exam 4 retake neuro

The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What will be the nurse's best answer?

"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.

The nurse is providing community education regarding strokes. Which information will be included? Select all that apply.

-A stroke is caused by interruption of blood ow to the brain. -Rapid recognition of stroke symptoms can help decrease poor outcomes. -A stroke causes neurological de cits.

A client is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care will the nurse describe to the client? Select all that apply.

-Application of topical antibiotic ointment -Use of an ocular pressure dressing

Which of the following nursing interventions will most likely facilitate effective communication with a hearing-impaired client? Select all that apply.

-Ask the client to repeat what was said in order to evaluate understanding -Repeat the question or rephrase it to the client -Reduce environmental noise and distractions before communicating

A patient had cataract surgery. What instructions would the nurse provide? Select all that apply.

-Avoid constipation or straining -Call the doctor for increased pain -Do not bend over from the waist -Do not lift more than 10 lbs

A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the nurse knows to include what in client teaching? Select all that apply.

-Footwear needs to be accurately sized. -Assistive devices may be needed to reduce the risk of falls. -inspect the lower extremities for skin breakdown

A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What will this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply.

-Glaucoma -Macular degeneration -Diabetic retinopathy

The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply.

-MRI -Transcranial Doppler flow study -Cerebral angiography

The advanced practice nurse is attempting to examine the client's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the client's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing interventions are most important to minimize nausea and vertigo during the procedure? Select all that apply.

-Maintain the irrigation using gentle pressure -Maintain the irrigation fluid at a warm temperature

An elderly client was admitted to the Medical-Surgial unit after a fall. What vital signs indicate Cushing's Triad? Select all that apply.

-Morning vital signs include blood pressure of 110/70 Afternoon vital signs include blood pressure of 130/50 -Morning vital signs include heart rate of 62 Afternoon vital signs include heart rate of 52

A family member of a client diagnosed with Huntington disease calls you at the clinic. She is requesting help from the Huntington's Disease Society of America. What kind of help can this client and family receive from this organization? Select all that apply.

-Public education -referrals -Information about this disease

The nurse is caring for a client with an altered level of conciousness and regularly assesses for potential complications. The nurse will assess for which complications? Select all that apply.

-Venous thromboembolism -Pneumonia -Contractures -Pressure ulcers

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What will the nurse identify as prominent risk factors for SCI? Select all that apply

-Young age -Alcohol or drug use -Male gender

Order: Phenobarbital sodium 100 mg IM Drug available: Phenobarbital sodium 125 mg/2 mL How many mLs should the patient receive?

1.6

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention will be most appropriate for this client?

Absolute bed rest in a quiet, nonstimulating environment

A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?

Applying thigh-high elastic stockings

The nurse is providing discharge education to an adult client who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the client is able to self-administer these medications safely and effectively?

Ask the client to demonstrate the instillation of her medications

During discharge teaching the nurse realizes that the client is not able to read medication bottles accurately and has not been taking her medications consistently at home. How will the nurse intervene?

Ask the social worker to investigate community support agencies

The nurse is performing a neurologic assessment of a client whose injuries have rendered her unable to follow verbal commands. How will the nurse proceed with assessing the client's level of consciousness (LOC)?

Assess the client's eye opening and response to stimuli

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What dysrhythmia does this client most likely have?

Atrial fibrillation

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations will the nurse expect in this client?

Bradycardia and hypertension

A nurse assesses a client and notes the client's position as indicated in the illustration below:

Decorticate posturing

A client is brought by ambulance to the ED after surgyering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what?

Evidence of hemorrhagic stroke

A client has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray?

Explain the location of items using clock cues

The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care will address what characteristic manifestation of this disease?

Facial paralysis

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse will gauge the client's LOC on the results of what diagnostic tool?

Glasgow Coma scale

The nurse is caring for a client who is in status epilepticus. What medication will the nurse anticipated administering to halt the seizure immediately?

Intravenous diazepam

The nurse is caring for a client who is postoperative following a craniotomy. What assessment will the nurse prioritize?

Monitor serum electrolytes

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding will the nurse expect for a client with this diagnosis?

Neck flexion produces flexion of knees and hips

The nurse is discussing the results of a client's diagnostic testing with the nurse practitioner. What Weber test result will indicate the presence of a sensorineural loss?

The sound is heard better in the ear in which hearing is better.

A client diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the client's care, the nurse will be aware that the effects of the tumor will primarily depend on what variable?

The specific hormones secreted by the tumor

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following health care provider prescriptions: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?

To avoid impeding venous outflow

A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?

Vigilant monitoring of fluid balance

The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What will the nurse be correct in teaching the client to avoid?

Washing his face

A child goes to the school nurse and reports being unable to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss?

Whisper test

A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the client's statements best demonstrates an adequate understanding?

"I need to call the doctor if I see flashing lights."

A client has been diagnosed with glaucoma and the nurse is preparing health education regarding the client's medication regimen. The client states that she is eager to "beat this disease" and looks forward to the time that she will no longer require medication. How should the nurse best respond?

"In fact, glaucoma usually requires lifelong treatment with medications."

A patient is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the patient indicate a good understanding of home management of this condition? Select all that apply.

-"Eye irrigations should be done with warm saline or water." -"I will throw away all my eye makeup when I get home." -"I won't touch the tip of the eyedrop bottle to my eye."

An adult client has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses

-"What medications are you currently taking" -"Does anyone else in your family struggle with headaches?" -"Are you exposed to any toxins or chemicals at work?" -'How would you describe your ability to cope with stress?"

A client is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the client, the nurse instructs the client to immediately call the office if the client experiences what? Select all that apply.

-A new oater in vision -Flashing lights -Increase in redness of the eye

A client has lost most of her vision as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action are most appropriate? Select all that apply.

-Assess and promote the client's coping skills during interactions with the client -Allow the client to express her feelings related to the vision loss

The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse will know that elderly clients with MS are known to be particularly concerned about what variables? Select all that apply.

-Becoming a burden on the family -Possible nursing home placement -Increasing disability

A middle-aged woman has sought care from her primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What signs or symptoms are most likely to have prompted the woman to seek care? Select all that apply.

-Depression -DiffIculty in coordination

The nurse is providing discharge education for a client with a new diagnosis of Ménière disease. What food will the client be instructed to limit or avoid? Select all that apply.

-Dill pickles -Canned sardines

A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? Select all that apply.

-Handwashing can prevent the spread of the disease to others -Avoid sharing face cloths, towels and eye drops

The nurse is caring for a client with a brain tumor who is experiencing symptoms due to compression and in infiltration of normal tissue. The pathophysiologic changes that result can cause what manifestations? Select all that apply.

-Increased ICP -Seizure activity -Altered pituitary function

While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the clients' cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action?

-Inform the surgeon of the possibility of a dural leak

A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions will the nurse perform? Select all that apply.

-Monitor pain levels and administer analgesics -Perform frequent neurologic assessments

A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that will be monitored for in this client? Select all that apply.

-Orthostatic hypotension -VTE -Autonomic dysreflexia

A male client presents to the clinic reporting a headache. The nurse notes that the client is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? Select all that apply.

-Photophobia -Positive Kernig sign

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for bene t and for harm. The nurse will be cognizant of what contraindications for thrombolytic therapy? Select all that apply.

-Recent intracranial pathology -Symptom onset greater than 3 hours prior to admission -Current anticoagulation therapy

The nurse caring for a client in ICU diagnosed with Guillain--Barré syndrome will prioritize monitoring for what potential complications? Select all that apply.

-Respiratory failure -Autonomic dysfunction

The registered nurse taking shift report learns that an assigned client is blind. How will the nurse best communicate with this client? Select all that apply.

-Speak directly to them using a normal tone of voice -State her name and role immediately after entering the client's room

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspects of the client's current health status is most likely to have precipitated this event? Select all that apply.

-The client has developed a pressure ulcer. -The client's urinary catheter became occluded.

A client is demonstrating confusion and difficulty focusing. Which assessment findings will the nurse evaluate as supporting a diagnosis of delirium rather than dementia? Select all that apply.

-The confusion cleared when the client is re-hydrated. -The client's mentation was clear yesterday.

An older adult client is diagnosed with a left cerebral hemorrhage. To meet the needs of the client and family, the nurse will provide teaching in which areas? Select all that apply.

-Transfer techniques -Nutrition support -Time adjustment to complete activities -How to use a sign board

A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? Select all that apply.

-Use a cotton swab to clean external auditory canal -Avoid scratching the external canal with finger nail or other objects

A client with a lower motor neuron injury due to a spinal cord injury is experiencing neurogenic paralysis of the bowel. Which actions will the nurse take to assist in relieving this patient's constipation? Select all that apply.

-administer stool softeners -Establish a pattern of planned bowel evacuation

A client with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care will the home health nurse focus? Select all that apply.

-pain control -Management of treatment complications -Administration of treatments -Assistance with self-care

The nurse is administering eye drops to a client with glaucoma. After instilling the client's first medication, how long will the nurse wait before instilling the client's second medication into the same eye?

5 minutes

A client is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate?

Administer morphine sulfate as prescribed

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

Alteration in level of consciousness (LOC)

A neurologic flow chart is often used to document the care of a client with a traumatic brain injury. At what point in the client's care will the nurse begin to use a neurologic flow chart?

As soon as the initial assessment is made

Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity?

Be aware of clients' medication regimens and collaborate with other professionals accordingly

A client who was diagnosed with Parkinson disease several months ago recently began treatment with levodopa-carbidopa. The client and his family are excited that he has experienced significant symptom relief. The nurse will be aware of what implication of the client's medication regimen?

Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?

Bruising over the mastoid

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Call the health care provider immediately

A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what will the nurse's primary assessment focus?

Cardiac and respiratory status

The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse will anticipate the use of what medications?

Cholinergics

Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear will be reported by the nurse immediately?

Clear, watery fluid is draining from the client's ear.

A hearing-impaired client is scheduled to have an MRI. What will be important for the nurse to remember when caring for this client?

Client is likely unable to hear the nurse during test.

The nurse enters an examination room to help with an eye examination. The client is directed toward the assessment chart shown below:

Color Vision

While completing a health history on a client who has recently experienced a seizure, the nurse will assess for what characteristic associated with the postictal state?

Confusion

The nurse is planning the care of a client with Parkinson disease. The nurse will be aware that treatment will focus on what pathophysiologic phenomenon?

Decreased availability of dopamine

A client is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière disease. What question is it most important for the nurse to ask the client in preparation for this test?

Do you currently take any tranquilizers or stimulants on a regular basis?

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?

Electroencephalography (EEG)

The nurse is admitting a 55-year-old male client diagnosed with a retinal detachment in his left eye. While assessing this client, what characteristic symptom will the nurse expect to find?

Flashing lights in the visual eld

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate?

Fluid restriction

A client has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the client will be kept in a prone position until otherwise ordered. What will the nurse do?

Follow the order because this position will help keep the retinal repair intact

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse will teach the family that these responses are typically a result of what cause?

Frustration around changes in function and communication

A client presents at the ED after receiving a chemical burn to the eye. What will be the nurse's initial intervention for this client?

Generously flush the affected eye with normal saline or water

A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane will be what color in a healthy ear?

Gray

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes decreased in older adults, what must be used with caution?

Hot or cold packs

A client has just returned to the unit from the PACU after surgery for a tumor within the spine. The client complains of pain. When positioning the client for comfort and to reduce injury to the surgical site, the nurse will position to client in what position?

In a flat side-lying position

A client presents to the ED reporting a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The client mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the client's diagnosis will be?

Labyrinthitis

A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment?

Loss of hearing, tinnitus, and vertigo

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How will the nurse best position the client?

Maintain head of bed (HOB) elevated at 30 to 45 degrees

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Maintaining a patent airway

A client is brought to the ED by her family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?

Making openings in the skull

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse will expect to administer what priority medication?

Mannitol

A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse will be correct in suspecting the presence of what complication?

Meningitis

A client with a spinal cord injury has experienced several hypotensive episodes. How will the nurse best address the client's risk for orthostatic hypotension?

Monitor the client's BP before and during position changes

Following a spinal cord injury a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse will be correct in implementing what priority nursing action?

Notify the neurosurgeon of the occurrence

The nurse is assessing a client with increased intracranial pressure (ICP). What assessment will the nurse prioritize?

Obeys commands with appropriate motor responses

The nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in this client's deficit?

Parietal--occipital area

The client in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a postlumbar puncture headache, what is the nurse's most appropriate action?

Position the client supine with the head of bed flat

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what will be the nurse's most appropriate action?

Prepare for interventions to increase the client's BP

After a subarachnoid hemorrhage, the client's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action?

Prepare to administer 3% NaCl by IV as prescribed

A client with Guillain--Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action?

Prepare to assist with intubation

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication?

Provide a board of commonly used needs and phrases

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action?

Provide interventions to increase cerebral perfusion pressure (CPP)

A client is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the client's LOC is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment nding?

Recognize that this may represent the peak of postsurgical cerebral edema

A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI will prioritize what action?

Removing all metal-containing objects

The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk will the nurse prioritize in this client's care?

Risk for falls

A client with Parkinson disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The client's nutritional needs will be met by what method?

Semisolid food with thick liquids

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of re ex activity in the spinal cord below the level of injury. What will the nurse suspect?

Spinal shock

A client is exploring treatment options after being diagnosed with cataracts that affect her vision. What treatment is most likely to be used in this client's care?

Surgical intervention

A hospitalized client with impaired vision must get a picture in their mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the client's room?

That all furniture remains in the same position

A client has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this client's health status?

The client needs to be assessed for nasopharyngeal cancer.

A client with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the client?

The client should discuss this new remedy with her ophthalmologist promptly.

A client diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What will the nurse teach this client?

The hearing loss will likely resolve with time after the drug is discontinued.

A 72-year-old man has been brought to his primary provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle will underlie the nurse's assessment and management of this client?

Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?

To remove atherosclerotic plaques blocking cerebral flow

A client with suspected Parkinson disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor?

When the client is resting

A client is having a "fight or flight response" after receiving bad news about his prognosis. What affect will this have on the client's sympathetic nervous system?

increase in the secretion of sweat

The nurse in an extended care facility is planning the daily activities of a client with postpolio syndrome. The nurse recognizes the client will best benefit from physical therapy when it is scheduled at what time?

n the morning