Med-Surg: Neurosensory

A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect? A. Swelling behind the affected ear B. Facial drooping on the affected side C. Nystagmus on the affected side D. Pearly gray color of the affected eardrum

A. Swelling behind the affected ear Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include swelling and pain behind the ear.

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

B. Blood pressure A temporary disturbance of the blood supply to the brain causes a TIA, which is a brief alteration in neurological function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should track his BP regularly to promote hypertension management and reduce the risk of another TIA or cerebrovascular accident.

A nurse is caring for a client who has Menieres disease. The nurse should identify that Meniere's disease affects which structure of the ear? A. Eustachian tube B. Cochlea C. Perichondrium D. Eardrum

B. Cochlea Meniere's disease is a condition of the inner ear in which excess fluid distorts the inner ear canal system. This distortion decreases hearing via dilation of the cochlear duct, leading to vertigo from damage to the vestibular system.

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 an understanding of the instructions? A. I will sleep on the affected side B. I will avoid bending over C. I will restrict caffeine in my diet D. I will take aspirin to relieve my pain

B. I will avoid bending over The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can create intraocular hemorrhage.

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? A. Visualizing the eardrum before irrigating B. Instilling 50 mL of fluid with each irrigation C. Using firm, continuous pressure while irrigating D. Warming the irrigation fluid to at least 37c (98f)

B. Instilling 50 mL of fluid with each irrigation When irrigating a client's ear, the nurse should use no more than 5-10 mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear, which would result in nausea, vomiting, or dizziness. The nurse should stop irrigating if the client experiences pain, nausea, vomiting, or dizziness.

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

B. Opacity visible behind the pupil With a cataract, the lens of the eye becomes thick and opaque with age and appears as opacity behind the pupil when a nurse shines a light on the area. - A: Pupils that are not reactive to light indicates changes in intracranial pressure and other alterations, not cataracts. - C: A white circle around the outside border of the iris is an arcus senilis, not a cataract. - D: Glaucoma, not cataracts, causes an increase in intraocular pressure

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? A. You can expect your vision to return immediately after the procedure B. You should avoid reading for 1 week C. You can remove eye shields when you're sleeping D. You should not lift objects that weigh more than 25 lb

B. You should avoid reading for 1 week The client should avoid reading and any activity that can cause rapid movement of the eye due to the risk of detachment of the retina. - A: The client's vision will not be restored immediately after the procedure because of swelling of the eye and the dilating effects of eye drops. The client's vision should return gradually overall several weeks. - C: The client should wear eye shields for 2-6 weeks after surgery when sleeping to protect the eye from injury - D: The client should not lift objects that weigh more than 20 pounds to prevent an increase in intraocular pressure

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

C. Dilated pupils Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately. - A: Battle's sign is bruising behind the ears and lower jaw that can occur from the trauma of a skull fracture. It does not indicate increased intracranial pressure. - B: Periorbital edema is a result of facial trauma. It does not indicate increased intracranial pressure. - D: A halo sign is a clear or yellow ring surrounding a spot of fluid or blood from the nose or ear. The ring indicates leakage of cerebral spinal fluid that can occur with a skull fracture. It does not indicate increased intracranial pressure.

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? A. Dry the ear canal with a cotton swab after swimming B. Apply an ice pack to the ear to relieve pain C. Instill a diluted alcohol solution into the ear after swimming D. Irrigate the ear with cool tap water to clean

C. Instill a diluted alcohol solution into the ear after swimming External otitis is an inflammation of the external auditory canal often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops to decrease bacterial and dry the external ear canal.

A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote the client's safety? A. Initiate seizure precautions B. Ensure the client receives a soft diet C. Provide an obstacle-free path for ambulation D. Instruct the client to use lukewarm water when showering

C. Provide an obstacle-free path for ambulation Although providing an obstacle-free path is a safety precaution for all clients, it is especially crucial for this client. Cranial nerve II is the optic nerve; therefore, the client has at least some visual challenges and will need an obstacle-free path for ambulation.

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

C. Recall To test recall or recent memory, the nurse should ask the client to provide details about how he arrives at the appointment and with whom. The nurse could also ask the client to name any health care providers he saw in the past few days. - A: To test remote memory, the nurse should ask the client for information from the distant past, such as the client's city of birth or the schools he attended. It is best to ask information that the nurse can verify. - B: To test immediate or new memory, the nurse should give the client 3 unrelated words, ask him to repeat them, and then ask him to repeat them again 5 minutes later. - D: To test past memory, the nurse should ask for the client's mother's maiden name or for a specific, important date in the client's history.

A nurse is assessing a client who reports an acute visual disturbance that he describes as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders? A. Cataracts B. Angle-closure glaucoma C. Retinal detachment D. Macular degeneration

C. Retinal detachment Th retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. Retinal detachment is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field.

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). This increase in 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

C. Rigid skull containing cranial contents The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP.

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

C. Severe eye pain Other manifestations of acute angle-closure glaucoma can include report of halos around lights, blurred vision, headaches, brow pain, and nausea and vomiting.

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 cannot name simple objects or formulate sentences or phrases B. The client has difficulty articulating correctly due to muscle weakness of the mouth and tongue C. The client is unable to understand words or sentences she hears D. The client speaks words that substitute for those she intends to say

C. The client is unable to understand words or sentences she hears Clients who cannot understand words or sentences they hear have receptive aphasia. - A: Clients who cannot name simple objects or formulate sentences or phrases has expressive aphasia. - B: Clients who have difficulty articulating correctly due to weakness or paralysis of the muscles that produce speech have dysarthria. - D: Clients who speak words in place of those they intend to say have apraxia.

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? (Select all that apply.) A. Lost vision can improve with eye drops B. Administer eye drops as needed for vision loss C. Glassess will be necessary to correct the accompanying presbyopia D. Driving can be dangerous due to the loss of peripheral vision E. Laser surgery can help reestablish the flow of aqueous humor

D, E D. Driving can be dangerous due to the loss of peripheral vision E. Laser surgery can help reestablish the flow of aqueous humor - Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can lead to complete vision loss if not treated - Laser surgery can reopen the trabecular meshwork and widen the canal of Schlemm

A nurse is teaching a client who has myopia about LASIK surgery. Which of the following is an adverse effect of LASIK surgery? A. Eyelid twitching B. Photosensitivity C. Intraocular hemorrhage D. Dry eyes

D. Dry eyes Adverse effects of LASIK surgery include dryness of the eyes and blurred vision

A nurse is caring for a client who has had repeated middle ear infections. The client reports that the provider said the infections are 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 structures? A. Oval window B. Auricle C. Tympanic membrane D. Eustachian tube

D. Eustachian tube The Eustachian tube connects the middle ear to the throat and allows equalization of pressure and drainage of fluids from the middle ear into the throat. - A: The oval window is located between the middle ear and the inner ear structures - B: The auricle is the external ear - C: The tympanic membrane, often referred to as the eardrum, separates the external ear from the middle ear

A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching? A. High-pitched sound heard in the ear B. Intermittent rapid eye movement C. Itching of the external canal D. Feeling of fullness in the ear

D. Feeling of fullness in the ear A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations include ear pain, a cracking sound when yawning or swallowing, and mild dizziness. - A: A client who has otitis media can develop a low-pitched sound in the affected ear - B: A client who has an inner ear disorder can develop nystagmus or rapid eye movement - C: A client who has external otitis can develop itching of the ear canal

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty? A. Finding the bathroom in the dark B. Driving at night C. Seeing numbers on highway signs D. Reading the newspaper

D. Reading the newspaper With presbyopia, the lens is unable to change shape to focus on near objects. Presbyopia develops with aging, beginning in middle age, and results from the decreased elasticity of the lens. - A: Difficulty finding the bathroom in the dark is most likely due to other changes in the vitreous or cornea - B: Difficulty driving at night is usually due to glare from oncoming car headlights. This is most likely due to astigmatism or other changes in the shape of the cornea. - C: Difficulty seeing numbers on the highway signs is most likely due to myopia, or nearsightedness, in which the cornea curves sharply and the focal point is in front of the retina. Objects in the distance are blurry, but those close up are clear.

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

D. Sclerosis of the ossicles Sclerosis of the ossicles, called otosclerosis, is an overgrowth of the tissue of the bones in the middle ear, which can cause tinnitus and conductive hearing loss. A stapedectomy is a surgical procedure that corrects otosclerosis by removing a portion of the stapes and inserting a prosthesis.