA). The interprofessional team is planning a transfer to a rehabilitation unit for follow-up care. Which nursing diagnosis is the PRIORITY?
impaired swallowing
A client with a spinal cord injury has a neurogenic bladder. When planning for discharge, the nurse anticipates that the client will need which procedure or program?
intermittent catheterization
A graduate nurse, working in a long-term facility, is caring for a client who has hearing loss. When observing the graduate, the nurse mentor would intervene if which action is taken by the graduate?
moves around and multitasks when speaking
In caring for a child immediately after a head injury, the nurse notes a blood pressure of 110/60, a heart rate of 78 beats/minute, dilated and nonreactive pupils, minimal response to pain, and slow response to name. Which symptom would cause the nurse the MOST concern?
nonreactive pupils
The nurse is caring for a client who underwent stapedectomy. Which position would have the GREATEST benefit for prevention of complications and promotion of comfort?
on the unaffected side
A client has a spinal cord transection at the T4 level. The nurse can expect the client to have which symptom?
paraplegia
A nurse is collecting data on a client who sustained a head injury after a fall from the roof. What signs and symptoms should the nurse observe the client for?
restlessness, disorientation, pupil dilation, and projectile vomiting
The nurse is caring for a post-op client following the removal of right cataract. What is the BEST position for the client after surgery?
supine
The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. Myasthenia gravis is associated with:
thymus gland hyperplasia.
A client with new-onset seizures of unknown cause is started on phenytoin, 750 mg IV now and 100 mg P.O. t.i.d. Which statement best describes the purpose of the loading dose?
to more quickly attain therapeutic levels.
A nurse is caring for a client who had a lumbar laminectomy 2 days ago. Which finding should the nurse report to the health care provider?
urine retention or incontinence
Which statement by the nurse to a parent regarding cerebral palsy would be accurate?
"Cerebral palsy is a condition that doesn't get worse."
A client who experienced a stroke that left her with residual right-sided weakness was just discharged to go home. The client lives in a two-story house in which the bathroom is located on the second floor. A home health care nurse is visiting the client for the first time. Which issue should the nurse address during this visit?
Client's ability to climb the stairs while using a walker
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign HIGHEST priority to which nursing diagnosis?
Ineffective breathing pattern
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?
Ineffective breathing pattern
a client's chronic progressive hearing loss results from excess bone formation around the oval window, which impedes normal stapes movement and prevents sound transmission. The nursing student is researching the disorder. What is the clinical terminology for this correctable middle ear disorder that the student would utilize in her research?
Otosclerosis
A client with a history of seizures suddenly says to the nurse, "I see bright lights and zigzag lines."
Pad side rails lower the height of the bed.
A client is admitted with Bell palsy. What should the nurse and health care team include in the plan of care?
Provide eye care
