chapter 49&50

The nurse is preparing to administer diazepam 10 mg IV. The available dose is diazepam 5 mg/mL. How many milliliters will the nurse administer?

2 ML

A client has no eye-opening response, no verbal response, and no motor response. Which Glasgow Coma Scale (GCS) score should the nurse assign to this client?

3

The nurse is caring for a client with a right middle cerebral stroke. Which action will the nurse take?

Rotate client so the right side of the bed is facing the door

The nurse is caring for a client with myasthenia gravis (MG). Which of the following interventions should the nurse implement?

Schedule anticholinesterase drugs so peak action occurs at times when muscle strength is needed.

A client about to undergo an electroencephalogram (EEG) asks the nurse what this test will do. Which response by the nurse is best?

"An EEG will determine whether you are having a seizure of slowed brain activity."

A client asks the nurse how to prevent a stroke. Which statement by the nurse is correct? Select all that apply.

"You should increase your daily exercise." "Excessive alcohol intake can increase your risk." "Strict blood glucose control is important."

The nurse is evaluating clients diagnosed with thrombotic stroke for treatment of tissue plasminogen activator (tPA). Which client should the nurse see first? Rank the clients in order of severity of their diagnosis, one being the most severe.

A 74-year-old with left facial weakness and right arm paralysis for the past 7 hr A 48-year-old who reports a severe headache, dizziness, and right-sided facial droop for the past 4 hr A 67-year-old with left-eye blindness and dysphagia for the past 3 hr A 28-year-old client with right-sided facial droop, nausea, and a severe headache for the past hr

The nurse is caring for a group of clients. Which client is at highest risk for developing restless leg syndrome (RLS)?

A client with kidney failure

The nurse is caring for a group of clients. Which client should the nurse see first?

A client with myasthenia gravis (MG) who is drooling and sweating

The nurse is planning care for a client with trigeminal neuralgia. Which of the following should the nurse plan to implement? Select all that apply.

Provide a soft bristle toothbrush for oral care Teach the patient to protect their face from heat or cold

The nurse is caring for a post-operative client after placement of a ventriculoperitoneal (VP) shunt for hydrocephalus. The client asks why there is a need for draining and where all the drained fluid is going. Which statement by the nurse indicates understanding of VP shunts?

The fluid drains into your abdomen."

The nurse is asked about the purpose of cerebrospinal fluid (CSF). Which teaching will the nurse provide to the client regarding CSF? Select all that apply.

Acts as a cushion or shock absorber for the central nervous system (CNS) Permits the exchange of nutrients and wastes between the blood and central nervous system (CNS) neurons

The nurse is preparing a meal for a client with dysphagia. What is the best action by the nurse?

Add a thickening agent to the client's liquids

A client who is diagnosed with a stroke is requesting a glass of water. Which action is appropriate for the nurse to take?

Check the client's dysphagia screen.

The nurse is caring for a client suffering from left-sided hemiopia. Which nursing diagnosis is priority for this client?

Disturbed sensory perception

The nurse is assessing a cranial nerve by checking for symmetry while the client frowns, smiles, and wrinkles their forehead. Which cranial nerve is being assessed?

Facial nerves

The nurse is assessing a client undergoing a computed tomography (CT) scan using contrast dye. Which symptoms require immediate intervention by the nurse? Select all that apply.

Nausea Diaphoresis Difficulty breathing Itching

The nurse is assisting a client who presents to the emergency department with left-sided weakness and slurred speech. Vital signs are blood pressure 208/100 mm Hg, pulse 88 beats per minute, and SpO2 98%. Which medication will the nurse anticipate administering?

Nicardipine

The nurse shows a pencil and a pen and asks the client to state what each is. Which of the following is the nurse assessing?

Perception

The nurse is caring for a client with expressive aphasia. Which intervention will the nurse perform to aid with communication?

Provide the client with a picture board

The nurse is caring for a client who has difficulty swallowing after a hemorrhagic stroke. Which nursing intervention is inappropriate for this client?

Provide the client with a straw for all meals

The nurse is caring for a client who develops Cushing's triad. Which of the following clinical manifestations can the nurse expect to find?

Widening pulse pressure

Which of the following is the part of the brain that enables learning, memory, and thought?

cerebrum

Which of the following can trigger an attack of pain in a client with trigeminal neuralgia (TN)?

chewing

A client staggers and bumps into objects when walking. Which priority action must the nurse initiate?

fall precautions

The nurse is assessing a client's neurological status. Which of the following should the nurse assess first?

level of consciousness

The nurse brings cinnamon and coffee to a client's bedside. Which cranial nerve is the nurse planning to assess?

olfactory

The nurse is caring for a client with suspected amyotrophic lateral sclerosis (ALS). For which procedure should the nurse prepare the client?

nerve biopsy

The nurse is caring for a client with ALS who appears short of breath and has a productive cough. Which action should the nurse take first?

notify health care provider

Which of the following describes a sympathetic response?

pupil dilation

Which of the following describes the categories used for the Full Outline of UnResponsiveness (FOUR) scale?

reflexes

The nurse is caring for a client with dysphagia. From which interdisciplinary team member should the nurse anticipate a consult?

speech therapy

A client who had a stroke states, "I want a... I want a... I want a..." Which communication tool will the nurse use when interacting with this client?

use a picture board

The nurse is providing teaching for a client who underwent a procedure to destroy the sensory portion of the trigeminal nerve. Which statement made by the client indicates a need for further education?

"I need to be gentle when rubbing my eyes."

The nurse is providing teaching regarding avoidance of multiple sclerosis (MS) triggers. Which statement made by the client indicates the need for further teaching?

"I should move to an area with a cold climate."

The nurse is reviewing orders for a client with myasthenia gravis (MG). Which order should the nurse question?

Atenolol

The nurse assists with the care of several clients presenting with stroke symptoms. Which client is a candidate for thrombolytic therapy?

A 56-year-old client reporting hiccups, drowsiness, and left-sided facial numbness starting 2 hr prior

The nurse assists with discharge of a client who has a stroke and is being prescribed a statin medication. Which client statement indicates that additional teaching is required?

"Muscle pains are normal for the first few weeks."

The nurse is preparing to administer dalfampridine 10 mg by mouth to a client with multiple sclerosis (MS). The available dose is dalfampridine 10mg tablets. How many tablets will the nurse administer? Enter the numeral only.

1

The nurse is evaluating several clients' risk factors for stroke. Which client is at highest risk for stroke? Rank in order of severity, one being the highest A client with obesity who has an unknown blood pressure and unknown irregular heartbeat A client who quit smoking yesterday and has a cholesterol level of 255 mg/dL A client who maintains a healthy weight and has an irregular heartbeat A client who is slightly overweight has a blood pressure of 115/74 mm Hg and no family history of stroke

1,2,3,4

The nurse obtains the following assessment data on a client using the Glasgow Coma Scale (GCS). What is the total score for a client who opens eyes to painful stimulus, whose verbal response is confused conversation, and who has localized pain?

11

Which of the following describes the number of pairs of cranial nerves?

12

A client's eyelids are open but not tracking, the client is able to localize pain, one pupil is wide and fixed, the client has a regular breathing pattern, and the client is not intubated. Using the Full Outline of UnResponsiveness (FOUR) Score Coma Scale, which score will the nurse assign this client?

13

The nurse is preparing to administer neostigmine 120 mg by mouth to a client with myasthenia gravis (MG). The available dose is neostigmine 15 mg tablets. How many tablets will the nurse administer? Enter the numeral only.

8 tablets

The nurse is calculating output for a client with myasthenia gravis (MG). The client has 400 mL of urine from an indwelling urinary catheter in the morning and 220 mL in the afternoon, and 200 mL of output in a chamber from a nasogastric tube connected to suction. Calculate the client's total output. Enter the numeral only.

820

The nurse is caring for a group of clients. Which client is at high risk for myasthenia gravis?

A 25-year-old woman with a thymus gland disorder

The nurse assists with care of a confused client who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg, pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Administer 2 L of oxygen per nasal cannula

The nurse is assisting with care of a client diagnosed with a hemorrhagic stroke. The client's vital signs are: blood pressure 184/100 mm Hg, pulse 102 beats per minute, and SpO2 97%. Which nursing intervention is priority?

Administer labetalol 20 mg intravenously

The nurse is assisting with care of a client diagnosed with a hemorrhagic stroke. The client's vital signs are: blood pressure 184/100 mm Hg, pulse 102 beats per minute, and SpO2 97%. Which nursing intervention is priority?

Administer labetalol 20 mg intravenously.

The nurse is assessing a client's eyes and notes that pupils are unequal in size. The nurse will document this finding as which of the following?

Anisocoria

A client's foot remains in a position of plantar flexion after a stroke. Which action will the nurse take?

Apply a splint to the client's foot

A client's spouse tells the nurse, "I'm having a lot of trouble caring for my husband after his stroke." Which nursing intervention is appropriate? Select all that apply

Collaborate with a social worker. Evaluate the need for home health nursing and physical therapy. Assist the spouse in identifying the client's functional level. Encourage the spouse to seek support groups. Provide support to the spouse if transfer to a skilled nursing facility is required.

Which of the following are common causes of mental changes in older adults? Select all that apply.

Depression Malnutrition Infection Side effects of medications

The nurse is caring for a client who is in myasthenic crisis. Which of the following clinical manifestations should the nurse expect to find? Select all that apply.

Difficulty speaking Weakness

A client is participating in a strenuous exercise program. Which physiologic response will the nurse expect find? Select all that apply.

Dilated bronchioles Decreased peristalsis Increased heart rate

The nurse is caring for a client with Guillain-Barre syndrome (GBS). Which clinical manifestations can the nurse expect to find? Select all that apply.

Dyspnea Urine retention Cardiac arrhythmias Paralytic Ileus

The nurse is caring for a client with frontal lobe damage following a hemorrhagic stroke. The client is displaying inappropriate behaviors toward staff. Which action will the nurse take?

Employ appropriate diversionary actions

The nurse is caring for a client who has left-sided neglect after a hemorrhagic stroke. Which nursing intervention is appropriate for this client? Select all that apply

Encourage client to check left side for skin breakdown Consult occupational therapy

The nurse is caring for a client with Bell's palsy. Which of the following interventions should the nurse implement?

Encourage the client to use a facial sling while eating

The nurse is caring for a client with myasthenia gravis (MG). Which clinical manifestations can the nurse expect to find? Select all that apply

Extreme muscle weakness Difficulty chewing

The nurse is determining four clients' Glasgow coma scale (GCS) scores. Rank the highest GCS score to the GCS lowest score. Spontaneous eye opening, confused conversation, localizes to pain Eye opening to verbal stimulus, uses inappropriate words, withdraws from pain Spontaneous eye opening, normal conversation, obeys commands Eye opening to painful stimulus, incomprehensible sounds, abnormal flexion

GCS assesses a client's eye opening, verbal response, and motor response. A GCS score of 15 is the highest possible score. Client 1 has a GCS of 13, client 2 has a GCS of 10, client 3 has a GCS of 15, and client 4 has a GCS of 7 (3,1,2,4)

The nurse is caring for a client with Bell's palsy. Which of the following is the most likely to have caused the condition?

Herpes zoster

The nurse is providing teaching for a client with Bell's palsy. Which of the following statements made by the client indicates an understanding of the teaching?

I need to use an electric razor when I shave."

A client sustains a chemical splash to the eye. Which cranial nerve will the nurse prioritize during assessments?

II optic

A client's vital signs change from BP 120/70 mm Hg, pulse 70 bpm, respirations 16 and regular, to BP 150/50 mm Hg, pulse 50 bpm, and respirations 12 and irregular. Which etiology should the nurse suspect?

Increased intracranial pressure

The nurse is caring for a client admitted for an ischemic stroke of the left cerebral artery. Which nursing diagnosis is a priority?

Ineffective tissue perfusion

The health-care provider suspects that a client has multiple sclerosis (MS). For which diagnostic test will the nurse prepare the client?

MRI

The nurse learns a client has a metal cerebral aneurysm clip. Which test will the nurse recommend for cancellation?

MRI

The nurse is caring for a client with the nursing diagnosis of Impaired physical mobility related to decreased motor function. Which nursing intervention is appropriate? Select all that apply

Maintain proper body alignment Encourage use of affected side during activities Perform range-of-motion exercises

The nurse is providing education regarding nutrition for a client with myasthenia gravis (MG). Which food choice made by the client indicates an understanding of the teaching?

Meatloaf with mashed potatoes and gravy

The nurse asks a client to repeat four words and to repeat them again in 5 minutes. Which of the following is the nurse assessing?

Memory

The nurse is caring for a client with multiple sclerosis (MS). Which intervention should the nurse plan to implement?

Monitor the client for signs of infection

Which of the following describe chronic neuromuscular disorders? Select all that apply.

Multiple sclerosis (MS) Myasthenia gravis (MG) Guillain-Barre syndrome (GBS)

The nurse is caring for a client with amyotrophic lateral sclerosis (ALS). Which of the following clinical manifestations should the nurse expect to find?

Muscle atrophy

The nurse is providing teaching for a client receiving azathioprine. Which statement made by the client indicates an understanding of the teaching?

My mom is sick, so I should not go see her."

A client's Glasgow coma scale (GCS) score changes from 14 to 11. Which action will the nurse take immediately? Select all that apply.

Obtain the client's blood sugar Notify the health-care provider (HCP) Measure the client's oxygen saturation Review the client's prescribed medications

The nurse asks a client recovering from a stroke to swallow a pill. However, the client does not respond to the nurse's request. What is the best nursing action?

Pantomime the action

The nurse assists with care of a client diagnosed with a hemorrhagic stroke. The client reports increased weakness in the left arm, double vision, and a headache. Which action will the nurse take first?

Perform a stroke scale screening

The nurse is reviewing orders for a client with restless leg syndrome (RLS). Which medication can the nurse expect to administer?

Pramipexole

The nurse is caring for a client with multiple sclerosis (MS) who is now on a ventilator. Which of the following will the nurse implement to promote effective communication? Select all that apply.

Provide a paper and pencil Give the patient a picture board Use a nonhurried and calm approach

The nurse is caring for a client with expressive aphasia. Which is an appropriate statement when communicating with the client?

State your name for me, please."

A client who suffered a head injury has a Glasgow coma scale (GCS) score of 13. Which conclusion can the nurse draw from this finding?

The client has a mild head injury.

The nurse is caring for a client scheduled for a computed tomography (CT) scan of the head. Which finding most concerns the nurse?

The client is allergic to contrast dye.

The nurse observes a student nurse checking cranial nerve function. Which action by the student nurse necessitates additional teaching? Select all that apply

The client is asked to frown, smile, and wrinkle the forehead when checking the trigeminal nerve.

The nurse is assigned to care for adult clients on a neurological unit. Which observation concerns the nurse?

The great toe extends and the other toes fan out when the sole of the foot is stroked.

The nurse is teaching a client about phenytoin. Which of the following should the nurse include in the teaching?

The need for meticulous oral care

The nurse is caring for a client diagnosed with a minor stroke. The client asks about taking both aspirin and clopidogrel. Which statement by the nurse is correct?

These medications reduce the chance of you having another stroke."

The nurse is caring for a client who has a residual hemiplegia after a stroke. The client begins to actively vomit. Which priority action will the nurse take?

Turn the client to the side immediately

The nurse is instructed to assess cranial nerve VI. Which cranial nerve will the nurse assess?

abducens