T5

The nurse is providing education to a group of young people about the dangers of tattoos and body piercings. Which of the following would the nurse describe as a possible result of a tongue piercing?

Brian Abscess

Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy? A. Encourage semiannual dental exams. B. Complete the course of antibiotics as prescribed. C. Use ophthalmic lubricant and protect the eye. D. Avoid stimuli that trigger pain.

C

The nurse is performing stroke risk screenings at a hospital open house. Identification of high-risk individuals is the goal of the screenings. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at highest risk for a stroke? A. Black man, age 50 with history of smoking B. White man, age 60 with history of uncontrolled hypertension C. Black man, age 60, with history of diabetes D. White woman, age 60 with history of excessive alcohol intake

B

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? (Ch. 45 pg. 1308) A. Bowel surgery B. A large volume enema C. Insertion of a nasogastric tube D. Digital stimulation

C

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? (Ch. 47 pg. 1370)A. The client should remain on bed rest until she expresses a desire to mobilize. B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C. Lack of mobility will greatly increase the client's risk of stroke recurrence. D. The client should mobilize as soon as she is physically able.

D

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? A. Ask the client if he has trouble breathing. B. Place antiembolism stockings on the client. C. Take the client's blood pressure. D. Ask the client if he has a headache.

A

Following diagnostic testing, a client has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in the client's plan of care? A. Supervise the client's activities of daily living closely. B. Initiate early ambulation to prevent complications of immobility. C. Provide a high-calorie, low-protein diet. D. Perform all of the client's hygiene and feeding.

A

The nurse is aware that, when assessing a patient for symptoms of a brain tumor, the symptom most frequently found is: A. Sharp, unrelenting headaches. B. Unilateral loss of motor coordination. C. Simple to generalized seizures. D. Vertigo and fainting.

C

The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? A. Observing the client's response to painful stimulus B. Assessing the client's sensitivity to temperature, touch, and pain C. Observing the reaction of pupils to light D. Using the Romberg test

C

A nurse is teaching about ischemic stroke prevention to a community group and emphasizes that control of hypertension, which is the major risk factor for stroke, is key to prevention. Ways to control hypertension include the Dietary Approaches to Stop Hypertension (DASH) diet. This diet includes which of the following? A. High amounts of low-fat dairy products B. Moderate amounts of fruits and vegetables C. Moderate amounts of animal protein D. Moderate amounts of low-fat dairy products

D

After assessing a client who is in postoperative recovery from surgery to resect a brain tumor, the nurse notes the client is at risk for aspiration. Which nursing intervention should be included in the client's postoperative care plan? A. Position client with head of bed elevated to 45 degrees B. Position client supine with call bell in close reach C. Position client in Trendelenberg with legs raised 15 degrees D. Position client side lying with head of bed elevated to 30 degrees

D

The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? A. Assessing frequently for loss of cognitive function B. Maintaining the client on bed rest C. Providing aids to compensate for loss of vision D. Using the incentive spirometer as prescribed

D

The nurse planning the care of a client with head injuries is addressing the client's nursing diagnosis of "sleep deprivation." What action should the nurse implement? A. Do not disturb the patient between 2200 and 0600. B. Administer a benzodiazepine at bedtime each night. C. Ensure that the client does not sleep during the day. D. Cluster overnight nursing activities to minimize disturbances.

D

To assess a client's cranial nerve function, a nurse should assess: A. orientation to person, time, and place. B. hand grip. C. arm drifting. D. gag reflex.

D

The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm? A. "Your physician wants to evaluate the location and condition of the aneurysm." B. "The headache can be an indication that the aneurysm is growing." C. "A headache means your aneurysm is leaking blood into the brain." D. "Don't worry. The aneurysm has probably been there since birth."

A

The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client to avoid? A. Washing his face B. Exposing his skin to sunlight C. Drinking large amounts of fluids D. Using artificial tears

A

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? A. Complaint of headache off and on for past month B. Frequent voiding C. Nausea D. No bowel movement since yesterday

C

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intraveneously. The nurse is careful to assess which of the following related to intake of nutrients? A. Urinary output and capillary refill B. Respiratory status C. Gag reflex and bowel sounds D. Condition of skin

C

Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? A. Administering hypertonic IV solution B. Initiating early mobilization C. Positioning to avoid hypoxia D. Maximizing PaCO2

C

A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention? A. Urine retention or incontinence B. Paresthesia in the dermatomes near the wounds C. Temperature of 99.2° F (37.3° C) D. More back pain than the first postoperative day

A

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply. A. Setting priorities for nursing interventions B. Initiating rehabilitation C. Making nursing assessments D. Anticipating needs and complications E. Ensuring that the patient regains full brain function

ABCD

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply. A. Decreased reactivity of the pupils B. Bradycardia C. Tachypnea D. Hemiparesis E. Hypotension F. Coma

ABDF

A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood tinged and asks what that means. The correct reply is which of the following? A. "It can mean the spinal cord was damaged or a traumatic puncture." B. "It can mean a traumatic puncture or a subarachnoid bleed." C. "It can mean a subarachnoid bleed or damage to the spinal cord." D. "It can mean a bleed around the hypothalamus or damage from the needle."

B

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. A. Low red blood cell (RBC) count B. Pain and stiffness of the extremities C. Purpura of hands and feet D. Cloudy cerebral spinal fluid E. Low white blood cell (WBC) count F. Low antidiuretic hormone (ADH) levels

CD

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. A. Elevating the head of the bed to 90 degrees B. Encouraging deep breathing and coughing every 2 hours C. Maintaining aseptic technique with an intraventricular catheter D. Administering prescribed antipyretics E. Frequent oral care

CDE

A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action? A. Intubation and mechanical ventilation B. An order for a head computed tomography scan C. IV administration of propofol D. Immediate craniotomy

D

The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of? A. Contusion B. Spinal shock C. Autonomic dysreflexia D. Concussion

C

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? A. Hypertension and narrowing pulse pressure B. Rising blood pressure and bradycardia C. Hypotension and bradycardia D. Hypotension and tachycardia

B

The nurse is conducting a preoperative assessment of a client who is scheduled for surgical removal of a primary spinal tumor. What should the nurse include in the preoperative session? Select all that apply. A. Preparing to transition to palliative care B. Question about current bowel and bladder control C. Methods of pain control after surgery D. Adjusting to changes in daily activities E. Ensuring privacy of client information from family members

BCD

In which specific instances should the nurse assess the client's cranial nerves? Select all that apply. A. When a neurogenic bladder develops B. In the presence of peripheral nervous system disease C. When a spinal reflex is interrupted D. With brain stem pathology E. When level of consciousness is decreased

BDE

A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate? A. Establishing an ambulation program using short leg braces B. Preventing autonomic dysreflexia by preventing bowel impaction C. Establishing an intermittent catheterization routine every 4 hours D. Managing spasticity with range-of-motion exercises and medications

C

A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. (Ch.46 pg. 1323) A. Place the client in positive pressure isolation B. Obtain a blood type and cross-match C. Perform frequent neurologic assessments D. Administer antipyretics as prescribed E. Monitor pain levels and administer analgesics

CDE

A client newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the client to implement? A. Apply cool compresses to the back of the neck daily. B. Perform active ROM exercises three times daily. C. Wear the cervical collar for at least 2 hours at a time. D. Sleep on a firm mattress.

D

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? A. Giving him a barbiturate B. Elevating the head of his bed C. Placing him on mechanical ventilation D. Performing a lumbar puncture

D

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family? (Ch. 45 pg. 1309) A. Rapid heart rate B. Runny nose C. Sweating D. Slight headache

C

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client? A. Auditory agnosia B. Lack of deep tendon reflexes C. Hemiplegia or hemiparesis D. Limited attention span and forgetfulness

A

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition? A. Raise the head of the bed and place the patient in a sitting position. B. Empty the bladder immediately. C. Examine the rectum for a fecal mass. D. Examine the skin for any area of pressure or irritation.

A

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? A. The client will remain free of injury if a seizure does occur. B. The client will verbalize an understanding of feelings that preempt seizure activity. C. The client will post emergency numbers on the refrigerator for ease of obtaining. D. The client will take the seizure medication at the same time daily.

A

Nursing students are reviewing information about Parkinson's disease in preparation for class the next day. The students demonstrate understanding of the material when they identify which of the following as a cardinal sign of this disorder? Select all that apply. A. Tremor B. Bradykinesia C. Intellectual decline D. Postural instability E. Rigidity

ABDE

A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options. A. Impaired cellular activity B. Insomnia C. Seizures D. Death E. Permanent neurologic dysfunction

ADE

A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? A. Support the client's full body weight with a waist belt during ambulation. B. Avoid mobilizing the client in the early morning or late evening. C. Have a colleague follow the client closely with a wheelchair. D. Ensure that the client's family members do not participate in mobilization.

C

A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? A. Stent placement B. Removal of the carotid artery C. Percutaneous transluminal coronary artery angioplasty D. Carotid endarterectomy

D

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing? A. IX B. VI C. IV D. XII

D

A patient has been diagnosed with a brain tumor, a glioblastoma multiforme. The nurse met with the family after the diagnosis to help them understand that: A. The tumor rarely spreads to other parts of the body. B. Chemotherapy, following surgery, has recently been shown to be a highly C. effective treatment. D. Surgery can improve survival time but the results are not guaranteed. E. Radiation is not an option because of the tumor's location near the brainstem.

D

The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply. A. Seizures B. Sudden, severe headache C. Loss of balance D. Altered level of consciousness E. Numbness or weakness of an extremity F. Vomiting

ABF

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply. A. Male gender B. Older adult C. Substance abuse D. Low-income community E. Young age

ACE

A client diagnosed with Parkinson's disease has developed slurred speech and drooling. The nurse knows that these symptoms indicate which of the following? A. Medication needs to be adjusted to higher doses. B. The client is exhibiting signs of medication overdose. C. The client is having an exacerbation. D. The disease has entered the late stages.

D

The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline with carbidopa-levodopa to the medication regime should result in which purpose? A. Slows the progression of the disease B. Prevents side effects from carbidopa-levodopa C. Relieves symptoms of dyskinesia D. Replaces dopamine

A

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would indicate that the patient is experiencing increased brain compression causing brainstem damage? A. Hyperthermia B. Bradypnea C. Tachycardia D. Hypertension

A

There is a high risk for ineffective coping in a client with a recent spinal cord injury. Which nursing interventions will assist the client with this process? Select all that apply. A. Involve the client actively in selfcare. B. Assist the client in accepting the severity of deficits. C. Offer encouragement as the client makes progress. D. Reassure the client by stating, "Everything is going to be all right."

AD

The causes of acquired seizures include what? (Mark all that apply.) A. Brain tumor B. Drug and alcohol withdrawal C. Cerebrovascular disease D. Metabolic and toxic conditions E. Hypernatremia

ABCD

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? A. Elevating the head of the bed to 30 degrees B. Performing range-of-motion (ROM) exercises on the left side C. Checking stools for occult blood D. Keeping skin clean and dry

A

The statements presented here match nursing interventions with nursing diagnoses. Which statements are true for a client with a stroke? Select all that apply. A. Impaired verbal communication: Repeat words and instructions. B. Impaired swallowing: Provide a pureed diet. C. Self-care deficit: Instruct the client on use of a walker. D. Impaired physical mobility: Provide wide-grip utensils during meals. E. Disturbed sensory perception: Stand on the client's unaffected side.

ABE

A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? (Ch. 45 pg. 1298) A. Serial arterial blood gases (ABGs) B. Vigilant monitoring of fluid balance C. Monitoring of the client's airway for patency D. Continuous BP monitoring

B

The nurse is caring for a client after lumbar puncture. The client reports a severe headache. Which actions should the nurse complete? Select all that apply. A. Position the client in the supine position. B. Administer analgesic medication. C. Administer fluids to the client. D. Maintain the client on bed rest. E. Prepare for an epidural blood patch.

BCD

A client has been admitted to the ICU after being recently diagnosed with an aneurysm and the client's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the client's plan of care? A. Elevate the head of the bed to 75 degrees. B. Leg exercises to prevent deep vein thrombosis C. Maintain the client on complete bed rest. D. Administer enemas when the client is constipated.

C

The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding? A. 0 B. 3+ C. 1+ D. 2+

C

The nurse is conducting a focused neurologic assessment and is assessing the client's gag reflex. How should the nurse best perform this aspect of the assessment? A. Observe the client swallowing a small mouthful of water B. Ask the client to swallow a small quantity of any soft food C. Lightly touch the client's pharynx with a cotton swab D. Depress the client's tongue with a sterile tongue depressor

C

A client has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The client is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment? A. Deep tendon reflexes B. Abdominal girth C. Hearing acuity D. Gag reflex

D

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? A. Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. B. Reassure the client that a headache is expected and will go away without treatment. C. Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. D. Notify the physician; a headache is an early sign of worsening neurologic status.

A

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is: A. 88 mm Hg. B. 52 mm Hg. C. 68 mm Hg. D. 48 mm Hg.

B

A new ancillary staff member is assisting the nurse with a client diagnosed with Parkinson's disease. The client needs assistance with eating but doesn't require thickened liquids to aid swallowing. Which instruction should the nurse give the ancillary staff member about eating assistance A. Clients with Parkinson's disease shouldn't have liquids; remove them from the dinner tray before serving food to the client. B. Make sure the client is sitting with the head of bed elevated to 90 degrees. C. Assist the client into a comfortable position and stay alert for coughing, which signifies aspiration. D. There are no special precautions for the client with Parkinson's disease.

B

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Of the two choices of posturing exhibited in the above image, which one demonstrates a deeper and more severe dysfunction? A. A (Armscrossed) B. B (Arms straight) C. both demonstrate severe dysfunction D. neither is considered severe

B

A patient is having a lumbar puncture and the physician has removed 20 mL of cerebrospinal fluid. What nursing intervention is a priority after the procedure? A. Have the patient lie flat for 1 hour and then sit for 1 hour before ambulating. B. Have the patient lie flat for 6 hours. C. Early ambulation D. Have the patient lie in a semi-Fowler's position with the head of the bed at 30º.

B

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? A. Numbness and tingling B. Pulse and blood pressure C. Respiratory pattern D. Pain level

B

What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? A. Have the client perform active range-of-motion (ROM) exercises once a day. B. Exercise the affected extremities passively four or five times a day. C. Schedule passive range of motion every other day. D. Keep activity limited, as the client may be overstimulated

B

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? A. Ataxia B. Gingival hyperplasia C. Alopecia D. Diplopia

B

A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply. A. Turn the client to the side. B. Provide verbal reassurance. C. Inspect the oral cavity and teeth. D. Physically restrain the client's movements.

AB

A client with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply. A. Administration of treatments B. Management of treatment complications C. Assistance with self-care D. Pain control E. Interpretation of diagnostic test

ABCD

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first? A. Reassure the client that headaches are expected during recovery from spinal cord injuries. B. Check the client's indwelling urinary catheter for kinks to ensure patency. C. Lower the HOB to improve perfusion. D. Administer PRN analgesia as prescribed.

B

A nurse is teaching a client who was recently diagnosed with myasthenia gravis. Which statement should the nurse include in her teaching? A. "You'll continue to experience progressive muscle weakness and sensory deficits." B. "The disease is a disorder of motor and sensory dysfunction." C. "This disease doesn't cause sensory impairment." D. "You'll need to take edrophonium (Tensilon) to treat the disease."

C

Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? A. Nausea B. Blood pressure 100/60 mm Hg C. Lethargy D. Periorbital edema

C

A client is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the client's LOC is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding? A. Alert the surgeon to the possibility of an intracranial hemorrhage. B. Understand that the surgery may have been unsuccessful. C. Recognize the need to refer the client to the palliative care team. D. Recognize that this may represent the peak of postsurgical cerebral edema.

D

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? A. Frequency of urination B. Burning sensation on urination C. Lower back pain D. Fever and change in urine clarity

D

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? (Ch. 46 pg. 1318) A. Padded tongue blade B. Nasal cannula and oxygen C. Sphygmomanometer D. Suction machine with catheters

D