Term 5 exam 2

A client being treated for a brain tumor is exhibiting signs and symptoms of cerebral edema. The nurse anticipates that the practitioner will most likely prescribe which agent? -Corticosteroid -Immunotherapy agent -Anticonvulsant agent -Diuretic

Corticosteroid

The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure? -IV phenobarbital -IV diazepam -IV lidocaine -Oral phenytoin

IV diazepam

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate? -Assess for facial weakness. -Initiate seizure precautions. -Assess visual acuity. -Ensure that client takes nothing by mouth.

Initiate seizure precautions.

What is the function of cerebrospinal fluid (CSF)? -It cushions the brain and spinal cord. -It acts as an insulator to maintain a constant spinal fluid temperature. -It acts as a barrier to bacteria. -It produces cerebral neurotransmitters.

It cushions the brain and spinal cord

A client with neurologic disorder is at risk for disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. Which nursing intervention facilitates the functional use of the limbs? -Keep extremities at neutral position. -Remove and reapply elastic stockings. -Change client's position. -Use a flotation mattress.

Keep extremities at neutral position

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves? VIII X III VII

X

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: -body temperature control. -balance and equilibrium. -visual acuity. -thinking and reasoning.

body temperature control

A client with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize? -Assessment of peripheral nervous function -Assessment of cranial nerve function -Assessment of nutritional status -Assessment of respiratory status

Assessment of nutritional status

The nurse is assisting in the discharge process where a female, paralyzed client is returning home with her husband and two children. Which of the following prescription classifications, used prior to hospitalization, is most important to relate to the physician when discharging? -Birth control pills -A rescue inhaler -An analgesic -An antihistamine

Birth control pills

A patient who has sustained a basal skull fracture is admitted to the neurological unit. The nurse should know that the patient should be observed for: -An area of bruising over the mastoid bone -Bleeding from the ears -An increase in pulse -Difficulty sleeping

Bleeding from the ears

Which diagnostic procedure would the nurse anticipate performing first if the goal was to obtain a thin "slice" of a muscular body area? -Computed tomography (CT) -Magnetic resonance imaging (MRI) -Positron emission tomography (PET) -Single-photon emission computed tomography (SPECT)

Computed tomography (CT)

Which medication classification is used preoperatively to decrease the risk of postoperative seizures? -Diuretics -Corticosteroids -Anticonvulsants -Antianxiety

Correct response: Anticonvulsants Explanation: Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the client with increased intracranial pressure.

A neurologic deficit is best defined as a deficit of the: -central and peripheral nervous systems with decreased, impaired, or absent functioning. -central nervous system that affects one body system. -central nervous system with absent functioning. -peripheral nervous system with decreased or impaired functioning.

central and peripheral nervous systems with decreased, impaired, or absent functioning

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The cerebrum is divided into two hemispheres and is further divided into four lobes per hemisphere. Which section of the brain controls and coordinates muscle movements? -cerebellum -cerebrum -brain stem -midbrain

cerebellum

A home health nurse is assisting the wheelchair-dependent, post-cerebrovascular accident client in transition from the rehabilitative center to home. Which of the following concerns would the nurse address first when assessing the client's home? -Steps to the front door -Tub for bathing -Throw rugs in the kitchen -Untrained companion staying with client

Steps to the front door

A client undergoes a scheduled electroencephalogram (EEG). Which of the following post-procedure activities should the nurse carry out for the client? -Allow the client to rest and shampoo the client's hair. -Provide the client with adequate caffeine-rich drinks. -Measure the level of consciousness (LOC) of the client. -Measure the heart and the pulse rate.

Allow the client to rest and shampoo the client's hair

In which of the following disease processes is the nurse most likely to care for a client in the chronic phase of a neurologic disease? -Transient ischemic attack (TIA) -Malignant brain tumor -Alzheimer disease -Pneumonia

Alzheimer disease

The clinic nurse caring for a client with Parkinson disease notes that the client has been taking levodopa and carbidopa for 7 years. For what common side effect should the nurse assess this client? -Pruritus -Dyskinesia -Lactose intolerance -Diarrhea

Dyskinesia

The nurse is caring for a client in the chronic phase of a neurologic deficit. The nurse knows that nursing management in this phase focuses on what goal? -Working with team members to plan a rehabilitation program -Retraining the client's bowel and bladder -Supporting the client during recovery -Preventing physical and psychological complications

Preventing physical and psychological complications

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? -Loss of bowel and bladder control -Choreiform movements -Suicidal ideations -Emotional apathy

Suicidal ideations

A high school basketball player collides with another player during a game, falls, and hits their head on the court. An MRI reveals small hemorrhages in brain tissue and edema at the injury site. The ED physician explains that the client has a cerebral ________ and further explains that the MRI indicates that the head's direct hit to the floor caused a ________ injury. -contusion; coup -contusion; contrecoup -concussion; coup -concussion; contrecoup

contusion; coup

The home care nurse is evaluating a post-cerebrovascular accident (CVA) client 1 week after returning to the home from a rehabilitation setting. Which of the following statements, made by the client, most concerns the nurse? -"I am so happy to be home, but I am not able to go upstairs to my bedroom." -"I find it difficult to get up so I am remaining in bed until the home health aide comes." -"My spouse goes to work in the morning and leaves my lunch at my bed stand." -"A lot of family is coming to see me, which is nice but makes me very tired."

"My spouse goes to work in the morning and leaves my lunch at my bed stand."

The nurse is caring for a client with tetraplegia following a motor vehicle accident. A family member of the client states, "I know there is grief associated with the loss of independence, but how do I help my loved one to move past that?" The nurse is most helpful to say which of the following? -"There is nothing you can do. It must come from the client." -"Grief is a normal process. Let's discuss offering support throughout the process." -"Ask your loved one what you can do and decorate the room to elevate mood." -"Provide comfort foods, which expresses your love and support."

"Grief is a normal process. Let's discuss offering support throughout the process."

A client for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the client? -"The test will temporarily limit blood flow through the brain." -"An allergy to iodine precludes getting the radio-opaque dye." -"The client will need to endure loud noises during the test." -"The test may result in dizziness or lightheadedness."

"The test may result in dizziness or lightheadedness."

A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following? -Respiratory function -Potential skin breakdown -Cardiac function -Cognition

-Respiratory function

A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? -Monitoring of pulse oximetry -Administration of a low-protein diet -Administration of thorough oral hygiene -Fluid restriction as prescribed

Administration of thorough oral hygiene

A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state? -Epileptic cry -Confusion -Urinary incontinence -Body rigidity

Confusion

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion? -Concussion -Contusion -Diffuse axonal injury -Intracranial hemorrhage

Contusion

Which cranial nerve is responsible for muscles that move the eye and lids? -Oculomotor -Trigeminal -Vestibulocochlear -Facial

Correct response: Oculomotor Explanation: The oculomotor (III) cranial nerve is also responsible for pupillary constriction and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The vestibulocochlear (VIII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? -Pupillary asymmetry -Irregular breathing pattern -Involuntary posturing -Declining level of consciousness (LOC)

Declining level of consciousness (LOC)

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for? -Pruritus -Dyskinesia -Lactose intolerance -Diarrhea

Dyskinesia Explanation: Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements)

The nurse is caring for a client who is hospitalized with an exacerbation of MS. To ensure the client's safety, what nursing action should be performed? -Ensure that suction apparatus is set up at the bedside. -Pad the client's bed rails. -Maintain bed rest whenever possible. -Provide several small meals each day.

Ensure that suction apparatus is set up at the bedside

An emergency department nurse is admitting a client brought in by the paramedics after falling from a tree stand. The client has fractured vertebrae at T3 and T4. The nurse knows the client is in the acute phase of neurologic deficit. What should the nurse know about the medical management of this client? -Goal is to keep the client stable and prevent or treat complications, such as pneumonia, and further neurologic impairment. -Goal is to plan a rehabilitation program in several domains according to the client's abilities and limitations. -Goal is to admit the client to a hospital for treatment of complications. -Goal is to stabilize the client and prevent further neurologic damage

Goal is to stabilize the client and prevent further neurologic damage.

A patient has been diagnosed with a deficiency of the major neurotransmitter acetylcholine. Based on this information, the nurse knows to assess the patient for complications associated with: -Fine movements. -Sleep patterns. -Heart rate and rhythm. -Emotional balance

Heart rate and rhythm.

The nurse is caring for a client who has a neurologic deficit. What would the nurse do to best assist the client in increasing peristalsis and encouraging defecation after suffering from a neurologic deficit? -Help the client to the bathroom at a particular time each day. -Administer a low-volume enema each day at the same time. -Encourage liquids throughout the day. -Encourage a high-fiber diet.

Help the client to the bathroom at a particular time each day

A nurse has just received a new client and is preparing to perform a neurologic assessment. Which of the following assessment tools should the nurse use to perform a neurologic assessment? -Cutaneous triggering -Mini-Mental Status Examination -Credé's maneuver -Mechanical lift

Mini-Mental Status Examination

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? -"I will have progressive muscle weakness." -"I will lose strength in my arms." -"My children are at greater risk to develop this disease." -"I need to remain active for as long as possible."

My children are at greater risk to develop this disease

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? -Perform active ROM exercises three times daily. -Sleep on a firm mattress. -Apply cool compresses to the back of the neck daily. -Wear the cervical collar for at least 2 hours at a time

Sleep on a firm mattress

The nurse is talking with a newly paralyzed client and his wife. The wife is trying to raise the client's spirits and begins talking about the possibility of them having a baby. When the wife is alone, which instruction is essential? -Continue to talk about a baby as it seems to give him hope. -Do not overwhelm the client with such a big decision. -There is a reduced ability for your husband to be able to father children. -We will provide you and the client with a counselor so that you can explore all options.

There is a reduced ability for your husband to be able to father children

An older adult man has been diagnosed with Parkinson's disease and has begun treatment with levodopa and carbidopa. When providing health education about his new medication regimen, what should the nurse teach the man? -"If you're consistent with taking your medication, you might not experience symptoms for several more years." -"This medication can cure Parkinson's disease, but this is not necessarily the case for everyone." -"The beneficial effects of this medication usually increase over time, so you may not get maximum relief for a few years." -"This medication helps significantly but the benefits tend to decrease over time."

This medication helps significantly but the benefits tend to decrease over time

A client with increased intracranial pressure is receiving mannitol via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment? -Blood pressure is rising. -Level of consciousness is improving. -Urine output is increased. -Hyperpyrexia is resolving.

Urine output is increased

A nursing instructor is teaching the senior nursing class about clients with neurologic disorders. The instructor tells the students that these clients are at risk of disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. What nursing intervention helps prevent plantar flexion? -Use of parallel bars or a walker -Application of an abdominal binder -Use of a footboard -Use of a flotation mattress

Use of a footboard

A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way? -Ascending paralysis -Numbness and tingling in the lower extremities -Weakness starting in the muscles supplied by the cranial nerves -Jerky, uncontrolled movements in the extremities

Weakness starting in the muscles supplied by the cranial nerves

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? IV IX VI XII

XII

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: -hold the client's arm still to keep him from hitting anything. -carefully move the client to a flat surface and turn him on his side. -allow the client to remain in the chair but move all objects out of his way. -place an oral airway in the client's mouth to maintain an open airway.

carefully move the client to a flat surface and turn him on his side.

In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson's disease and Huntington's disease is the development of ________ in clients with advanced Huntington's disease. -hallucinations and delusions -depression -bradykinesia -muscle fasciculations

hallucinations and delusions

A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client: -has an abnormal posture response to stimuli. -is not responding to stimuli. -is hyperresponsive on the left. -is hyporesponsive on the left.

is not responding to stimuli.

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The brain stem consists of the midbrain, pons, and medulla oblongata. Which part of the brain contains regulatory centers for heartbeat, vasomotor activity, and breathing? -medulla oblongata -midbrain -pons -cerebral cortex

medulla oblongata

A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply. -respiratory distress -increasing ICP -seizure activity -difficulty swallowing

respiratory distress difficulty swallowing

To evaluate a client's cerebellar function, a nurse should ask: -"Do you have any problems with balance?" -"Do you have any difficulty speaking?" -"Do you have any trouble swallowing food or fluids?" -"Have you noticed any changes in your muscle strength?"

"Do you have any problems with balance?"

The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how the client can ever recover if demyelination of the nerves is occurring. What would be the nurse's best response? -"Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease." -"In Guillain-Barré, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible." -"I know you understand that nerve cells do not remyelinate, so the health care provider is the best one to answer your question." -"For some reason, in Guillain-Barré, Schwann cells become activated and take over the remyelination process."

"Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease."

A patient has left-sided hemiplegia as the result of a brain attack (cerebrovascular accident). While being dressed, the patient states in a disgusted tone of voice, "I feel like a 2-year-old. I can't even get dressed by myself." What is the nurse's best response? -"It's hard to feel dependent on others." -"Most people who have had a stroke feel this way." -"It must be terrible not being able to move your arm." -"You are feeling down today, but things will get better."

"It's hard to feel dependent on others."

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following? -"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." -"The blood will replace the cerebral spinal fluid that has leaked out." -"The blood can repair damage to the spinal cord that occurred with the procedure." -"The blood provides moisture at the site, which encourages healing."

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

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

-Administering prescribed antipyretics -Maintaining aseptic technique with an intraventricular catheter -Frequent oral care

The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered? Select all that apply. -Loop diuretics -Anticonvulsants -Corticosteroids -Analgesics -Antibiotics -Antidepressants

-Anticonvulsants -Analgesics -Antibiotics

As part of a start-of-shift nursing assessment, the nurse is documenting a patient's neurological status according to the Glasgow Coma Scale (GCS). What responses will the nurse assess to determine the patient's GCS score? Select all that apply. -Best sensory response -Best judgment -Best eye opening -Best verbal response -Best motor response

-Best eye opening -Best verbal response -Best motor response

A nurse is assisting a team of providers in the recovery phase for a client with a neurologic deficit. A program of care will be outlined to meet immediate and long-term goals. What would the nurse anticipate seeing on the plan of care? Select all that apply. -Client will meet with an occupational therapist to determine which adaptive devices will assist with eating and grooming. -Client will meet with a nutritionist to address nutritional deficiencies. -Client will enroll in a physical therapy program. -Client will meet with an orthopedic surgeon to discuss surgical intervention for a contracture.

-Client will meet with an occupational therapist to determine which adaptive devices will assist with eating and grooming. -Client will meet with a nutritionist to address nutritional deficiencies. -Client will enroll in a physical therapy program

A client is brought to the emergency department (ED) by family members who tell the triage nurse that the client doesn't recognize them. The client is diagnosed with a neurologic deficit. What other conditions are considered neurologic deficits? Select all that apply. -Impaired speech -Abnormal bladder elimination -Muscle strength -Normal gait -Paralysis

-Impaired speech -Abnormal bladder elimination -Paralysis

Which are possible long-term complications of spinal cord injury? Select all that apply. -respiratory arrest -areflexia -autonomic dysreflexia -respiratory infection

-autonomic dysreflexia -respiratory infection

The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication? -1 hour after the antibiotic has infused and daily for 7 days -15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days -2 hours prior to the administration of antibiotics for 7 days -It can be administered every 6 hours for 10 days.

15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days

Working hard to memorize the functions of the cranial nerves is a typical part of nursing school. Not only is it important to correlate the proper nerve number and name, but including the proper function makes this task quite a challenge! Which cranial nerves are enabling you to read this question? -All options are correct. -oculomotor -abducens -trochlear

All options are correct

The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer? -Headache and pain in the neck -Claustrophobia -Allergic reaction to the imaging material -Allergic reaction to radioactive rays

Allergic reaction to the imaging material

Which term describes the fibrous connective tissues that cover the brain and spinal cord? -Meninges -Dura mater -Arachnoid mater -Pia mater

Correct response: Meninges Explanation: The meninges have three layers: the dura mater, arachnoid mater, and pia mater. The dura mater is the outermost layer of the protective covering of the brain and spinal cord. The arachnoid is the middle membrane, and the pia mater is the innermost membrane of this protective covering.

Which cranial nerve is responsible for facial sensation and corneal reflex? -Oculomotor -Vestibulocochlear -Facial -Trigeminal

Correct response: Trigeminal Explanation: The trigeminal (V) cranial nerve is also responsible for mastication. The oculomotor (III) cranial nerve is responsible for the muscles that move the eye and lid, pupillary constriction, and lens accommodation. The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium. The facial nerve is responsible for salivation, tearing, taste, and sensation in the ear

A client with a neurologic deficit is feeling frustrated because it is very difficult to pronounce words since having a stroke. The client is struggling with: -dysarthria. -dysphasia. -ataxia. -dysphagia.

Correct response: dysarthria. Explanation: Dysarthria is characterized by poor articulation of words due to muscle weakness or loss of muscle control.

The nurse is assessing a client's level of consciousness. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, "What do you want?" Which level of conscious should the nurse document? -conscious -semi-comatose -somnolent -stuporous

Correct response: somnolent Explanation: Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that is conscious is alert and responds to stimulation immediately. A client is documented as semi comatose when the client only responds to superficial, relatively mild painful stimuli.

An 80-year-old man has been brought to the emergency department (ED) by his daughter, who states that her father has become confused and agitated over the past several days. The daughter expresses fear that her father is "getting senile" and states that this concern is what prompted her to seek care. The ED nurse and the other members of the care team should prioritize which of the following aspects of assessment? -Assessing for cranial nerve defects -Assessing the man's nutritional status -Correlating the man's cognitive function with his motor function -Differentiating delirium from dementia

Differentiating delirium from dementia

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? -Shortness of breath -Sensitivity to bright light -Muscle spasms -Drooping eyelids

Drooping eyelids

Which activity should be avoided in clients with increased intracranial pressure (ICP)? -Suctioning -Enemas -Position changes -Minimal environmental stimuli

Enemas

Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field? -Place patient in a room near the nursing station. -Announce yourself when approaching the client. -Ensure a clutter-free walkway. -Instruct on adaptive plates with rims.

Ensure a clutter-free walkway

Which cerebral lobes is the largest and controls abstract thought? -Temporal -Frontal -Parietal -Occipital

Frontal

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? -Alopecia -Gingival hyperplasia -Diplopia -Ataxia

Gingival hyperplasia

To help assess a client's cerebral function, a nurse should ask: -"Have you noticed a change in your memory?" -"Have you noticed a change in your muscle strength?" -"Have you had any problems with coordination?" -"Have you had any problems with your eyes?

Have you noticed a change in your memory?

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? -Immediate craniotomy -An order for a head computed tomography scan -Intubation and mechanical ventilation -IV administration of propofol

Immediate craniotomy

A nurse is providing care to a client who has been diagnosed with metastatic brain cancer. When developing the client's plan of care, which outcome would the nurse most likely identify? -Improved quality of life -Elimination of distressing signs and symptoms -Removal of all or part of the tumor -Reduced incidence of recurrence

Improved quality of life

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? -Restrain the client to prevent injury. -Open the client's jaws to insert an oral airway. -Place client in high Fowler position. -Loosen the client's restrictive clothing

Loosen the client's restrictive clothing.

The nurse is providing education about meningitis to a community group of adolescents preparing for their first year at college and who plan to live in a dormitory. Which of the following would be important to include? -Obtain the meningococcal conjugated vaccine. -Delay the college experience until age 25 years. -Avoid contact with others and large gatherings. -Eat all meals in isolation.

Obtain the meningococcal conjugated vaccine.

A nurse is caring for a client diagnosed with neurologic deficit who has recently become responsive when interacted with. What therapy should the nurse suggest to help strengthen muscles that are under voluntary control? -Occupational therapy -Range-of-motion (ROM) exercises -Recreational therapy -Music Therapy

Occupational therapy

A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result? -Positive Romberg test, indicating a problem with level of consciousness -Negative Romberg test, indicating a problem with body mass -Negative Romberg test, indicating a problem with vision -Positive Romberg test, indicating a problem with equilibrium

Positive Romberg test, indicating a problem with equilibrium

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? -Rising blood pressure and bradycardia -Hypotension and bradycardia -Hypotension and tachycardia -Hypertension and narrowing pulse pressure

Rising blood pressure and bradycardia

The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms? -Autonomic nervous system -Central nervous system -Peripheral nervous system -Sympathetic nervous system

Sympathetic nervous system

A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of: -Increasing forgetfulness and confusion -Tremors and muscle rigidity -Visual disturbances and muscle weakness -Fatigue and respiratory difficulties

Tremors and muscle rigidity

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? -Using the incentive spirometer as prescribed -Maintaining the client on bed rest -Providing aids to compensate for loss of vision -Assessing frequently for loss of cognitive function

Using the incentive spirometer as prescribed

The nurse is instructing the client on how to perform Credé's maneuver. In which situation is this maneuver helpful? -When a client is experiencing a vagal response during a bowel movement -When a client is experiencing orthostatic hypotension upon arising -When a client is attempting to empty the bladder -When a client is experiencing numbness of the lower extremities

When a client is attempting to empty the bladder

The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? Falls Audio hallucinations Respiratory depression Labile BP

falls

A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase? -preventing further neurologic damage -reporting changes to the physician -destabilizing client's condition -assessing vital signs frequently

preventing further neurologic damage

A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to: -smell and identify a nonirritating, aromatic odor. -read an eye chart from a distance of 20?. -elevate the shoulders, both with and without resistance. -stick out the tongue and move it rapidly from side to side and in and out.

stick out the tongue and move it rapidly from side to side and in and out.

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? -Place the patient in the supine position. -Administer diphenhydramine (Benadryl) for the allergic reaction. -Administer atropine to control the side effects of edrophonium. -Call the rapid response team because the patient is preparing to arrest

Administer atropine to control the side effects of edrophonium

The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? -Solumedrol -Dextromethorphan -Dexamethasone -Furosemide

Dexamethasone

A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? -"When did you last have something to eat or drink?" -"When did you last take any medication?" -"Are you allergic to seafood or iodine?" -"How much do you weigh?"

"Are you allergic to seafood or iodine?"

A patient with Parkinson's disease asks the nurse what can be done to prevent problems with bowel elimination. What would be an intervention that would assist this patient with a regular stool pattern? -Take psyllium (Metamucil) daily. -Take a laxative whenever bloating is experienced. -Adopt a diet with moderate fiber intake. -Adopt a high-fiber diet.

Adopt a diet with moderate fiber intake

To alleviate pain associated with trigeminal neuralgia, a client is taking carbamazepine. What health education should the nurse provide to the client before initiating this treatment? -Concurrent use of calcium supplements is contraindicated. -Blood levels of the drug must be monitored. -The drug is likely to cause hyperactivity and agitation. -Carbamazepine can cause tinnitus during the first few days of treatment.

Blood levels of the drug must be monitored.

The ED is notified that a 6-year-old child is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? -Promoting adequate circulation -Treating the child's increased ICP -Assessing secondary brain injury -Preserving brain homeostasis

Preserving brain homeostasis

During the acute phase of a debilitating cerebrovascular accident, which nursing intervention is most helpful in promoting the rehabilitation of the client? -Prevention of joint contractures -Promotion of critical thinking ability -Creation of a positive environment -Use of adaptive equipment

Prevention of joint contractures

A client with a neurologic deficit has been admitted to the nursing unit. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Which of the following action should the nurse perform immediately? -Use the Glasgow Coma Scale. -Use the Mini-Mental Status Examination. -Report the change to the physician. -Monitor the blood pressure.

Report the change to the physician.

Which nursing technique best allows the client with slight expressive aphasia to communicate his feelings about using adaptive equipment in public? -Use a communication board to express thoughts. -Enlist a close family member to interpret words. -Sit beside client and patiently assist in interpreting communication. -Allow the client time to process the words to express and return later for the conversation.

Sit beside client and patiently assist in interpreting communication

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? -Take small meals of nutrient and calorie-dense food. -Increase the intake of calcium and proteins. -Include additional servings of fruits and raw vegetables. -Include fish, liver, and chicken in diet.

Take small meals of nutrient and calorie-dense food

A nurse is caring for a client with recent history of migraines. What aspect of this client's current status may rule out the safe use of triptans? -The client is 75 years old. -The client's migraines are linked to psychosocial stress. -The client has angina. -The client has hypertension.

The client has angina

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? -chewing -swallowing -smelling -tasting

chewing