Chapter 9 Neuro
The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response?
"Alteplase dissolves clots and may cause more bleeding into your wife's brain."
The nurse is preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching?
"I will avoid exercise because the pain gets worse."
Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP) when caring for a client with a thrombotic stroke who has residual left-sided weakness? Select all that apply.
Assisting the client to reposition every 2 hours Reapplying pneumatic compression boots Reminding the client to perform active range-of-motion (ROM) exercises Setting up meal trays and assisting with feeding Using a lift to assist the client up to a bedside chair
A client who has Alzheimer disease is hospitalized with new-onset angina. Her spouse tells the nurse that he does not sleep well because he needs to be sure the client does not wander during the night. He insists on checking each of the medications the nurse gives the client to be sure they are "the same pills she takes at home." Based on this information, which nursing problem is most appropriate for this client?
Care provider role stress
After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)?
Checking the client's vital signs
The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action?
Contact the Rapid Response Team.
The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student requires that the nurse intervene most rapidly?
Entering the room without putting on a protective mask and gown
A client with multiple sclerosis tells the unlicensed assistive personnel (UAP) after physical therapy that she is too tired to take a bath. What is the priority nursing concern at this time?
Fatigue
The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? Select all that apply.
Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. Drugs such as nitroglycerin and nifedipine should be avoided. Abortive therapy is aimed at eliminating the pain during the aura. A potential side effect of medications is rebound headache. Complementary therapies such as biofeedback and relaxation may be helpful.
The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6°F (39.2°C) orally. Which prescribed intervention should be implemented first?
Infuse ceftriaxone 2000 mg IV to treat the infection.
A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment?
Monitor respiratory effort and oxygen saturation level.
The RN notes that a client with myasthenia gravis has an elevated temperature (102.2°F [39°C]), an increased heart rate (120 beats/min), and a rise in blood pressure (158/94 mm Hg) and is incontinent of urine and stool. What is the nurse's best action at this time?
Notify the health care provider immediately.
A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client?
Position the client sitting up in bed before he or she is fed.
The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN?
Setting up oxygen and suction equipment
An LPN/LVN, under the RN's supervision, is assigned to provide nursing care for a client with Guillain-Barré syndrome (GBS). What observation should the LPN/LVN be instructed to report immediately?
Shallow respirations and decreased breath sounds
The nurse is providing care for a client newly diagnosed with early Alzheimer disease (AD). On assessment, which finding would the nurse expect to discover?
Short-term memory impairment
The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void? Select all that apply.
Stroking the client's inner thigh Pulling on the client's pubic hair Pouring warm water over the client's perineum Tapping the bladder to stimulate the detrusor muscle
The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IV push every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns the nurse the most?
The client no longer recognizes family members.
The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding?
The client's condition is deteriorating.
A 70-year-old client with alcoholism who has become lethargic, confused, and incontinent during the last week is admitted to the emergency department. His wife tells the nurse that he fell down the stairs about a month ago but that "he didn't have a scratch afterward." Which collaborative interventions will the nurse implement first?
Transport the client to the radiology department for a computed tomography (CT) scan.
Which nursing action will be implemented first if a client has a generalized tonic-clonic seizure?
Turn the client to one side.
A client with Guillain-Barré syndrome (GBS) is to undergo plasmapheresis to remove circulating antibodies thought to be responsible for the disease. Which client care action should the nurse delegate to the experienced unlicensed assistive personnel (UAP)?
Weigh the client before and after the procedure.
Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit?
A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due
For which client with severe migraine headaches would the nurse question an order for sumatriptan?
A 48-year-old client with hypertension
After the nurse receives the change-of-shift report at 7:00 am, which client must the nurse assess first?
A 63-year-old client with multiple sclerosis (MS) who has an oral temperature of 101.8°F (38.8°C) and flank pain
A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene?
"It's OK to take over-the-counter medications."
Which client should the charge nurse assign to a new graduate RN who is orientating to the neurologic unit?
A 67-year-old client who had a stroke 3 days ago and has left-sided weakness
Which client should the charge nurse assign to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week?
A 68-year-old client with chronic amyotrophic lateral sclerosis (ALS)
A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take first?
Check the Foley tubing for kinks or obstruction.
The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) when providing nursing care for a client with a spinal cord injury?
Checking and recording the client's vital signs every 4 hours
The nurse is in charge of developing a standard plan of care for an Alzheimer disease care facility and is responsible for assigning and supervising resident care given by LPNs/LVNs and delegating and supervising care given by unlicensed assistive personnel (UAP). Which activity is best to assign to the LPN/LVN team leaders?
Checking for improvement in resident memory after medication therapy is initiated
All of the following nursing care activities are included in the care plan for a 78-year-old man with Parkinson disease who has been referred to the home health agency. Which activities will the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
Checking for orthostatic changes in pulse and blood pressure Reminding the client to allow adequate time for meals Assisting the client with prescribed strengthening exercises
A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN/LVN? Select all that apply.
Checking the client's skin for pressure from the device Observing the halo insertion sites for signs of infection Cleaning the halo insertion sites with hydrogen peroxide Administering oral medications as ordered
The nurse is preparing a nursing care plan for a client with a spinal cord injury (SCI) for whom problems of decreased mobility and inability to perform activities of daily living (ADLs) have been identified. The client tells the nurse, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing concern takes priority?
Difficulty with coping
The RN is supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene?
Instructing the client to sit up straight and the client responds with a puzzled expression
A 23-year-old client with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to assign to an LPN/LVN whom the nurse is supervising? Select all that apply.
Observing and documenting the onset and duration of any seizure activity Administering phenytoin 200 mg PO three times a day Turning the client to his or her side to avoid aspiration
What is the priority nursing concern for a client experiencing a migraine headache?
Pain
A client with Parkinson disease has a problem with decreased mobility related to neuromuscular impairment. The nurse observes the unlicensed assistive personnel (UAP) performing all of these actions. For which action must the nurse intervene?
Performing the client's complete bathing and oral care
A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of greatest concern?
The white blood cell count is 2300/mm3 (2.3 x 109/L).
The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? Select all that apply.
When did you first experience the headache symptoms? What is your health care provider's name? What year and month is this? What is the name of this health care facility?
