Neurosensory Disorders

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

30-degree head elevation

When determining how to administer analgesics to a client who has been receiving opiates for pain relief administered by injection, the nurse should consider using patient-controlled analgesia since it is more effective because:

the client will control the amount of pain medication administered.

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean them from sedation therapy. A nurse needs further assessment data to determine whether

the nurse will have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability?

"I can participate in sexual activity but might not experience orgasm."

The client with spinal cord compression due to a tumor is questioning the treatment that will be given. Which statement by the nurse is most accurate?

"Radiation will shrink the tumor and relieve pressure on nerves and spine."

The client with a cervical spinal cord injury is admitted to the rehabilitation unit with skeletal traction (Gardner-Wells Traction). What nursing actions are a priority when caring for the client? Select all that apply.

-Assess the client's skin integrity. -Maintain proper body alignment. -Assess client's neurological function.

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

Escape the source of pain.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?

Face the client and establish eye contact.

A short time after cataract surgery, the client has nausea. What should the nurse do first?

Medicate the client with an antiemetic, as prescribed.

Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin?

Notify the health care provider (HCP) if vision changes occur.

The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which intervention should the nurse consider?

Thicken all liquids before offering to the client.

One day after cataract surgery, the client is having discomfort from bright light. What should the nurse advise the client to do?

Use sunglasses that wrap around the side of the face when in bright light.

A client returns from a myelogram, for which an iodized oil was used. The nurse should include which instruction in the plan of care?

assessment of lower extremity movement and sensation

A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for stroke?

being obese

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition?

decrease in level of consciousness (LOC)

A client's laboratory tests indicate that the client has hypercalcemia. The nurse should assess the client for:

depressed reflexes.

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

edrophonium

The son of an older adult reports that his father just "stares off into space" more and more in the last several months but then eagerly smiles and nods once the son can get his attention. What further assessments should the nurse make?

hearing loss

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?

inner ear

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

instilling one drop of pilocarpine 0.25% into both eyes four times daily.

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

irrigating the ear gently.

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

maintain respiratory function.

Following nasal surgery, the client has packing in the nose. The nurse should:

perform frequent mouth care.

The primary goal in the plan of care for the client after cataract removal surgery is to:

promote safety at home.

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction?

pulling up the client under the left shoulder when getting the client out of bed to a chair

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing

raccoon's eyes and Battle's sign.

In discharge planning after scleral buckling, the nurse should teach the client to avoid which activity during the early recovery period?

reading

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?

semi-Fowler

The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which activity is contraindicated?

sitting all afternoon in the room

A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention?

urine retention or incontinence

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?

using a "picture board" for the client to point to pictures

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?

Establish a regular voiding schedule.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?

Explain how to overcome a freezing gait by telling the client to march in place.

A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the priority?

Instruct the client to remain in bed.

Following a stroke, a client has dysphagia and left-sided facial paralysis. Which feeding technique will be most helpful at this time?

Offer solid foods from the unaffected side of the mouth.

The nurse is assessing the level of consciousness for a client who just had open heart surgery. When asked, the client can give his name but is not sure about where he is or the time of day. What should the nurse do next?

Tell the client where he is and the time of day.

The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. What information should the nurse include in the teaching plan?

"Keep active, use stress reduction strategies, and avoid fatigue."

After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in the legs, and calls the nurse in excitement to report the leg movement. Which response by the nurse would be the most accurate?

"The movements occur from muscle reflexes that cannot be initiated or controlled by the brain."

A client has just undergone a lumbar puncture (LP). Which finding should the nurse immediately report to the health care provider (HCP)?

A moderate amount of serous fluid was noted on the lumbar dressing.

"The client's ICP remains elevated."

A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The health care provider calls and asks for a report on the client's condition. Based on the documentation below, how would the nurse respond?

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 bpm; and respiratory rate of 30 shallow breaths/min. What should the nurse do first?

Activate the Rapid Response Team (RRT).

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

Alternatively patch one eye every 2 hours.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment.

Upon review of a client's phenytoin levels, a nurse notes a value of 16 mcg/ml. What should the nurse do next?

No action is needed at this time because the drug level is normal. Normal therapeutic serum phenytoin level ranges from 10 to 20 mcg/ml.

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

Readminister the residual to the client, and continue with the feeding.

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?

Test the nasal drainage for glucose.

The emergency department protocol provides for administration of alteplase (tPA) for clients with confirmed acute coronary syndrome (ACS). The nurse contacts the healthcare provider to clarify the order for the client with which health history?

atrial fibrillation and a mild stroke one month ago

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

compliance with the prescribed medication regimen

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called

conductive hearing loss.

Sensorineural hearing loss results from which condition?

damage to the cochlear or vestibulocochlear nerve

An auto mechanic accidentally has battery acid splashed in their eyes. The coworkers irrigate the eyes with water for 20 minutes, then take the mechanic to the emergency department of a nearby hospital, where the mechanic receives emergency care for corneal injury. The physician orders 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 nurse knows that dexamethasone exerts its therapeutic effect by

decreasing leukocyte infiltration at the site of ocular inflammation.

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

When completing a nursing assessment on a client admitted with a neck injury, which findings would indicate an incomplete spinal cord injury (SCI)?

evidence of voluntary motor and sensory function below the level of injury

The nurse is assessing a client's motor response after brain surgery. The nurse pinches the client's skin to elicit a response and observes the client's arms and legs moving straight out and the feet and toes bend downward. How should the nurse document this response?

extension posturing

Atropine sulfate is contraindicated as a preoperative medication for which client? A client with:

glaucoma.

The nurse is assessing a client for movement after halo traction placement for a C8 fracture. What should the nurse do to test the client's ability to move? Ask the client to:

grasp the nurse's hands with both hands and squeeze.

Which is an expected outcome for a client with Parkinson's disease who has had a pallidotomy?

improved functional ability

Which nursing goal is realistic to establish with a client who has multiple sclerosis (MS)?

improved muscle strength

Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment? The activity level is:

increased gradually; the client can resume usual activities in 5 to 6 weeks.

The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring?

intake and output

Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure?

loss of consciousness, body stiffening, and violent muscle contractions

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

occipital

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

midbrain

Which of the following nursing intervention can prevent a client from experiencing autonomic dysreflexia?

monitoring the patency of an indwelling urinary catheter

A client with quadriplegia is experiencing severe muscle spasms. To relieve them, a physician orders baclofen, 5 mg P.O. three times daily. What is the principal indication for baclofen?

muscle spasms with paraplegia or quadriplegia from spinal cord lesions

A client has short-term memory loss. To help the client cope with memory loss, the nurse should:

place a single-date calendar where the client can view it.

A client with a ruptured intervertebral disc at L4-L5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. How should the nurse interpret this finding?

postural deformity.

After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eye drops. What is the expected outcome of applying pressure?

prevents the medication from entering the tear duct.

A nurse is monitoring a client for adverse reactions to atropine eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?

tachycardia

Which respiratory pattern indicates increasing intracranial pressure in the brain stem?

slow, irregular respirations

A client is scheduled for surgery is confused and shows signs of dementia. The nurse should ask which person to sign the consent for the client?

spouse

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent?

succinylcholine

Which clinical manifestation should the nurse assess when a client has acute angle-closure glaucoma?

sudden eye pain

At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia?

to coincide with the peak action of drug therapy

The nurse is providing medication teaching for a client who has been prescribed carbamazepine for a seizure disorder. What client statement would indicate that additional instruction is required?

"If I have a seizure, I should take two tablets immediately."

A client suspected of acetaminophen toxicity reports that they ingested the medication at 7 p.m. (1900). At what time should the nurse anticipate laboratory tests to assess the acetaminophen level?

11:00 p.m. (2300)

A registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel are caring for a group of clients. The RN asks the assistive personnel to check the pulse oximetry level of a client who underwent a laminectomy. The assistive personnel reports that the pulse oximetry reading is 89% on room air. The client has a prescription for oxygen at 2 L/min for a pulse oximetry level below 92%. The RN is currently assessing a postoperative client who just returned from the postanesthesia care unit. How will the RN proceed?

Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

Risk for injury related to neurologic deficit

The nurse is educating a client and family about macular degeneration. Which photo would be utilized to best illustrate what these clients typically see?

See picture

The nurse is admitting a client diagnosed with multiple sclerosis (MS). Which medication would the nurse expect to find on the client's record?

baclofen

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

bending over the sink to wash the face

A nurse is caring for a client in a vegetative state following a traumatic head injury. During the initial assessment, the nurse notes that the client has difficulty digesting a new tube feeding formula. When she contacts the dietician to discuss the change in the tube-feeding formula, the nurse is demonstrating the nursing role of

client advocate.

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?

decreased acetylcholine level

A client has chronic open-angle glaucoma. What should the nurse ask the client about when conducting a focused assessment?

decreasing peripheral vision

The nurse is observing the unlicensed assistive personnel (UAP) give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which?

positions the client on the back with a small pillow under the head

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial?

regular exercise

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

respiratory acidosis

A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority?

risk for injury

A nurse is caring for a client with myasthenia gravis. What assessment findings would indicate an emergency?

sudden dyspnea, intensification of dysphagia, and dysarthria

A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place them closer to the nurses' station because of their tendency to

wander.

A client recently experienced a stroke with accompanying left-sided paralysis. The family voices concerns about how to best interact with the client. They report the client doesn't seem aware of their presence when they approach the client on the left side. What advice should the nurse give the family?

"The client is unaware of their left side. You should approach them on the right side."

A nurse is educating a client's family on Alzheimer's disease. Which statement by the nurse would cause the charge nurse to intervene?

"Routine administration of donepezil at the same time every day can cure the disease."

A client who has apnea during sleep would require which of the following interventions? Select all that apply.

-Refer to primary healthcare provider -Assess sleep routine/hours -Have client keep a sleep diary

Four days after surgery for internal fixation of a C3-C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which features of the wheelchair are appropriate for the needs of this client? Select all that apply.

-back and head that are high -seat that is lower than normal -chair controlled by the client's breath

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?

"Assume a reclining or flat position."

The nurse is teaching a young female about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client makes which statement?

"I'll use one of the barrier methods of contraception."

A 35-year-old client diagnosed with multiple sclerosis three years ago presents the nurse with an advance directive refusing intubation, mechanical ventilation, and tube feedings. How should the nurse respond?

"You should review this information with your healthcare provider at every admission."

What information about vision would be most important for the nurse to include in the discharge plan of a client who had cataract removal?

"You'll need to relearn to judge distances accurately."

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply.

-Assist the client to the floor. -Turn the client to the side. -Place a pillow under the client's head.

Which information should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply.

-Carefully test the temperature of bath water. -Avoid hot water bottles and heating pads. -Inspect the skin daily for injury or pressure points. -Wear warm clothing when outside in cold temperatures.

A nurse is providing discharge instructions on phenytoin to a female client with tonic-clonic seizure disorder. Which instructions would the nurse include? Select all that apply.

-Monitor the body for any skin rash. -Perform good oral hygiene, including daily brushing and flossing. -Receive necessary periodic blood work. -Report any problems with walking or coordination, slurred speech, or nausea.

The nurse is caring for a child with a head injury. Place the following assessments in order of priority, starting with the nursing assessment the nurse should perform first.

1. Level of consciousness. 2. Motor strength. 3. Vital signs. 4. Decreased urine output.

Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures?

Administer carbamazepine 200 mg PO, twice per day.

A client undergoes intense rehabilitation after a cerebrovascular accident (CVA) and is being discharged with residual hemiparesis. What is the most important responsibility of the case manager?

Assess capabilities, demonstrate the use of assistive devices, and assess how the client will manage at home.

A client with amyotrophic lateral sclerosis (ALS) is admitted with weight loss and malnutrition. The client can swallow without difficulty. While caring for the client, the nurse discovers that the weight loss is related to the client's refusal to eat. The client states to the nurse that they would rather die than remain alive with this disease. How should the nurse intervene?

Explore the client's feelings about dealing with ALS using open-ended questions.

A nurse is assessing a client with meningitis. The nurse places the client in a supine position and flexes the client's leg at the hip and knee. The nurse notes resistance when straightening the knee and the client reports pain. The nurse should document what neurologic sign as positive?

Kernig's sign

The nurse is assigned to care for a client with an ocular prosthesis who is having surgery under a local anesthetic. Prior to surgery, what should the nurse do?

Leave the prosthesis in place.

Sodium polystyrene sulfonate is prescribed for a client following a crush injury. Which finding indicates the drug has been effective?

The serum potassium is 4.0 mEq/L (4.0 mmol/L).

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

absence of reflexes along with flaccid extremities