ATI

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer? Albumin 25% Dextran 70 Hydroxyethyl glucose Mannitol 25%

Mannitol 25% Cushing's Triad is an indication that the client is experiencing increased intracranial pressure. The nurse should administer mannitol 25%, an osmotic diuretic that promotes diuresis to treat cerebral edema.

A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate? Hypernatremia Oliguria Weight loss Increased thirst

Oliguria The nurse should expect a client who has developed SIADH following a craniotomy to manifest oliguria. The decrease in urine output can be dramatic with output less than 20 mL/hr

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? Paresthesia Hemiplegia Quadriplegia Paraplegia

Paraplegia Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1. Quadriplegia, or paralysis of all four extremities, is seen with spinal cord injuries in the cervical vertebrae above C7.

A nurse is teaching a client who has multiple sclerosis about a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? -"Do not take antihistamines with this medication." -"Take the medication on an empty stomach." -"Stop taking the medication immediately for a headache." -"Expect to develop diarrhea initially."

"Do not take antihistamines with this medication." The nurse should instruct the client not to take antihistamines while taking baclofen. Antihistamines will intensity the depressant effects of baclofen.

A nurse is teaching a client who has multiple sclerosis and a new prescription for dantrolene. Which of the following statements by the client indicates an understanding of the teaching? -"I need to apply a sunscreen when I go outside." -"I can take an over-the-counter antihistamine for allergies when I'm taking this drug." -"I should take this medication when my spasms are bad." -"My muscle strength should improve a lot in 2 to 3 days."

"I need to apply a sunscreen when I go outside." This medication can cause photosensitivity; therefore, the client should protect her skin by wearing a hat and using sunscreen while in sunlight.

A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching? -"I will monitor my husband for coughing while he is eating." -"I will monitor for a change in my husband's voice after he swallows." -"I will monitor my husband for tilting his head forward when he swallows." -"I will monitor my husband for pocketing food in his mouth."

"I will monitor my husband for tilting his head forward when he swallows." A client who tilts his head forward while eating reduces the risk for dysphagia.

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? -"Wear an eye patch on the right eye at all times." -"Plan to relax in a hot tub spa each day." -"Engage in a vigorous exercise program." -"Implement a schedule to include periods of rest."

"Implement a schedule to include periods of rest." The nurse should assist the client in developing a schedule that includes periods of exercise followed by periods of rest to maintain muscle strength and coordination.

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? -Administer antibiotics when available. -Reduce environmental stimuli. -Document intake and output. -Maintain seizure precautions.

Administer antibiotics when available. The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS. Antibiotic therapy has a marked effect on the course and prognosis of the illness.

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide? -Phenytoin turns urine blue. -Alcohol increases the chance of phenytoin toxicity. -Avoid flossing the teeth to prevent gum irritation. -Take an antacid with the medication if indigestion occurs

Alcohol increases the chance of phenytoin toxicity. The nurse should include in the home instructions that alcohol alters the blood level of phenytoin.

A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client? -Narrowing pulse pressure -Drainage of clear fluid from the ears -Alternating periods of alertness and unconsciousness -Extensive bruising in the mastoid area

Alternating periods of alertness and unconsciousness Alternating periods of alertness and unconsciousness is a common manifestation of an epidural hematoma.

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? Kernig's sign Nuchal rigidity Brudzinski's sign Bradykinesia

Brudzinski's sign This client is manifesting a positive Brudzinski's sign, which is indicated when the hips and knees flex when neck is flexed. A positive Brudzinski's sign is a common sign of meningitis.

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? -"DIC is controllable with lifelong heparin usage." -"DIC is characterized by an elevated platelet count." -"DIC is caused by abnormal coagulation involving fibrinogen." -"DIC is a genetic disorder involving a vitamin K deficiency."

DIC is caused by abnormal coagulation involving fibrinogen." DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage.

Pt is in MG crisis. which factor is a possible cause the myasthenic crisis -Developing a respiratory infection -Taking too much prescribed medication -Diet high in protein -Not exercising enough

Developing a respiratory infection the most common triggers of myasthenic crises are respiratory infection, not taking, or taking too little, of the prescribed medication, surgery, and high environmental temperatures.

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take? -Teach controlled coughing and deep breathing. -Provide a brightly lit environment. -Elevate the head of the bed 20°. -Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day.

Elevate the head of the bed 20°. The nurse should elevate the head of the bed less than 25° to promote reduction of intracranial pressure.

A nurse is evaluating the laboratory report for a client who has severe diarrhea and a fever. Which of the following laboratory findings should the nurse identify as an indication that the client has a parasitic infection rather than a bacterial infection? Elevated eosinophil count Decreased neutrophil count

Elevated eosinophil count Eosinophils are a type of white blood cell which increases in the presence of parasitic infection and allergic reactions

A nurse is caring for an adolescent client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the client's parent is the nurse's priority? -"He takes a 2-hour nap every day after school." -"He says he feels sick to his stomach after taking this medication." -"He has so many new bruises on his body." -"He says his mouth is always dry."

He has so many new bruises on his body." When using the urgent vs non-urgent approach to client care, the nurse determines that the priority concern is frequent bruising because this is a manifestation of carbamazepine toxicity. Carbamazepine toxicity can cause bone marrow depression, including leukopenia, anemia, and thrombocytopenia. The parent should monitor the client for bruising, bleeding, and sore throat and have periodic blood work drawn to monitor for myelosuppression.

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache? -Administer pain medication. -Darken the client's room and close the door. -Increase fluid intake. -Elevate the head of the bed to 30º.

Increase fluid intake. The client who has had a lumbar puncture is at risk for continued leaking of CSF from the puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is helpful in quickly replacing the cerebrospinal fluid that was removed during the procedure and increasing fluids will facilitate resolution of the headache. The client should also be instructed to remain in a prone position for 6 hours to prevent leaking of CSF fluid.

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure? Brisk pupillary reaction to light. Increased sleeping Tachycardia Depressed fontanels

Increased sleeping Following a head injury, an infant's level of consciousness can deteriorate, show signs of excessive sleeping, and eventually go into a coma.

A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system? Auscultate cuff blood pressure. Palpate pulse pressure. Obtain a central venous pressure. Monitor the pulmonary artery pressure.

Monitor the pulmonary artery pressure. Clients who have a large percentage of burned body surface area require critical care and accurate monitoring. The pulmonary artery pressure provides an accurate assessment of the cardiovascular system by detecting changes in both right and left heart pressure which can indicate possible development of pulmonary edema, as well monitor overall fluid status.

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test? -A pill-rolling tremor appears. -Muscle contractions become progressively stronger. -Electrical charge in a muscle increases in intensity. -Muscle strength shows no change.

Muscle contractions become progressively stronger. A positive Tensilon test is indicated by a 4 to 5 min period of improved muscle tone and strength.

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? -Administer a nitrate antihypertensive. -Assess the client for bladder distention. -Place the client in a high-Fowler's position. -Obtain the client's heart rate.

Place the client in a high-Fowler's position. The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse's initial action should be to place the client in a high-Fowler's position to assist in providing immediate reduction in blood pressure and intracranial pressure.

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.) -Provide a suction setup at the bedside. -Elevate the side rails near the head when the client is in bed. -Place the bed in the lowest position. -Keep an oxygen setup at the bedside. -Furnish restraints at the bedside.

Provide a suction setup at the bedside is correct. The nurse should provide a suction setup at the bedside to provide oral suctioning as needed following the seizure to prevent aspiration. Elevate the side rails near the head when the client is in bed is correct. The nurse should raise the side rails near the head of the bed to help keep the client in the bed. The nurse should check the facility policy for specific guidelines because raising all side rails can be considered a restraint. Elevate the rails of the bed to prevent a fall during a seizure. Place the bed in the lowest position is correct. The nurse should place the bed in the lowest position to prevent injury if a fall should occur during a seizure. Keep an oxygen setup at the bedside is correct. The nurse should monitor the client's oxygen saturation during a seizure and provide supplemental oxygen as prescribed.

A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority? Intracranial pressure Serum electrolytes Temperature Respiratory status

Respiratory status When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respirations, noting the rate and pattern, and evaluating arterial blood gases. Following intracranial surgery, even slight hypoxia can worsen cerebral ischemia.

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion? Photophobia Nuchal rigidity Positive Kernig's sign Restlessness

Restlessness Clients who have meningitis can be at risk for developing increased ICP. The nurse should monitor the client's vital signs and neurological status at least every four hours. Indications of increased ICP include increased restlessness and confusion, a decreased level of consciousness, and the presence of Cushing's triad (severe hypertension, widened pulse pressure, and bradycardia).

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse? -Slow the rate to 20 mL/hr. -Continue the rate at 125 mL/hr. -Slow the rate to 50 mL/hr. -Increase the rate to 250 mL/hr.

Slow the rate to 50 mL/hr. The nurse should decrease the rate to 50 mL/hr to minimize cerebral edema and prevent increased intracranial pressure

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? -Instruct the client to cough and deep breathe. -Place the client in a supine position. -Place a warming blanket on the client. -Use log rolling to reposition the client.

Use log rolling to reposition the client. Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned.

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? Dehydration Seizures Burns Shivering

shivering The hypothermia blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption.

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect? -A lucid period followed by an immediate loss of consciousness -A change in the level of consciousness that develops over 48 hr -Neurologic deficits that increase up to 2 weeks post-injury -Cognitive perception that decreases over several months post-injury

A lucid period followed by an immediate loss of consciousness The nurse should expect the client who has an epidural hematoma to have a lucid period followed by an immediate loss of consciousness, which is caused by arterial bleeding into the space between the dura and skull

A nurse is preparing to administer phenytoin 50 mg by intermittent IV bolus to a client who has a seizure disorder. Which of the following actions should the nurse take? -Slow the injection if the medication crystallizes. -Dilute the medication before injecting. -Follow the IV injection with sterile water. -Administer the medication over 1 min.

Administer the medication over 1 min. The nurse should administer phenytoin slowly, no faster than 50 mg/min.

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next? Complete a vascular assessment. Administer an antipyretic. Decrease environmental stimuli. Assess the cranial nerves.

Assess the cranial nerves. The greatest risk to the client is from increased intracranial pressure (ICP) which may lead to herniation of the brain and death. The nurse should perform neurological assessments including evaluation of the cranial nerves at least every 4 hr. Early neurological changes to be monitoring for include a decrease in the level of consciousness, the development of Cushing's triad (severe hypertension, widened pulse pressure, and bradycardia), and changes in pupillary reaction.

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first? -Observe for cerebrospinal fluid (CSF) leaks from the evacuation site. -Assess for an increase in temperature. -Check the oximeter. -Monitor for manifestations for increased intracranial pressure.

Check the oximeter. The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to maintain a patent airway. Checking the oximeter is the first indicator of poor oxygen exchange which can cause cerebral edema.

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate? Fresh fish Cheddar cheese Cherries Chicken

Cheddar cheese The nurse should eliminate aged cheeses from the diet of a client who is prescribed selegiline. Cheddar cheese contains tyramine, which can cause a hypertensive crisis.

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.) -Confusion -Bradycardia -Hypotension -Nonreactive dilated pupils -Slurred speech

Confusion is incorrect. A change in the level of consciousness is an early sign of neurologic status. This is often manifested as restlessness, irritability, and confusion. Bradycardia is correct. Bradycardia is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have tachycardia Nonreactive dilated pupils is correct. Increased intracranial pressure can lead to nonreactive dilated pupils or constricted nonreactive pupils. Hypotension is incorrect. Severe hypertension is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have hypotension. Slurred speech is incorrect. Slowed speech can be an early sign of increased intracranial pressure. Late manifestations include stupor, progressing to coma, and abnormal motor responses, including decorticate and decerebrate posturing.

MG is caused by what hypersensitivies Immediate Cytotoxic mmune complex-mediated

Cytotoxic The nurse should recognize myasthenia gravis as a cytotoxic hypersensitivity. Other examples of this hypersensitivity include autoimmune hemolytic anemia and Goodpasture's syndrome.

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? -Decreased level of consciousness -Tachypnea -Bilateral weakness of extremities -Hypotension

Decreased level of consciousness As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness, decrease. Other manifestations include severe headache, irritability, and pupils that are slow to react or are unreactive to light.

A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? Delay in disease progression Improved bladder function Relief of depression Decreased tremors

Decreased tremors Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty walking, and problems with balance and coordination. Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may be helpful in controlling tremors in the early stage of the disease.

A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings? Nuchal rigidity Pupils reactive to light Head turns to follow light Elevated temperature

Elevated temperature Fever, sometimes accompanied by chills, is a manifestation of bacterial infection.

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) Headache Neck pain and stiffness Slurred speech Pupillary changes Disorientation

Headache is correct. A client who has increasing ICP might manifest a headache. Slurred speech is correct. A client who has increasing ICP might manifest slurred speech. Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes. Disorientation is correct. A client who has increasing ICP might display disorientation or confusion.

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.) Hypotension Polyuria Hyperthermia Absence of bowel sounds Weakened gag reflex

Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal cord. Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client to develop a paralytic ileus. Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake. Polyuria is incorrect. The nurse should check the client for bladder distention and inability to urinate due to ineffective function of the bladder muscles. Hyperthermia is incorrect. The nurse should monitor the client for hypothermia caused by a lack of lack of sympathetic input.

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching? -"I will notify my doctor before taking any other medications." -"I have made an appointment to see my dentist next week." -"I know that I cannot switch brands of this medication." -"I'll be glad when I can stop taking this medicine."

I'll be glad when I can stop taking this medicine." Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsant medications commonly require them for lifetime administration, and phenytoin should not be stopped without the advice of the client's provider.

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? -Difficulty reading -Inability to recognize his family members -Right hemiparesis -Aphasia

Inability to recognize his family members The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury? Dextrose 5% in water Dextrose 5% in 0.9% sodium chloride 0.9% sodium chloride Lactated Ringer's

Lactated Ringer's Lactated Ringer's is used in the first 24 hr following a burn injury because it is a crystalloid solution whose composition and osmolality most closely resembles plasma.

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? -Check the client for a fecal impaction. -Examine the client for areas of skin breakdown. -check the client's bladder for distention. -Place the client in a sitting position.

Place the client in a sitting position. The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertension.

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? Extension of the arms Pronation of the hands Plantar flexion of the legs External rotation of the lower extremities

Plantar flexion of the legs Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tracts.

A nurse is caring for a toddler who arrives at the emergency department with burns to his lower legs. Which of the following actions should the nurse take? Apply ice to the burns. Place the child in a tub of cool water. Pour tepid water over the burns. Cover the burns with a blanket.

Pour tepid water over the burns. Tepid water reduces pain and swelling and conducts the heat of the burns away from the skin

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take? -Prepare the client for mechanical ventilation. -Administer an anticholinesterase medication. -Instruct the client to perform the pursed lip breathing. -Prepare to administer a vasoconstrictor.

Prepare the client for mechanical ventilation. The client who is experiencing a myasthenic crisis is at risk for loss of adequate respiratory function. The nurse should closely monitor the client's respiratory status and prepare for possible mechanical ventilation.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? -Provide client supervision. -Limit client physical activity. -Speak loudly to the client. -Leave the television on continuously.

Provide client supervision. Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment.

A nurse is developing a plan of care for a client following a lumbar puncture. Which of the following actions should the nurse include in the plan? (Select all that apply.) -Provide oral fluids. -Monitor for nausea. -Maintain fetal position. -Check level of consciousness. -Check sensation in the toes.

Provide oral fluids is correct. Adequate hydration will decrease the risk of a spinal headache. Spinal headaches occur when cerebral spinal fluid (CSF) is decreased suddenly. Adequate hydration will aid in the replacement of CSF. Monitor for nausea is correct. Nausea and vomiting might occur with an increase in intracranial pressure or meningitis. If the client develops persistent nausea or vomiting, the nurse should monitor for other manifestations and report the findings to the provider. Additional findings to report include change in vital signs, headache, change in level of consciousness, nuchal rigidity, drainage, redness, or swelling at the puncture site. Check level of consciousness is correct. A change in the client's level of consciousness (LOC) might indicate meningitis or a loss of cerebral spinal fluid (CSF). Check sensation in the toes is correct. . Following a lumbar puncture (LP), the client should be kept flat and still, often in a prone position. This helps decrease leakage of cerebral spinal fluid (CSF) from the LP site. The fetal position is used during the LP procedure, not after

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected? -Pushes the painful stimulus away -Extends her body toward the painful stimulus -Shows no reaction to the painful stimulus -Flexes the upper and extends the lower extremities in response to the painful stimulus

Pushes the painful stimulus away Pushing away a painful stimulus is an expected response.

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? -Provide a nonskid mat to alleviate plate movement. -Encourage the client to use his right hand when feeding himself. -Remind the client to look for food on the left side of the tray. -Encourage the use of the wide grip utensils.

Remind the client to look for food on the left side of the tray. The nurse's action to remind the client to look for food on the left side of the tray will train the client to scan the tray by moving his head and eyes, which will help to resolve the problem of homonymous hemianopsia.

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? Tachycardia Amnesia Hypotension Restlessness

Restlessness Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? Severe headache Bradycardia Blurred vision Oriented to person, place, and year

Severe headache The nurse should expect a client who has meningitis to manifest a severe headache due to meningeal inflammation The nurse should expect a client who has meningitis to manifest tachycardia. manifest photosensitivity.

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider? -Edematous bruise on forehead -Small drops of clear fluid in left ear -Pupils are 4 mm and reactive to light -Glasgow Coma Scale (GCS) score of 12

Small drops of clear fluid in left ear Clear fluid in the ear canal might be cerebrospinal fluid (CSF) and indicates a basilar skull fracture. CSF drainage is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents. This finding should be reported to the provider.

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication? -Have the client empty his bladder. -Put up the side rails on the client's bed. -Ask the client to take a few sips of water. -Place the client in low Fowler's position.

Ssk the client to take a few sips of water. Clients who have myasthenia gravis, an autoimmune disorder, have weakness of the muscles of the face and throat, which increases the risk for aspiration. The nurse should check the client's ability to swallow before administering oral medication

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.) -Massage over erythematous bony prominences. -Implement turning schedule every 4 hr. -Use pillows to keep heels off the bed surface. -Keep the client's skin dry with powder. -Minimize skin exposure to moisture.

Use pillows to keep heels off the bed surface is correct. The nurse should keep the heels off the bed to prevent skin breakdown on the client's heels. Minimize skin exposure to moisture is correct. The nurse should minimize skin exposure to moisture to prevent skin breakdown.

.A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? Confusion Weakness Increased intracranial pressure Increased urinary output

Weakness Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory distress or predispose the client to respiratory infections.

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? -Gradual onset of several hours -Manifestations preceded by a severe headache -Maintains consciousness -History of neurologic deficits lasting less than 1 h

anifestations preceded by a severe headache A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke.

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? -The client states having a severe headache. -The client's bladder becomes distended. -The client's blood pressure becomes elevated. -The client states having nasal congestion.

he client's bladder becomes distended. Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face.

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? Transient ischemic attack (TIA) Hemorrhagic stroke Thrombotic stroke Embolic stroke

hemorrhagic stroke A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including sudden onset of a severe headache, a decrease in the level of consciousness, and seizures. Hemorrhagic strokes occur when bleeding occurs in the brain caused by the rupture of an aneurysm or arteriovenous malformation, hypertension and atherosclerosis, or trauma.

The nurse should expect to find bradykinesia or difficulty _______ in a client who has Parkinson's disease.

moving

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse? PaC02 35 mm Hg Intracranial pressure (ICP) 18 mm Hg Pulse oximetry 96% Blood pressure 140/82 mm Hg

ntracranial pressure (ICP) 18 mm Hg This client's ICP level is above the expected reference range of 10 to 15 mm Hg. ICP increases with suctioning, coughing, sneezing, straining, and frequent positioning.

A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop? -Place sandbags to maintain right plantar flexion. -Position soft pillows against the bottom of the feet. -Apply a protective boot to the right ankle. -Splint the right lower extremity to maintain proper alignment.

pply a protective boot to the right ankle. The nurse should apply padded splints or protective boots to the right ankle to keep the foot at a right angle to the leg to prevent footdrop

nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? Hypotension Tachycardia Irritability Tinnitus

rritability The nurse should monitor the client for behavioral changes, such as confusion, restlessness, and irritability as manifestations of increased intracranial pressure