Med-Surg: Neurosensory

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

B. Protect the client's head

A nurse is assessing a client who has a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eight cranial nerve (CN VIII)? A. Dizziness and hearing loss B. Weakness of a side of the tongue C. Facial droop and asymmetrical smile D. Loss of the same visual field in both eyes

A. Dizziness and hearing loss Dizziness and hearing loss reflect alterations in the vestibulocochlear area, which CN VIII innervates - B: Weakness of the tongue indicates damage to CN XII - C: Facial droop and an asymmetrical smile indicate damage to CN VII - D: Loss of the same visual field in both eyes (hemianopsia) indicates damage to the optic tract, which connects to CN II

A nurse is caring for a client who had a cerebrovascular accident (CVA). The client appears alert and engaged 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

A. Expressive aphasia A client who has expressive aphasia understands speech but has difficulty speaking and writing. This typically occurs as a result of a lesion at Broca's area of the frontal lobe. - B: A client who has dysarthria has slurred speech. The nurse cannot determine if this client has dysarthria due to the lack of verbal response. - C: A client who has visual receptive aphasia has difficulty understanding written words. - D: A client who has dysphagia has difficulty swallowing.

A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual cause of MS. Which of the following responses should the nurse make? A. Each client is different; we cannot predict what will happen B. I can see that you are worried, but it's too soon to predict what will happen C. Acute episodes are usually followed by remissions, which can vary in duration D. It's too early to think about the future; let's focus on the present and take each day as it comes

C. Acute episodes are usually followed by remissions, which can vary in duration The client is asking an information-seeking question, so the nurse should provide the client with factual information. The nurse should inform the client that MS is a chronic autoimmune disorder characterized by remissions and exacerbations, with exacerbations becoming more frequent and intense as the disease progresses.

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? A. Use enemas to treat constipation caused by daily medications B. Take a hot bath when muscles ache C. Eat a low-calorie diet D. Set an alarm to ensure medication dosages are taken on time

D. Set an alarm to ensure medication dosages are taken on time The nurse should instruct the client to take medication dosages on time to maintain a therapeutic blood level. Dosages should not be missed or postponed because this can cause an exacerbation of the disease.

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? A. Add gestures when speaking with the client B. Ask open-ended questions C. Limit visitors to 3 at a time D. Use different words if the client does not understand a statement

A. Add gestures when speaking with the client The nurse should use gestures when speaking with the client to increase the client's understanding of the conversation. - B: The nurse should ask questions that can be answered with "yes" or "no" to reduce the client's confusion - C: The nurse should limit visitors to 2 at a time to reduce the client's confusion - D: The nurse should use the same words when repeating a statement to reduce the client's confusion

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 caring for a client who has a cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected? A. Wernicke's area B. Cerebral cortex C. Basal ganglia D. Hypothalamus

D. Hypothalamus The nurse should identify that the hypothalamus, located below the cerebrum of the brain, is responsible for the regulation of body temperature. - A: Wernicke's area is responsible for language and speech comprehension - B: The cerebral cortex is involved in complex thought processes and higher functions of the brain - C: The basal ganglia are involved in a variety of functions, including motor control and learning, but not the regulation of body temperature

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 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

D. Report of a headache Autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.

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

D. Right-sided hemiplegia The nurse should expect right-sided hemiplegia following intracranial bleeding in the left hemisphere in the brain. - A: The nurse should expect the client to have spasticity of the right foot as a latent manifestation of a stroke. This finding is caused by right-sided hemiplegia. - B: A negative Babinski reflex is an expected finding in a healthy adult. This test is performed by stroking upward along the lateral edge of the sole of the foot. In infancy, a positive response (hyperextension of the toes with a dorsiflexion of the great toe) is expected. - C: Ocular hypertension is a characteristic of glaucoma, not intracranial hemorrhage

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 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

A. Widened pulse pressure A widening of the pulse pressure (I.e. the difference between the systolic and diastolic pressure) is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, nausea, and vomiting

A 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? A. The client's serum osmolarity is 310 mOsm/L B. The client's pupils are dilated C. The client's heart rate is 56/min D. The client is restless

A. The client's serum osmolarity is 310 mOsm/L Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP. - B: Dilated pupils, pinpoint pupils, and asymmetrical pupils are manifestations of increased ICP - C: Bradycardia is a manifestation of increased ICP - D: Restlessness and behavioral changes are manifestations of increased ICP

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? A. An aura is a sensory warning that a seizure is imminent B. An aura is a continuous seizure in which seizures occur in rapid succession C. An aura is a period of sleepiness following the seizure D. An aura is a brief loss of consciousness accompanied by staring

A. An aura is a sensory warning that a seizure is imminent An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or smelling an odor. - B: A continuous seizure state is a medical emergency called status epileptics and requires immediate medical support - C: A period of sleepiness or lethargy following a seizure is referred to as the postictal state - D: A brief loss of consciousness accompanied by staring is a manifestation of an absence, or petit mal, seizure. These seizures primarily occur in children.

A nurse asks 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 pressure D. Macular degeneration

A. Cerebellar dysfunction Cerebellar dysfunction causes a loss of position sense (proprioception), which results in a positive Romberg sign. - B: Dysfunction of the occipital lobe causes a loss of vision. - C: An increase in intraocular pressure is a manifestation of glaucoma - D: Macular degeneration causes a loss of vision in the center of the visual field due to retinal damage

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 coffee C. Use a tongue blade to provoke a gag reflex D. Have the client smile and raise his eyebrows

A. Have the client open his mouth and say "aah" The vagus nerve has both sensory and motor functions. To test the motor function, the nurse should have the client open his mouth and say, "aah." The palate and the uvula should move upward in response. The nurse should also assess the client's voice quality for hoarseness. - B: Asking the client to identify the scent of coffee assesses the function of cranial nerve I, the olfactory nerve - C: Using a tongue blade to provoke a gag reflex assesses the function of cranial nerve IX, the glossopharyngeal nerve - D: Having the client smile and raise his eyebrows assesses the function of cranial nerve VII, the facial nerve

During a neurological assessment, a nurse asks 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

A. Remote The nurse tests remote or long-term memory by asking questions such as where and when the client was born, his age, when he graduated high school, and what the names, ages, and birth dates of his children are. The nurse can later verify this information with the client's family or friends. - B: Sensory memory is a short-term, momentary recollection of some form of stimuli from the environment. Recalling demographics of the client's children does not test sensory memory. - C: The nurse tests immediate or new memory by giving the client a 3-step command and observing for completion of all 3 steps - D: The nurse tests recall or recent memory by asking questions about recent activities that the nurse can verify in the client's medical record, such as how the client got to the facility or which provider he saw in the past few days

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 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

A. The client rigidly extends his arms A client who exhibits a decerebrate posture rigidly extends and pronates the 4 extremities and externally rotates the wrists. Decerebrate posturing indicates a severe brain stem injury and late neurological decline.

A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following pieces of information should the nurse include? A. You might need glasses after the surgery B. You may drive home after the procedure C. Continue to wear your contact lenses until the day of the surgery D. Expect complete healing and clear vision in about a week

A. You might need glasses after the surgery LASIK is a type of refractive laser eye surgery that ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, overcorrection or under correction of refractive errors is possible, so some clients will need prescription eyeglasses despite having had LASIK surgery.

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

B. Clear fluid coming from the nares Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture. - A: Although a client who has a depressed fracture of the forehead might also have additional head trauma, this finding does not indicate a basilar skull fracture, which occurs at the base of the skull - C: Motor loss on one side of the body is an indication of an injury to the cerebral hemisphere. The motor dysfunction will be contralateral to the site of the injury, similar to the results of a stroke. Loss of motor function can also be an indication that injury has occurred to the spinal cord. - D: Although a client who has bleeding from the scalp might also have additional head trauma, this finding does not indicate a basilar skull fracture

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (Select all that apply.) 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

B, C, E B. Monitor vital signs every 2 hr C. Assess neurological status every 4 hr E. Keep the client's room darkened - The nurse should monitor the client's vital signs to assess for changes consistent with increased intracranial pressure - The nurse should monitor the client's neurological status at least every 4 hours or more frequently if the client's status indicates. The course of encephalitis is unpredictable, so the client should be monitored closely for any indications of deteriorating neurological functioning. - The nurse should provide the client with a low-stimulation environment to promote comfort and decrease agitation - A: West Nile virus is an arbovirus that is transmitted after a person is bitten by an infected organism such as a mosquito. The nurse should follow standard precautions when caring for a client with encephalitis due to West Nile virus. - D: A client who has encephalitis is at risk for increased intracranial pressure; therefore, the nurse should maintain the head of the client's bed at 30-45 degrees

A nurse is caring for a client who has received sedation. When the nurse applies nailed pressure, the client withdraws his hand. The nurse should document this response as indicating which of the following? A. Confusion B. Arousal C. Orientation D. Attention

B. Arousal The nurse should document that the client is demonstrating some degree of arousal. Withdrawing the hand in response to nailed pressure indicates responsiveness to sensory stimulation.

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 assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul

B. Cheyne-Stokes Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death. - A: A client who has orthopnea experiences shortness of breath when in a supine position and is able to breathe easily when sitting upright - C: Paradoxical respirations (flail chest) is a pattern of breathing in which the chest wall contracts during inspiration and expands during expiration. This can occur in a client who has sustained rib fractures. - D: Kussmaul respirations are a deep, rapid respiratory pattern of hyperventilation that can occur in a client who has diabetic ketoacidosis

A nurse is reviewing the laboratory results of a lumbar 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

B. Elevated protein An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include increased protein in the cerebrospinal fluid.

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 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

B. Place the client in a high-Fowler's position According to evidence-based practice, the nurse should first place the client in a high-Fowler's position to decrease the client's blood pressure and reduce the risk of end-organ damage from the sudden rise in blood pressure.

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 B. Respiratory effort C. Decision-making ability D. Temperature control

B. Respiratory effort The nurse should monitor the respiratory effort of a client who has an injury to the brainstem. The medulla in the brainstem controls the respiratory center. - A: The nurse should monitor understanding of speech for a client who has an injury to the temporal lobe of the brain - C: The nurse should monitor decision making and situational reactions of a client who has an injury to the frontal lobe of the brain - D: The nurse should monitor the temperature control of a client who has an injury to the hypothalamus

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

B. Weakness of the distal extremities ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain and the spinal cord, causing muscle wasting, spasticity, and eventually paralysis. Early manifestations of ALS include increasing muscle weakness, especially involving the distal arms and legs (hands and feet), speech, swallowing, and breathing. - A, C, & D: ALS does not affect the sensory nervous system, does not cause visual changes, and does not affect the autonomic nervous system or temperature regulation.

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 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? A. No food or fluids consumed for 4 hr B. Difficulty recalling recent events C. Development of hives when eating shrimp D. Paresthesias in both hands

C. Development of hives when eating shrimp An allergy to shellfish is a contraindication for the use of contrast media during a CT scan. The nurse should inform the provider and explain to the client that this factor might alter how the technician performs the CT scan.

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 is caring for a client during the first 72 hr following a cerebrovascular accident (CVA). Which of the following actions should the nurse take? A. Turn the client's head to the side with the head of the bed elevated 60 degrees B. Place the head of the bed flat with pillows under the client's neck and feet C. Elevate the head of the bed 25-30 degrees with the client in a neutral midline position D. Position the client in a dorsal recumbent position with pillows under the head and knees

C. Elevate the head of the bed 25-30 degrees with the client in a neutral midline position Elevating the head of the bed 25-30 degrees with the client's head in a neutral midline position helps prevent an increase in intracranial pressure. Increased intracranial pressure is a major risk factor for complications in the first 72 hr following the onset of a CVA. - A, B, & D: These positions are unlikely to be comfortable for a client immediately following a CVA. Additionally, they place the client at risk for increased intracranial pressure.

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? A. Occipital B. Temporal C. Frontal D. Limbic

C. Frontal The nurse should identify that the posterior portion of the frontal lobe is responsible for the verbal expression of thoughts. - A: The occipital lobe is responsible for vision - B: The temporal lobe is responsible for understanding speech - D: The limbic lobe is responsible for memory and learning

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? A. Decreased blood glucose B. Decreased bronchospasms C. Increased urine output D. Increased temperature

C. Increased urine output Mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys. Increased urine output and decreased intracranial pressure are therapeutic effects of this medication.

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 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? A. Metered-dose inhaler B. Continuous passive motion machine C. Oral-nasal suction equipment D. External defibrillator pads

C. Oral-nasal suction equipment A client who has myasthenia gravis is at risk of aspiration due to progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.

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.

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's priority? A. Monitory urinary output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure precautions

C. Provide supplemental oxygen The first action the nurse should take when using the ABC approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical ventilation because these findings indicate decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death.

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 caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions? A. Trendelenburg B. Prone C. Semi-Fowler's D. Sims'

C. Semi-Fowler's To prevent an increase in intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30 degrees. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure.

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 providing teaching to a client who is scheduled for an electroencephalogram. Which of the following pieces of information should the nurse share? A. You'll feel some mild electrical sensations like static electricity during the procedure B. Do not eat or drink anything except water after midnight C. Shampoo your hair before the procedure and don't use any styling products afterward D. It's common to have temporary short-term memory loss after the procedure

C. Shampoo your hair before the procedure and don't use any styling products afterward An EEG is a painless test that records the electrical activity of the brain. For the test, the technician attaches electrodes to the scalp to record the tiny electrical charges released by nerve cells in the brain. For the electrodes to adhere to the scalp, the client's hair has to be clean and free of oil and hair-care products. - A: The EEG electrodes only monitor brain activity; they do not stimulate it. Therefore, the client will not feel any electrical sensations during the procedure. - B: The client should not fast for an EEG because hypoglycemia can affect diagnostic results; however, the client should not drink any beverages that contain caffeine on the day of the test - D: Temporary short-term memory loss is common after electroconvulsive therapy, not after an EEG

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 assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect? A. Tonic-clonic seizures B. Report of a severe headache C. Weakness of the lower extremities D. Decreased level of consciousness

C. Weakness of the lower extremities Guillain-Barre syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities. - A, B, & D: These are not characteristics of Guillain-Barre syndrome

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 providing teaching to a class about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching? A. A TIA can cause irreversible hemiparesis B. A TIA can be the result of cerebral bleeding C. A TIA can cause cerebral edema D. A TIA can precede an ischemic stroke

D. A TIA can precede an ischemic stroke TIAs are considered a manifestation of advanced atherosclerotic disease an often precede an ischemic stroke. Manifestations of a TIA include the loss of vision in an eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness.

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? A. An EEG measures the electric signals to your brain from hearing, sight, and touch B. An EEG measures the electrical activity in your muscles C. An EEG identifies the magnetic fields produced by electrical activity in your brain D. An EEG records the electrical activity of your brain cells

D. An EEG records the electrical activity of your brain cells An EEG measures brain waves via multiple electrodes the technician will attach to the scalp. An EEG provides information the provider can use to identify various problems, including seizure disorders, sleep disorders, inflammation, bleeding, and migraine headaches.

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 B. Yellow tag C. Green tag D. Black tag

D. Black tag The nurse should assign a black tag, or a class IV label, to clients who are not expected to live and will be allowed to die naturally. Dilated pupils that are fixed or nonreactive to light are a poor prognostic sign and can indicate severely increased intracranial pressure. In a mass casualty situation, the overall goal is to provide lifesaving treatment to the greatest number of people possible. - A: Red tags are for clients who have life-threatening injuries but a high possibility of survival once they are stabilized - B: Yellow tags are for clients who have major injuries that are not yet life-threatening - C: Green tags are for clients who have minor injuries that are not life-threatening and do not need immediate attention

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 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.