Unit 6- Neurosensory Disorders

When assessing a client who has had spinal anesthesia, which finding is expected?

Sensation returns to the toes first and then progresses to the perineal area. Spinal anesthesia is an extensive conduction nerve block that is produced when a local anesthetic is introduced into the subarachnoid space at the lumbar level. A few minutes after induction of a spinal anesthetic, anesthesia and paralysis affect the toes and perineum and then, gradually the legs and abdomen. When the autonomic nervous system is blocked, vasodilation occurs and hypotension occurs. The client will feel sensation to the toes before the perineal area. A spinal headache due to loss of fluid is a severe headache that occurs while in the upright position, but is relieved in the lying position.

A client is to have a hypophysectomy. To minimize the risk of postoperative respiratory complications, what should the nurse instruct the client to do?

Take deep breaths. Deep breathing is the best choice for helping prevent atelectasis. The client should be placed in the semi-Fowler's position (or as prescribed) and taught deep breathing, sighing, mouth breathing, and how to avoid coughing. The client should receive sufficient medication to control postoperative pain. Frequent position changes help loosen lung secretions, but deep breathing is most important in preventing atelectasis. Coughing is contraindicated because it increases intracranial pressure and can cause cerebrospinal fluid to leak from the point at which the sella turcica was entered.

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates

cranial nerves IX and X. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck their head on the pier railing. According to friends, "The client was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, the client 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?

declining level of consciousness (LOC) With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

A client uses timolol maleate eye drops. What is the expected outcome of this drug?

reducing aqueous humor formation Timolol maleate is commonly administered to control glaucoma. The drug's action is not completely understood, but it is believed to reduce aqueous humor formation, thereby reducing intraocular pressure. Timolol does not constrict the pupils; miotics are used for pupillary constriction and contraction of the ciliary muscle. Timolol does not dilate the canal of Schlemm.

When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of

10 to 20 mm Hg. Normally, pressure in the anterior chamber of the eye remains relatively constant at 10 to 20 mm Hg.

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

compliance with the prescribed medication regimen The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?

15 The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of eye opening, best motor response, and best verbal response on a scale of 3 to 15. The client who scores the best on all three assessments scores 15 points.

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?

infection The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP, not complications.

The primary nursing goal for a client with myasthenia gravis is to:

maintain respiratory function. In myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure.Providing a safe environment and emotional support are secondary goals.Pain is not commonly associated as a problem of myasthenia gravis.

A client has been hospitalized with a diagnosis of myasthenia gravis. The client has been talking on the phone. The nurse enters the room right after the client has recovered from choking on a sandwich. What should the nurse do next?

Tell the client to swallow when the chin is tipped down on the chest. Bending the chin down toward the chest decreases the risk of food entering the trachea and causing aspiration into the lungs. The client should sit up at a 90-degree angle when eating. Eating and talking increase the risk of aspiration as well as muscle fatigue; the nurse should encourage the client to avoid talking while chewing and swallowing. The client should rest before eating because muscle fatigue can contribute to choking.

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?

even, unlabored respirations A characteristic feature of Guillain-Barré syndrome is ascending weakness, which usually begins in the legs and progresses upward to the trunk, arms, and face. Respiratory muscle weakness, evidenced by even, unlabored respirations, is a particularly dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore, although warm, dry skin; urine output of 40 ml/hour; and a soft, nondistended abdomen are pertinent assessment data, those related to respiratory function and status are most significant.

An older adult has vertigo accompanied with tinnitus as the result of Ménière's disease. The nurse should instruct the client to restrict which dietary element?

sodium Ménière's disease is commonly seen in older women; the disorder is caused by pressure within the labyrinth of the inner ear as a result of excess endolympha resulting in swelling in the cochlea. Therefore, the nurse should instruct the client about dietary restrictions of sodium to reduce fluid retention. Pharmacologic treatment includes antivertiginous drugs and diuretics. If the client is prescribed a diuretic, the fluid and electrolytes are monitored. The amount of protein does not have a direct influence in this disease process.

Upon review of a client's phenytoin levels, a nurse notes a value of 16 mcg/ml. What should the nurse do next?

No action is needed at this time because the drug level is normal. Normal therapeutic serum phenytoin level ranges from 10 to 20 mcg/ml. No nursing action is needed at this time.

One day after cataract surgery, the client is having discomfort from bright light. What should the nurse advise the client to do?

Use sunglasses that wrap around the side of the face when in bright light. To prevent discomfort from bright light the client should wear sunglasses that cover the front and side of the face, thus minimizing light that comes into the eye from any direction. It is not necessary to remain in dim light or inside. Attaching sun shields or sunglasses to existing glasses will not cover the eye sufficiently, and bright light will come in on the side of the face. It is not necessary to patch the affected eye.

The nurse is discussing discharge instructions with a client with myasthenia gravis who is taking pyridostigmine. The nurse should tell the client to:

administer artificial tears. The nurse instructs the client regarding use of artificial tears because eyelid and extraocular muscles are frequently affected by myasthenia gravis and there is a risk of corneal abrasion if the eyelids do not close completely. The client is encouraged to maintain social contacts and prevent social isolation. Medication is taken in the morning, prior to activities, so the client is able to complete them. A nutritious diet is encouraged, and there is no indication to limit protein.

The nurse is admitting a client diagnosed with multiple sclerosis (MS). Which medication would the nurse expect to find on the client's record?

baclofen Multiple sclerosis (MS) is a progressive disease characterized by demyelination of the brain and spinal cord. This disease causes a number of manifestations including muscle spasticity. Therefore, baclofen will be given on a routine basis. Antibiotics are not routinely needed. Sinemet is given for Parkinson's disease, not for MS. Methotrexate is given for rheumatoid arthritis.

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called

conductive hearing loss. Conductive hearing loss results from interference with the conduction of sound waves (sound transmission) from the tympanic membrane to the inner ear. The stapes must move freely for sound to be transmitted. Bone tissue overgrowth causes the stapes to become fixed or immobile (ankylosed) in the oval window, preventing sound transmission. In a functional hearing loss, no organic lesion is found. Fluctuating hearing loss is a form of sensorineural hearing loss that varies over time. Sensorineural hearing loss affects the inner ear and involves the cochlea and eighth cranial nerve.

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean them from sedation therapy. A nurse needs further assessment data to determine whether

the nurse will have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. When the client isn't sedated, they may make attempts to remove the ET tube without realizing what they are doing. The nurse needs to obtain information to determine whether it's necessary to request an order for restraints. The nurse doesn't need to obtain additional data to determine if the nutritional protocol will continue to reflect the client's needs because this aspect of care won't change. The client doesn't require additional assessments to continue I.V. administration of medications. I.V. medication clearly needs to continue because the client is intubated. The staff nurse doesn't need to monitor payment status because client sedation shouldn't affect payment status.

A client is discharged to home following hospitalization for percutaneous endoscopic gastrostomy tube placement to assist with nutrition. The client's primary diagnosis is amyotrophic lateral sclerosis (ALS). The client can transfer from the bed to a chair but can't walk. The client and their family are concerned about the client's ability to maintain mobility at the highest possible level following a surgical procedure. The nursing diagnosis most appropriate for this client is

Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate. The family's focus should be on Impaired physical mobility. Although the client's spouse may be experiencing caregiver role strain, the client's unrealistic expectations may not be the cause of the strain. Impaired memory and Hopelessness don't apply to the concerns of this client and family.

When teaching a client about levodopa-carbidopa therapy for Parkinson's disease, a nurse should include which instruction?

"Be aware that your urine may appear darker than usual." Levodopa-carbidopa, used to replace insufficient dopamine in the client with Parkinson's disease, may cause harmless darkening of the urine. The drug doesn't cause eye spasms, although blurred vision is an expected adverse effect. The client should take levodopa-carbidopa shortly before meals, not at bedtime, and must continue to take it for life.

Which statement indicates the client understands the expected course of Ménière's disease?

"Control of the episodes is usually possible, but a cure is not yet available." There is no cure for Ménière's disease, but the wide range of medical and surgical treatments allows for adequate control in many clients. The disease often worsens, but it does not spread to the eyes. The hearing loss is usually unilateral.

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?

"Assume a reclining or flat position." The client needs to assume a safe and comfortable position during an attack, which may last several hours. The client's location when the attack occurs may dictate the most reasonable position. Ideally, the client should lie down immediately in a reclining or flat position to control the vertigo. The danger of a serious fall is real. Placing the head between the knees will not help prevent a fall and is not practical because the attack may last several hours. Concentrating on breathing may be a useful distraction, but it will not help prevent a fall. Closing the eyes does not help prevent a fall.

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 bpm; and respiratory rate of 30 shallow breaths/min. What should the nurse do first?

Activate the Rapid Response Team (RRT). RRTs, or medical emergency teams, provide a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. Calling the neurosurgeon or consulting the CNS may not result in a rapid response. The Trendelenburg position is usually used in treating shock, but because the client has had brain surgery, the head should not be lower than the trunk.

Which technique is appropriate when the nurse is irrigating an adult client's ear to move cerumen?

Allow the irrigating solution to run down the wall of the ear canal. The irrigating solution should not be allowed to drop directly on the tympanic membrane because this may cause discomfort or damage.Ear irrigation is considered to be a clean procedure unless the integrity of the tympanic membrane has been damaged.The solution should be at body temperature; when instilled, it should be allowed to run down the side of the ear canal.A cotton ball should be placed loosely in the ear canal so it does not exert pressure on the tympanic membrane.

Following a scleral buckling, what should the nurse instruct the client to do during the postoperative period?

Assess for eye drainage. After eye surgery, the client should be taught to assess for excessive or purulent drainage that may indicate infection.Coughing should be avoided as this increases intraocular pressure.Pressure dressings are not applied to the eyes after surgery, although general eye patching may be used temporarily.Activity may vary but usually does not require strict bed rest.

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?

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

Collect the drainage. The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.

A client who is prescribed by the health care provider (HCP) to take aspirin daily in order to prevent thrombus formation reports having ringing in the ears. The nurse advises the client to take which measure?

Contact the HCP. Because aspirin is ototoxic, the ringing in the ears is likely caused by long-term aspirin use. The nurse advises the client to contact the HCP; if the aspirin is to be discontinued, other drugs may be ordered. The client is not instructed to stop taking the drug without discussing the change with the HCP. Acetaminophen does not have the same antithrombotic properties as aspirin. Increasing fluid intake will not stop the ringing in the ears.

A client is stabilized in the emergency department and moved to the neurologic intensive care unit with a diagnosis of spinal cord injury at level C4-C5. The nurse is working with an experienced unlicensed assistive personnel (UAP). Which items can the nurse delegate to the UAP? Select all that apply.

Ensure that oxygen is flowing at 5 liters per minute by nasal cannula. Check the client's pulse oximetry reading every 1 hour. An experienced UAP would be able to make sure the oxygen is flowing, the setting is correct, and the cannula is correctly positioned; the UAP would also know how to measure oxygen saturation rate by pulse oximetry. Assessments, auscultation of lungs, and client teaching require additional education, training, and skill and are appropriate for the RN scope of practice.

The nurse is educating a client and family about macular degeneration. Which photo would be utilized to best illustrate what these clients typically see?

Macular degeneration is a medical condition that typically affects the eyesight of older adults. The central vision is most affected in clients, thus revealing a blurred or distorted image in the middle of the visual field. Peripheral vision is usually maintained. The visual field is neither totally blurred, unless in an advanced case, nor completely clear.

The nurse is assessing a client with a spinal cord injury for the development of deep vein thrombosis. Which is the most effective way to determine deep vein thrombosis in this client?

Measure leg girth. Measuring the leg girth is the most appropriate method because the usual signs, such as a positive Homans' sign, pain, and tenderness, are not present. Other means of assessing for deep vein thrombosis in a client with a spinal cord injury are through a Doppler examination and impedance plethysmography.

Which goal is a priority for a client who has undergone surgery for retinal detachment?

Prevent an increase in intraocular pressure. After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal. Control of pain with analgesics is a secondary goal. The client should avoid getting soap and water in the eye when bathing. Maintaining a darkened environment is not necessary for this client.

A client who has apnea during sleep would require which of the following interventions? Select all that apply.

Refer to primary healthcare provider Assess sleep routine/hours Have client keep a sleep diary The client with periods of apnea may require a more thorough assessment including a sleep routine/hour and sleep diary as well as a referral to a primary healthcare provider. Pursed-lip breathing has no influence on sleep apnea. Family may sleep in the same room.

A client who has Ménière's disease reports having frequent attacks of vertigo. The nurse should include which information in the client's teaching plan? Select all that apply.

Sit down if dizzy. Avoid bright lights if they make the symptoms worse. Consider using a cane to maintain balance during an attack. During an acute attack of vertigo, it is best for the client to sit or lie down in a quiet room, avoid sudden position changes, and avoid bright lights if they aggravate the symptoms. Safety is of utmost importance as clients can lose their balance during an attack of vertigo; using a cane can prevent falls. There is not conclusive evidence about the effects of diet, but a low-sodium diet may be helpful in decreasing the number of attacks; the client should also avoid caffeine. Headaches typically are not a component of the vertigo attack.

Which approach would be most effective when the nurse is communicating with a client who has a hearing impairment?

Stand in front of the client and speak slowly and clearly. Stand close to and directly in front of the client to greatly facilitate communication. Speak slowly and clearly and minimize distractions in the environment.The nurse should face the client; that way the client can see the nurse's mouth at all times for lip-reading.Yelling at the client distorts the voice and further hinders understanding.The nurse should have the client validate understanding of the conversation by repeating what was said.

A client who has glaucoma has been prescribed timolol eye drops. The nurse should give which instructions about the administration of the eye drops?

The medication may cause some transient eye discomfort. Timolol can cause some eye discomfort when administered. It is important for the client to continue to take the drug. Glaucoma eye dropsshould be administered as prescribed, not whenever the client desires. The client with glaucoma needs to take eye medication on an ongoing basis to control the disorder and prevent vision damage. There is no need to refrigerate the drug.

When a client is recovering as expected from spinal anesthesia the nurse should assess:

degree of response to pinpricks in the legs and toes. Return of sensation in the toes and legs marks recovery from spinal anesthesia.Because the client receiving spinal anesthesia is conscious, he will not ordinarily be disoriented.The client's respiratory status is not affected by spinal anesthesia.Capillary refill time is an indicator of circulatory status, not neurologic status.

Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which body system?

gastrointestinal The most common toxicities from NSAIDs are gastrointestinal disorders (nausea, epigastric pain, ulcers, bleeding, diarrhea, and constipation). Renal dysfunction, pulmonary complications, and cardiovascular complications from NSAIDs are much less common.

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report

light flashes and floaters in front of the eye. The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double vision is common in clients with cataracts.

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for:

sudden, severe hypertension With a cervical injury, the client has sympathetic fibers that can be stimulated to fire reflexively. The firing is cut off from brain control and is both reflexive and massive. It classically produces pounding headache and dangerously elevated blood pressure, "goose bumps," and profuse sweating.Bradycardia, paralytic ileus, and hot, dry skin typically occur during spinal shock, not during autonomic dysreflexia.

A client preparing to undergo a lumbar puncture states they don't think they will be able to get comfortable with their knees drawn up to the abdomen and the chin touching their chest. The client asks if they can lie on their left side. Which statement is the best response by the nurse?

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform." The nurse should explain that the knee-chest position is necessary to make the procedure safer and easier to perform. Lying on the left side won't make the procedure easy or safe to perform. The nurse shouldn't simply tell the client there is no other option because the client is entitled to understand the rationale for the required position. Reporting the client's concerns to the physician won't meet the client's needs in this situation.

When caring for a client with Guillain-Barré syndrome, the nurse can delegate which activity to the unlicensed assistive personnel (UAP)?

Reposition client every 2 hours. Assessments, teaching, and suctioning are roles of the nurse. Basic care with frequent positioning is the most appropriate to delegate to the UAP.

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply.

The physician was correct to stop resuscitation efforts. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. By initiating a code blue, the nurse didn't follow the client's advance directive and DNR order. The physician was correct to follow the client's wishes and stop resuscitation efforts. The physician had the authority to stop the code.

Which is the best positioning for a client who has a fractured spine as a result of a diving accident?

supine with the head midline The best initial position for a person with a cervical fracture is supine with the head immobilized and midline. This position prevents flexion, rotation, and extension of the neck. The other choices are incorrect because they don't create alignment.

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin. Client teaching about this drug should include which instruction?

"Schedule follow-up visits with your physician for blood tests." A client taking phenytoin to control seizures must undergo routine blood testing to monitor for therapeutic serum phenytoin levels. Typically, the client takes the medication for 1 year after the original seizure, then is reevaluated for continued therapy. During phenytoin therapy, the client may drive and operate machinery. This drug may cause a decreased heart rate and hypotension.

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

increased intracranial pressure (ICP) When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.

A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a corticosteroid ointment, one-half inch in the lower conjunctival sac four times a day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent

increased intraocular pressure (IOP). Headache and blurred vision are symptoms of increased IOP, such as from glaucoma. Ophthalmic corticosteroids may trigger an episode of acute glaucoma in susceptible clients. Although the effects of some drugs may diminish with continued use, this doesn't happen with ophthalmic corticosteroids. Incorrect ointment application doesn't cause headache or blurred vision.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position.The student nurse should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

The nurse is caring for a client admitted with seizures. Which nursing action is important when caring for a client during a postictal state? Select all that apply.

keeping the client side lying padding the side rails setting up suction The nurse will keep the client side lying, pad the side rails and set up suction for a client in a postictal state. Restraining the client and inserting anything into the mouth is contraindicated during a seizure.

Following nasal surgery, the client has packing in the nose. The nurse should:

perform frequent mouth care. Mouth breathing dries the oral mucous membranes. Frequent mouth care is necessary for comfort and to combat the anorexia associated with the taste of blood and loss of the sense of smell.Checking the nares for ulcerations and monitoring the temperature every 4 hours are not necessary.Nose drops are not instilled with packing in place.

The primary goal in the plan of care for the client after cataract removal surgery is to:

promote safety at home. Promoting safety is a priority goal for this client. The client's vision will not be clear, and the client may need to wear an eye patch after surgery. Orienting the client to the physical environment, assisting the client during ambulation, and following other safety precautions to reduce the risk of injury are required. Cardiac output and fluid volume excess are unrelated to cataract surgery. Maintaining a darkened environment is neither necessary nor safe.

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?

"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." The nurse should instruct the client to avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes) for 30 days after a stapedectomy. Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. The client's first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. The client must avoid shampooing and swimming to keep the dressing and the ear dry.

The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. What should the nurse do next?

Readminister the residual to the client, and continue with the feeding. Gastric residuals are checked before administration of enteral feedings to determine whether gastric emptying is delayed. A residual of less than 50% of the previous feeding volume is usually considered acceptable. In this case, the amount is not excessive and the nurse should reinstill the aspirate through the tube and then administer the feeding. If the amount of gastric residual is excessive, the nurse should notify the HCP and withhold the feeding. Disposing of the residual can cause electrolyte and fluid losses.

Which is the most effective way for a nurse to assess for posterior nasal bleeding in a client who has had nasal surgery?

Use a penlight to inspect the back of the pharynx for bleeding. The best way for the nurse to detect posterior nasal bleeding is to use a penlight to observe the back of the pharynx.The nasal drip pad will remain dry with posterior nasal bleeding.Checking the client's hemoglobin and hematocrit every 8 hours will not help detect bleeding in its earliest stages.Nausea can occur postoperatively for several reasons; bleeding is just one reason.

A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?

establishing an intermittent catheterization routine every 4 hours The paraplegic client with an L1-L2 injury will demonstrate flaccid paralysis. Developing an intermittent catheterization routine offers a way of manually draining the bladder, eliminating the need for an indwelling urinary catheter. With an injury at L1-L2, ambulation may be possible with long leg braces but not with short leg braces. Spasticity and autonomic dysreflexia are seen in clients with upper motor injuries above T6, not L1-L2 injuries.

The nurse is assessing a client with retinal detachment. The nurse should assess the client for:

flashing lights and visual field loss. A client with retinal detachment frequently reports flashing lights in the affected eye followed by a loss of vision commonly described as a curtain being slowly drawn across the eye.The detachment is painless, and the client will not report pain.Retinal detachment does not involve the eye muscles.Retinal detachment does not cause lacrimation.

After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eye drops. What is the expected outcome of applying pressure? Pressure:

prevents the medication from entering the tear duct. Applying pressure against the nose at the inner canthus of the closed eye after administering eye drops prevents the medication from entering the lacrimal (tear) duct. If the medication enters the tear duct, it can enter the nose and pharynx, where it may be absorbed and cause toxic symptoms. Eye drops should be placed in the eye's lower conjunctival sac. Applying pressure will not prevent the drug from running down the face as long as the drops are instilled in the eye. Pressure does not affect the cornea or facilitate distribution of the medication over the eye surface.

A nurse is monitoring a client for adverse reactions to atropine eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?

tachycardia Systemic absorption of atropine can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. The drug also may cause dry mouth. It isn't known to cause hypotension or apnea.

A nursing goal immediately following surgery for a client who has had a cataract removed is:

the client describes methods to prevent an increase in intraocular pressure. Preventing an increase in intraocular pressure is the primary concern after cataract removal.Vision will remain unclear temporarily after surgery.Cataracts do not cause headaches.Pain medication at home is not required.

A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by

turning the client's head suddenly while holding the eyelids open. To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client's eyes deviate to the side of ice water introduction. The nurse touches the client's cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the client's pupil helps evaluate brain stem and cranial nerve III function; normally, the client's pupil responds by constricting.

A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention?

urine retention or incontinence Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery. An increase in back pain is more common because on the second postoperative day the long-acting local anesthetic, which may have been injected during surgery, will wear off. Although paresthesia is common after surgery, progressive weakness or paralysis may indicate spinal nerve compression. A mild fever is also common after surgery but is considered significant only if the temperature reaches 101° F (38.3° C).

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?

using a "picture board" for the client to point to pictures Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. What should the nurse do to protect the client without increasing the intracranial pressure (ICP)?

Wrap the hands in soft "mitten" restraints. It is best for the client to wear mitts, which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the sheet restrict movement and add to feelings of being confined, all of which would add to the agitation and increase ICP.

The nurse should inform a client with Ménière's disease that before an attack of the disease, the client may experience:

a feeling of inner ear fullness. Many clients are able to identify an incipient attack of Ménière's disease by a feeling of fullness in the ear that reflects the evolving congestion.Severe headaches are not associated with Ménière's disease.Ménière's disease does not affect vision.Nausea may result after the classic symptom occurs.

A client is experiencing autonomic dysreflexia. The nurse should first:

place the client in Fowler's position. Autonomic dysreflexia is a medical emergency. The rising blood pressure can cause cerebrovascular accident, blindness, or even death. Placing the client in Fowler's position lowers blood pressure. Administering nitroprusside IV is appropriate if the conservative measures are ineffective. Although notifying the health care provider is important, it is more essential that the nurse intervene immediately in the situation. A urine sample for culture should be obtained if the client has an elevated temperature and no other cause for the dysreflexia is found. A urinary tract infection may be causing symptoms.

The nurse is observing the unlicensed assistive personnel (UAP) give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which?

positions the client on the back with a small pillow under the head The UAP should position an unconscious client on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he or she aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to

support the joint where the tendon is being tested. The nurse should support the joint where the tendon is being tested to prevent the attached muscle from contracting. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.

A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place them closer to the nurses' station because of their tendency to

wander A client with Alzheimer's disease is at risk for injury because of their tendency to wander. Placing them closer to the nurses' station makes it easier to monitor them and better ensures their safety if the client begins to wander. Placing the client closer to the nurses' station won't help the client remember to eat, change position often, or modify their behavior.

The nurse is teaching a young female about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client makes which statement?

"I'll use one of the barrier methods of contraception." An alternative or additional method of birth control must be used because oxcarbazepine reduces the effectiveness of oral contraceptives. Higher doses of oral contraceptives will not help in achieving this purpose, but the client needs an additional or alternative method of birth control. The client does not need advice about when to start a family. A side effect of oxcarbazepine may be weight gain, but it is typically gradual.

The nurse receives a physician's order to administer 1,000 mL of intravenous (I.V.) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.

31 The drip rate is calculated using the following formula: Volume of infusion (in milliliters)/Time of infusion (in minutes) × drip factor (in drops/milliliter) = drops/minute. Therefore, 1,000 mL/480 minutes × 15 drops/mL = 31 gtt/minute.

A client with a head injury is being monitored for increased intracranial pressure (ICP). The client's blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore their cerebral perfusion pressure (CPP) is

52 mm Hg. To determine CPP, subtract the ICP from the mean arterial pressure (MAP).

A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg? Record your answer using a whole number.

80 To obtain the MAP, use this formula: MAP = [systolic BP + (2 X diastolic BP)]/3 MAP = [120 + (2 X 60)]/3 MAP = 240/3 = 80.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment. A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

A client has an impairment of cranial nerve II. Which safety precautions must the nurse implement? Select all that apply.

Clear any obstacles in a path for walking. Instruct on the use of a wheeled walker. Cranial nerve II is the optic nerve, which guides vision. Clearing the path of obstacles and providing instructions on the use of a wheeled walker are both safety measures associated with this type of impairment. The other choices are not reflective of the function of cranial nerve II.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?

Explain how to overcome a freezing gait by telling the client to march in place. Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bed rest. A muscle relaxant is not indicated.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?

Face the client and establish eye contact. When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. Enunciating each word is unnecessary. The nurse should allow the client at least 30 seconds to respond to questions or follow a command. Clients with aphasia may need more time to process and understand information. Nurses should use short, simple sentences and avoid frequently changing topics. It is unnecessary to speak in a louder or softer voice than normal.

When communicating with a client who has aphasia, which approaches are helpful? Select all that apply.

Present one thought at a time. Speak with normal volume. Make use of gestures. Encourage pointing to the needed object. The goal of communicating with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating.

A client with a T2-to-T3 spinal cord injury suddenly has a throbbing headache and blurred vision. The client is flushed and sweating on the upper trunk and face, and the hairs on the arms are raised. What should the nurse do first?

Raise the head of the bed. The client with a spinal cord injury above T6 who suddenly experiences clinical manifestations of autonomic stimulation, such as flushing, sweating, and pilocarpia, is demonstrating life-threatening autonomic dysreflexia. The cluster of manifestation results from noxious stimuli, such as a full bladder, or lying on a foreign object, such as a plastic cap or crinkled paper, which the client cannot feel. As soon as the noxious stimulus is removed, the manifestations begin to subside. When the client demonstrates clinical manifestations of autonomic dysreflexia, the nurse should first elevate the head of the bed immediately to decrease the intracerebral pressure caused by the hypertension that developed from autonomic stimulation. The nurse can next check for a distended bladder or foreign object. The client's blood pressure will be elevated; the nurse should assess vital signs frequently.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.

A client is receiving cyclobenzaprine for management of a herniated lumbar disk. Which finding indicates the drug is providing the intended relief?

The client's muscles are not in spasm. Cyclobenzaprine is a muscle relaxant, given to relieve muscle spasm and the related pain. Cyclobenzaprine does not have an effect on the client's ability to take deep breaths.Sedatives and tranquilizers are not typically used in the conservative treatment of herniated lumbar disks.

Which measure should the nurse teach the client with adult macular degeneration (AMD) as a safety precaution?

Turn the head from side to side when walking. To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. A patch does not address the problem of hemianopsia. Appropriate client positioning and placement of personal items will increase the client's ability to cope with the problem but will not affect safety.

The client with a head injury receives mannitol during surgery to help decrease intracranial pressure. Which finding indicates that the drug is having the desired effect?

Urine output increases. mannitol is an osmotic diuretic that helps decrease intracranial pressure through its dehydrating effects. The drug is acting in the desired manner when urine output increases.It may be desirable to decrease pulse rate, decrease blood pressure, or relax muscles, but mannitol is not used to accomplish these.

The client will have an electroencephalogram (EEG) in the morning. The nurse should instruct the client to have which foods/fluids for breakfast?

a full breakfast as desired without coffee, tea, or energy drinks Beverages containing caffeine, such as coffee, tea, cola, and energy drinks, are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee. The client does not need to be on a liquid diet or NPO.

An older adult has hearing loss and a sensation of fullness in both ears. The nurse should examine the ears for:

accumulation of cerumen in the external canal. Cerumen (ear wax) commonly gets impacted in older clients in the external canal. Otalgia is the "fullness" sensation or pain that an older client may experience when the cerumen becomes impacted.External otitis is an inflammation of the outer ear and would not explain the symptoms the client is experiencing.A bony growth (exostosis) arises from the surface of a bone and would not explain the symptoms the client is experiencing.

A new nurse has been assigned to the neurologic intensive care unit. Which client would be best to assign the nurse? A client:

admitted 48 hours ago with bacterial meningitis who requires antibiotic administration The client with bacterial meningitis is in the most stable condition, so the nurse assigned to the neurologic intensive care unit should be assigned to this client. The nurse could also be familiar with the administration of antibiotics. The other clients require assessments and care from RNs who are more experienced in caring for clients with neurologic diagnoses.

After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which activity would be contraindicated?

bending over the sink to wash the face Bending over the sink to wash the face is contraindicated after cataract surgery because it increases intraocular pressure.Walking without assistance, performing isometric exercises, and lying in bed on the nonoperative side are not contraindicated.

To assess a client's cranial nerve function, a nurse should assess

gag reflex. The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.

Which nursing action addresses the primary concern for a client with Guillain-Barré syndrome?

preparing for mechanical ventilation As this disease progresses, the nurse can expect the client to have weakness and possible paralysis of the diaphragm. This may lead to respiratory failure and require mechanical ventilation. This is the primary concern for the client. The other issues are not as high a priority as maintaining a patent airway.

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should

stay with the client and encourage them to eat. Staying with the client and encouraging them to feed themself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake.

A nurse is caring for a client with myasthenia gravis. What assessment findings would indicate an emergency?

sudden dyspnea, intensification of dysphagia, and dysarthria Myasthenia gravis is an acquired autoimmune disorder characterized by abnormal skeletal muscles. Clinical manifestations of a myasthenia crisis include increased muscle weakness, respiratory distress, and difficulty talking or chewing. Intensification of muscle weakness affecting breathing, swallowing, and speech is an emergency.

Which statement by a client with a seizure disorder who has been prescribed topiramate indicates the client has understood the nurse's instruction about this drug?

"I will drink six to eight glasses of water a day." Toxic effects of topiramate include nephrolithiasis, and clients are encouraged to drink six to eight glasses of water a day to dilute the urine and flush the renal tubules to avoid stone formation. Topiramate is taken in divided doses because it produces drowsiness. Although eating fresh fruits is desirable from a nutritional standpoint, this is not related to the topiramate. The drug does not have to be taken with meals.

A nurse is educating a client recently diagnosed with early glaucoma. Which client statement indicates further teaching is necessary?

"I will take my latanoprost eye drops as soon as I start to feel pain." Treatments for glaucoma include medicated eye drops that help drain fluid in the eye, thereby decreasing the intraocular pressure. Latanoprost is a prostaglandin agonist that should be administered daily. This medication is ineffective if the client takes it only when feeling pain. Constipation or straining to have a bowel movement can increase intraocular pressure; therefore clients should increase their fluids and fiber intake. It's important for the client to attend all healthcare provider appointments and get routine eye examinations to monitor the extent of the disease. Glaucoma presents with increased intraocular pressure that can damage the optic nerve, leading to visual disturbances.

The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. What information should the nurse include in the teaching plan?

"Keep active, use stress reduction strategies, and avoid fatigue." The nurse's most positive approach is to encourage a client with MS to keep active, use stress reduction strategies, and avoid fatigue because it is important to support the immune system while remaining active. A quiet, inactive lifestyle is not necessarily indicated. Good health habits are not likely to alter the course of the disease, although they may help minimize complications. Practicing using aids that will be needed for future disabilities may be helpful but also can be discouraging.

After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in the legs, and calls the nurse in excitement to report the leg movement. Which response by the nurse would be the most accurate?

"The movements occur from muscle reflexes that cannot be initiated or controlled by the brain." The movements occur from muscle reflexes and cannot be initiated or controlled by the brain. After the period of spinal shock, the muscles gradually become spastic owing to an increased sensitivity of the lower motor neurons. It is an expected occurrence and does not indicate that healing is taking place or that the client will walk again. The movement is not voluntary and cannot be brought under voluntary control.

The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure and monitors the blood pressure for signs of widening pulse pressure. The client's current blood pressure is 170/80 mm Hg. What is the client's pulse pressure? Record your answer using a whole number.

90 Pulse pressure is the difference between the systolic blood pressure and the diastolic blood pressure. For this client, pulse pressure is 170 - 80 = 90.

A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?

Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in their care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; the nurse may wait until they complete the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record.

After cataract removal surgery on the left eye, the client sits up and reports having sharp pain in the operative eye. What should the nurse do next?

Contact the health care provider. Sudden, sharp pain after eye surgery may indicate that the client has intraocular hemorrhage. The nurse should immediately contact the healthcare provider (HCP). Covering the eye will not manage intraocular hemorrhage. Pain medication will not be effective to manage hemorrhage. The nurse should help the client return to a recumbent position.

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.

Ease the client to the floor. Maintain a patent airway. Obtain vital signs. Record the seizure activity observed. To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded.

A client in the postanesthesia care unit with a left below-the-knee amputation has pain in the left big toe. What should the nurse do first?

Give the client the prescribed opioid analgesic. The nurse's first action should be to administer the prescribed opioid analgesic to the client because this phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain. Although it does relieve the client's apprehensions to be told that phantom sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation. Usually phantom sensation will go away. However, showing the client that the toes are not there does nothing to provide the client with relief.

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays have not been read, so the nurse does not know whether the client has a cervical spinal injury. The nurse develops a plan of care and includes which action?

Maintain the client in a flat position, except for logrolling as needed. When caring for the client with a possible cervical spinal injury who is wearing a cervical collar, the nurse must keep the client flat to decrease mobilization and prevent further injury to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. What should the nurse do next?

Notify the health care provider (HCP). ICP is highest in the early morning, and the client with hydrocephalus may be experiencing signs of increased ICP that need to be treated. The increased ICP is not related to fluid levels, and the nurse should not advise the client to increase fluid intake. While ICP does fluctuate during the day, it is highest in the morning, and the nurse should notify the HCP. Pain medication will not treat the potentially increasing ICP and may mask important signs of increasing ICP.

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

Risk for injury related to neurologic deficit Because a cerebral contusion causes altered cognition, the nurse should identify Risk for injury related to neurologic deficit as the primary nursing diagnosis and focus on interventions that promote client safety and prevent further injury. Disturbed sensory perception (visual) related to neurologic trauma, Feeding self-care deficit related to neurologic trauma, and Impaired verbal communication related to confusion are pertinent but don't take precedence over client safety.

The nurse observes that when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors?

The tremors sometimes disappear with purposeful and voluntary movements. Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson's disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client.

The nurse is caring for a client with a diagnosis of cerebrovascular accident (CVA) with left-sided hemiparesis. What would be important nursing measures in the acute phase of care? Select all that apply.

Turn and position every 2 hours. Perform passive range of motion on the affected side. Support the affected side with pillows. A client with hemiparesis to the left side would need assistance to turn and position to prevent skin breakdown. Passive range of motion would be performed to the affected side, and active range of motion would be encouraged to the unaffected side. Support with pillows will help to prevent breakdown and contractures. Neither passive nor active range of motion would be necessary to both sides as the client has use of the unaffected side.

When assessing the client with Parkinson's disease, the nurse should observe the client for:

a stiff, masklike facial expression. Typical signs of Parkinson's disease include drooling; a low-pitched, monotonous voice; and a stiff, masklike facial expression.Dry mouth is not associated with Parkinson's disease.Aphasia is not a symptom of Parkinson's disease.An exaggerated sense of euphoria would not be typical; more likely, the client would exhibit depression, probably related to the progressive nature of the disease and the client's difficulties dealing with it.

When developing the home care plan for a client with glaucoma, the nurse should encourage the client to:

add extra lighting to his home. Miotic agents may compromise a client's ability to adjust safely to night vision. For safety, extra lighting should be added to the home.The client does not need to curtail fluid intake.It is not necessary to wear dark glasses when using computers, tables, or cell phones.Exercise is permitted, although excessive exertion should be avoided.

Nursing care management of the child with bacterial meningitis includes which interventions? Select all that apply.

administration of IV antibiotics decreased environmental stimuli neurologic checks every 4 hours Antibiotics are indicated for the treatment of bacterial meningitis. Clients with bacterial meningitis often have increased ICP. It is necessary to maintain adequate hydration. However, infusing fluids at 1½ maintenance can increase ICP, further risking neurologic damage due to cerebral edema. Most children with meningitis are sensitive to sound, light, and stimulation. Decreasing environmental stimuli and keeping the room dim and quiet are essential. Frequent neurologic checks are necessary to monitor any changes in the child's level of consciousness. Anticonvulsants are not indicated unless the child experiences seizures as a result of the meningitis.

The nurse is assessing a client who has had Huntington's disease for the past 8 years. Which clinical manifestation finding would require the nurse to notify the client's primary healthcare provider?

akathisia Motor restlessness is a sign of overmedication, and therefore should be reported to the client's primary healthcare provider. The other clinical manifestations are expected in a client with Huntington's disease.

A nurse has received a shift report on four clients. Which client should the nurse assess first?

an older adult returning to the unit after having a carotid endarterectomy The nurse should first assess the client returning from a carotid endarterectomy, who requires close monitoring. The client who had a rhizotomy will require pain assessment after the nurse addresses the client returning from surgery. The clients admitted for observation are stable and are lower priorities than the client returning from a carotid endarterectomy.

When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated?

asking the client to speak louder when tired Asking a client to speak louder even when tired may aggravate the problem. Asking the client to speak slowly and distinctly and to repeat hard-to-understand words helps the client to communicate effectively.

Which action is contraindicated for a client with seizure precautions?

assessing the client's oral temperature with a glass thermometer Temperatures are not assessed orally with a glass thermometer because the thermometer could break and cause injury if a seizure occurred.The client can perform personal hygiene.There is no clinical reason to discourage the client from wearing his or her own clothes.As long as there are no other limitations, the client should be encouraged to be out of bed.

The emergency department protocol provides for administration of alteplase (tPA) for clients with confirmed acute coronary syndrome (ACS). The nurse contacts the healthcare provider to clarify the order for the client with which health history?

atrial fibrillation and a mild stroke one month ago Due to the risk of bleeding, a recent stroke (within 2 months) is an absolute contraindication to thrombolytic therapy. The nurse should hold the administration of alteplase (tPA) and notify the healthcare provider. The nurse should also check the client's history for anticoagulant use, which could also result in contraindication for tPA. Having had no previous history of cardiovascular disease or having the classic risk factors such as hypertension, dyslipidemia, and peripheral artery disease would not preclude the use of tPA nor would a past history of myocardial infarction with angioplasty a year ago.

A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temperature 99°F (37°C), pulse 100 bpm, respirations 18 breaths/min, and blood pressure 130/70 mm Hg. The nurse should report which changes, if they occur, to the health care provider (HCP)? Select all that apply.

bradycardia widening pulse pressure The nurse should immediately report changes that indicate increasing intracranial pressure (ICP): bradycardia, increasing systolic pressure, and widening pulse pressure. As ICP increases and the brain becomes more compressed, respirations become rapid, BP decreases, and the pulse slows further; these are very ominous signs. Decreased arterial BP and tachycardia can indicate bleeding elsewhere in the body. Decreasing urinary output indicates decreased tissue perfusion. The nurse monitors changes and notifies the HCP if trends continue.

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an I.V. injection of a medication. What is the medication the nurse tells the client they'll receive during this test?

edrophonium The most useful and reliable diagnostic test for myasthenia gravis is the edrophonium test. Within 30 to 60 seconds after injection of edrophonium, most clients with myasthenia gravis will demonstrate a marked improvement in muscle tone that lasts about 4 to 5 minutes. Cyclosporine, an immunosuppressant, is used to treat myasthenia gravis, not to diagnose it. Immunoglobulin G is used during acute relapses of the disorder. Azathioprine is an immunosuppressant that's sometimes used to control myasthenia gravis symptoms.

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order

famotidine Adverse effects of methylprednisolone sodium succinate and other steroids include GI bleeding and wound infection. To help prevent GI bleeding, the physician is likely to order an antacid or a histamine2-receptor antagonist such as famotidine. Naloxone, nitroglycerin, and atracurium aren't used to prevent adverse effects of steroids. Naloxone, an endogenous opioid antagonist, has been studied in animals for its action in inhibiting release of endogenous opioids after spinal cord injury. (Endogenous opioids are thought to contribute to secondary damage to spinal cord tissue by reducing microcirculatory blood flow.) Nitroglycerin is used to dilate the coronary arteries. Atracurium is a nondepolarizing muscle relaxant.

The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring?

intake and output After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.

A physician is assessing a client's ear and notes excess bone formation around the oval window. Which additional assessment finding should the nurse anticipate?

low-frequency hearing loss Excess bone formation around the oval window indicates otosclerosis, which is characterized by low-frequency hearing loss. The tympanic membrane is normal, not sclerosed, with this disorder, and bone conduction usually occurs longer than air conduction. Chronic ear infections aren't a characteristic of otosclerosis.

The client finds the chronic tinnitus of Ménière's disease extremely irritating. The nurse should instruct the client to:

mask the tinnitus with background music. The chronic tinnitus associated with Ménière's disease can be extremely intrusive and frustrating for clients. Attempting to mask tinnitus with a low-level competing sound, such as music, is often recommended.Quiet environments appear to worsen the client's perception of the problem.Vitamin B6 will not affect the tinnitus.A hearing aid is not a treatment for tinnitus.

A nurse is monitoring a client for adverse reactions to dantrolene. Which adverse reaction is most common?

muscle weakness The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis. Muscle weakness is rarely severe enough to cause slurring of speech, drooling, or enuresis. Although excessive tearing and urine retention are adverse reactions associated with dantrolene use, they aren't as common as muscle weakness.

A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the health care provider (HCP) immediately?

new onset of footdrop Neurologic symptoms, such as footdrop, or bowel or bladder changes, should be reported to the HCP immediately. When musculoskeletal strain causes back pain, these symptoms may take 4 to 6 weeks to resolve. As an accompanying symptom of acute low back pain, the client may have a diffuse, aching sensation in the L4 to L5 area, pain in the lower back when the leg is lifted, or pain that radiates to the hip.

The nurse assesses a parent's understanding of cerebral palsy. The nurse determines that the parent has an accurate understanding of cerebral palsy when she describes it as a term applied to impaired movement resulting from which factor?

nonprogressive brain damage caused by injury The term cerebral palsy (CP) refers to a group of nonprogressive disorders of upper motor neuron impairment that result in motor dysfunction due to injury. In addition, a child may have speech or ocular difficulties, seizures, hyperactivity, or cognitive impairment. The condition of congenital malformed blood vessels in the ventricles is known as arteriovenous malformations. Viral infection and metabolic imbalances do not cause CP.

The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which activity is contraindicated?

sitting all afternoon in the room After a lumbar laminectomy, a client should not sit for prolonged periods in a chair because of the increased pressure against the nerve root and incision site. Assisting with daily hygiene is an appropriate activity during the initial postoperative period because, as with any surgical procedure, the client needs to return to an optimal level of functioning as soon as possible. There is no limitation on the client's participation in daily hygiene activities except for individual responses of pain, nausea, vomiting, or weakness. Lying flat in bed is appropriate because it does not cause stress on the spinal column where the laminectomy was performed and the disc tissue was removed. Positions that should be avoided are those that would cause twisting and flexion of the spine. Walking in the hall is an acceptable activity. It promotes good postoperative ventilation, circulation, and return of peristalsis, which are needed for all surgical clients. In addition, walking provides the postoperative lumbar laminectomy client an opportunity to build up endurance and muscle strength and to promote circulation to the operative and incision sites for healing without twisting or stressing them.

The nurse is developing the discharge teaching plan for a client after a lumbar laminectomy L4-L5. What action should the nurse encourage the client to avoid when returning to work in 6 weeks?

sitting whenever possible After a lumbar laminectomy L4-L5, a client who is returning to work should avoid sitting whenever possible. If the client must sit, he or she should sit only in chairs that allow the knees to be higher than the hips and support the arms to maintain correct body alignment and reduce undue stress on the spine. Maintaining good body postures is most important after a lumbar laminectomy L4-L5. By 6 weeks after the surgery, the client should have regained stamina. To maintain correct body posture, the client should also place one foot on a step stool during prolonged standing. Sleeping on the back with a support under the knees is effective in maintaining correct body posture. Maintaining an average weight for height is important in maintaining a healthy back because carrying extra weight causes undue stress on back muscles.

A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside?

suction machine with catheters MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution, but should not be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator.

Which is not a typical clinical manifestation of multiple sclerosis (MS)?

sudden bursts of energy With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS.

Which clinical manifestation should the nurse assess when a client has acute angle-closure glaucoma?

sudden eye pain Acute angle-closure glaucoma produces abrupt changes in the angle of the iris. Clinical manifestations include severe eye pain, colored halos around lights, and rapid vision loss. Gradual loss of central vision is associated with macular degeneration. The loss of color vision, or achromatopsia, is a rare symptom that occurs when a stroke damages the fusiform gyrus. It most often affects only half of the visual field.

A client with suspected myasthenia gravis is scheduled for a edrophonium test. The nurse identifies which test finding that most likely indicates a positive test result?

temporary muscle improvement Administration of the edrophonium test will have no effect with a normal client but will cause a temporary improvement of muscle weakness in a client with myasthenia gravis.

A client is scheduled for a prostatectomy, and the anesthetist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse prepares the client according to the anesthetist's instructions. Which statement by the anesthetist would the nurse question?

"Position the client supine on the operating table, and prepare the site for injection." The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and to ensure proper anesthetic distribution. The nurse would assist the client in a sitting or lateral position; lying supine is inappropriate as it obstructs the site of injection. Reviewing and verifying the last dose of anticoagulants will alert the nurse to a risk for bleeding. Obtaining vital signs is important to get baseline readings for comparison during and after the procedure. Sindce respiratory paralysis is a complication of subarachnoid injections, continuously monitoring the client's oxygen saturation is an appropriate intervention. Asking the nurse to hold the client firmly during the procedure will prevent sudden client movement that may displace the needle and cause injury to the nerve root.

A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client?

"You're in the hospital. You were in an accident and unconscious." It is important to first explain where a client is to orient him or her to time, person, and place. Offering to get the family and asking questions to determine orientation are important, but the first comments should let the client know where he or she is and what has happened. It is useful to be empathetic to the client, but making a comment such as "I'll bet you are a little confused" is not helpful and may cause anxiety.

Which information should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply.

Carefully test the temperature of bath water. Avoid hot water bottles and heating pads. Inspect the skin daily for injury or pressure points. Wear warm clothing when outside in cold temperatures. A client with impaired peripheral sensation does not feel pain as readily as someone whose sensation is unimpaired; therefore, water temperatures should be tested carefully. The client should be advised to avoid using hot water bottles or heating pads and to protect against cold temperatures. Because the client cannot rely on minor pain as an indicator of damaged skin or sore spots, the client should carefully inspect the skin daily to visualize any injuries that he cannot feel. The client should not be instructed to avoid kitchen activities out of fear of injury; independence and self-care are also important. However, the client should meet with an occupational therapist to learn about assistive devices and techniques that can reduce injuries, such as burns and cuts that are common in kitchen activities.

A nurse is planning discharge for a client who had right-sided weakness from a stroke. During the hospitalization, the client received physical, occupational, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene?

Inform the case manager of the concern, and request resources to assist after discharge. As the coordinator of care, the nurse must assess the client's needs and initiate referrals for the appropriate healthcare team members to coordinate services needed after discharge. The nurse isn't responsible for contacting agencies to provide care after discharge. Alerting the healthcare provider is helpful; however, that step doesn't ensure the necessary services will be provided after discharge. Acknowledging the concern is therapeutic, but the nurse is unable to know for certain if the client can perform all self-care at home.

A client with amyotrophic lateral sclerosis (ALS) is admitted with weight loss and malnutrition. The client can swallow without difficulty. While caring for the client, the nurse discovers that the weight loss is related to the client's refusal to eat. The client states to the nurse that they would rather die than remain alive with this disease. How should the nurse intervene?

Explore the client's feelings about dealing with ALS using open-ended questions. The nurse shouldn't just support the client's decision. Instead, using open-ended questions, the nurse should explore the client's feelings about living with ALS. After obtaining more information, the nurse should notify the physician of the client's wishes. The nurse shouldn't discuss the client with family members without the client's permission; doing so is a breach of client confidentiality. After evaluating the client, the physician can determine whether a psychiatric consult is necessary.

When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis?

Improved muscle strength after I.V. administration of edrophonium chloride. Extreme muscle weakness is present in both cholinergic crisis and myasthenic crisis. In cholinergic crisis, I.V. edrophonium chloride, a cholinergic agent, does not improve muscle weakness; in myasthenic crisis, it does. Diaphoresis and increased salivation are not present in cholinergic crises.

A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do?

Notify the health care provider (HCP) of the client's breathing pattern. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the HCP immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen, and the depth of breathing is assisted by the ventilator. The HCP will determine changes in the ventilator settings.

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bpm, respirations are 22 breaths/min, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88 mm Hg, and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? All options must be used.

Provide sedation. Hyperoxygenate. Suction the airway. Suction the mouth. Increased agitation with suctioning will increase ICP; therefore, sedation should be provided first. The client should be hyperoxygenated before and after suctioning to prevent hypoxia since hypoxia causes vasodilation of the cerebral vessels and increases ICP. The airway should then be suctioned for no more than 10 seconds. The mouth can be suctioned once the airway is clear to remove oral secretions. Once the mouth is suctioned, the suction catheter should be discarded.

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?

Test the nasal drainage for glucose. Because cerebrospinal fluid (CSF) contains glucose, testing nasal drainage for glucose helps determine whether it's CSF. The nurse should look for a halo sign only if the drainage is blood tinged. A client with a suspected CSF leakage shouldn't blow their nose; doing so could increase the risk of injury. The nurse should contact the physician after completing the assessment.

The nurse is caring for a client who is scheduled to undergo a computerized tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information would the nurse include in a preprocedural teaching plan? Select all that apply.

The test may require removal of watches, bracelets, or earrings. A contrast dye may be given before the test. Throat irritation and facial flushing may occur if contrast dye is used. It is necessary to report any known allergies to iodine or seafood prior to the procedure. The nurse would inform the client who is scheduled to undergo a CT scan that a contrast medium may be administered before the procedure and that the dye can cause throat irritation and facial flushing. Because the dye is iodine based, it is essential for the client to report any known allergies to iodine or seafood before testing begins. Removal of watches, bracelets, or earrings or other metal objects may be needed if they interfere with the test. The CT scan is not invasive or dangerous. The client will not be able to take routine medications for 12 to 24 hours beforehand, depending upon the medication.

After receiving a change-of-shift report at 0700, the nurse should assess which client first?

a 63-year-old with multiple sclerosis who has an oral temperature of 101.8° F (38.8° C) and flank pain Urinary tract infections are a frequent complication in clients with multiple sclerosis because of the effect on bladder function; therefore, that client should been seen first by the nurse. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The client should be notified immediately so that antibiotic therapy can be started quickly. The other clients should be assessed soon, but do not have needs as urgent as this client.

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition?

decrease in level of consciousness (LOC) A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

A client has chronic open-angle glaucoma. What should the nurse ask the client about when conducting a focused assessment?

decreasing peripheral vision Although COAG is usually asymptomatic in the early stages, peripheral vision gradually decreases as the disorder progresses. Eye pain is not a feature of COAG but is common in clients with angle-closure glaucoma. Excessive lacrimation is not a symptom of COAG; it may indicate a blocked tear duct. Flashes of light are a common symptom of retinal detachment.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include

diminished responsiveness. Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

Which nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma?

disorientation, increasing blood pressure, bradycardia, and bradypnea Alterations in consciousness and disorientation over the past 2 hours are indicative of increased intracranial pressure. Vital sign changes also indicate the vasomotor control centers in the brain are affected, resulting in increased pulse pressure and bradycardia. Bradypnea indicates that the respiratory center is also affected. Each of the other choices represents normal findings on a Glasgow coma scale, except for hypoventilation.

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?

edrophonium Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma.

A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order

electromyography (EMG). To help confirm ALS, the physician typically orders EMG, which detects abnormal electrical activity of the involved muscles. To help establish the diagnosis of ALS, EMG must show widespread anterior horn cell dysfunction with fibrillations, positive waves, fasciculations, and chronic changes in the potentials of neurogenic motor units in multiple nerve root distribution in at least three limbs and the paraspinal muscles. Normal sensory responses must accompany these findings. Doppler scanning, Doppler ultrasonography, and quantitative spectral phonoangiography are used to detect vascular disorders, not muscular or neuromuscular abnormalities.

When completing a nursing assessment on a client admitted with a neck injury, which findings would indicate an incomplete spinal cord injury (SCI)?

evidence of voluntary motor and sensory function below the level of injury Initial assessment of neurologic integrity will assess motor and sensory abilities. Incomplete spinal cord injury would be indicated by some motor and sensory functioning below the level of injury. This confirms there is a potential for recovery. Flaccid paralysis would indicate complete severing or transection of the spine. Spinal shock may occur, especially with complete transection, but usually will manifest as hypotension and bradycardia. Another complication, especially with transection, can be bladder distension.

The nurse is assessing a client's motor response after brain surgery. The nurse pinches the client's skin to elicit a response and observes the client's arms and legs moving straight out and the feet and toes bend downward. How should the nurse document this response?

extension posturing The client is exhibiting extension posturing indicating severe brain stem or midbrain damage which may be a sign of irreversible damage. Flaccid paralysis occurs when there is no resistance to passive range of motion or voluntary movement. Flexion posturing, is a sign of brain damage and communication with nerves in the spinal cord and not as dangerous a sign as extension posturing. Chronic spastic paralysis results from damage to the voluntary movement system between the brain and the muscles.

A nurse is caring for a client who's had surgery to repair a hip fracture. The client says their left hand and arm are numb and they can't move the extremity. The nurse contacts the physician, who suspects brachioplexus nerve damage. What additional priority assessment does the nurse need?

function of the client's left hand before the operation Functioning of the affected limb before surgery is the priority assessment information the nurse needs to determine the level of change in the client. The nurse doesn't need to assess function of the right hand or arm because the client has no problem with them. Copies of the operating room notes may indicate positioning but may not be useful in further diagnosis. X-ray won't reveal damage to the brachioplexus nerve.

The son of an older adult reports that his father just "stares off into space" more and more in the last several months but then eagerly smiles and nods once the son can get his attention. What further assessments should the nurse make?

hearing loss Blank looks, decreased attention span, positioning of the head toward sound, and smiling/nodding in agreement once attention is gained are all behaviors that indicate hearing loss in adults. It is common to confuse sensory deficits for a change in cognitive status. The nurse should focus assessments of sensory function on considering any pathophysiology of existing or new-onset deficits and consider all client factors that might contribute to deficits.

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for

hypoxia Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.

Which nursing goal is realistic to establish with a client who has multiple sclerosis (MS)?

improved muscle strength MS is a progressive, chronic neurologic disease characterized by patchy demyelination throughout the central nervous system. This interferes with the transmission of electrical impulses from one nerve cell to the next. Care for the client with MS is directed toward maintaining muscle strength, preventing deformities, preventing and treating depression, and providing client motivation. MS affects speech, coordination, and vision, but not cognition.

After an eye examination, a client is diagnosed with open-angle glaucoma. The physician orders pilocarpine ophthalmic solution, 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by

instilling one drop of pilocarpine 0.25% into both eyes four times daily. The abbreviation "gtt" stands for drop, "i" is the apothecary symbol for the number 1, "OU" signifies both eyes, and "q.i.d." means four times per day. Therefore, one drop of pilocarpine 0.25% should be instilled into both eyes four times daily.

A client has been diagnosed with an acute episode of angle-closure glaucoma. The client asks the nurse what will be done. What should the nurse tell the client about this health problem? Acute angle-closure glaucoma:

is a medical emergency that can rapidly lead to blindness. Acute angle-closure glaucoma is a medical emergency that rapidly leads to blindness if left untreated. Treatment typically involves miotic drugs and surgery, usually iridectomy or laser therapy. Both procedures create a hole in the periphery of the iris, which allows the aqueous humor to flow into the anterior chamber. Bed rest does not affect the progression of acute angle-closure glaucoma. Steroids are not a treatment for acute angle-closure glaucoma; in fact, they are associated with the development of glaucoma.

A parent of a child with a moderate head injury asks the nurse, "How will you know if my child is getting worse?" The nurse should tell the parents that best indicator of the child's brain function is which factor?

level of consciousness The level of consciousness (LOC) is the best indicator of brain function. If the child's condition deteriorates, the nurse would notice changes in LOC before any other changes and should notify the health care provider (HCP) that these changes are occurring. Changes in vital signs and pupils typically follow changes in LOC. Motor strength is primarily assessed as a voluntary function. With changes in levels of consciousness, there may be motor changes.

Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure?

loss of consciousness, body stiffening, and violent muscle contractions A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (e.g., jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking.

The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which topic is most important to include in the plan?

maintaining a safe environment The primary focus is on maintaining a safe environment because the client with Parkinson's disease usually has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking. This type of gait commonly causes the client to fall or to have trouble stopping. The client should maintain a balanced diet, enhance the immune system, and enjoy diversional activities; however, safety is the primary concern.

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate?

meningeal irritation Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign and Kernig's sign don't indicate increased ICP, encephalitis, or low CSF pressure.

A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which condition?

meningitis Head trauma and fractures place an individual at high risk for meningitis. A client who is febrile with increasing drowsiness should be investigated for posttraumatic meningitis. It is unlikely that pneumonia, renal failure, or a paralytic ileus would occur as a result of a basal skull fracture.

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction?

pulling up the client under the left shoulder when getting the client out of bed to a chair Pulling the client up under the arm can cause shoulder displacement. A belt around the waist should be used to move the client. Passive range-of-motion exercises prevent contractures and atrophy. Raising the foot of the bed assists in venous return to reduce edema. High top tennis shoes are used to prevent foot drop.