med surg neuro ati

a nurse in the emergency department is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. which of the following clients should the nurse assess first

a client who is difficult to arouse and is unable to respond to questions

a nurse is triaging clients during a mass casualty event. which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils a. red tag-- life threatening injuries b. yellow tag-major injuries not life threatening c. green tag--minor injuries/not life threatening or need immediate attention d. black tag--not expected to live and will die naturally

black tag--not expected to live and will die naturally

a nurse is caring for a client who has Meniere's disease. the nurse should identify that Meniere's disease affects which structure of the ear. cochlea: inner ear problem a. eustachian tube-infection of the middle ear b. cochlea c. perichondrium d. eardrum

cochlea

a nurse is caring for a client who has a hearing impairment. which of the following actions should the nurse take when communicating with the client

face the client when speaking

a nurse is assessing a client who recently experienced a head injury. which of the findings should the nurse identify as an indication of short-term memory impairment a. inability to remember current age b. inability to count backward c. inability to locate eyeglasses d. inability to recall names of family members

inability to locate eyeglasses

a nurse is assessing a client who has a high-thoracic spinal cord injury. the nurse should identify which of the following findings as a manifestation of autonomic dysreflexia a. flushing of the lower extremities b. hypotension c. tachycardia d. report of a headache

report of a headache

a nurse is caring for a client who is postoperative following a frontal craniotomy. the nurse should place the client in which of the following position a. Trendelenburg b. prone c. semi-fowler's d. Sims

semi-fowler's

a nurse is assessing a client who has a new diagnosis of mastoiditis. which of the following manifestation should the nurse expect

swelling behind the affected ear

a nurse is reviewing the medical history of a client who is scheduled for a magnetic resources imaging (MRI) examination of the cervical vertebra. which of the following pieces of information in the client's history is a contraindication to this procedure a. the client has a new tattoo b. the client is unable to sit upright. c. the client has a history of peripheral vascular disease d. the client has a pacemaker

the client has a pacemaker

a nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). which of the following findings is an early manifestation of ALS a. sensory dysfunction b. weakness of the distal extremities c. decreased vision d. altered temperature regulation

weakness of the distal extremities

a nurse is assessing a client who has Guillain-barre (ascending weakness and paralysis) syndrome. which of the following findings should the nurse expects a. tonic-closure seizures b. report of a severe headache c. weakness of the lower extremities d. decreased level of consciousness

weakness of the lower extremities

a nurse is assessing a client who sustained a recent head injury. which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure a. widened pulse pressure b. tachycardia c. periorbital edema d. decrease in urine output

widened pulse pressure

a nurse is providing preoperative teaching for a client who will undergo laser assisted in situ keratomleusis (LASIK) surgery which of the following pieces of information should the nurse include

you might need your glasses after the surgery

a nurse is caring for a client who has a left intracranial hemorrhage from a stroke. which of the following findings should the nurse expect a. spasticity of the left foot b. negative Babinski reflex c. ocular hypertension d. right-sided hemiplegia

. right-sided hemiplegia

a nurse is preparing a client for an electroencephalogram (EEG). when the client asks the nurse what this test does which of the following responses should the nurse provide

EEG records the electrical activity to your brain. help provide info on seizure disorder, sleep disorder, inflammation, bleeding and migraine headaches

a nurse is preparing a client who has a brain tumor for computed tomography (CT). which of the following factors affects the manner in which the nurse will prepare the client for the scan

development of hives when eating shrimps

a nurse is assessing a client who has cataracts. which of the following findings should the nurse expect a. pupils nonreactive to light b. opacity visible behind the pupil c. white circle around the outside border of the iris d. increased intraocular pressure

opacity visible behind the pupil

a nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). which of the following instructions should the nurse include in the teaching

thoroughly shampoo her hair prior to the EEG

a nurse is walking along the unit when she sees smoke coming from the central supply room. after activating the fire alarm, which of the following actions should the nurse take

turn off sources of oxygen near the fire place wet towels at the base of the fire

a nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). which of the following pieces of information should the nurse include in the teaching

-driving can be dangerous due to the loss of peripheral vision -laser surgery can help reestablish the flow of aqueous humor

a nurse is providing teaching to a class about transient ishemic atracks. (TIA). which of the following pieces of information should the nurse include in the teaching

TIA can precede an ischemic stroke

a nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis. the client asks the nurse about the usual course of MS. which of the following responses should the nurse make

acute episodes are usually followed by remissions, which can vary in duration

a nurse is caring for a client who has moderate Alzheimer's disease. which of the following actions should the nurse take

add gestures when speaking with the client

a nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. which of the onset of the following instructions should the nurse include in the teaching a. place a warm compress on your forehead b. darken the lights c. light a scented d. drink a caffeinated

darken the lights

a nurse is caring for a client during the first 72 hr following cerebrovascular accident (CVA). which of the following actions should the nurse take

elevate the head of the bed 25 to 30 degree with the client in a neutral midline position

a nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. which of the following supplies should the nurse place at the client's bedside

oral -nasal suction equipment

a nurse is caring for a client who has an impairment of cranial nerve II (visual challenges) which of the following actions should the nurse perform to promote the client's safety

provide an obstacle-free path for ambulation

a nurse is assessing a client who report vision loss. the client describes the loss as beginning with a flash of light following a curtain across the field of vision. the nurse should identify that these manifestations indicates which of the following eye disorder a. glaucoma b. retinal detachment c. macular degeneration- decline of central vision d. cataracts-blurred vision/decrease color perception

retinal detachment-no pain

a nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG) in the morning. which of the following pieces of information should the nurse share

shampoo your hair before the procedure and don't use any styling product afterward

a nurse is preparing a client for an electroencephalogram (EEG.) which of the following pieces of information should the nurse share with the client

you will begin by lying still with your eyes close -takes 45min-2hr

a nurse is teaching a client about computed tomography (CT) scanning of the brain which of the following teaching points should the nurse include

you will have to lie very still on a long, narrow table during the test takes 5 min client lie supine

a nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. which of the following statements by the client indicates an understanding of the teaching

an aura is a sensory warning that a seizure is imminent

a nurse is caring for a client who has received sedation. when the nurse applies nailbed pressure, the client withdraw his hand. the nurse should document this response as indicating a. confusion b. arousal c. orientation d. attention

arousal

a nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. (disorder of the inner ear affecting balance and hearing). which of the following instruction should the nurse include in the teaching in the teaching? a. avoid bearing down b. increase caffeine intake c. avoid sudden movements d. increase sodium intake

avoid sudden movements

a nurse is preparing an older adult client who had a transient ischemic attack (TIA) for discharge. the nurse should teach the client to monitor which of the following parameters at home a. blood glucose b. blood pressure c. daily weight d. sensation in the feet

blood pressure

a nurse ask a client to stand with her feet together and her eyes open. after a few seconds, the nurse asks the client to close her eyes. if the client begins to fall, the nurse should interpret this finding as a positive Romberg test, indicating which of the following alterations a. cerebellar dysfunction b. occipital lobe dysfunction c. increased intraocular d. macular degeneration

cerebellar dysfunction

a nurse responds to a call from an assistive personnel that a client just had a seizure and is unconscious. which of the following assessments is the nurse's priority a. measure the client's vital signs b. perform a neurological examination c. check airway patency d. assess the client for injuries

check airway patency

a nurse is assessing a client who is unconscious. the client has a rhythmical breathing pattern of a rapid deep respirations followed by rapid shallow respirations, alternating with period of apnea. the nurse should document that the client is experiencing which of the following types of respirations a. orthopea b. cheyne-stokes c. paradoxical -chest wall contracts during inspiration and expand during expiration d. Kussmaul: deep, rapid respiration

cheyne-stokes

a nurse in an emergency department is assessing a client who sustained a fall off of a roof. which of the following findings should the nurse identify as an indication of a basilar skull fracture a. depressed fracture of the forehead b. clear fluid coming from the nares c. motor loss on one side of the body d. bleeding from the top of the scalp

clear fluid coming from the nares

a nurse is caring for a client who has receptive aphasia which of the following communication problems should the nurse expect when assessing the client a. the client can not name object or formulate sentences or phrases--expressive aphasia b. the client can not articulate correctly due to muscle weakness of the mouth and tongue--dysarthria The c.client is unable to understand words or sentences she hears d. the client speaks words that substitute for those she intends to say--apraxia

client is unable to understand words or sentences she hears

a nurse is assessing an older adult client for physiological changes that can occur with age. which of the following findings should the nurse expect? a. increase saliva production b. decrease sense of taste c. increase sense of smell d. decrease chest wall rigidity

decrease sense of taste

a nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. which of the following findings should the nurse expect a. reduced left-sided motor function b. difficult with speech c. impulsive behavior d. neglect of the left side of the body

difficult with speech

a nurse is caring for a client who experienced a traumatic brain injury. which of the following findings indicates the client is experiencing increased intracranial pressure a. battle's sign b. periorbital edema c. dilated pupils d. halo sign

dilated pupils

a nurse is assessing a client who has a head injury with a possible skull fractures. which of the following finding should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve (CN VIII) a. dizziness and hearing loss b. weakness of a side of the tongue--CN XII c. facial droop and asymmetrical smile--CN VII d. loss of the same visual field in both eyes--CN II

dizziness and hearing loss

a nurse is teaching a client who has myopia about laser-assisted in situ keratomileusis (LASIK) surgery. which of the following is an adverse effect of LASIK surgery a. eyelid twitching b. photosensitivity c. intraocular hemorrhage d. dry eyes

dry eyes

a nurse is performing a neurological assessment for a client who has a brain tumor. which of the following findings should indicate cranial nerve involvement. a. dysphagia b. positive babinski sign c. decreased deep-tendon reflexes d. ataxia

dysphagia

a nurse is providing teaching about degenerative complications to the partner of a client who has a new diagnosis of parkinson's disease. which of the following manifestation is the priority a. dysphagia b. emotional liability c. impaired speech d. self-care dependency

dysphagia

a nurse is reviewing the laboratory results of a lumber puncture (LP) for a client who has manifestations of bacterial meningitis. which of the following findings should the nurse expect a. elevated glucose b. elevated protein c. presence of RBCs d. presence of D-dimer

elevated protein

a nurse is caring for a client who has had repeated middle ear infections. the client reports that the provider said the infection is due to an obstruction of the structure that connects the middle ear to the throat. the nurse should identify that the provider was referring to which of the following structure

eustachian tube

a nurse is caring for a client who had a cerebrovascular accident. the client appears alert and engage during a visit but does not respond verbally to questions. the nurse should document this as which of the following alterations a. expressive aphasia b. dysarthria c. receptive aphasia d. dysphagia

expressive aphasia

a nurse is teaching a class of new parent about otitis media. which of the following manifestations should the nurse include in the teaching? a. high-pitched sound heard in the ear b. intermitted rapid eye movement c. itching of the external canal d. feelings of fullness in the ear

feelings of fullness in the ear

a nurse is caring for a client who has expressive aphasia following a stroke. the nurse should identify that stroke affect which of the following lobes of the client's brain a. occipital- vision b. temporal-understanding speech c. frontal-verbal expression of thoughts d. limbic-memory and learning

frontal-verbal expression of thoughts

a nurse is preparing to test the function of cranial nerve X. which of the following assessment procedures should the nurse use? a. have the client open his mouth and say "aah" b. ask the client to identify the scent of a coffee c. use a tongue blade to provoke a gag reflex d. have the client smile and raise his eyebrows

have the client open his mouth and say "aah"

a nurse is caring for a client who has a cerebral lesion and develops hyperthermia. which of the following areas of the client brain is affected. a. wernicke's area-- language and speech comprehension b. cerebral cortex--thought process and higher function of brain c. basal ganglia- motor control and learning d. hypothalamus

hypothalamus

a nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. which of the following statements by the client indicates understanding of the instruction

i will avoid bending over

a nurse names 3 object for a client to remember, ask the client to repeat them, and tells the client he will have to repeat them again in a few minutes. after 5 min, the nurse asks the client to name the object. the nurse is using this strategy to test which type of memory a. remote b. sensory c. immediate d. recall

immediate

a nurse in an emergency department has assessed a client's airway, breathing, and circulation following a head injury from a fall at work. which of the following actions is the priority for the nurse to perform next?

immobilize the client's cervical spine

a nurse is assessing a client who has increased intracranial pressure and has received intravenous mannitol. which of the following findings indicates a therapeutic effect of this medication.

increased urine output

a nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. which of the following instructions should the nurse include in the teaching

instill a diluted alcohol solution into the ear after swimming

a charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. which of the following actions requires the charge nurse to intervene

instilling 50 mL of fluid with each irrigation instead of 5-10ml

a nurse is assessing a client who was admitted to the facility for observation following a closed head injury. which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status a. vital sign b. body posture c. level of consciousness d. examination of pupils

level of consciousness

a nurse is providing teaching to the family of a client who has stage II Alzheimer's disease. which of the following pieces of information should the nurse include in the teaching

limit choices offered to the client

a nurse is planning care for a client following a stroke. which of the following interventions should the nurse identify as the priority in the client's plan of care

monitor the client for increased intracranial pressure

a nurse is caring for a client who has encephalitis due to the west Nile virus. which of the following actions should the nurse take a. place the client in respiratory isolation b. monitor vital signs every 2 hr c. assess neurological status every 4 hr d. maintain the client in a modified Trendelenburg position e. keep the client's room darkened

monitor vital signs every 2 hr c. assess neurological status every 4 hr keep the client's room darkened

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. after checking the client's vital signs, which of the following actions should the nurse perform next a. administer nifedipine b. place the client in a high-fowler's position c. check for urinary retention d. check for a fecal impaction

place the client in a high-fowler's position.

a nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. the nurse should instruct the client's family to take which of the following actions first in the event of a seizure. a. reorient the client b. protect the client's head c. loosen constrictive clothing d. turn the client onto his side

protect the client's head

an emergency room nurse is assessing a client who has a new traumatic brain injury. the nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. which of the following actions is the nurse priority

provide supplemental diuretic

a nurse is reviewing the medical history of s client who has presbyopia. with which of the following activities should the nurse expect the client to have difficulty.

reading the newspaper

during a neurological assessment, a nurse asks how the client arrived at the appointment and with whom. which of the following types of memory is the nurse testing a. remote b. immediate c. recall d. past

recall/recent

a nurse is caring for a client who has dementia and is experiencing anxiety. which of the following actions should the nurse take

redirect the client to a different activity with a small group of people

a nurse is providing discharge teaching to a client who has had a transient ischemic attack (TIA). which of the following instructions should the nurse include

reduce dietary sodium

during a neurological assessment, a nurse ask the client to name all of his children, their ages, and their birth dates. which of the following types of memory is the nurse testing? a. remote b. sensory c. immediate d. recall

remote

a nurse is caring for a client who has a brainstem injury. which of the following physiological functions should the nurse monitor a. understanding speech -temporal lobe b. respiratory effort-the medulla in the brainstem control the respiratory center c. decision-making ability-frontal lobe d. temperature control-hypothalamus

respiratory effort-the medulla in the brainstem control the respiratory center

a home health nurse is interviewing the adult child of a client who has alzheimer disease. the child is the client's sole caregiver and report feeling fatigued and overwhelmed. which of the following referrals should the nurse make for the caregiver a. attorney b. physical therapy c. respite care d occupational therapy

respite care

a nurse is caring for a client who has closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). this increase an ICP is due to which of the following a. decreased cerebral perfusion b. leakage of cerebral spinal fluid c. rigid skull containing cranial contents d. brain herniated into the brainstem

rigid skull containing cranial contents

a nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. which of the following pieces of information in the client's medical record should the nurse identify as a risk factor for tinnitus a. use of hydrochlorothiazide b. chronic use of acetaminophen c. allergic external otitis d. sclerosis of the ossicles

sclerosis of the ossicles

a nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis (MG). which of the following pieces of information should the nurse include

set an alarm to ensure medication dosages are taken on time eat high calorie diet avoid over heating

a nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. the nurse should anticipate the client to report which of the following manifestations a. multiple floaters b. flashes of light in front of the eye c. severe eye pain d. double vision

severe eye pain halos around the light blurred vision brow pain, headache, N/V

a nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. the nurse suspects the client has manifestations of diabetes insipidus. which of the following laboratory values should the nurse plan to obtain to assess for DI a. blood urea nitrogen b. blood glucose c. urine ketones d. specific gravity

specific gravity

a nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. which of the following reactions should the nurse anticipate when drawing a blood sample? a. the client rigidly extends his arms b. the client internally flexes his wrists c. the client curls into a fetal position d. the client internally rotates his legs

the client rigidly extends his arms

a nurse is caring for a client who is recovering from resent stroke. which of the following assessments is the nurse's priority

the client's ability to clear oral secretions to reduce aspiration

the nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure (ICP). which of the following findings indicates that the medication is having a therapeutic effect

the client's serum osmolarity is 310 mOsm/L

a nurse is caring for a client who begins to have a generalized tonic-clonic seizure while lying in bed. which of the following actions should the nurse take a. insert an oral airway b. turn the client onto a side c. restrict movement of the client's limbs d. place a pillow under the client's head

turn the client onto a side

a nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. which of the following instructions should the nurse include in the teaching

you should avoid reading for 1 week