DrP nerological remediation

A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first?

Place the head and neck in alignment.

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm?

Sudden severe headache

A client with the diagnosis of schizophrenia is given one of the antipsychotic drugs. The nurse understands that antipsychotic drugs can cause extrapyramidal side effects. Which effect is cause for the greatest concern?

Tardive dyskinesia

On the psychiatric unit a client has been receiving high doses of haloperidol (Haldol) for 2 weeks. The client says, "I just can't sit still, and I feel jittery." Which side effect does the nurse suspect that the client is experiencing?

Akathisia

A nurse is collecting data on a client with Parkinson disease. Which findings support this diagnosis? Select all that apply.

Nonintention tremors Masklike facial expression Low-pitched monotonous voice

A client is at risk for increased intracranial pressure (ICP). Which assessment finding reflects an increase in ICP?

Unequal pupil size

A nurse provides teaching regarding vitamin B12 injections to a client with pernicious anemia. The nurse concludes that the teaching was understood when the client makes which statement?

"I must take the drug monthly, for the rest of my life."

A nurse is assessing clients who are to be given the smallpox vaccination. Which client should the nurse remove from the immunization line for medical counseling?

45-year-old woman with breast cancer

Which client is considered at the highest risk for a dissecting aneurysm?

55-year-old black male with uncontrolled hypertension

The nurse concludes that the gradual occlusion of the internal or common carotid arteries, manifested by transient ischemic attacks, may occur because of what reason?

Atherosclerosis of the vascular system

A client with a gunshot wound has severe hemiplegia associated with abnormal body posturing and fixed and dilated pupils. What is the nursing priority in this condition?

Monitoring respiratory rate

The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period?

Bladder control

A nurse is aware that after the administration of alprazolam (Xanax) is started, it is important to observe the client for side effects. What is the nurse's initial action?

Checking the client's blood pressure

After a preschooler undergoes craniotomy for the removal of a brain tumor, the nurse identifies an area of serosanguineous drainage about the size of a quarter on the child's dressing. What is the immediate response by the nurse?

Circling the area with nonabsorbable ink

A nurse is providing palliative care to four clients with cancer. The nurse reviews the clients' medical data and learns that different treatment measures have been prescribed to the clients. Which client does the nurse anticipate will have an increased incidence of thrombophlebitis, pulmonary embolus, and stroke?

Client 3

What should be included in the plan of care for a client with vascular dementia?

Details of supportive care interventions

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify?

Difficulty swallowing saliva

An infant who is exhibiting signs of increased intracranial pressure (ICP) is admitted to the pediatric intensive care unit. What care should the nurse implement that is specific for this infant's condition?

Elevating the infant's head higher than the hips

A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion?

Emboli associated with atrial fibrillation

The nurse is caring for a client who is recovering from a stroke. The primary health care provider has referred the client for rehabilitative care. Which interventions by the nurse help to make a successful referral process? Select all that apply.

Explain the need for referral to the client and family. Provide the referral with adequate client information. Determine what the referral recommends for client care.

A client had a bypass graft because of an abdominal aortic aneurysm. Postoperative prescriptions include measurements of the client's abdominal girth. Which serious problem may be indicated by an increasing abdominal girth?

Graft leakage

When completing a neurological assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion?

Inability to stand with feet together when eyes are closed

A client with Parkinson disease complains about a problem with elimination. What should the nurse encourage the client to do?

Increase residue in the diet

What does the nurse understand that clients with myasthenia gravis, Guillain-Barre syndrome, and amyotrophic lateral sclerosis (ALS) share in common?

Increased risk for respiratory complications

Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing?

Increasing intracranial pressure

A family member of a client with a hemorrhagic stroke asks about anticoagulant therapy. The nurse explains what about anticoagulant therapy for the client?

It is contraindicated because it will increase bleeding

A nurse is caring for an infant with meningitis. When the nurse extends the baby's leg, the hamstring muscles go into spasm and the infant begins to cry. What sign or reflex is the infant exhibiting?

Kernig sign

A client with Parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic the client complains of some numbness in the left hand. What is the nurse's priority intervention?

Make arrangements immediately for further medical evaluation by the client's primary health care provider

A client diagnosed with Bell's palsy has many questions about the course of the disorder. What does the nurse explain?

Most clients recover from the effects in several weeks

Selegiline is prescribed for a client with Parkinson disease who is having an inadequate response to levodopa therapy. What information does the nurse include when teaching the client about the addition of this drug to the regimen?

Primary healthcare provider should be contacted immediately if a severe headache occurs.

A man is found to have paranoid schizophrenia, and the practitioner prescribes a typical antipsychotic medication. After taking the medication for 1 month the client comes to the clinic and says, "I feel stiff, my hands shake, and I started drooling." The picture illustrates the client's physical status observed by the nurse in the clinic. What extrapyramidal side effect does the nurse conclude has developed?

Pseudoparkinsonism

The nurse is caring for a client with increased intracranial pressure (ICP). What clinical manifestations are associated with increased ICP? Select all that apply.

Psychotic behaviors Jacksonian seizures Nausea and vomiting

A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. The nurse concludes that the medication is appropriate for this client because it does what?

Restores the dopamine levels in the brain

A nurse is caring for a client with Parkinson's disease. The nurse notes that the client belongs to a distinct culture and is estranged from family members. Which nursing activities display the use of evidence-based practice, as per the 21st century competencies of the Institute of Medicine? Select all that apply.

The nurse refers to several journals to understand the client's cultural practices of the client. The nurse collaborates with an interpreter to teach the client about medical procedures. The nurse evaluates data about the incidence of Parkinson's disease in the client's community. The nurse customizes the care plan based on extensive research about the client's culture.

A nurse is caring for two clients. One has Parkinson disease and the other has myasthenia gravis. For what common complication associated with both disorders, should the nurse assess these clients?

difficulty swallowing

A urine specimen is needed to test for the presence of ketones in a client who is diabetic. What should the nurse do when collecting this specimen from an indwelling urinary catheter?

Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine.

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons?

babinski response

A nurse is caring for a client newly diagnosed with Guillain-Barré syndrome. The nurse expects which procedure will be considered as a treatment option?

Plasmapheresis

During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment?

Pulsating abdominal mass

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent?

The client may or may not be allowed to give consent.

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, the nurse suspects the tumor is located where?

cerebellum

A client has clinical manifestations of rigidity, tremor, bradykinesia, and impaired postural reflexes. Which condition can be suspected in the client?

parkinso disease

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurological examination. What should the nurse document in the client's medical record?

"Exhibits a positive Babinski sign."

A client who recently was told by her practitioner that she has extensive terminal metastatic carcinoma of the breast tells the nurse that she believes an error has been made. She states that she does not have breast cancer, and she is not going to die. The nurse determines that the client is experiencing which stage of death and dying?

Denial

A healthcare provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply .

Double vision Difficulty swallowing saliva Drooping of the upper eyelids

The nursing staff has a team conference on acquired immunodeficiency syndrome (AIDS) and discusses the routes of transmission of the human immunodeficiency virus (HIV). The discussion reveals that there is no risk of exposure to HIV when an individual does what?

Makes a donation of a pint of whole blood

A client is admitted to the hospital with a diagnosis of Parkinson disease. Which common signs of Parkinson disease does the nurse expect to identify when completing a nursing admission history and physical? Select all that apply.

Muscle rigidity Blank facial expression

A male client with dementia due to Parkinson's disease has been placed in a nursing home. His wife appears tired and angry on her first visit with her husband. As she is leaving she says to the unit nurse in a sarcastic tone, "Let's see what you can do with him." What is the most therapeutic response by the nurse?

"It sounds like it's been difficult for you."

While a client with an abdominal aortic aneurysm is being prepared for surgery, the client complains of feeling lightheaded. The client is pale and has a rapid pulse. The nurse concludes that the client is what?

going into shock

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What clinical manifestations will the nurse expect to find?

Hyponatremia and decreased urine output

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. What should the nurse document?

Vesicular breath sounds

A client is admitted to the hospital with a tentative diagnosis of Guillain-Barre syndrome. Which question by the nurse best will elicit information that supports this diagnosis?

"Have you experienced an infection recently?"

Thirty minutes after administering fluphenazine (Prolixin) to a client, the nurse notes that the client's jaw is rigid, the client is drooling, and her speech is slurred. There are a number of as-needed prescriptions in the client's chart. What should the nurse administer?

Benztropine (Cogentin), 2 mg intramuscularly

The nurse understands that shock associated with a ruptured abdominal aneurysm is called what?

Hypovolemic shock

A client with a 5-year history of myasthenia gravis is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. The nurse expects what client response?

Strength decreases with repeated muscle use

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for which side effects of the medication? Select all that apply.

Vomiting Anorexia Changes in mood

A client is admitted to the hospital with the diagnosis of Parkinson disease. What medication should the nurse expect the health care provider to prescribe to relieve the client's physiological responses to this disease?

levodopa

Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, what should the nurse promote the use of?

raised toilet seat

A client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, how does the nurse document this gait?

shuffling

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which manifestations of excessive levels of ADH should the nurse assess the client? Select all that apply.

weight gain hyponatremia