hesi neuro

A nurse is caring for an anxious, fearful client. Which client response indicates sympathetic nervous system control?

Skin pallor

Goldman's applanation tonometer

which is the most common method used to determine intraocular pressure.

A nurse is counseling a client with amyotrophic lateral sclerosis (ALS) about management of this disorder. What important suggestion should the nurse make to the client?

"Activities should be spaced throughout the day."

After a left cataract extraction, a client reports severe discomfort in the operated eye. The nurse concludes that this problem may be caused by which condition?

Hemorrhage into the eye

A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which areas of paralysis should the nurse find upon assessment? .

L leg and arm not face

Which condition is characterized with an involuntary and rapid twitching of the client's eyeball?

Nystagmus

A home care nurse is counseling a client with amyotrophic lateral sclerosis (ALS). What information should the nurse include in the discussion? .

Spacing activities throughout the day is a strategy to help conserve the client's energy. Alternate ways to communicate (e.g., writing, electronic devices) should be used when speech becomes difficult because of muscle weakness. Large groups should be avoided to limit the risk of infection; respiratory complications are the leading cause of death. Opioids are not used because they may depress respirations. Lower-extremity pain usually is not a problem associated with ALS. Braces and splints, not restraints, may be used.

Which may cause a foreign body sensation in the eye?

Superficial corneal erosion

Which beta-adrenergic blocker is prescribed to clients with glaucoma?

Betaxolol

The family member of a client with newly diagnosed Guillain-Barré syndrome comes out to the nurse's station and informs the nurse that the client is having difficulty breathing. What is the first action the nurse should do?

Go with the family member to assess the client.

The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve VII. What will the nurse observe upon assessment?

Inhibition of tear production

A client is diagnosed with myasthenia gravis. Which response does the nurse expect the client to demonstrate?

Muscle use reduces strength, and rest increases strength; eyelid movement, chewing, swallowing, speech, facial expression, and breathing often are affected [1] [2]. Muscle strength increases with rest and decreases with activity. Anticholinesterase drugs improve muscle strength. Anticholinesterase drugs increase, not decrease, muscle strength.

keratoconjunctivitis sicca, or dry eye syndrome

dullness of the corneal light reflex and tears with mucus strands.

Naproxen, ibuprofen, and acetaminophen are indicated for relieving mild migraines.

"Pain is not a characteristic symptom of this condition."

A nurse provides education to a client with myasthenia gravis about how to prevent myasthenic crisis. The nurse evaluates that the teaching is effective when the client makes which statement?

"The healthcare provider may need to adjust the dosage of my medication if I'm more active."

A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, what should the nurse teach the client to do?

Advance the cane and the affected extremity simultaneously.

A client has returned from spinal surgery. Which action is essential for the nurse to take?

Circulation and sensation are the priority. Alteration in circulation and sensation indicates damage to the spinal cord; if this occurs, the healthcare provider must be notified immediately. After surgery, the healthcare provider's prescription should specify if the client is permitted oral fluids. The prone position is avoided; log-rolling from side to side is preferred. Although observing the client's bowel movements and voiding patterns will be done, it is not the priority.

A nurse is caring for a client with glaucoma. Which rationale associated with the need for treatment of this condition should the nurse include in a teaching program?

Lost vision cannot be restored.

A client with dementia and chronic confusion is suspected to have Alzheimer disease. Which imaging technique is specific for Alzheimer disease?

Magnetic resonance spectroscopy (MRS)

The nurse is caring for a client who had a brain attack (cerebrovascular accident) and who has varying moods. The moods range from anger to depression to concern about the aphasia, hemiparesis, and the gavage feedings. Which behavior best indicates the client's acceptance of physical limitations?

Performs tube feedings without assistance

A client is admitted to the emergency department with head and chest injuries sustained in a motor vehicle accident. What clinical findings indicate that the client is responding to medical intervention and is ready to be transferred from the emergency department to a critical care unit?

Stable vital signs and pain

What action should the nurse take to prevent precipitating a painful attack in a client with tic douloureux?

The nurse should avoid walking swiftly past the client because drafts or even slight air currents can initiate pain [1] [2]. The client may assume any position of comfort, but pressure on the face while in the prone position may trigger an attack. Although the procedure for oral hygiene may be modified, it is not discontinued. Massaging may trigger an attack and should be avoided.

A nurse is teaching a client with multiple sclerosis (MS) about how to manage urinary retention. Which instructions should the nurse include in the teaching session?

Using Credé maneuver Monitoring for and reporting signs of urinary tract infection

arcus senilis

which is characterized by a milky, white-gray ring encircling the periphery of the cornea. This occurs due to cholesterol deposits in the peripheral cornea.

The registered nurse (RN) is teaching new nurses how to obtain information when introducing themselves to clients suspected of having nervous system disorders. Which statement made by a new nurse indicates the need for further learning?

 "I should observe the client's ability to perform hand hygiene." "I should wait to assess the speech of the client until later."

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true?

. These seizures cause the client to fall because of the decreased muscle tone, which may result in injury. This type of seizure tends to be most resistant to drug therapy.

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? .

Anorexia, nausea, and vomiting occur because of pressure on the brain. Increasing pressure on the vital centers in the brain and irritation of cerebral tissue result in irritability and seizures. Increased intracranial pressure disrupts neurons and neurotransmitters, resulting in faulty impulse transmission and an altered level of consciousness.

Before performing a visual system assessment, the nurse observes that the client is dressed in an unusual color combination of clothes. The client's eye examination reveals changes in the retina. Which condition might this client have?

Decrease in cones

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

Difficulty swallowing

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)?

Hypertension and bradycardia

A client comes into the emergency room (ER) after hitting his head while playing basketball. He is alert and oriented. Which is a priority nursing intervention?

Immobilize the client's head and neck. All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. ROM would be contraindicated at this time. The head CT would be prescribed next.

Which cerebral lobe includes the speech area that allows the client to process words into coherent thoughts?

Wernicke's area (language area), which allows processing of words into coherent thought and understanding of written or spoken words, is located in the temporal lobe. The limbic lobe controls the emotional and visceral patterns in the brain. The frontal lobe consists of Broca's area, which is the speech area responsible for formation of words into speech. The occipital lobe contains the primary visual center.

A man walks into the emergency room (ER) with sunglasses on and tells the nurse that he fell off a ladder and hit his head and was unconscious for a few minutes. What is the most appropriate next question the nurse should ask the client?

he nurse cannot quickly assess the client for raccoon eyes [1] [2] unless the sunglasses are removed. Raccoon eyes is periorbital ecchymosis around the eyes. If bilateral, it is highly suggestive of basilar skull fracture. It is caused by rupture of the meninges causing the venous sinuses to bleed into the arachnoid villi and cranial sinuses, resulting in pooling of blood around the eyes. It most often is associated with fractures of the anterior cranial fossa and requires immediate attention. It is also important to assess for any loss of consciousness, other injuries, and the height of the fall. However, visually assessing the client comes first.

A client reports a severe, sharp, stabbing headache and intense pain in and around the eye that lasts for up to 1 hour. History reveals that the client had similar episodes of headaches previously which lasted for ten weeks. What other symptoms may be manifested by the client? .

Cluster headaches are short headaches occurring in episodes, with characteristic sharp stabbing pain. Pain occurs in the oculotemporal or oculofrontal regions or deep around the eye. The headaches may be persistent for about 4 to 12 weeks followed by a period of remission of 9 to 12 months. Cluster headaches are associated with other symptoms, including rhinorrhea (a runny nose), tearing of eyes (lacrimation), myosis (pupillary constriction), and ptosis (drooping eyelids). Vertigo is a neurologic change seen in a migraine with aura. Phonophobia is sound sensitivity and is seen in a migraine without aura.

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. Which diagnostic test result will the nurse check for confirmation of this diagnosis?

Computed tomography

The nurse is caring for a client who reports excessive tearing. Which disorders does the nurse suspect could be responsible for the client's condition?

A chalazion is an inflammation of a sebaceous gland in the eyelid manifested by excessive tearing and light sensitivity. An entropion is a disorder of the eyelid that causes pain and excessive tearing. Conjunctivitis also causes excessive tearing, a bloodshot appearance, and itching.

A nurse is caring for an older adult with a history of recent memory loss. Which action should the nurse take?

Employ electronic devices that provide alerts

While assessing an older adult with decreased perception of touch, the nurse provides instructions to the client to reduce the risk associated with falling. Which statements made by the nurse are beneficial to the client?

"If you are unable to change your position frequently request assistance." "Look where your feet are placed while walking." "Wear shoes that give good support while walking."

Which type of brain tumor can originate from cells that form the myelin sheath around nerves?

Acoustic neuromas can originate from cells that form the myelin sheath around the nerves. Meningiomas originate from the meninges; they can be a benign or malignant. Astrocytomas can originate from supportive tissues, glial cells, and astrocytes. Ependymomas can originate from the ependymal epithelium. It can range from benign to highly malignant.

A client is admitted to the emergency department with a head injury. A computed tomography (CT) scan shows a subdural hematoma. How should the nurse interpret this finding of a subdural hematoma?

Blood between the dura mater and the arachnoid layer

What should the nurse instruct the client to do to limit triggering the pain associated with trigeminal neuralgia?

Chew on the unaffected side.

A nurse obtains the nursing history from a client who has open-angle (chronic) glaucoma. The nurse anticipates that the client will report which finding during the history?

Increased intraocular pressure damages the optic nerve, interfering with peripheral vision. f

A client who sustained a head injury reports bland taste of food. Upon examination, the nurse finds that there is loss of taste perception from the anterior two-thirds region of the tongue. What is the origin of the involved nerve?

Inferior pons

When performing a neurologic check on a client with a head injury, the nurse identifies a diminished corneal reflex in the left eye. What does appropriate nursing care for a client with an absent corneal reflex include?

Instilling artificial tears frequently

Which is a clinical manifestation of a cluster headache?

Ipsilateral tearing of the eye severe right-sided headache with runny nose, droopy eyelids, and tearing of the eye on the right side Oral glucosamine and lithium are specifically prescribed to treat cluster headache. "Pulsating pain is the characteristic type of pain that occurs in cluster headaches."

A nurse begins planning for the discharge of a client who had a brain attack (cerebrovascular accident, CVA) with residual hemiparesis and hemianopsia. Which information should the nurse include in the discharge teaching plan for this client?

Significance of a safe environment

A client is admitted to the ambulatory health clinic with a diagnosis of Bell palsy. What is most appropriate for the nurse to do?

Teach facial exercises.

The nurse is teaching a client about self-ear irrigation for cerumen removal at home. Which statements made by the client indicate the nurse needs to follow up?

The nurse will follow up on incorrect information to correct these misconceptions. During self-ear irrigation for cerumen removal, the syringe should be filled with lukewarm water only; hot water can damage the ear and can make the client dizzy or nauseous. Extra water present in the ear should be removed by using a hair dryer on a low setting near the ear

The nursing is caring for four different clients with eye disorders. Which client should be assessed for asthma before prescribing beta-adrenergic blockers?

reduce outflow of aqueous humor increased intraocular pressure

A client with myasthenia gravis has increased difficulty swallowing. Which action will the nurse take to prevent the aspiration of food?

take an anticholinesterase muscle stimulant.

The nurse is supporting cognitive ability in clients with Alzheimer disease. Which actions will the nurse take?

 Providing a limited number of choices to support decision-making Strategies that assist orientation without challenging the client and that encourage -safe independence and decision-making support cognitive function in Alzheimer disease, such as clocks, calendars, limited number of choices, and allowing safe independence.

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?

 Blank facial expression Muscle rigidity Nonintention tremors Masklike facial expression Low-pitched monotonous voice

When a disaster occurs, the nurse may have to first treat mass hysteria that is indicated by what response?

Panic

A tentative diagnosis of Guillain-Barré syndrome is made. The nurse assesses for what major clinical manifestations of the syndrome?

Paresthesias and paralysis result from patchy demyelinization of the peripheral nerves, nerve roots, root ganglia, and spinal cord and are related to a diagnosis of Guillain-Barré syndrome.

On which principle should a nurse base client teaching when planning to assist a client to reestablish a regular pattern of defecation?

Peristalsis is initiated by the gastrocolic reflex.

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

Babinski response hyperreflexia

A client develops hydrocephalus two weeks after cranial surgery for a ruptured cerebral aneurysm. The nurse concludes that the hydrocephalus probably is related to which physiologic response?

Blocked absorption of fluid from the arachnoid space

While interacting with a client who reported visual changes, the nurse finds that the client is frequently exposed to the sun. Which conditions might this client have? .

Cataracts develop when oxidative damage to the lens occurs due to chronic exposure to ultraviolet light. Pterygium (a thickened, triangular bit of pale tissue that extends from the inner canthus to the nasal border of the cornea) is caused by chronic sun exposure. Biochemical changes in the lens protein causes pinguecula, which is a small yellowish spot usually on the medial aspect of the conjunctiva. This condition is caused by tissue damage related to chronic exposure to ultraviolet light. Entropion is a condition characterized by changes in the eyelid, which occurs due to a loss of orbital fat and decreased muscle tone. Arcus senilis is caused by excess cholesterol deposits on the cornea.

A client who is diagnosed as having a herniated nucleus pulposus reports pain. What should the nurse most likely conclude is the cause of this client's pain?

Compression of the spinal cord by the extruded nucleus pulposus

A client is admitted to the hospital with the diagnosis of a right-sided brain attack (stroke). The client is right-handed. Which task will be most difficult for this client?

Dressing every morning If the client is right-handed, there will be difficulty with dressing because it requires the use of two hands, and some clothing requires movement of both sides of the body when dressing. A right-handed client is able to continue to use the right hand for eating meals, writing letters, and combing the hair because it is the left side that is affected by a lesion on the right side of the brain.

Which information should be included in the teaching plan for the client diagnosed with epilepsy?

Gingival hyperplasia is a common side effect of phenytoin. Regular brushing and flossing decrease gingival hyperplasia. While lifelong treatment with antiseizure medication often is required, some people are able to be weaned from antiseizure medication after they have been seizure free for a period of several years (generally 3 to 5) and have a normal EEG and neurologic examination. Driving laws for people with epilepsy vary from state to state. For example, some states require a seizure-free period of several months, and some states require a seizure-free period of up to a year before a driver's license can be issued or reinstated. It is not necessary for the person who has experienced a single seizure to be taken to the hospital unless it is a first-time seizure, the seizure is prolonged, or the seizure results in bodily harm.

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client?

Lethargy is an early sign of a changing level of consciousness; changing level of consciousness is one of the first signs of increased intracranial pressure. Nausea is a subjective symptom, not a sign, that may be present with increased intracranial pressure. Sunset eyes are a late sign of increased intracranial pressure that occur in children with hydrocephalus. Hyperthermia is a late sign of increased intracranial pressure that occurs as compression of the brainstem increases. Increased ICP causes unequal pupils as a result of pressure on the third cranial nerve. It causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. ICP increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? .

Resting tremors flatten effect Slow voluntary movements Parkinson disease involves destruction of the neurons of the substantia nigra, reducing dopamine. The cause of this destruction is unknown. Disintegration of the myelin sheath is associated with multiple sclerosis. Breakdown of upper and lower motor neurons is associated with Lou Gehrig disease or amyotrophic lateral sclerosis. Reduced acetylcholine receptors at synapses are associated with myasthenia gravis.

A client has a history of progressive carotid and cerebral atherosclerosis and experiences transient ischemic attacks (TIAs). How does the nurse explain TIAs to the client?

Temporary episodes of neurologic dysfunction

Which test is used to diagnose diseases of the vestibular system?

The caloric test stimulus is used to check for nystagmus, nausea and vomiting, falling, or vertigo. These conditions are associated with diseases of the vestibular system. The Rinne test is a tuning fork test, which aids in differentiating between conductive and sensorineural hearing loss. Pure-tone audiometry determines the client's hearing range in terms of decibels (dB) and Hertz (Hz). This test is used to diagnose conductive and sensorineural hearing loss. An auditory brain stem response test provides diagnostic information related to acoustic neuromas, brain stem problems, and strokes.

A client with a diagnosis of polyarteritis nodosa asks the nurse for information about this disorder. What information should the nurse include in the response?

The disorder is considered one of hypersensitivity, and the exact cause is unknown. autoimmune response plays a role in the development of polyarteritis, although drugs and infections may precipitate it. The disorder often is fatal, usually as a result of heart or renal failure. Men are affected three times more often than women. Arteriolar pathology can affect any organ or system.

During a health fair, the nurse takes an adult's blood pressure, and it is 200/120 mm Hg. The nurse should base the next nursing intervention on what understanding?

There is an increased risk for having a cerebrovascular accident (brain attack). This client is in stage 3 hypertension and needs immediate medical intervention. Exercise would not have increased the blood pressure to this level. The "white coat syndrome" would not increase the blood pressure to this level. Obtaining information regarding prescribed medications will delay obtaining emergency care; the client needs medical care regardless of what medications are being taken.

A client is awaiting surgery for a ruptured lumbar nucleus pulposus. Which activities should the nurse inform the client will most likely increase pain? .

  Bearing down when having a bowel movement Coughing excessively

A client with glaucoma is receiving a carbonic anhydrase inhibitor. Which statement made by the client will require the nurse to notify the primary healthcare provider?

"I am allergic to sulfonamides." Carbonic anhydrase inhibitors are used for the treatment of glaucoma. These drugs are similar to sulfonamides, and if a client is allergic to the sulfonamides, they may have a chance of developing an allergy.

The registered nurse (RN) is teaching a client about cholinergic crisis. Which statement made by the client indicates the nurse needs to intervene?

"I will have decreased urine output." The client will not have decreased urine output because decreased output relates to a myasthenia gravis crisis, not a cholinergic crisis. Myasthenic crisis is an exacerbation of myasthenia gravis symptoms caused by insufficient anticholinergic drugs and is characterized by decreased urine output.

A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" What is the nurse's best response?

no pain in MS

After assessing a client, the nurse anticipates that the client has a chalazion. Which statement made by the client helps the nurse reach this conclusion?

A chalazion is the painless inflammation of a sebaceous gland in the eyelid; a client with chalazion reports light sensitivity and excessive tearing. A hordeolum is an infection of the eyelid sweat glands that leads to painful areas on the skin surface of the eyelid. Entropion is an eyelid disorder in which the client always feels a foreign body in the eyes. Keratoconjunctivitis sicca or dry eye syndrome is a condition in which the client may experience a foreign body sensation and burning and itching eyes.

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, the nurse should promote the use of which equipment?

A raised toilet seat -will reduce strain on the back muscles and make it easier for the client to rise from the seat without injury. The client is not bedridden and will not need side rails for the bed or a trapeze above the bed. Clients with Parkinson disease have poor balance and a propulsive gait, which makes it unsafe to use crutches.

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?

A client diagnosed with Guillain-Barré syndrome may have plasmapheresis as part of treatment. Plasmapheresis is the removal of plasma from withdrawn blood followed by the reconstitution of its cellular components in an isotonic solution and the reinfusion of this solution. A client with Guillain-Barré syndrome, in the absence of kidney disease, does not need hemodialysis. Guillain-Barré syndrome is not a hematological disorder; thrombolytic therapy is not required. Guillain-Barré syndrome is not an autoimmune disorder; immunosuppressive therapy is not required.

A nurse performs a Rinne test during physical assessment of a client. The client indicates that the sound is louder when the vibrating tuning fork is placed against the mastoid bone than when held closely to the ear. What conclusion should the nurse make about these results?

Conductive hearing loss [1] [2] involves impaired transmission of sound waves to the inner ear so that sound transmitted directly through bone is perceived louder and longer than through air conduction. Clients with normal hearing or sensorineural deficit perceive air conduction of sound waves louder and longer than bone conduction. The Rinne test is not related to inflammation of the mastoid.

A client with a history of stabbing pain in the eyes and blurring and gradual loss of vision is examined by an ophthalmologist, a neurologist, and an internist, all of whom find no organic cause. When eye complaints increase, the client is admitted to a mental health unit. What is the priority nursing intervention?

Focusing on daily activities while avoiding discussion of the eye discomfort

A client is diagnosed with hyperopia and has insufficient corneal thickness for a LASIK flap. Which surgical procedure should the nurse anticipate being most likely performed by the primary healthcare provider in this condition?

Photorefractive keratectomy (PRK) Photorefractive keratectomy (PRK) is suitable for clients who have insufficient corneal thickness and have hyperopia. In this procedure the epithelium is removed and the laser sculpts the cornea to correct the refractive error. Phakic intraocular lenses are referred to as implantable contact lenses; they are implanted without removing the eye's natural lens. These are used for clients with a high degree of myopia or hyperopia. A refractive intraocular lens is an implant which is used for clients with a high degree of myopia or hyperopia. It involves removal of the client's natural lens and implantation of an intraocular lens. In laser-assisted in situ keratomileusis (LASIK), a laser or a surgical blade is used to create a flap in the cornea.

A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question?

The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure. Anticonvulsants may be administered prophylactically after traumatic brain injury to limit the risk for seizures, which will further increase intracranial pressure. Osmotic diuretics may be used to draw fluid from the cerebral tissue into the vascular space to decrease cerebral edema and intracranial pressure. Elevation of the head of the bed helps reduce cerebral edema as the result of gravitational force on the fluid.

Which cranial nerve is responsible for the client's equilibrium?

The vestibulocochlear nerve located in the pons-medulla junction is responsible for equilibrium of the body. The vagus nerve located in the medulla is responsible for sensations from the pharynx, larynx, thoracic, and abdominal viscera. The trochlear nerve located in the lower midbrain is responsible for eye movement with superior oblique muscles. The glossopharyngeal nerve located in the medulla is responsible for taste and sensations from the posterior one third of the tongue and the pharynx.

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure?

Widening pulse pressure Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased, not increased, heart rate.