Med-Surg: Neurologic and Sensory Systems

Which visual system assessment technique provides a magnified view of the retina and optic nerve head? 1. Keratometry 2. Ophthalmoscopy 3. Visual acuity testing 4. Confrontation visual filed test

2. Ophthalmoscopy

A client who sustained a head injury reports to the nurse that food always tastes unappealingly bland even though the food is has been prepared to be flavorful. Which area of the brain would the nurse suspect to be affected in the client? 1. Frontal lobe 2. Parietal lobe 3. Occipital lobe 4. Temporal lobe

2. Parietal lobe

Which physiological response is the likely cause of a client developing hydrocephalus 2 weeks after cranial surgery for a ruptured cerebral aneurysm? 1. Vasospasm of adjacent cerebral arteries 2. Ischemic changes in the Broca speech center 3. Increased production of cerebrospinal fluid (CSF) 4. Blocked absorption of fluid from the arachnoid space

4. Blocked absorption of fluid from the arachnoid space

Which intervention would the nurse implement to prevent precipitating a painful attack in a client with tic douloureux? 1. Avoid walking swiftly past the client. 2. Keep the client in the prone position. 3. Discontinue oral hygiene temporarily. 4. Massage both sides of the face frequently.

1. Avoid walking swiftly past the client.

Which factors can trigger a client's migraine attacks? Select all that apply. One, some, or all responses may be correct. 1. Fatigue 2. Vertigo 3. Aphasia 4. Sleep problems 5. Tingling sensations 6. Hormonal fluctuations

1. Fatigue 4. Sleep problems 6. Hormonal fluctuations

A client who had a brain attack (cerebrovascular accident, CVA) frequently cries when family members visit. The family members report being upset by the crying. Which explanation for the client's behavior would the nurse provide? 1. Having difficulty controlling reactions 2. Demonstrating a premorbid personality 3. Mourning the loss of functional abilities 4. Conveying unhappiness about the situation

1. Having difficulty controlling reactions

The nurse finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, reports experiencing back pain and an inability to move the legs. Which action would the nurse implement first? 1. Leave the individual lying on the back with instructions not to move, and seek additional help. 2. Roll the individual onto the abdomen, place a pad under the head, and cover with any material available. 3. Gently raise the individual to a sitting position to determine whether the pain either diminishes or increases in intensity. 4. Gently lift the individual onto a flat piece of lumber and, using any available transportation, rush to the closest medical institution.

1. Leave the individual lying on the back with instructions not to move, and seek additional help.

The nurse assessed a client who experienced a recent brain attack (stroke) and has a residual right-sided hemiplegia. Which rationale explains the importance of the nurse identifying mobility restrictions or neuromuscular abnormalities when assessing this client? 1. Shortening and eventual atrophy of the affected muscles will occur. 2. Hypertrophy of the muscles eventually will result from disuse. 3. Extension rigidity can occur, making therapy painful and difficult. 4. Decreased movement on the affected side predisposes the client to infection.

1. Shortening and eventual atrophy of the affected muscles will occur.

A client with a cervical injury reports the sudden onset of a severe headache and nasal congestion. For which clinical manifestations would the nurse assess? 1. Suprapubic distention 2. Increased spinal reflexes 3. Adventitious breath sounds 4. Imminent development of shock

1. Suprapubic distention

A client admitted to the hospital after an accident has clear drainage oozing from the ear. Which action would the nurse take? 1. Test the fluid for glucose and apply a sterile dressing. 2. Position the client so that the unaffected ear is dependent. 3. Cover the area with sterile gauze while applying slight pressure. 4. Clean the client's outer ear with normal saline and insert a cotton ball.

1. Test the fluid for glucose and apply a sterile dressing.

Which actions would the nurse take for a client who underwent cerebral angiography? Select all that apply. One, some, or all responses may be correct. 1. Wipe off the gel applied before the test 2. Maintain pressure dressing for 2 hours 3. Remove the electrodes gently and thoroughly 4. Obtain vital signs and complete neurological checks 5. Check dressing for bleeding and swelling around the site

2. Maintain pressure dressing for 2 hours 4. Obtain vital signs and complete neurological checks 5. Check dressing for bleeding and swelling around the site

A friend transports an adult client to the emergency department and states, "All of us were partying at a club, and all of a sudden my friend collapsed." The client's vital signs are temperature 99.2°F (37.3°C), pulse 152 beats per minute, respirations 32 breaths per minute, blood pressure 163/92 mm Hg. Which action would the nurse implement next, after completing the physical assessment and health history from the client? 1. Allow the friend to stay at the bedside until next of kin arrive; reassess the client in 1 hour. 2. Relay the client's status to the health care provider; insert the prescribed intravenous (IV) line. 3. Assign the client to a private room and place a cool cloth on the client's forehead. 4. Place the client in a dimly lit room and perform a neurological assessment every 15 minutes.

2. Relay the client's status to the health care provider; insert the prescribed intravenous (IV) line.

Having been immobilized in a body cast or traction for an extended time, the client questions why the therapist uses a tilt table. Which response would explain the function of a tilt table? 1. "The therapy assists in preventing hypertension." 2. "The therapy encourages gradual increases in activity." 3. "The therapy maintains circulation to the skin surface." 4. "The therapy assists in preventing loss of calcium from long bones."

4. "The therapy assists in preventing loss of calcium from long bones."

A client who has a history of seizures is scheduled for an arteriogram at 10:00 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9:00 AM. Which action would the nurse take? 1. Omit the 9:00 AM dose of the medication. 2. Give the same dosage of the medication rectally. 3. Administer the medication with 30 mL of water at 9:00 AM. 4. Ask the health care provider to prescribe an alternative.

4. Ask the health care provider to prescribe an alternative.

The spouse of a client who had a cerebrovascular accident seems unable to accept the goal that the client will participate in self-care. Which response would the nurse make? 1. Tell the spouse to let the client do things independently. 2. Allow the spouse to assume total responsibility for the client's care. 3. Explain that the nursing staff has full responsibility for the client's activities. 4. Ask the spouse for assistance in planning activities most helpful to the client.

4. Ask the spouse for assistance in planning activities most helpful to the client.

Which activities would the nurse recommend to a client who asks for advice about insomnia? Select all that apply. One, some, or all responses may be correct. 1. Drink a glass of wine. 2. Engage in vigorous exercise before bedtime. 3. Eat foods containing lysine. 4. Follow the same bedtime ritual each night. 5. Perform deep-breathing exercises

4. Follow the same bedtime ritual each night. 5. Perform deep-breathing exercises

A client with quadriplegia attends tilt table therapy daily and asks why the angle of the table gradually increases each day. Which response would the nurse use? 1. The tilt table facilitates client's ability to develop muscle strength to turn from side to side. 2. The tilt table assists in preventing the development of pressure injuries. 3. The tilt table promotes hyperextension of the spinal column to prevent contractions. 4. The tilt table provides therapeutic weight bearing to limit loss of calcium from the bones.

4. The tilt table provides therapeutic weight bearing to limit loss of calcium from the bones.

The primary health care provider prescribes an adrenergic agonist to a client with increased intraocular pressure. Which question would the nurse ask the client before administering the medication? 1. "Do you take antidepressants?" 2. "Do you have any respiratory disorders?" 3. "Do you wear eyeglasses?" 4. "Do you have allergies to sulfonamides?"

1. "Do you take antidepressants?"

Which assessment finding is most consistent with a myasthenic crisis? 1. Difficulty breathing 2. Decline in physical mobility 3. Disturbed sensory perception 4. Decreased tolerance to activity

1. Difficulty breathing

Which statement provides the rationale as to the importance of the nurse teaching clients with quadriplegia the use an adaptive wheelchair? 1. The client with quadriplegia is unlikely to regain the ability to walk. 2. Use of the adaptive wheelchair prepares the client for wearing braces. 3. The adaptive wheelchair assists clients in overcoming orthostatic hypotension. 4. Clients with quadriplegia have the strength in their upper extremities to self-transfer.

1. The client with quadriplegia is unlikely to regain the ability to walk.

The nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked. Which finding would the nurse document? 1. "Has intact plantar reflexes" 2. "Exhibits a positive Babinski sign" 3. "Demonstrates normal sensory function" 4. "Able to perform active range of motion"

2. "Exhibits a positive Babinski sign"

Which physiological process can be corrected with a prescribed convex lens? 1. Constriction of the pupil 2. Convergence of images behind the retina 3. Descent of inverted images onto the retina 4. Presence of an unevenly curved retinal surface

2. Convergence of images behind the retina

After 3 months of rehabilitation after a craniotomy, a client still is having motor speech difficulty. Which would the nurse do to promote the client's use of speech? 1. Correct the client's mistakes immediately. 2. Respond to the client's efforts of speaking. 3. Use simple sentences when interacting with the client. 4. Explain again why the client is having difficulty communicating.

2. Respond to the client's efforts of speaking.

Which condition may cause a foreign body sensation in the eye? 1. Herniated orbital fat 2. Superficial corneal erosion 3. Inflammation of anterior uveal tract 4. Infection of sebaceous gland of eyelid

2. Superficial corneal erosion

An adult client with low-functioning Down syndrome (trisomy 21) appears in the emergency department via ambulance after an accident. Which assessment method would be the best instrument to use when determining this client's level of pain? 1. Asking the client's parent 2. Using the Wong-Baker FACES Pain Rating Scale 3. Observe the client's body language 4. Explain and use the 0 to 10 pain scale

2. Using the Wong-Baker FACES Pain Rating Scale

Which recommendation would the nurse give to the client with trigeminal neuralgia? 1. Drink iced liquids. 2. Avoid oral hygiene. 3. Apply warm compresses. 4. Chew on the unaffected side.

3. Apply warm compresses.

Which intervention is useful in promoting comfort for the client experiencing a headache? 1. Massage 2. Heat therapy 3. Cold therapy 4. Relaxation strategies

3. Cold therapy

Which condition is due to decreased elasticity of the ocular lens? 1. Myopia 2. Hyperopia 3. Presbyopia 4. Astigmatism

3. Presbyopia

The nurse providing care for a client admitted to the psychiatric unit with a bipolar disorder strives to provide adequate nutrition during the client's manic phase. Which statement explains the challenge of meeting this client's nutritional needs? 1. The client is too depressed to eat. 2. The client lacks the energy to eat. 3. The client is too busy keeping active to eat. 4. The client is on a restricted diet, limiting cheese. 5. The client is unable to eat favorite foods.

3. The client is too busy keeping active to eat.

Which condition is associated with unevenly curved surfaces of the client's cornea? 1. Myopia 2. Hyperopia 3. Emmetropia 4. Astigmatism

4. Astigmatism

Which information, if reported by a client within 4 hours after repair of a retinal detachment, would the nurse plan to communicate to the primary health care provider? 1. Has not voided 2. Cannot open the eye 3. Cannot remember the date 4. Has sharp pain in the eye

4. Has sharp pain in the eye

A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects to react to which clinical manifestation? 1. Ventricular fibrillation and decreased perfusion 2. Dysfunction of the vagus nerve with hiccups 3. Retention of sensation but paralysis of the lower extremities 4. Respiratory paralysis and cessation of diaphragmatic contractions

4. Respiratory paralysis and cessation of diaphragmatic contractions

Which cerebral lobe includes the speech area that allows the client to process words into coherent thoughts? 1. Limbic lobe 2. Frontal lobe 3. Occipital lobe 4. Temporal lobe

4. Temporal lobe

The nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Which statement explains the nurse's rational? 1. Deep tendon reflexes have been lost. 2. There is partial transection of the cord. 3. There is damage above the sixth thoracic vertebra. 4. Flaccid paralysis of the lower extremities has occurred.

3. There is damage above the sixth thoracic vertebra.