Saunders Neurological

A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment? 1. Taste 2. Smell 3. Vision 4. Hearing

Vision

A client has a cerebellar lesion. The nurse would plan to obtain which item for use by this client? 1. Walker 2. Slider board 3. Raised toilet seat 4. Adaptive eating utensils

Walker

The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply. 1. Eye opening 2. Reflex response 3. Best verbal response 4. Best motor response 5. Pupil size and reaction

1. Eye opening 3. Best verbal response 4. Best motor response

The nurse is evaluating the respiratory outcomes for a client with Guillain-Barré syndrome. The nurse determines that which are acceptable outcomes for the client? Select all that apply. 1. Spontaneous breathing 2. Oxygen saturation of 98% 3. Adventitious breath sounds 4. Normal arterial blood gas levels 5. Vital capacity within normal range

1. Spontaneous breathing 2. Oxygen saturation of 98% 4. Normal arterial blood gas levels 5. Vital capacity within normal range

The nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? 1. 5 mm Hg 2. 8 mm Hg 3. 14 mm Hg 4. 22 mm Hg

22 mm Hg

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration? 1. Using adult diapers 2. Inserting a Foley catheter 3. Establishing a toileting schedule 4. Padding the bed with an absorbent cotton pad

Establishing a toileting schedule

A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation? 1. Annual influenza vaccination 2. Ingestion of increased fruits and vegetables 3. An established routine of walking 2 miles each evening 4. A recent period of extreme outside ambient temperatures

Ingestion of increased fruits and vegetables

The nurse is planning discharge teaching for a client started on acetazolamide for a supratentorial lesion. Which information about the primary action of the medication should be included in the client's education? 1. It will prevent hypertension. 2. It will prevent hyperthermia. 3. It decreases cerebrospinal fluid production. 4. It maintains adequate blood pressure for cerebral perfusion.

It decreases cerebrospinal fluid production.

A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? 1. Observe the client demonstrating the transfer technique. 2. Start a restorative nursing program before an injury occurs. 3. Seize the opportunity to discuss potential nursing home placement. 4. Determine the number of falls that the client has had in recent weeks.

Observe the client demonstrating the transfer technique.

The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which assessment question? 1. "Are you consistently fatigued?" 2. "Are you having muscle spasms?" 3. "Are you getting up at night to urinate?" 4. "Are you having normal bowel movements?"

"Are you getting up at night to urinate?"

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement? 1. "Here's the MedicAlert bracelet I obtained." 2. "I should take my medications an hour before mealtime." 3. "Going to the beach will be a nice, relaxing form of activity." 4. "I've made arrangements to get a portable resuscitation bag and home suction equipment."

"Going to the beach will be a nice, relaxing form of activity."

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? 1. "I will wash my face with cotton pads." 2. "I'll have to start chewing on my unaffected side." 3. "I should rinse my mouth if toothbrushing is painful." 4. "I'll try to eat my food either very warm or very cold."

"I'll try to eat my food either very warm or very cold."

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."

"We need to remind him to turn his head to scan the lost visual field."

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. 1. Postictal status 2. Duration of the seizure 3. Changes in pupil size or eye deviation 4. Seizure progression and type of movements 5. What the client ate in the 2 hours preceding seizure activity

1. Postictal status 2. Duration of the seizure 3. Changes in pupil size or eye deviation 4. Seizure progression and type of movements

A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should take which actions? Select all that apply. 1. Giving the client thin liquids 2. Thickening liquids to the consistency of oatmeal 3. Placing food on the unaffected side of the mouth 4. Allowing plenty of time for chewing and swallowing 5. Leave the client alone so that the client will gain independence by feeding self

2. Thickening liquids to the consistency of oatmeal 3. Placing food on the unaffected side of the mouth 4. Allowing plenty of time for chewing and swallowing

A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply. 1. Fever 2. Seizures 3. Hypoxia 4. Ischemia 5. Hypotension 6. Increased intracranial pressure (ICP)

3. Hypoxia 4. Ischemia 5. Hypotension 6. Increased intracranial pressure (ICP)

The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client? 1. 400 to 500 mL with each meal and 500 to 600 mL in the evening before bedtime 2. 400 to 500 mL with each meal and additional fluids in the morning but not after midday 3. 400 to 500 mL with each meal, with all extra fluid concentrated in the afternoon and evening 4. 400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon

400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon

The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the appropriate nursing intervention? 1. Assist the client to eat with the left hand to build strength. 2. Provide a pureed diet that is easy for the client to swallow. 3. Inform the client that a feeding tube will be placed if progress is not made. 4. Provide a variety of foods on the meal tray to stimulate the client's appetite.

Assist the client to eat with the left hand to build strength.

The nurse is assessing the client's gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment finding? 1. Spastic 2. Ataxic 3. Festinating 4. Dystrophic or broad-based

Ataxic

The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record? 1. Muscle wasting 2. Mild clumsiness 3. Altered mentation 4. Diminished gag reflex

Mild clumsiness

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1. Clustering nursing activities 2. Hyperoxygenating before suctioning 3. Maintaining 20 degree flexion of the knees 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed (HOB) at 30 degrees elevation

2. Hyperoxygenating before suctioning 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed (HOB) at 30 degrees elevation

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse instructs the client about the purpose of the TENS unit. Which statement by the client indicates the need for further teaching? 1. "The unit relieves pain." 2. "Electrodes are attached to the skin." 3. "The unit will reduce the need for analgesics." 4. "Hospitalization is required because the unit is not portable."

"Hospitalization is required because the unit is not portable."

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching? 1. "I will rest each afternoon after my walk." 2. "I should cough and deep breathe many times during the day." 3. "I can change the time of my medication on the mornings when I feel strong." 4. "If I get abdominal cramps and diarrhea, I should call my health care provider."

"I can change the time of my medication on the mornings when I feel strong."

The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs further teaching if the client makes which statements? 1. "I will perform facial exercises." 2. "I will expose my face to cold to decrease the pain." 3. "I will massage my face with a gentle upward motion." 4. "I will wrinkle my forehead, blow out my cheeks, and whistle frequently."

"I will expose my face to cold to decrease the pain."

A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client? 1. "This is not a stroke, and many clients recover in 3 to 5 weeks." 2. "This is caused by a small tumor, which can be removed easily." 3. "This is similar to a stroke, but all symptoms will reverse without treatment." 4. "This is a temporary problem, with treatment similar to that for migraine headaches."

"This is not a stroke, and many clients recover in 3 to 5 weeks."

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? 1. "When did the injury occur?" 2. "Was the client awake and talking right after the injury?" 3. "What medications has the client received since the fall?" 4. "What was the client's level of consciousness before the injury?"

"Was the client awake and talking right after the injury?"

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the client in which position? 1. Prone 2. Supine 3. Semi Fowler's with the hip and the neck flexed 4. Head of the bed elevated 30 degrees with the head in midline position

Head of the bed elevated 30 degrees with the head in midline position

The nurse is caring for a client with an intracranial aneurysm who has been alert. Which signs and symptoms are an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. 1. Mild drowsiness 2. Drooping eyelids 3. Ptosis of the left eyelid 4. Slight slurring of speech 5. Less frequent spontaneous speech

1. Mild drowsiness 4. Slight slurring of speech 5. Less frequent spontaneous speech

he home health nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals related to decreased muscle strength. Which suggestions should the nurse give to the client? Select all that apply. 1. Chew food thoroughly. 2. Cut food into very small pieces. 3. Sit straight up in the chair while eating. 4. Lift the head while swallowing liquids. 5. Swallow when the chin is tipped slightly downward to the chest.

1. Chew food thoroughly. 2. Cut food into very small pieces. 3. Sit straight up in the chair while eating. 5. Swallow when the chin is tipped slightly downward to the chest.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should plan to place the client in which positions? Select all that apply. 1. Head midline 2. Neck in neutral position 3. Flat, with head turned to the side 4. Head of bed elevated 30 to 45 degrees 5. Head of bed elevated with the neck extended

1. Head midline 2. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees

The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply. 1. Speaking to the client at a slower rate 2. Allowing plenty of time for the client to respond 3. Completing the sentences that the client cannot finish 4. Looking directly at the client during attempts at speech 5. Shouting words if it seems as though the client has difficulty understanding

1. Speaking to the client at a slower rate 2. Allowing plenty of time for the client to respond 4. Looking directly at the client during attempts at speech

The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse include when planning care for this client? Select all that apply. 1. Using a RotoRest bed 2. Ensuring that weights hang freely 3. Removing the weights to reposition the client 4. Assessing the integrity of the weights and pulleys 5. Comparing the amount of prescribed traction with the amount in use

1. Using a RotoRest bed 2. Ensuring that weights hang freely 4. Assessing the integrity of the weights and pulleys 5. Comparing the amount of prescribed traction with the amount in use

A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2? 1. It will cause arteriovenous shunting. 2. It will cause vasodilation of blood vessels in the brain. 3. It will cause blood vessels in the circle of Willis to collapse. 4. It will cause hyperresponsiveness of blood vessels in the brain

It will cause vasodilation of blood vessels in the brain.

The nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are part of the circle of Willis? Select all that apply. 1. Basilar artery 2. Vertebral artery 3. Anterior cerebral artery 4. Internal carotid arteries 5. Posterior cerebral artery

3. Anterior cerebral artery 4. Internal carotid arteries 5. Posterior cerebral artery

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 1. Insert nasal packing. 2. Document the findings. 3. Contact the health care provider (HCP). 4. Monitor the client's blood pressure and check for signs of increased intracranial pressure.

Contact the health care provider (HCP).

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/minute range. The client is also complaining of nausea. Which cranial nerve damage should the nurse expect that the client is experiencing? 1. Vagus (CN X) 2. Hypoglossal (CN XII) 3. Spinal accessory (CN XI) 4. Glossopharyngeal (CN IX)

Vagus (CN X)

The nurse is performing an assessment on a client with a head injury and notes that the client is assuming this posture. The nurse contacts the health care provider and reports that the client is exhibiting which posture?

Decorticate rigidity

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1. A negative Kernig's sign 2. Absence of nuchal rigidity 3. A positive Brudzinski's sign 4. A Glasgow Coma Scale score of 15

A positive Brudzinski's sign

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client? 1. Dilated pupils 2. Lumbar trauma 3. A cervical cord injury 4. Altered level of consciousness

A cervical cord injury

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? 1. A walker 2. Eyeglasses 3. A hearing aid 4. A bath thermometer

A hearing aid

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem? 1. Intracranial pressure 2. A long-term sequela of the 3. A worsening of the original 4. A short-term problem that will resolve in about 1 month

A long-term sequela of the injury

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? 1. Ask the family to deliver the care. 2. Leave the client alone until ready to participate. 3. Advise the client that rehabilitation progresses more quickly with cooperation. 4. Acknowledge the client's anger and continue to encourage participation in care.

Acknowledge the client's anger and continue to encourage participation in care.

The nurse is evaluating a function of the limbic system as a part of the neurological status of a client. What should the nurse assess? 1. Experience of pain 2. Affect or emotions 3. Response to verbal stimuli 4. Insight, judgment, and planning

Affect or emotions

An older client in an acute state of disorientation is brought to the hospital emergency department by the client's daughter. The daughter states that the client was "clear as a bell this morning." The nurse determines from this piece of information that which is an unlikely cause of the disorientation? 1. Hypoglycemi 2. Alzheimer's disease 3. Medication dosage 4. Impaired circulation to the brain

Alzheimer's disease

A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse should keep which most important items available at the client's bedside? 1. Oxygen and metered-dose inhaler 2. Ambu bag and suction equipment 3. Pulse oximeter and cardiac monitor 4. Incentive spirometer and cough pillow

Ambu bag and suction equipment

The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation? 1. Brain death 2. A cerebral lesion 3. A temporal lesion 4. An intact brainstem

An intact brainstem

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. On the basis of these findings, the nurse determines that the client is experiencing parasympathetic stimulation of which cranial nerve? 1. Vagus (CN X) 2. Hypoglossal (CN XII) 3. Spinal accessory (CN XI) 4. Glossopharyngeal (CN IX)

Vagus (CN X)

The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech? 1. Intact 2. Rambling 3. Characterized by literal paraphasia 4. Associated with poor comprehension

Associated with poor comprehension

A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis? 1. Atropine sulfate 2. Morphine sulfate 3. Protamine sulfate 4. Pyridostigmine bromide

Atropine sulfate

The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do? 1. Prevent stressful situations. 2. Avoid activities that may cause fatigue. 3. Avoid contact with people with an infection. 4. Avoid activities that may cause pressure near the face.

Avoid activities that may cause pressure near the face.

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. The nurse should expect to note documentation of which early symptom of this disease? 1. Aphasia 2. Agnosia 3. Difficulty with swallowing 4. Balance and coordination problems

Balance and coordination problems

The nurse is caring for a client with a neurological deficit involving the hippocampus. On assessment of the client, which signs and symptoms would most likely be noted? 1. Disoriented to client, place, and time 2. Affect flat, with periods of emotional lability 3. Cannot recall what was eaten for breakfast today 4. Unable to add and subtract; does not know who is president

Cannot recall what was eaten for breakfast today

The nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed? 1. Buspirone 2. Fluphenazine 3. Chlorpromazine 4. Prochlorperazine

Chlorpromazine

The nurse reviews the health care provider's (HCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the HCP should the nurse question? 1. Clear liquid diet 2. Bilateral calf measure 3. Monitor vital signs frequently 4. Passive range-of-motion (ROM) exercises

Clear liquid diet

The nurse is assessing a client's muscle strength and notes that when asked, the client cannot maintain the hands in a supinated position with the arms extended and eyes closed. How should the nurse correctly document this finding on the medical record? 1. Client is demonstrating ataxia. 2. Client is exhibiting pronator drift. 3. Client appears to have nystagmus. 4. Client examination reveals hyperreflexia.

Client is exhibiting pronator drift.

The nurse is caring for a client diagnosed with a hydrocephalus. Which should the nurse anticipate as being the cause of this disorder? 1. Closure of cranial sutures 2. Small aqueduct of Sylvius 3. Enlarged foramen of Monro 4. Increased number of arachnoid villi

Closure of cranial sutures

A client who suffered a stroke is prepared for discharge from the hospital. The health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action should the nurse include in the client's plan of care? 1. Implement ROM exercises to the point of pain for the client. 2. Consider the use of active, passive, or active-assisted exercises in the home. 3. Encourage the client to be dependent on the home care nurse to complete the exercise program. 4. Develop a schedule of ROM exercises every 2 hours while awake even if the client is fatigued.

Consider the use of active, passive, or active-assisted exercises in the home.

A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom? 1. A symmetrical smile 2. Difficulty closing the eyelid on the affected side 3. Narrowing of the palpebral fissure on the affected side 4. Paroxysms of excruciating pain in the lips and cheek on the affected side

Difficulty closing the eyelid on the affected side

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention should the nurse plan to implement? 1. Check cranial nerve functioning. 2. Determine the cause of the accident. 3. Draw blood for arterial blood gas analysis. 4. Perform a pulmonary wedge pressure measurement.

Draw blood for arterial blood gas analysis.

Which assessment finding should the nurse expect to note in the client hospitalized with a diagnosis of stroke who has difficulty chewing food? 1. Dysfunction of vagus nerve (cranial nerve X) 2. Dysfunction of trigeminal nerve (cranial nerve V) 3. Dysfunction of hypoglossal nerve (cranial nerve XII) 4. Dysfunction of spinal accessory nerve (cranial nerve XI)

Dysfunction of trigeminal nerve (cranial nerve V)

A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be most concerned about? 1. Glaucoma 2. Emphysema 3. Hypertension 4. Diabetes mellitus

Emphysema

The nurse is caring for a client who is on bed rest as part of aneurysm precautions. The nurse should avoid doing which action when giving respiratory care to this client? 1. Encouraging hourly coughing 2. Assisting with incentive spirometer 3. Encouraging hourly deep breathing 4. Repositioning gently side to side every 2 hours

Encouraging hourly coughing

The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? 1. Extend the arms. 2. Extend the tongue. 3. Turn the head toward the nurse's arm. 4. Focus the eyes on the object held by the nurse.

Extend the tongue.

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? 1. GCS = 3 2. GCS = 6 3. GCS = 9 4. GCS = 11

GCS = 9

The nurse has taught a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that further teaching is needed if the client states the need to take which action? 1. Bend at the knees to pick up objects. 2. Increase fiber and fluid intake in the diet. 3. Strengthen the back muscles by swimming or walking. 4. Get out of bed by sitting straight up and swinging the legs over the side of the bed.

Get out of bed by sitting straight up and swinging the legs over the side of the bed.

The nurse is positioning a client who has increased intracranial pressure. Which position should the nurse avoid? 1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees

Head turned to the side

The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications? 1. A history of diarrhea 2. A flattened abdomen 3. Hyperactive bowel sounds 4. Hematest-positive nasogastric tube drainage

Hematest-positive nasogastric tube drainage

A client brought to the emergency department had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what should the nurse include in the client's assessment? 1. Loss of consciousness 2. Presence of diaphoresis 3. History of prior trauma 4. Rotating eye movements

History of prior trauma

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. On the basis of these findings the nurse suspects dysfunction in which area of the brain? 1. Cerebrum 2. Cerebellum 3. Hippocampus 4. Hypothalamus

Hypothalamus

The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly? 1. Thalamus 2. Hypothalamus 3. Limbic system 4. Reticular activating system

Hypothalamus

A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care? 1. Inability to care for self 2. Interruption in skin integrity 3. Interruption in physical mobility 4. Inability to perform daily activities

Interruption in physical mobility

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? 1. Bilateral loss of pain and temperature sensation 2. Ipsilateral paralysis and loss of touch and vibration 3. Contralateral paralysis and loss of touch, pressure, and vibration 4. Complete paraplegia or quadriplegia, depending on the level of injury

Ipsilateral paralysis and loss of touch and vibration

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client? 1. Take and record vital signs every 4 to 8 hours. 2. Prophylactically hyperventilate during the first 24 hours. 3. Treat a central fever with the administration of antipyretic medications such as acetaminophen. 4. Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? 1. Take the temperature. 2. Listen to breath sounds. 3. Observe for dyskinesias. 4. Assess extremity muscle strength.

Listen to breath sounds.

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? 1. Electrolyte panel 2. Liver function studies 3. Renal function studies 4. Blood glucose level determination

Liver function studies

The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern? 1. Difficulty articulating words 2. Lung vital capacity of 10 mL/kg 3. Paralysis progressing from the toes to the waist 4. A blood pressure (BP) decrease from 110/78 mm Hg to 102/70 mm Hg

Lung vital capacity of 10 mL/kg

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? 1. Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 2. The client has compulsive habits that should be ignored as long as they are not harmful. 3. The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. 4. Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that the family needs further teaching if they verbalize to call the health care provider (HCP) for which client sign or symptom? 1. Vomiting 2. Minor headache 3. Difficulty speaking 4. Difficulty awakening

Minor headache

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? 1. PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 2. PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 30 to 35 mm Hg (30 to 35 mm Hg) 3. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 4. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)

PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)

The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the health care provider (HCP)? 1. Backache 2. Headache 3. Neck stiffness 4. Feelings of fatigue

Neck stiffness

The nurse is caring for a client diagnosed with Alzheimer's disease. The nurse should anticipate that the client has changes in which component of the nervous system? 1. Glia 2. Peripheral nerves 3. Neuronal dendrites 4. Monoamine oxidase

Neuronal dendrites

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate? 1. Document the findings. 2. Reinforce the dressing. 3. Notify the health care provider (HCP). 4. Mark the area of drainage with a pen and monitor for further drainage.

Notify the health care provider (HCP).

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor? 1. Getting too little exercise 2. Taking excess medication 3. Omitting doses of medication 4. Increasing intake of fatty foods

Omitting doses of medication

The nurse is caring for a client with bacterial meningitis. The nurse should anticipate that an antibiotic with which characteristics will be prescribed for the client? 1. One that has a long half-life 2. One that acts within minutes to hours 3. One that can be easily excreted in the urine 4. One that is able to cross the blood-brain barrier

One that is able to cross the blood-brain barrier

A client with a traumatic brain injury is able, with eyes closed, to identify a set of keys placed in his or her hands. On the basis of this assessment finding, the nurse determines that there is appropriate function of which lobe of the brain? 1. Frontal 2. Parietal 3. Occipital 4. Temporal

Parietal

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? 1. Notify the health care provider (HCP). 2. Loosen tight clothing on the client. 3. Place the client in a sitting position. 4. Check the urinary catheter tubing for kinks or obstruction.

Place the client in a sitting position.

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? 1. Keeping the client on a stretcher 2. Logrolling the client onto a soft mattress 3. Logrolling the client onto a firm mattress 4. Placing the client on a bed that provides spinal immobilization

Placing the client on a bed that provides spinal immobilization

A client with neck and upper extremity pain has been diagnosed with cervical radiculitis. What does the nurse anticipate as being the cause of these clinical manifestations? 1. Pressure on a spinous process 2. Pressure on a spinal nerve root 3. Pressure on a central spinal cord 4. Pressure on a posterior facet joints

Pressure on a spinal nerve root

A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? 1. Difficulty speaking 2. Problem with understanding language 3. Difficulty controlling voluntary motor activity 4. Problem with articulating events from the remote past

Problem with understanding language

The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position following the procedure? 1. Prone in semi Fowler's position 2. Supine in semi Fowler's position 3. Prone with a small pillow under the abdomen 4. Lateral with the head slightly lower than the rest of the body

Prone with a small pillow under the abdomen

The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse plan to do to ensure client safety? 1. Speak loudly to the client. 2. Test the temperature of the shower water. 3. Check the temperature of the food on the dietary tray. 4. Provide a clear path for ambulation without obstacles.

Provide a clear path for ambulation without obstacles.

The nurse cares for a client immediately following a lumbar laminectomy procedure. The client reports numbness and tingling down the left lateral thigh and knee. What is the next action for the nurse to take? 1. Document the assessment. 2. Contact the health care provider (HCP). 3. Inform the client that this is to be expected. 4. Question the client about preoperative symptoms.

Question the client about preoperative symptoms.

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? 1. Reduce environmental noise. 2. Allow visitors as desired by the client and family. 3. Awaken the client every 2 to 3 hours to monitor mental status. 4. Cluster nursing activities to reduce the number of interruptions.

Reduce environmental noise.

At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's airway is patent if which data are identified? 1. Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear 2. Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear 3. Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally 4. Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath sounds in lung bases

Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear

The nurse is assessing the client's level of consciousness and documents that the client has delirium. On the basis of this documentation, the nurse should determine that there is damage to which area of the nervous system? 1. Temporal lobe and frontal lobe 2. Hippocampus and frontal lobe 3. Limbic system and cerebral hemispheres 4. Reticular activating system and cerebral hemispheres

Reticular activating system and cerebral hemispheres

The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse should plan to place the client in which position? 1. Prone 2. Supine 3. Side-lying 4. Semi Fowler's

Semi Fowler's

The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which position? 1. Prone position 2. Supine position 3. Semi Fowler's position 4. Dorsal recumbent position

Semi Fowler's position

The nurse is teaching a client with paraplegia measures to maintain skin integrity. Which instruction will be most helpful to the client? 1. Shift weight every 2 hours while in a wheelchair. 2. Change bed sheets every other week to maintain cleanliness. 3. Place a pillow on the seat of the wheelchair to provide extra comfort. 4. Use a mirror to inspect for redness and skin breakdown twice a week.

Shift weight every 2 hours while in a wheelchair.

The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? 1. Walking on the toes 2. Unsteady and staggering 3. Shuffling and propulsive 4. Broad-based and waddling

Shuffling and propulsive

The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which condition that is a complication of hypothermia blanket use? 1. Frostbite 2. Skin breakdown 3. Arterial insufficiency 4. Venous insufficiency

Skin breakdown

A client has suffered damage to Broca's area of the brain. Which priority assessment should the nurse perform? 1. Speech 2. Hearing 3. Balance 4. Level of consciousness

Speech

A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse determines that the client's clinical manifestations are due to what type of physiologic response? 1. Vagal 2. Peripheral nervous system 3. Sympathetic nervous system 4. Parasympathetic nervous system

Sympathetic nervous system

Which intervention should the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace? 1. Tell the client to inspect the environment for safety hazards. 2. Inform the client about the importance of sitting as much as possible. 3. Inform the client that lotions and body powders can be used for skin breakdown. 4. Instruct the client to tighten the brace during meals and to loosen it for the first 30 minutes after each meal.

Tell the client to inspect the environment for safety hazards.

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The client asks for a snack and something to drink. The nurse should offer which best snack to the client? 1. Cocoa with honey and toast 2. Hot herbal tea with graham crackers 3. Iced coffee and peanut butter and crackers 4. Vanilla wafers and room-temperature water

Vanilla wafers and room-temperature water

The nurse is caring for a client who was admitted for a stroke (brain attack) of the temporal lobe. Which clinical manifestations should the nurse expect to note in the client? 1. The client will be unable to recall past events. 2. The client will have difficulty understanding language. 3. The client will demonstrate difficulty articulating words. 4. The client will have difficulty moving 1 side of the body.

The client will have difficulty understanding language.

CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous (from the surgery) and surrounded by an area of clear or straw-colored drainage. The typical appearance of CSF drainage is that of a "halo." The nurse also would further verify actual CSF drainage by testing the drainage for glucose, which would be positive. 1. The left side of the body 2. The right side of the body 3. Both sides of the body equally 4. Cranial nerves only, such as speech and pupillary response

The left side of the body

The nurse is caring for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care? 1. Place the client in Sims' position. 2. Change the drainage tubing every 48 hours. 3. Level the transducer at the lowest point of the ear. 4. Use strict aseptic technique when touching the monitoring system.

Use strict aseptic technique when touching the monitoring system.

An older client is brought to the hospital emergency department by a neighbor who heard the client talking and found him wandering in the street at 3 a.m. The nurse should first determine which data about the client? 1. His insurance status 2. Blood toxicology levels 3. Whether he ate his evening meal 4. Whether this is a change in usual level of orientation

Whether this is a change in usual level of orientation

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa, in which position? 1. 15 degrees of Trendelenburg's 2. Side-lying with the head of the bed flat 3. With the head of the bed elevated at least 30 degrees 4. With the head of the bed elevated no more than 10 degrees

With the head of the bed elevated at least 30 degrees

The nurse is testing the spinal reflexes of a client during neurological assessment. Which assessment by the nurse would help to determine the adequacy of the spinal reflex? 1. Cough reflex 2. Withdrawal reflex 3. Munro-Kellie reflex 4. Accommodation reflex

Withdrawal reflex

The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit specific information regarding this client's disorder? 1. "Do your eyes feel dry?" 2. "Do you have any spasms in your throat?" 3. "Are you having any difficulty chewing food?" 4. "Do you have any tingling sensations around your mouth?"

"Are you having any difficulty chewing food?"

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? 1. "I can sit down to put on my pants and shoes." 2. "I try to exercise every day and rest when I'm tired." 3. "My son removed all loose rugs from my bedroom." 4. "I don't need to use my walker to get to the bathroom."

"I don't need to use my walker to get to the bathroom."

The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse? 1. "It's a local reaction to nasal stuffiness." 2. "It's due to a hypoglycemic effect on the cranial nerve." 3. "Release of catecholamines with infection or stress leads to the pain." 4. "Pain is due to stimulation of the affected nerve by pressure and temperature.

"Pain is due to stimulation of the affected nerve by pressure and temperature."

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week

1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 4. Turning and repositioning the client at least every 2 hours

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. 1. Loosening restrictive clothing 2. Restraining the client's limbs 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward 5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

1. Loosening restrictive clothing 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward

The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions should be included in the plan? Select all that apply. 1. Leave the lights on in the client's room at night. 2. Place a blood pressure cuff at the client's bedside. 3. Close the shades in the client's room during the day. 4. Allow the client to drink 1 cup of caffeinated coffee a day. 5. Allow the client to ambulate 4 times a day with assistance.

2. Place a blood pressure cuff at the client's bedside. 3. Close the shades in the client's room during the day.

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. 1. Use products that contain alcohol. 2. Position the client on his or her side. 3. Brush the teeth with a small, soft toothbrush. 4. Cleanse the mucous membranes with soft sponges. 5. Use lemon glycerin swabs when performing mouth care.

2. Position the client on his or her side. 3. Brush the teeth with a small, soft toothbrush. 4. Cleanse the mucous membranes with soft sponges.

The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional? 1. A psychologist 2. A social worker 3. A neuropsychologist 4. A vocational rehabilitation specialist

A neuropsychologist

The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings? 1. Normal 2. Abnormal 3. Insignificant 4. Inconclusive

Abnormal

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? 1. Is disoriented to person, place, and time 2. Affect is flat, with periods of emotional lability 3. Cannot recall what was eaten for breakfast today 4. Demonstrates inability to add and subtract; does not know who is the president of the United States

Affect is flat, with periods of emotional lability

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? 1. Altered breathing pattern 2. Increased likelihood of injury 3. Ineffective oxygen consumption 4. Increased susceptibility to aspiration

Altered breathing pattern

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? 1. Return of spinal shock 2. Malignant hypertension 3. Impending brain attack (stroke) 4. Autonomic dysreflexia (hyperreflexia)

Autonomic dysreflexia (hyperreflexia)

The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? 1. Blood pressure 2. Motor response 3. Pupillary response 4. Level of consciousness

Blood pressure

At 8:00 a.m., A client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98°F (37.2°C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99°F (36.7°C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? 1. Reorient the client. 2. Retake the vital signs. 3. Call the health care provider (HCP). 4. Administer an antihypertensive PRN (as needed).

Call the health care provider (HCP).

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1. Confusion 2. Bradycardia 3. Sluggish pupils 4. A widened pulse pressure

Confusion

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self

Consistently uses adaptive equipment in dressing self

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition should the nurse document? 1. Occipital lobe impairment 2. Damage to the auditory association areas 3. Frontal lobe and optic nerve tracts damage 4. Difficulty with concept formation and abstraction areas

Damage to the auditory association areas

The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse reviews the health care provider's documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome? 1. Multifocal seizures 2. Altered level of consciousness 3. Abrupt onset of a fever and headache 4. Development of progressive muscle weakness

Development of progressive muscle weakness

The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs further teaching if the client states an intention to take which action? 1. Refrain from smoking alone. 2. Take all prescribed medications on time. 3. Have the spouse nearby when showering. 4. Drink alcohol in small amounts and only on weekends.

Drink alcohol in small amounts and only on weekends.

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Flashlight and incentive spirometer 4. Electrocardiographic monitoring electrodes and intubation tray

Electrocardiographic monitoring electrodes and intubation tray

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1. Elevate the head of the bed. 2. Examine the rectum digitally. 3. Assess the client's blood pressure. 4. Place the client in the prone position.

Elevate the head of the bed.

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? 1. Head of bed flat, head and neck midline 2. Head of bed flat, head turned to the nonoperative side 3. Head of bed elevated 30 to 45 degrees, head and neck midline 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side

Head of bed elevated 30 to 45 degrees, head and neck midline

The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs? 1. Shuffling gait 2. Inability to urinate 3. Decreased appetite 4. Irregular bowel movements

Inability to urinate

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome? 1. Encourage communication. 2. Provide a consistent daily routine. 3. Promote adequate bowel elimination. 4. Increase the client's awareness of the affected side.

Increase the client's awareness of the affected side.

The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action? 1. Wears a turban to cover the incision 2. Indicates that facial puffiness will be a permanent problem 3. Verbalizes that periorbital bruising will disappear over time 4. States an intention to purchase a hairpiece until hair has grown back

Indicates that facial puffiness will be a permanent problem

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? 1. Had a very mild stroke 2. Most likely suffered a transient ischemic attack 3. May have difficulty with language abilities only 4. Is likely to have perceptual and spatial disabilities

Is likely to have perceptual and spatial disabilities

The nurse is preparing for the admission to the unit of a client with a diagnosis of seizures and asks the nursing student to institute full seizure precautions. Which item if noted in the client's room would need to be removed and warrants the need to review seizure precautions with the student? 1. Oxygen source 2. Suction machine 3. Padded tongue blade 4. Padding for the side rails

Padded tongue blade

The clinic nurse is reviewing the record of a client scheduled to be seen in the clinic. The nurse notes that the client is taking selegiline hydrochloride. The nurse suspects that the client has which disorder? 1. Diabetes mellitus 2. Parkinson's disease 3. Alzheimer's disease 4. Coronary artery disease

Parkinson's disease

The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client? 1. Keep the window blinds open. 2. Turn on a small spotlight above the client's head. 3. Make sure the door to the room is open at all times. 4. Prohibit or limit the use of a radio or television and reading.

Prohibit or limit the use of a radio or television and reading.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month

Respiratory or gastrointestinal infection during the previous month

The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan? 1. Maintain the client in a flat position. 2. Restrict fluid intake for a period of 2 hours. 3. Assess the client's ability to void and move the extremities. 4. Inspect the puncture site for swelling, redness, and drainage.

Restrict fluid intake for a period of 2 hours.

The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? 1. Unchanged weight 2. Shift intake 950 mL, output 900 mL 3. Blood urea nitrogen (BUN) 10 mg/dL (3.6 mmol/L) 4. Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)

Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1. Taking medications as scheduled 2. Eating large, well-balanced meals 3. Doing muscle-strengthening exercises 4. Doing all chores early in the day while less fatigued

Taking medications as scheduled

A client who had a stroke (brain attack) has right-sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem? 1. Teach the client to scan the environment. 2. Place all objects within the left visual field. 3. Place all objects within the right visual field. 4. Ensure that the family brings the client's eyeglasses to hospital.

Teach the client to scan the environment.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? 1. Sudden loss of consciousness occurred. 2. Signs and symptoms occurred suddenly. 3. The client experienced paresthesias a few days before admission to the hospital. 4. The client complained of a severe headache, which was followed by sudden onset of paralysis.

The client experienced paresthesias a few days before admission to the hospital.

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? 1. The client will be easily fatigued. 2. The client will have difficulty speaking. 3. The client will have difficulty swallowing. 4. The client will exhibit neglect of the affected side.

The client will exhibit neglect of the affected side.

The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care? 1. The client's fingers and toes are cool to touch. 2. The client's body temperature is 98°F (36.7°C). 3. The client remains in a fetal position when in bed. 4. The client complains of coolness in the hands and feet only.

The client's body temperature is 98°F (36.7°C).

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? 1. The intracranial pressure reading is normal. 2. The intracranial pressure reading is elevated. 3. The intracranial pressure reading is borderline. 4. An intracranial pressure reading of 8 mm Hg is low.

The intracranial pressure reading is normal.

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

Nail bed pressure

A client is somewhat nervous about undergoing magnetic resonance imaging (MRI). Which statement by the nurse would provide the most reassurance to the client about the procedure? 1. "The MRI machine is a long, narrow, hollow tube and may make you feel somewhat claustrophobic." 2. "You will be able to eat before the procedure unless you get nauseated easily. If so, you should eat lightly." 3. "Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure." 4. "It is necessary to remove any metal or metal-containing objects before having the MRI done to avoid the metal being drawn into the magnetic field."

"Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure."

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will be careful because the device alters balance." 4. "I will wash the skin daily under the lamb's wool liner of the vest."

"I will drive only during the daytime."

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. 1. Keep suction equipment at the bedside. 2. Elevate the head of the bed 30 degrees. 3. Keep the client lying in a supine position. 4. Keep the head and neck in good alignment. 5. Administer prescribed respiratory treatments as needed.

1. Keep suction equipment at the bedside. 2. Elevate the head of the bed 30 degrees. 4. Keep the head and neck in good alignment. 5. Administer prescribed respiratory treatments as needed.

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? 1. "Have you had any headaches in the past few days?" 2. "Have you recently been having difficulty with seeing at nighttime?" 3. "Have you had any sudden episodes of passing out in the past few days?" 4. "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

"Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks? 1. "I need to restrict my carbohydrate intake." 2. "I need to drink at least 3 L of fluid per day." 3. "I need to maintain a low-fat and low-cholesterol diet." 4. "I need to be sure to consume foods that are low in sodium."

"I need to be sure to consume foods that are low in sodium."

The nurse is providing instructions to a client who will be taking phenytoin. Which statement, if made by the client, would indicate an understanding of the information about this medication? 1. "I need to perform good oral hygiene, including flossing and brushing my teeth." 2. "I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." 3. "I should take my medication before coming to the laboratory to have a blood level drawn." 4. "I should monitor for side effects and adjust my medication dose depending on how severe the side effects are."

"I need to perform good oral hygiene, including flossing and brushing my teeth."

The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse should plan to ask the client which question to elicit the most specific information regarding this disorder? 1. "Do you have any visual problems?" 2. "Are you having any problems hearing?" 3. "Do you have any tingling in the face region?" 4. "Is the pain experienced a stabbing type of pain?"

"Is the pain experienced a stabbing type of pain?"

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. 1. Giving tepid sponge baths 2. Applying a hypothermia blanket 3. Covering the client with blankets 4. Administering acetaminophen per protocol 5. Placing ice packs over the client's abdomen and in the axilla and groin

1. Giving tepid sponge baths 2. Applying a hypothermia blanket 4. Administering acetaminophen per protocol

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1. Head midline 2. Neck in neutral position 3. Head of bed elevated 30 to 45 degrees 4. Head turned to the side when flat in bed 5. Neck and jaw flexed forward when opening the mouth

1. Head midline 2. Neck in neutral position 3. Head of bed elevated 30 to 45 degrees

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent

1. Padding the side rails of the bed 2. Placing an airway at the bedside 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client? Select all that apply. 1. Provide oral hygiene after each meal. 2. Assess swallowing ability frequently. 3. Allow the client sufficient time to eat. 4. Maintain a suction machine at the bedside. 5. Provide a full liquid diet for ease in swallowing.

1. Provide oral hygiene after each meal. 2. Assess swallowing ability frequently. 3. Allow the client sufficient time to eat. 4. Maintain a suction machine at the bedside.

The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply. 1. Provide physical aspects of care. 2. Prevent pushing or straining activities. 3. Limit caffeinated coffee to 1 cup per day. 4. Keeping the lights on in the client's room. 5. Maintain the head of the bed at 15 degrees.

1. Provide physical aspects of care. 2. Prevent pushing or straining activities. 5. Maintain the head of the bed at 15 degrees.

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply. 1. Providing sensory cues 2. Giving simple, clear directions 3. Providing a stable environment 4. Keeping family pictures at the bedside 5. Encouraging family members to visit at the same time

1. Providing sensory cues 2. Giving simple, clear directions 3. Providing a stable environment 4. Keeping family pictures at the bedside

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

1. The client is aphasic. 2. The client has weakness on the right side of the body. 4. The client has weakness on the right side of the face and tongue.

The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. 1. Thicken liquids. 2. Assist the client with eating. 3. Assess for the presence of a swallow reflex. 4. Place the food on the affected side of the mouth. 5. Provide ample time for the client to chew and swallow.

1. Thicken liquids. 2. Assist the client with eating. 3. Assess for the presence of a swallow reflex. 5. Provide ample time for the client to chew and swallow.

A client had a transsphenoidal resection of the pituitary gland. The nurse notes drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse should look for drainage that is of which characteristic? 1. Serosanguineous only 2. Bloody with very small clots 3. Sanguineous only with no clot formation 4. Serosanguineous, surrounded by clear to straw-colored fluid

Serosanguineous, surrounded by clear to straw-colored fluid

A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family had hoped. The nurse plans to implement which approach as most helpful to the client and family at this time? 1. Emphasize progress in a realistic manner. 2. Set high goals to give the client something to "aim for." 3. Tell the family to be extremely optimistic with the client. 4. Inform the client and family of standardized goals of care.

Emphasize progress in a realistic manner.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

Exhaling during repositioning

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family? 1. Discouraging the family from touching the client 2. Explaining equipment and procedures on an ongoing basis 3. Ensuring adherence to visiting hours to ensure the client's rest 4. Encouraging the family not to "give in" to their feelings of grief

Explaining equipment and procedures on an ongoing basis

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves? 1. Eye movements 2. Response to verbal stimuli 3. Affect, feelings, or emotions 4. Insight, judgment, and planning

Eye movements

The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse should expect to observe which finding in the client? 1. Facial drooping 2. Periorbital edema 3. Ptosis of the eyelid 4. Twitching on the affected side of the face

Facial drooping

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

Flaccid paralysis

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose.

Fluid separates into concentric rings and tests positive for glucose.

The nurse is providing discharge education to a client diagnosed with trigeminal neuralgia. Which medication will likely be prescribed upon discharge for this condition? 1. Lorazepam 2. Gabapentin 3. Carisoprodol 4. Chlordiazepoxide

Gabapentin

The nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath sounds. Which judgment should the nurse formulate for the client? 1. Impaired nutritional intake 2. Increased risk for aspiration 3. Increased likelihood for injury 4. Susceptibility to fluid volume deficit

Increased risk for aspiration

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action? 1. Drinking a total of 1000 mL/day 2. Giving herself an enema every morning before breakfast 3. Taking stool softeners daily and a glycerin suppository once a week 4. Initiating a bowel movement every other day, 45 minutes after the largest meal of the day

Initiating a bowel movement every other day, 45 minutes after the largest meal of the day

The nurse is creating a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client? 1. Place an eye patch on the left eye. 2. Place personal articles on the client's right side. 3. Approach the client from the right field of vision. 4. Instruct the client to turn the head to scan the right visual field.

Instruct the client to turn the head to scan the right visual field.

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? 1. It is possible the client can hear the family. 2. The family needs immediate crisis intervention. 3. The client might have wanted a visit from the hospital chaplain. 4. The family could benefit from a conference with the health care provider.

It is possible the client can hear the family.

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1. Updating the home safety sheet 2. Leaving the client in an unchilled area of the room 3. Noting a bowel movement on the client progress note 4. Recording the amount of urine obtained with catheterization

Leaving the client in an unchilled area of the room

The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction? 1. Temperature 2. Blood pressure 3. Ability to speak 4. Level of consciousness

Level of consciousness

A thymectomy accomplished via a median sternotomy approach is performed in a client with a diagnosis of myasthenia gravis. The nurse creates a postoperative plan of care for the client that should include which intervention? 1. Monitor the chest tube drainage. 2. Restrict visitors for 24 hours postoperatively. 3. Maintain intravenous infusion of lactated Ringer's solution. 4. Avoid administering pain medication to prevent respiratory depression.

Monitor the chest tube drainage.

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1. Giving client full control over care decisions and restricting visitors 2. Providing positive feedback and encouraging active range of motion 3. Providing information, giving positive feedback, and encouraging relaxation 4. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

Providing information, giving positive feedback, and encouraging relaxation

A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? 1. Walker 2. Slider board 3. Raised toilet seat 4. Adaptive eating utensils

Raised toilet seat

At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention? 1. Tightened screws 2. Red skin areas under the jacket 3. Clean and dry lamb's wool jacket lining 4. Finger-width space between the jacket and the skin

Red skin areas under the jacket

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? 1. Sounds will not be heard clearly unless they are loud. 2. Obtain assistance with ambulation if the client is lightheaded. 3. Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed. 4. Use a check-off system for administering anticonvulsant medications to avoid missing doses.

Sounds will not be heard clearly unless they are loud.

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? 1. Body stiffening 2. Spasms of the entire body 3. Sudden loss of consciousness 4. Brief flexion of the extremities

Spasms of the entire body