NGN Hearing impairment

Instilling 50 mL of fluid with each irrigation

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene?

Increased urine output

A nurse is assessing a client who has increased ICP and has received IV mannitol. Which of the following findings indicates a therapeutic effect of this medication?

Specific gravity

A nurse is assessing a client who is postop following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following lab values should the nurse plan to obtain to assess for DI?

Cheyne-Stokes

A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations?

Inability to locate eyeglasses

A nurse is assessing a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment?

Retinal detachment

A nurse is assessing a client who reports an acute visual disturbance that he describes as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders?

Retinal detachment

A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders?

Level of consciousness

A nurse is assessing a client who was admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status?

The client's serum osmolarity is 310 mOsm/L

A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased ICP. Which of the following findings indicates that the medication is having a therapeutic effect?

Decreased sense of taste

A nurse is assessing an older adult client for physiological changes that can occur with age. Which of the following findings should the nurse expect?

Elevate the head of the bed 25 to 30 degrees with the client in a neutral midline position

A nurse is caring for a client during the first 72 hr following a CVA. Which of the following actions should the nurse take?

Turn the client onto a side

A nurse is caring for a client who begins to have a generalized tonic-clonic seizure while lying in bed. Which of the following actions should the nurse take?

Cochlea

A nurse is caring for a client who has Meniere's disease. The nurse should identify that Meniere's disease affects which structure of the ear?

Respiratory effort

A nurse is caring for a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor?

Rigid skull containing cranial contents

A nurse is caring for a client who has a closed TBA and is experiencing increased ICP. This increase in ICP is due to which of the following?

Face the client when speaking

A nurse is caring for a client who has a hearing impairment. Which of the following actions should the nurse take when communicating with the client?

Right-sided hemiplagia

A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect?

Provide an obstacle-free path for ambulation

A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote the client's safety?

Hypothalamus

A nurse is caring for a client who has cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected?

Redirect the client to a different activity with a small group of people

A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following actions should the nurse take?

Monitor vital signs every 2 hr Assess neuro status every 4 hr Keep the client's room darkened

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take?

Frontal

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain?

Eustachian tube

A nurse is caring for a client who has had repeated middle ear infections. The client reports that the provider said the infections are due to an obstruction of the structure that connects the middle ear to the throat. The nurse should identify that the provider was referring to which of the following structures?

Add gestures when speaking with the client

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take?

The client's ability to clear oral secretions

A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessment is the nurse's priority?

Dysphagia

A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement?

Blood pressure

A nurse is preparing an older adult client who had a TIA for discharge. The nurse should teach the client to monitor which of the following parameters at home?

Have the client open his mouth and say, "aah"

A nurse is preparing to test the function of cranial nerve X. Which of the following procedures should the nurse use?

Dysphagia

A nurse is providing teaching about degenerative complications to the partner of a client who has a new diagnosis of Parkinson's disease. Which of the following manifestations is the priority?

Driving can be dangerous due to the loss of peripheral vision. Laser surgery can help reestablish the flow of aqueous humor.

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of info should the nurse include in the teaching?

Black tag

A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils?

Provide supplemental oxygen

An ED nurse is assessing a client who has a new TBI. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority?

Respite care

A home health nurse is interviewing the adult child of a client who has Alzheimer's disease. The child is the client's sole caregiver and reports feeling fatigued and overwhelmed. Which of the following referrals should the nurse make for the caregiver?

Cerebellar dysfunction

A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a positive Romberg test, indicating which of the following alterations?

Instill a diluted alcohol solution into the ear after swimming

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching?

Difficulty with speech

A nurse in a rehab center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect?

Clear fluid coming from the nares

A nurse in an ED is assessing a client who sustained a fall off a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture?

Oral-nasal suction equipment

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside?

Immobilize the client's cervical spine

A nurse in the ED has assessed a client's ABCs following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next?

A client who is difficult to arouse and is unable to respond to questions

A nurse in the ED is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries of the head and extremities. Which of the following clients should the nurse assess first?

Dizziness and hearing loss

A nurse is assessing a client who as a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the 8th cranial nerve?

Weakness of the lower extremities

A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect?

Report of a headache

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia?

Severe eye pain

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations?

Swelling behind the affected ear

A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect?

Opacity visible behind the pupil

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect?

Widened pulse pressure

A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?

Dilated pupils

A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure?

Expressive aphasia

A nurse is caring for a client who had a CVA. The client appears alert and engaged during a visit but does not respond verbally to questions. The nurse should document this as which of the following alterations?

The client rigidly extends his arms

A nurse is caring for a client who has a TBI and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample?

Arousal

A nurse is caring for a client who has received sedation. When the nurse applies nailbed pressure, the client withdraws his hand. The nurse should document this response as indicating which of the following?

The client is unable to understand words or sentences she hears

A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client?

Place the client in a high-Fowler's position

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next?

Semi-Fowler's

A nurse is caring for a client who is postop following a frontal craniotomy. The nurse should place the client in which of the following positions?

Monitor the client for increased ICP

A nurse is planning care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the client's plan of care?

"An EEG records the electrical activity of your brain cells."

A nurse is preparing a client for an EEG. When the client asks the nurse what this test does, which of the following responses should the nurse provider?

"You'll begin by lying still with your eyes closed."

A nurse is preparing a client for an EEG. Which of the following pieces of info should the nurse share with the client?

Development of hives when eating shrimp

A nurse is preparing a client who has a brain tumor for CT. Which of the following factors affects the manner in which the nurse will prepare the client for the scan?

Reduce dietary sodium

A nurse is providing discharge teaching to a client who has had a TIA. Which of the following instructions should the nurse include?

"I will avoid bending over."

A nurse is providing discharge teaching to a client who is postop following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions?

"You should avoid reading for 1 week."

A nurse is providing discharge teaching to a client who is postop following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching?

Protect the client's head

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seiruze?

"You might need glasses after the surgery."

A nurse is providing teaching for a client who will undergo LASIK surgery. Which of the following pieces of info should the nurse include?

TIA can precede an ischemic stroke

A nurse is providing teaching to a class about TIA. Which of the following pieces of info should the nurse include in the teaching?

Thoroughly shampoo her hair prior to the EEG

A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard EEG. Which of the following instructions should the nurse include in the teaching?

Avoid sudden movements

A nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching?

"Darken the lights."

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching?

"Acute episodes are usually followed by remissions, which can vary in duration."

A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual cause of MS. Which of the following responses should the nurse make?

Set an alarm to ensure medication dosages are taken on time

A nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis (MG). Which of the following pieces of info should the nurse include?

"Shampoo your hair before the procedure and don't use any styling products afterward."

A nurse is providing teaching to a client who is scheduled for an electroencephalogram in the morning. Which of the following pieces of info should the nurse share?

Limit choices offered to the client

A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease. Which of the following pieces of info should the nurse include in the teaching?

Weakness of the distal extremities

A nurse is providing teaching to the family who has a new diagnosis of ALS. Which of the following findings is an early manifestation of ALS?

Elevated protein

A nurse is reviewing the lab results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?

Reading the newspaper

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty?

The client has a pacemaker

A nurse is reviewing the medical history of a client who is scheduled for a MRI exam of the cervical vertebra. Which of the following pieces of info in the client's history is a contraindication to this procedure?

Sclerosis of the ossicles

A nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. Which of the following pieces of info in the client's medical record should the nurse identify as a risk factor for tinnitus?

Feeling of fullness in the ear

A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?

"You'll have to lie very still on a long, narrow table during the test."

A nurse is teaching a client about CT scanning of the brain. Which of the following teaching points should the nurse include?

"An aura is a sensory warning that a seizure is imminent."

A nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. Which of the following statements by the client indicates an understanding of the teaching?

Dry eyes

A nurse is teaching a client who has myopia about laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following is an adverse effect of LASIK surgery?

Turn off sources of oxygen near the fire

A nurse is walking along the unit when she sees smoke coming from the central supply room. After activating the fire alarm, which of the following actions should the nurse take?

Immediate

A nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the client he will have to repeat them again in a few minutes. After 5 minutes, the nurse asks the client to name the objects. The nurse is using this strategy to test which type of memory?

Check airway patency

A nurse responds t a call from an assistive personnel that a client just had a seizure and is unconscious. Which of the following assessments is the nurse's priority?

Recall

During a neuro assessment, a nurse asks how the client arrived at the appointment and with whom. Which of the following types of memory is the nurse testing?

Remote

During a neuro assessment, a nurse asks the client to name all of his children, their ages, and their birth dates. Which of the following types of memory is the nurse testing?