Neurosensory Disorders

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? "Do not eat anything for 12 hours before the test." "Avoid thinking about personal matters for 12 hours before the test." "Do not shampoo your hair for 24 hours before the test." "Avoid stimulants and alcohol for 24 to 48 hours before the test."

"Avoid stimulants and alcohol for 24 to 48 hours before the test."

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? "Suction the client's secretions between bites of food." "Feed the client quickly, there are four more client's to feed." "Position the client in a sitting position before feeding." "Check the client's gag and swallow reflexes."

"Position the client in a sitting position before feeding."

A client with Parkinson disease tells the nurse of plans to take St. John's wort for depression in addition to the prescribed carbidopa-levodopa. What is the nurse's best response? "St. John's wort is an herbal remedy that can be used to treat depression." "St. John's wort must be taken in large doses to help reduce depression." "St. John's wort can cause a toxic reaction with the Parkinsonian drugs." "If you take St. John's wort and Parkinsonian drugs, take them on alternate days."

"St. John's wort can cause a toxic reaction with the Parkinsonian drugs."

The nurse is caring for a client who is scheduled to undergo a computerized tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information should the nurse reinforce from a preprocedural teaching plan? Select all that apply. The CT scan is considered an invasive procedure, but it is not dangerous. The test requires standing alone without assistance. It is necessary to report any known allergies to iodine or seafood prior to the procedure. Throat irritation and facial flushing may occur if contrast dye is used. All medications must be withheld for 12 hours prior to the procedure. A contrast dye may be given before the test.

A contrast dye may be given before the test. Throat irritation and facial flushing may occur if contrast dye is used. It is necessary to report any known allergies to iodine or seafood prior to the procedure.

A client with quadriplegia is in spinal shock. What should the nurse expect? Spasticity of all four extremities Hyperreflexia along with spastic extremities Absence of reflexes along with flaccid extremities Positive Babinski's reflex along with spastic extremities

Absence of reflexes along with flaccid extremities

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? Depression Excessive drug use Delirium Alzheimer's disease

Alzheimer's disease

A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair. How should the nurse intervene first? Put a padded tongue blade into the client's mouth and restrain her extremities. Initiate the code team response. Assist the client to a side-lying position on the floor, and protect her with linens. Record the type of seizure and the time that it occurred.

Assist the client to a side-lying position on the floor, and protect her with linens.

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? Placing hand rolls on the balls of each foot Putting slippers on the client's feet Attaching braces or splints to each foot and leg Crossing the client's ankles every 2 hours

Attaching braces or splints to each foot and leg

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? Visual acuity Body temperature control Thinking and reasoning Balance and equilibrium

Body temperature control

The nurse is scheduled to administer an otic medication. Which action should the nurse perform first? Check and verify the proper client's name. Hold an emesis basin under the client's ear. Place the client in the semi-Fowler's position. Warm the solution to prevent dizziness.

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? Ask the client when prescribed medication was last taken. Place the client in a darkened room and check on the client in 30 minutes. Turn the client on the client's back. Check the client's vital signs and remove restrictive clothing.

Check the client's vital signs and remove restrictive clothing.

The nurse is reviewing the medical record for a client in a long-term care facility. The nurse notes an entry by the primary care physician indicating the client is colorblind. The nurse understands this condition results from a problem with which structure(s) of the eye? Cones Aqueous humor Rods Lens

Cones

A client comes to the emergency department after hitting his or her head in a motor vehicle collision. The client is alert and oriented. Which nursing intervention should be done first? Immobilize the client's head and neck. Call for an immediate chest x-ray. Open airway using head tilt/chin lift maneuver. Perform full range of motion (ROM).

Immobilize the client's head and neck.

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 while providing mouth care. Avoid providing mouth care. Maintain the client on nothing-by-mouth status. Continue providing mouth care because the client's gag reflex is intact.

Make sure a tonsil suction device is readily available while providing mouth care.

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. Instill artificial tears. Encourage the client to close his eyes. Turn out the lights in the room.

Notify the physician

A client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 mm Hg and heart rate of 50 beats/minute. Which nursing intervention should be done first? Place the client flat in bed. Give one sublingual nitroglycerin tablet. Raise the head of the bed immediately to 90 degrees. Check patency of the indwelling urinary catheter.

Raise the head of the bed immediately to 90 degrees.

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes highest priority? Feeding self care deficit: related to neurologic trauma Impaired verbal communication related to confusion Risk for injury related to neurologic deficit Disturbed sensory perception (visual) related to neurologic trauma

Risk for injury related to neurologic deficit

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? Apply suction to the catheter during insertion only. Suction for 10 to 15 seconds at a time. Regulate the suction machine to 300 cm suction. Pass the suction catheter into the opening of the tracheostomy tube 2 to 3 cm.

Suction for 10 to 15 seconds at a time.

A client accidentally 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 eliminate the need for medical care To serve as a stopgap measure until help arrives To hasten formation of scar tissue To prevent vision loss

To prevent vision loss

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? It is normal to expect that the pupils may be unusually small. Wear dark glasses in bright light because the pupils are dilated. Be careful because the blink reflex is paralyzed. Avoid wearing regular glasses when driving.

Wear dark glasses in bright light because the pupils are dilated.

The nurse is explaining the purpose of the electroencephalogram (EEG) to the client. What does the nurse reinforce that the EEG measures? percent of functioning brain tissue sites of brain injury extent of intracranial bleed activity of the brain

activity of the brain

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 inserting nasal and ear packing with sterile gauze suctioning the nose to maintain airway patency positioning the client flat in bed

checking the fluid for glucose with a dipstick

A nurse collecting data on a post-craniotomy client finds the urinary catheter bag with 1,500 mL the first hour and the same amount for the second hour. Which complication should the nurse suspect as a cause of this amount of output? Cushing's syndrome hyperglycemia diabetes insipidus adrenal crisis

diabetes insipidus

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. e-mailing information about a client to a friend at home. documenting medications before administration. determining a client's identity from a computer chart.

documenting medications after administration.

A client with suspected multiple sclerosis (MS) undergoes a lumbar puncture. When reviewing the results of the laboratory analysis of the cerebrospinal fluid (CSF), what does the nurse expect to find? increased glucose concentrations increased protein levels blood or increased red blood cells elevated white blood cells (WBCs)

increased protein levels

The nurse is working on a surgical floor. The nurse must logroll a client following a: laminectomy. thoracotomy. hemorrhoidectomy. cystectomy.

laminectomy.

When obtaining the health history from a client with retinal detachment, the nurse expects the client to report: light flashes and floaters in front of the eye. a recent driving accident while changing lanes. headaches, nausea, and redness of the eyes. frequent episodes of double vision.

light flashes and floaters in front of the eye.

The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: increase the dose of muscle relaxants. avoid naps during the day. take a hot bath. rest in a room set at a comfortable temperature.

rest in a room set at a comfortable temperature.

A 1-year-old child is brought to the emergency department with a mild respiratory infection and a temperature of 101.3° F (38.5° C). Otitis media is diagnosed. Which sign would the nurse also expect to find? high-pitched, barking cough pearl-gray tympanic membrane tugging on the ears excessive drooling

tugging on the ears

A nurse has administered timolol to a client with glaucoma. What symptom would be of greatest concern to the nurse? blurred vision hypertension sudden eye pain wheezing

wheezing

The nurse is reinforcing education for a client after cataract surgery. Which statement indicates that a client needs additional education? "I'll wear an eye shield to protect the eye." "I'll avoid bending over to tie my shoelaces." "I can't wait to pick up my granddaughter." "I'll avoid eating until the nausea subsides."

"I can't wait to pick up my granddaughter."

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 headache 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? Irregular breathing pattern Involuntary posturing Declining level of consciousness Pupillary asymmetry

Declining level of consciousness

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease? Risk for injury related to vertigo Acute pain related to vertigo Imbalanced nutrition: Less than body requirements related to nausea and vomiting Risk for deficient fluid volume related to vomiting

Risk for injury related to vertigo

Which hormone deficiency should the nurse suspect as the underlying cause of diabetes insipidus in a postoperative craniotomy client? thyroid-stimulating hormone (TSH) antidiuretic hormone (ADH) follicle-stimulating hormone (FSH) luteinizing hormone (LH)

antidiuretic hormone (ADH)

The nurse is reviewing a client's laboratory values and finds documentation of a phenytoin level of 32 mg/dL. Which signs and symptoms should the nurse monitor this client for? Select all that apply. tonic-clonic seizure urinary incontinence ataxia confusion sodium depletion

ataxia confusion

The nurse is caring for a client with stroke in evolution. Which nursing intervention is priority? Place the client in the supine position. Restrict dietary and parenteral fluids. Have tracheal suction available at all times. Thicken all dietary liquids.

Have tracheal suction available at all times.

A 10-year-old child is admitted to the hospital with clear drainage from the right ear after falling off a bicycle. The nurse is testing the fluid to determine if it is cerebrospinal (CSF) fluid. The parent asks what the function of CSF is. How would the nurse respond? Select all that apply. "CSF produces cerebral neurotransmitters." "CSF acts as an insulator to maintain a constant spinal fluid temperature." "CSF removes waste products from the brain." "CSF acts as a barrier to bacteria." "CSF cushions the brain and spinal cord."

"CSF cushions the brain and spinal cord." "CSF removes waste products from the brain."

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 Assessment of the client's gait Evaluation of bowel and bladder functions Examination of the fundus of the eye

Evaluation of the corneal reflex response

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? Make sure that the restraints fit snuggly to restrict the client from reaching his nose, arms, or perineal area. Apply one wrist restraint at a time. Place a sign over the client's bed warning staff to avoid removing the restraints. Fasten the restraint to the bed frame using a quick-release knot.

Fasten the restraint to the bed frame using a quick-release knot.

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. Glaucoma is easily corrected with eyeglasses. Yearly screening for people ages 20 to 40 is recommended. The disorder will not lead to complete loss of vision.

Glaucoma can be painless with loss of peripheral vision.

Friends come to visit a client admitted with new-onset ischemic stroke. The stroke has caused aphasia and right-sided weakness. The client has an advance directive and an identified healthcare power of attorney. The friends ask the nurse about the client's condition. How should the nurse respond? "You'll have to ask the client how they're feeling." "I'm not at liberty to discuss their condition with you. You'll have to speak to the client's power of attorney if you'd like information." "I can't tell you anything about the client's condition." "The client is unable to communicate as a result of a stroke, so I'll tell you what I think they'd want you to know."

"I'm not at liberty to discuss their condition with you. You'll have to speak to the client's power of attorney if you'd like information."

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 Dressing or grooming self-care deficit Disturbed sensory perception (tactile) Impaired physical mobility

Ineffective breathing pattern

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. The client has questions about the paralysis. What information will the nurse tell the client about the paralysis? "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." "It must be hard to accept the permanency of your paralysis." "The paralysis caused by this disease is temporary." "You'll first regain use of your legs and then your arms."

"The paralysis caused by this disease is temporary."

The nurse is caring for a client with stroke in evolution. Which nursing intervention is priority? Place the client in the supine position. Thicken all dietary liquids. Have tracheal suction available at all times. Restrict dietary and parenteral fluids.

Have tracheal suction available at all times.

A nurse is caring for a client post-transurethral transection of the prostate (TURP). The client tells the nurse that he has to void. What is the appropriate nursing action? Irrigate the catheter. Notify the health care provider. Let the client void around the catheter. Remove the catheter.

Irrigate the catheter.

A client with Alzheimer's disease 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? Relocation stress syndrome related to hospitalization Decisional conflict related to lack of relevant treatment information Risk for caregiver role strain related to increased client care needs Defensive coping related to diagnosis of Alzheimer's disease

Risk for caregiver role strain related to increased client care needs

A nursing student has been assigned care of a patient with the diagnosis of autonomic dysreflexia and is unfamiliar with this diagnosis. What would be appropriate actions by the nursing student? Select all that apply. Research the condition in the dictionary and consult with other nurses. Ask the family how they plan to care for the patient. Review the condition in a textbook and review the chart and nursing care plan. Assess the client's knowledge about the condition and consult the physician. Search the Internet for evidence-based practice in a peer-reviewed journal.

Search the Internet for evidence-based practice in a peer-reviewed journal. Review the condition in a textbook and review the chart and nursing care plan.